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Inspection on 14/01/08 for The Georgiana

Also see our care home review for The Georgiana for more information

This inspection was carried out on 14th January 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Care is provided to residents by a team of staff who are happy and caring and who involve and interact appropriately with the residents. One resident told us, "It is OK here, very OK". The home is clean and tidy and decorated to a good standard. Residents are able to choose how they spend their time and where they sit. Residents are offered a choice of menu at each meal and can have three cooked meals a day if this is their preference. Activities are provided for those who want to join in. The home has links with the local community and welcomes in visitors. The home also has good relationships with the visiting community nurses who support the home, to provide any nursing duties, at least twice a week.

What has improved since the last inspection?

The manager, with the support of the staff team, has made the necessary improvements to ensure that the requirements made at the last inspection would not be repeated. There has been an on-going programme of repair, refurbishment and decoration as needed. Where possible residents and/or families had been involved in the care planning processes and reviewing the care plans. The home has ensured that all allegations and incidents of abuse are followed up promptly and action taken, including timely reporting to the safeguarding team and ourselves. The home has made suitable adaptations with appropriate equipment to benefit the residents when moving.

What the care home could do better:

All care plans should be reviewed at least every month to ensure that the changing needs of the residents are recorded. Residents must be assessed by a person trained in risk assessments in order to identify service user who are at risk of such things as developing, pressure sores or weight loss. There must be enough staff on duty during the night to ensure the residents and staffs safety.The home must ensure that the results of service user surveys are published and made available to current and prospective service users, their representatives, and other interested parities. All staff must be correctly supervised six times a year.

CARE HOMES FOR OLDER PEOPLE The Georgiana 10 Compton Avenue Luton LU4 9AZ Lead Inspector Sally Snelson Key Unannounced Inspection 14th January 2008 12:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Georgiana Address 10 Compton Avenue Luton LU4 9AZ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01582 570650 No email yet. 3/7/2007 Heritage Care Homes Ltd Mrs Mary Ainsbury Care Home 44 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (44) of places The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 2007 Brief Description of the Service: The Georgiana is located in a residential suburb of Luton within walking distance of a train station. The amenities of the town are a short car journey away. The home had been purpose built almost three years previously to meet the environmental standards detailed by the National Minimum Standards 2001 for the care of forty-four frail older people. The proprietor is Heritage Care Homes Ltd that also operated two other care homes in the vicinity. The accommodation is distributed over three floors that are accessed via staircases and a shaft lift. The upper floor is used for administrative purposes, food storage and preparation. The building had been designed to provide four distinct living areas. Each had a lounge/diner and convenient access to toilet and bathing facilities. Small kitchenette facilities for the use of service users were located on the ground and first floor. The home had a hairdressing room that could also be used for chiropody treatment. All of the bedrooms, which are for single occupation, are fitted with call bells and have en suite toilet and washbasin facilities. The building has been decorated and furnished to a high standard and provided an attractive and comfortable environment. The fee is in the range of £420.00 to £450.00 The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users’ views and information received about the service since the last inspection. This inspection of The Georgiana was the second key inspection. It was unannounced and took place from 12.15pm on 14th January 2008. Sally Snelson undertook the inspection and as it was the second inspection did not request a second information document (AQAA) but continued to use the information from the one provided prior to the last inspection in September 2007. The manager Mrs Mary Ainsbury was present until 16.30hrs, the proprietor, Mr SM Hussain, was made aware of the inspection but was unable to attend easily. Feedback was given to the manager throughout the inspection and by telephone contact the day after the inspection. During the inspection the care of three people who used the service, known as residents was case tracked. Case tracking involved reading residents records and comparing what was documented to what was provided. In addition to sampling files, people who lived at the home, staff and visitors were spoken to and their opinions sought. Any comments received from staff or service users about their views of the home plus all the information gathered on the day was used to form a judgement about the service. The inspector would like to thank all those involved in the inspection for their input and support. What the service does well: Care is provided to residents by a team of staff who are happy and caring and who involve and interact appropriately with the residents. One resident told us, “It is OK here, very OK”. The home is clean and tidy and decorated to a good standard. The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 6 Residents are able to choose how they spend their time and where they sit. Residents are offered a choice of menu at each meal and can have three cooked meals a day if this is their preference. Activities are provided for those who want to join in. The home has links with the local community and welcomes in visitors. The home also has good relationships with the visiting community nurses who support the home, to provide any nursing duties, at least twice a week. What has improved since the last inspection? What they could do better: All care plans should be reviewed at least every month to ensure that the changing needs of the residents are recorded. Residents must be assessed by a person trained in risk assessments in order to identify service user who are at risk of such things as developing, pressure sores or weight loss. There must be enough staff on duty during the night to ensure the residents and staffs safety. The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 7 The home must ensure that the results of service user surveys are published and made available to current and prospective service users, their representatives, and other interested parities. All staff must be correctly supervised six times a year. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5,6 Quality in this outcome area is good. Prior to being admitted into the home prospective residents were assessed by the manager to ensure that the staff team, and the equipment in the home, made The Georgiana a suitable place for them to live. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager confirmed that the Statement of Purpose and the Service Users Guide was kept under review and updated as information altered. The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 10 In all of the care files sampled there was a dated and signed copy of the initial enquiry and the initial assessment. The file also included any information from previous care establishments or placing social workers, if it was available. The manager reported that now the Local Authority worked a brokerage system less inappropriate initial enquires were being made. She sated she was able to reject more enquires prior to the pre-admission assessment, if it was apparent, from the information provided at the point of contact, that the home could not meet the needs of the prospective resident. The pre-admission tool was thorough, and when completed correctly ensured that there was sufficient information for care decisions to be made and for care plans to be formulated. Residents confirmed that their initial stay at the home was for a trial period to ensure that they settled appropriately. The Georgiana did not provide intermediate care. The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is adequate. Care plans were written for all the care needs, but on the occasions when they had not been reviewed and altered to reflect the changing needs of the resident, the correct care may not be given. Medication procedures were being followed correctly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a published document in the form of a book that they used for care planning. This book reminded staff what areas of care needed planning and reminded staff when care reviews were due. However the document did not give an opportunity for any goals to be recorded. The books could appear confusing, as reviews of care plans and risk assessments were completed further on in the book and it could look as though some risk assessment had The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 12 not been reviewed since they were written, until the reader moved into another section of the book. However staff were familiar with the format and were using them correctly. Since the last inspection, wherever possible, either the residents, or their families, were being asked to read the plans and agree them. As a requirement had been made at the previous inspections that care plans must be reviewed by families it may be useful for staff to document the reasons why, on occasions, it was not possible. Of the three care plans sampled in detail, two, including that of a new resident, had been reviewed within the last month but the third had not been reviewed for the last seven weeks. This was particularly concerning as this particular residents condition had altered in that time. A forth care plan was sampled; it had been reviewed monthly. Staff confirmed that they were aware of the changed needs of the resident, so it was considered that the outcome for this resident would not be compromised unless staff that did not know her were on duty. The manager stated that a full care review was planned for this resident at the end of the month to which her family had been invited. As already mentioned risk assessments were in place and we saw that when a resident’s risk of developing a pressure sore increased, appropriate advice had been sought. At the change of each shift the staff walk around the home and visited every resident as part of the procedure for handing over care needs. If resident’s conditions were discussed at this time confidentiality could be compromised, but if this time was used to greet residents and check on their well-being it was to be commended. Medication records had been completed accurately and procedures followed correctly. The manager or a senior staff member carried out a weekly medication audit. The manager reported good relationships with the supplying pharmacists. Throughout the inspection residents were treated with respect by staff. We witnessed the transfer of residents via a hoist at teatime so that they could sit at the dining room table. This was done correctly and staff explained the procedure throughout. The care plan documentation encouraged staff to speak to residents about their end of life wishes. These were documented in their care plans. As yet there was nothing to suggest that the recent changes in the mental capacity act had been taken into account, when recording wishes. The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. Resident’s have the opportunity to take part in activities within the home and to receive visitors at times suitable to them. This encourages socialisation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: When residents were first admitted to the home they were asked if there were certain times when they would not want a visitor, such as mealtimes, or if there were any people that they did not wish to see. This was documented and staff respected these wishes. Throughout the inspection visitors were welcomed into the home. Some residents chose to entertain in their bedrooms and others remained in one of the lounges. The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 14 An activity co-ordinator was employed to work with residents in groups and individually. There was a diary of the activities on offer, which included any planned entertainment. Displayed in the home was artwork that residents had created. A record was kept of the activity provided on a certain day and if the resident had chosen to participate in it or not. Over the Christmas period the residents had enjoyed several parties, including one attended by the mayor to celebrate the 105th birthday of a resident, and a trip to the pantomime. Last year a group of residents and staff went away for a holiday. This was much appreciated. The inspection started before lunchtime and it was noted that residents had the choice of liver or steamed fish with mashed potatoes, cauliflower and broccoli. At teatime they were offered the choice of corned beef hash and spaghetti in tomato sauce or soup and sandwiches. The cook had an assistant and they served the food for the main meal from hot locks, which were taken to the dining rooms on each of the two floors. The cook told us that he planned the menus in advance and used a combination of fresh and frozen vegetables according to availability. He said he spent time talking to the residents about their food preferences and as a result was currently offering a cooked breakfast three times a week which was greatly appreciated and looked forward to by some. One of the residents whose care was case tracked was on a very specialist diet. The cook admitted that this had been difficult at first and he had to source help, but was now confident in the preparation. The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. A robust complaints procedure and the staffs increased knowledge of safeguarding procedures ensured the safety of the residents living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager stated that there had been no complaints made to the home since the last inspection. In addition there had not been any complaints made to us about the home. The complaints file identified that the last complaint investigated was in May 2007. It was noted that the methodology was appropriate and that it was completed in a timely fashion. The home also had a compliment file, which was not examined but appeared well used. Since the last inspection the staff had reported appropriately any accidents, falls, or unexplained injuries to us, and the safeguarding team. The manager stated that she felt that the home now had a good relationship with the safeguarding team and could ask for advise from them. The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,26 Quality in this outcome area is good. The home was clean and well furnished and provided the residents who lived there with a comfortable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was clean and tidy and with the exception of one area free from any offensive odours. For operational purposes the home was divided into ground floor and first floor areas, accessed by stairs or a lift. Residents used the communal areas in which their bedrooms were situated, but were free to access any of the home The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 17 or garden. Doors to the outside were not locked, but they were fitted with an alarm to alert staff if someone went out of the building. The rooms of the three residents case tracked were looked at. They were clean and tidy, had all the required furniture and there was evidence that resident’s could personalise them with small pieces of furniture and ornaments of their own. In the last few inspection reports there had been an outstanding requirement, made as a result of recommendations made as part of an environmental risk assessment. The owner was criticized for not keeping to agreed timescales. At this inspection it was noted that where possible, and where still required, handrails had been fitted to toilet areas. The home had also purchased a number of free standing raised toilet seats with handrails to be used in ensuite bathrooms. These were distributed following new risk assessments. The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. During the day the staff compliment appeared to meet the needs of the resident’s but at night only one member of staff on one of the floors at any one time could compromise the care provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the inspection there were eight staff on duty in addition to the manager, two cleaners, two kitchen staff and a person responsible for the laundry. This was considered to be sufficient for the number of residents. However the practise of having three staff and one on–call at night was, and had been, a cause for concern. The manager confirmed that this staffing ratio was kept under review and that additional staff were always on duty if it was assessed that there was a raised level of need. However because for operational purposes the home was divided into the two floors, and this meant that, at any one time, one member of staff would be alone. We sampled the personal files of three staff members. This included one who had been with the home less than six months, one who had come from abroad The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 19 and one who had worked at the home for more than two years. All had the correct documentation and were neat and tidy. In addition to recruitment documentation, staff files included supervision notes (See next section of this report), and training certificates. At the last inspection it was found that some staff had been employed from abroad, via an agency, without the manager checking their pre-employment documentation. This was because she believed it to have been done by the agency and the Responsible Individual who had made the arrangements with the agency. It was found that this was not so and there were some discrepancies. The manager had since checked each file and ensured that there was a reference from this person’s last place of work, that staff were not working excess hours if they were on a student visa, and that contracts were altered if their employment at the home changed. The manager had a training plan that indicated what training staff had completed over the last year. She also had lists of, training opportunities and which staff would like to do particular courses. The home would benefit from these lists being merged so that that it was apparent who needed, not only initial training, but also refresher courses. Staff files indicated that staff had participated in a variety of training, some that were considered mandatory, and some that were more specialist, such as dementia awareness. There was nothing to suggest that anyone in the home had been trained to carry out the variety of risk assessments that were being completed. A high proportion of the staff had NVQ qualifications and during the inspection we spoke to an assessor who was working with six senior staff working towards NVQ level 2 in leadership. The home also had a volunteer who was studying for Registered Managers Award as part of her personal development to return to work. The volunteer had been Criminal Record Bureau checked by the home and was helping with activities and other non-care duties. The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is adequate. The manager is committed to providing a good quality of care to the resident’s and as a result supports the staff to increase their knowledge. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager, who had on the day of the inspection returned from a week’s annual leave, was very welcoming and helpful throughout the inspection. She stated that while she had been on leave, although she had told staff to contact her if they needed to, she had for the first time had no interruptions. She The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 21 believed this was a mark of the staff’s, particularly the senior carers, maturity and increased ability. The manager had a number of years experience of working with the elderly and showed a commitment to the home and the staff who worked there. Following the last inspection we had a meeting with the owner Mr Hussain, to discuss the action we would need to take if the final judgement for the home did not improve. The manager reported that as a result of this, the owner had agreed all of the changes, and the purchase of any equipment she had suggested. The home had an on-going quality assurance system. Questionnaires had last been sent out six months ago and were on the managers ‘to-do’ list to be repeated during January. Stakeholder questionnaires were sent to involved individuals such as, the supplying pharmacist, visiting G.P’s and community nurses. The manager wrote an action plan from the results of the survey. It was noted that the resident’s surveys did not presently offer anonymity, and it was suggested that the next survey should offer this option to see if people responded any differently. Staff and resident meetings were held at times. The home would benefit from these taking place more regularly. The owner was carrying out the visits required by Regulation 26, but the report submitted was very basic and would not help the manager provide best care. Any personal monies held in the home on behalf of the residents were stored individually in a locked cabinet in the manager’s office. We looked at the records for the three residents we were tracking. Two of these had small amounts of money held by the home; both reconciled with the records kept. However it was noted that the visiting hairdresser did not offer a receipt but signed the individual’s record of transaction as proof of payment. We believed that this system could be open to abuse and suggested that receipts were issued. The manager stated that the families were provided with quarterly statements of their relative’s transactions. We noted that staff were having a supervision of their work by a senior member of staff at least six times a year, this was in addition to meeting with the manager every six months for an appraisal. However this did not reflect best practice as standard 36 required staff to be supervised six times a year and have the opportunity to cover all areas of practice, the philosophy of the care in the home and career development, and not to have their working practices supervised. Staff confirmed that the manager was supportive and would discuss any issues both personal and professional at any time. The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 22 The manager and staff had updated policies and procedures as identified at the last inspection and the manager had a plan to ensure that policies were reviewed regularly. The fire service had carried out a fire inspection of the building during November. This had identified a door that would benefit from being removed; the handyman had done this immediately. The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(2)(b) (c) Requirement The home must ensure to reflect changing needs of the service users’ in their care plan including the medication section. This requirement had been made following the last inspection and given a timescale for 31/10/07 It had almost been met at this inspection. 2. OP8 Schedule3 (3)(n) The home must ensure that service user are assessed, by a person trained to do so, to identify service user who are at risk of developing, pressure sores and appropriate intervention is recorded in the care plan. This requirement had been made following the last inspection and given a timescale for 31/10/07 It had almost been met at this inspection, but there was no evidence that staff had been trained in risk assessments. The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 25 Timescale for action 01/03/08 01/04/08 3. OP27 18(1)(a) 4. OP30 18(1)(a) The home must have adequate 01/04/08 staff to ensure all the assessed needs of all the service users’ are met on all the shifts. (Previous time scale31/10/07) The home must ensure that 01/04/08 there is a staff training and development programme and ensures staff fulfil the aims of the home and meet the changing needs of the service users. This was almost met. The home must ensure that the results of service user surveys are published and made available to current and prospective service users, their representatives, and other interested parities. Staff must have the type of supervision that is detailed in standard 36 of the national Minimum standards 01/04/08 5. OP33 24(1)(a) (b) 6. OP36 18(2) 01/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4 Refer to Standard OP7 OP33 OP33 OP35 Good Practice Recommendations Staff should consider documenting the reasons why, on occasions, residents or their relatives do not agree care plans. The manager should consider having more regular meetings with staff and residents. The responsible individual should provide more information to the manager following his monthly visits. The hairdresser should give residents receipts for the money taken for hairdressing. The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Georgiana DS0000044852.V355963.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!