Inspection on 24/05/05 for The Laurels

This inspection was carried out on 24th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

Other inspections for this house

The Laurels 03/07/07

The Laurels 26/07/06

The Laurels 29/11/05

The Laurels 16/11/04

The Laurels 08/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Laurels 43 Salisbury Road Harrow Middlesex HA1 1NU Lead Inspector Judith Brindle Unannounced 24 May 2005 9.50am 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 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 Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Laurels Address 43 Salisbury Road Harrow Middlesex HA1 1NU 020 8861 4320 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Bernadette Mitchell Mrs Bernadette Mitchell CRH PC 6 Category(ies) of OP 6 registration, with number of places The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person who cannot without significant assistance ascend or descend stairs shall reside on the first floor of the home. Date of last inspection 16/11/04 Brief Description of the Service: The Laurels is a care home providing personal care and accommodation for up to 6 older people. The care home is located in central Harrow, within a few minutes walk or drive from a variety of shops, banks, restaurants, a park and other amenities including public transport facilities located within Harrow. Mrs B Mitchell owns the care home, and is also the registered manager. The home was first registered in 1993. The building is a semi-detached house located on a quiet residential road near the centre of Harrow. The home is in keeping with other houses within the area. The home has four single rooms, and one shared room. One of the single rooms has en-suite facilities. Three rooms are located on the first floor and two bedrooms are situated on the ground floor. The home has an enclosed, accessible, and well-maintained garden. The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place during 4.5 hours during a day in May 2005. The registered manager was present during the inspection. The inspector was pleased to meet and talk with all the residents, and the staff on duty during the inspection. There were no vacancies at the time of the inspection. A tour of the premises took place. Care records, and some staff personnel records were among a variety of records inspected. Observation by the inspector of residents and staff interaction also formed part of the inspection process. Commission for Social Care Inspection feedback/comment cards for residents, relatives, and those who have contact with the service were supplied to the registered person following the inspection. What the service does well: What has improved since the last inspection? What they could do better: Records could be more easily accessible, in better order and further developed. The registered person had difficulty locating some documentation requested by The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 6 the inspector during the inspection. Some required documentation was supplied to the Commission for Social Care Inspection following the inspection. Some recorded documentation, and information needs to be reviewed more frequently. There needs to be development in record keeping to provide evidence of action taken by staff in regard to their care and support of residents. This includes the recording of all resident’s activities, and better recording of health and safety checks. The registered person should carry out the planned installation of a ‘walk in’ shower in the bathroom upstairs. The registered person needs to provide evidence of her commitment to meet the requirements from Commission for Social Care Inspection inspections. Most of the requirements from the previous inspection had not been met. These need to be met. 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 Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2, 3 (6 is not applicable) Arrangements are in place to ensure that residents have access to information, and documentation in regard to the service provided. Each resident has a contract/statement of terms and conditions, which includes information for residents about the fees, and the service provided. The residents’ needs are assessed prior to moving into the care home, to ensure that the service can meet prospective residents’ needs. EVIDENCE: Following the inspection the registered manager supplied the Commission for Social Care Inspection the documentation and information required to meet the previous inspection requirement in regard to the service user guide. The service user guide included required documentation, for example, information about the service, and the complaints procedure. The registered person reported that a copy of the service user guide would be supplied to all residents. The four residents’ care plans inspected all included documentation in regard to a statement of terms and conditions of occupancy. This documentation The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 9 includes information in regard to the fees, and the service provided to residents by the care home. Individual placement agreements from the relevant purchasing authority were accessible within the care plan. The care home has an admission procedure. There have not been any residents admitted to the care home for over a year. The care plans inspected all included documentation in regard to the assessment of individual service user needs. There was recorded evidence of assessment of residents’ needs completed by the registered person. Assessment documentation, and information included dietary needs, mobility needs, social needs, mental health needs, and personal care needs. There was evidence of some assessment from specialist healthcare professionals. The information was accessible by staff, and in a format that was clear. The previous inspection requirement in regard to confidentiality needs to be met by the registered person. Staff who spoke with, and who were observed by the inspector had understanding of residents’ assessed needs, and residents confirmed that their needs were being met, and that staff were ‘kind and understanding’. The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9, and10 Arrangements are in place to ensure that residents’ health, and personal care needs are met, and that there privacy and dignity is respected. There needs to be further development in recorded staff guidance, to ensure that identified needs of residents are being fully met by staff. Medication is stored and administered safely. EVIDENCE: All the residents have an individual plan of care. The sample of four care plans inspected contained accessible recorded information in regard to identification of residents’ needs. Staff guidance to meet these needs was generally recorded. There was evidence that a residents’ changing need had been recently identified and staff guidance recorded to meet this need. There needs to be consistency in recording staff action to meet residents needs, and further development in recorded staff guidance for meeting some identified needs. This includes risk assessment, and residents’ bathing needs. There was evidence that some care plan documentation had been reviewed regularly, but this was not consistent, some care plan documentation was dated 2003. The registered person needs to ensure that all aspects of the resident’s plan of care are regularly reviewed. A previous requirement in regard to confidentiality needs to be met. The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 11 Risk assessment of falls, and risk in regard to a resident accessing the community independently, medication risk assessment, and involvement in everyday living skills risk assessment were recorded. This documentation had been recently reviewed. There needs to be further development in risk assessments, which need to include for example; pressure area care risk assessment, bathing risk assessments, and individual and/or general residents’ financial risk assessments. A manual handling recorded residents risk assessment was dated 2003 and needs evidence of having been reviewed. The care home has policy for the management and prevention of pressure sores. The registered manager reported that there were no residents who have pressure sores. There was evidence from residents, records, and staff that residents accessed specialist healthcare services as needed by them. A resident spoke of having had a GP appointment recently, and of receiving chiropody care, and of having an ‘eye check’. There was recorded evidence that the manager seeks advice from community healthcare specialists. The inspector was informed by the registered person that a resident had recently received assessment of a health need, by a community nurse, and the resident had been provided with a night pressure relieving aid. Day and night residents’ progress records are maintained. The home has a medication policy. The registered person needs to ensure that the requirements following the Commission for Social Care Inspection pharmacist inspection are all met. Medication is stored in a locked facility. A staff member spoke positively of the recent medication training that she had received. Medication is recorded appropriately, though there were some gaps in recording of medication administered. Staff were observed to have an understanding and respect for resident’s privacy and dignity, and interacted with residents in a sensitive and respectful manner. Residents spoke very positively of the care and support that they received from staff. The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and15 Arrangements are in place for meeting leisure and social activities, but there needs to be development in recorded confirmation that residents receive the opportunity to participate in regular preferred activities. Residents are supported in maintaining contact with relatives, and significant others. Meals provided are varied and wholesome. EVIDENCE: Care plan documentation included information in regard to residents’ preferred leisure interests. Some activities were recorded in residents’ daily progress records. These included, bingo, reading the newspaper, listening to music, and spending time in the garden. The manager spoke of other activities that residents participated in, and enjoyed, these included exercise sessions. These should be recorded, and there needs be recorded evidence that residents are consulted about activities and that they are offered varied and regular recreational interests. Records confirmed that a resident attended church with staff support. A resident was observed to play dominoes and scrabble during the unannounced inspection. A resident spoke of her enjoyment of a recent football match on television, and of the celebrations within the care home following the match. A resident, and staff spoke of the resident having access to ‘talking’ books as part of a leisure activity. One resident went independently The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 13 into Harrow during the inspection. She spoke of this being a regular activity that she ‘enjoyed’. Following lunch the residents spent sometime sitting around the dining table chatting and laughing. Staff joined in the ‘chit chat’ and relaxed banter. Residents spoke of the contact that they had with their relatives. Residents confirmed how very important this contact was to them. Records, residents’ and staff reported that contact with family, and with significant others consisted of visits from relatives, and telephone contact. A resident received a call from a relative during the unannounced inspection. From speaking to the registered manager it was evident that she was very knowledgeable and understanding of the residents’ family/friend contacts, and was active and supportive in assisting residents to maintain, and develop this contact. The menu was available for inspection. Meals recorded were varied and wholesome. The lunchtime meal on the day of the inspection corresponded with the menu. Lunch was unhurried and choice was offered. Some residents enjoyed second helpings of food during lunch. Residents all spoke of enjoying the meals provided. Food eaten was recorded. Drinks were offered frequently to residents during the inspection. Fresh fruit was accessible. Records confirmed that a resident had received a nutrition assessment. The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Arrangements are in place for handling complaints objectively. Systems are in place in regard to responding to any suspicion or allegation of abuse. Arrangements needs to be in place for recording any financial transactions on behalf of residents, to ensure that the actions by staff in regard to residents monies are transparent and fully recorded. EVIDENCE: The home has a complaints policy. The registered manager supplied documentation to the Commission for Social Care Inspection following the inspection, which confirmed that the complaints policy was recorded in the service user guide documentation. There were no complaints recorded. The care home has the Local Authority protection of vulnerable adults policy and procedure. There are also accessible ‘in house’ procedures in regard to responding to suspicion or allegation of abuse. The home has a whistle blowing policy, and an anti harassment policy. The manager has received abuse awareness training, and reported that she had plans for staff to attend Local Authority protection of vulnerable adults training. Records informed the inspector that staff had received some in house abuse awareness training. There is an ‘aggression’ towards staff’ policy, challenging behaviour policy, and gifts to staff policy, and anti harassment policy. Financial procedures, in regard to resident’s monies need further development to ensure that residents are not at risk from abuse. A previous requirement in regard to residents’ finances needs to be met. Individual and/or general financial risk assessments (taking in account of residents being encouraged to The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 15 be as independent as possible in regard to handling their monies) need to be recorded in regard to residents’ monies. The registered person supplied the CSCI with recorded evidence that a service user had a specific financial risk assessment in regard to the management of her monies. The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 22, 23 and 26 The home is well maintained and ‘homely’. The residents are provided with clean comfortable and safe surroundings. Arrangements are in place to ensure that there are sufficient bathroom facilities. Plans to develop these facilities should be of benefit to the residents in providing a more accessible bathing facility on the first floor of the care home. Resident’s bedrooms are personalised. EVIDENCE: The care home is located close to central Harrow. The house is in keeping with other houses in the area. There is parking for two vehicles on the forecourt at the front of the house. The environment is warm, and bright and airy. The home is well maintained, and furnishings and fittings are of quality. The registered manager informed the inspector that a ‘walk in’ bath was to be installed in a bathroom upstairs within the next few weeks. This should be actioned by the registered person. The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 17 The registered manager informed the inspector that the carpet in a residents’ room was to be replaced. It is recommended that this is actioned by the registered person. The garden is enclosed, and well maintained and has numerous attractive plants. There is garden furniture. Residents spoke of spending time in the garden during good weather. Several residents were observed to use specialist walking frames and sticks. There are handrails located in some communal areas, and in the bathrooms. The registered manager informed the inspector that there was a fault with the call bell system and that this was due to be repaired on the day of the inspection. The call bell system must be in working order. The residents’ bedrooms that were inspected showed evidence of some individual personalisation. This included displayed photographs and ornaments. The home is very clean. Care staff complete the cleaning duties. Laundering facilities are located away from food preparation and food storage areas. The home has an infection control policy and disposal of clinical waste policy. The door of the laundry dryer machine needs repair. The registered manager reported that staff had recently received training in regards to infection control. Records confirmed that there was accessible information in regard to infection control. An inspection from Environmental Health Officer took place in 2004 and the premises were satisfactory. Fridge and freezer temperature records were available for inspection. The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,and 30 Arrangements are in place to ensure that the number and skill mix of staff on duty enable needs of service users to be met. All required staff personnel records need to be available for inspection to ensure that there is evidence that all required safeguards offer protection to people living within the care home. Staff training records need to be further developed to provide evidence that staff have received appropriate training to be competent and skilled at meeting residents’ varied needs. EVIDENCE: The staff rota was available for inspection. The registered person needs to ensure that the shift hours worked by staff are recorded on the staff rota. There are two staff on duty during the day and one wake night staff. The registered manager works several shifts during the week. The manager is generally very accessible as she lives close to the care home. A sample of staff personnel information was inspected. There was evidence that staff had completed a satisfactory Criminal Records Bureau check. The registered manager was unable to access all the required staff personnel information. This information and documentation needs to be available for inspection, and will be fully inspected at the next inspection. Records, and staff confirmed that staff had completed appropriate training, which included moving and handling training, food and hygiene training and first aid training. Some staff had recently completed dementia care training and medication training. The registered manager reported that staff receive The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 19 health and safety ‘in house’ training. This needs to be documented. The registered manager informed the inspector that a staff member had almost completed an NVQ level 2 care course. Records informed the inspector that staff had completed an induction programme, but the format and content of this programme was not recorded. This record must be available for inspection, and was discussed with the registered person. The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35 37 and 38 The manager is competent and experienced to manage, and run the care home. Effective quality assurance systems need to be in place to ensure that the quality of the service for residents is monitored. Arrangements need to be in place to ensure that all staff are appropriately supervised so that they have understanding, and competence to meet residents needs. Arrangements need to be in place to ensure that records in regard to the service provided for residents are available for inspection and are accessible. Arrangements are in place to ensure that resident’s health; safety and welfare needs are promoted and protected. Further development of some safety records need to be actioned. EVIDENCE: The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 21 The registered manager has managed the care home since it opened in 1993. She demonstrated knowledge, understanding and sensitivity in regard to all the residents needs during the inspection. Staff, records and residents confirmed that there were clear lines of accountability within the care home. The registered manager reported that she had almost completed NVQ level 4 in management training. Some radiators are covered. There is a recorded risk assessment in regard to uncovered radiators, and electrical systems had received required checks. Records confirmed that gas safety checks had been carried out. Records and the registered person confirmed that there had been an inspection by the fire service in 2004. The manager reported requirements had been met, which included the fitting of a door safety device. The home has a fire risk assessment. This should be reviewed at least annually. There were records of fire checks taking place. The records of fire drills were not accessible at the time of the inspection. The manager reported that one had recently taken place. This information was supplied by the registered person to the Commission following the inspection. Fire drill records must be available for inspection at anytime. Fire call point checks were not recorded since November 2004. These are recorded in the documentation as ‘weekly’ checks, and so need to take place weekly. The requirements in regard to residents’ finances need to be met (see Standard 18). The care home has a financial affairs policy. The registered manager informed the inspector that residents have their finances managed by relatives or with support from relatives. Policies and procedures were available for inspection. There was recorded evidence that some policies had been reviewed. The home has a staff supervision policy. There needs to be recorded evidence that staff receive regular ‘formal’ staff supervision. This was discussed with manager, and was a previous requirement. COSHH safety data records were available for inspection. A health and safety check of the service was recorded as having taken place on the 18/4/05. The resident’s accident record book should be in a format that meets Data Protection Act 1998 requirements. Staff accidents need to be recorded in a manner that meets Data Protection Act 1998 requirements. The certificate of employers liability insurance was up to date. It was located amongst paperwork in the kitchen. This certificate needs to be displayed prominently. The registered person had difficulty accessing some records requested by the inspector. All records need to be accessible and available for inspection. Generally records that were available for inspection were in good order, and up to date. Those that need review are recorded in this report. There needs to be a recorded risk assessment in regard to a portable heater that was observed located in a resident’s room, and if not assessed as low risk it needs to be removed. The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 2 x x x 3 STAFFING Standard No Score 27 2 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x 1 x 2 1 2 2 The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 23 YES Are there any outstanding requirements from the last inspection? 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 7 Regulation Reg 12 13(4)15 (2) Requirement There needs to be development in recorded staff guidance for meeting all assessed needs of residents, including pressure area care needs, bathing needs and risk assesment. All care plan documentation including risk assessment needs evidence of regular review. All requirements from the CSCI pharmacist inspection need to be met. There needs to be recorded staff guidance in regard to the administration of eye drops. Previous timescale not met 1/1/05. It must be recorded at all times when medication to residents is administered. There needs to be a policy/procedure in regard to confidentiality. There needs to be recorded evidence that staff have received training and information in regard to the issue of confidentiality. Previous timescale 1/3/05 not met. There needs be evidence that residents are consulted about Timescale for action 1/9/05 2. 9 Reg 13 (2)(4) 1/9/05 3. 10 Reg 12(4) 1/9/05 4. 12 Reg 16(n) 1/9/05 Page 24 The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 5. 18 and 35 Reg 12, 13(6) 6. 18 and 35 Reg 12, 13(6) 7. 8. 9. 10. 11. 22 19 27 29 30 Reg Reg 23 Reg 17 and 18 Reg 13 (6)17(2) (3) 12. 33 Reg 24 (1)(2)(3) 13. 36 Reg 18(2) 14. 37 Reg 17(3) activities and that they are offered varied and regular ones. The registered person needs to record any transactions that she might make on behalf of service users in regard to supporting them in making payments for services such as hairdressing.Timescale 1/3/04 not met. Individual and/or general financial risk assessments (taking in account of residents being encouraged to be as independent as possible in regard to handling their monies) need to be recorded in regard to residents’ monies. The call bell system must be in full working order. The door of the clothes/laundry drying facility needs repair. The registered person needs to ensure that the shift hours worked by staff are recorded All staff personnel records need to be accessible and available for inspection. All staff training needs to be recorded. There needs to recorded evidence that all staff have completed an induction programme. The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care in the care home. Previous timescale 1/5/04 not met. There needs to be recorded evidence that staff receive regular ‘formal’ staff supervision. Previous timescale 1/2/05 not met. All records need to be accessible and available for inspection. 1/8/05 1/8/05 1/7/05 1/8/05 1/9/05 1/8/05 1/9/05 1/9/05 1/8/05 1/7/05 Page 25 The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 15. 38 Reg 17 16. 38 Reg 25 17. 38 reg 23(4) 18. 38 Reg 13(4)23 Staff accidents need to be recorded in a manner that meets Data Protection Act 1998 requirements. The employers certificate of liability insurance needs to be displayed prominently in the care home. Fire drill records must be available for inspection at anytime. Weekly fire checks within the home need to take place weekly. There needs to be a recorded risk assessment in regard to a portable heater located in the home. 1/8/05 1/8/05 1/7/05 1/7/05 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. 5. Refer to Standard 12 21 23 38 38 Good Practice Recommendations All activities participated in by residents should be recorded. The walk in bathing facility should be actioned by the registered person. The carpet in a residents bedroom should be replaced. The fire risk assessment should be reviewed at least annually. The resident’s accident record book should be in a format that meets Data Protection Act 1998 requirements. The Laurels G62-G11 S17546 The Laurels v212184 240505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection 4th Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 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. 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