Inspection on 03/02/06 for The Limes

This inspection was carried out on 3rd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Limes 29/10/08

The Limes 09/06/08

The Limes 03/07/07

The Limes 27/04/06

The Limes 03/10/05

The Limes 07/02/05

The Limes 01/09/04

Similar services:

Claremont House

Chesham House

Oak Ridge

Argyll House

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

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

CARE HOMES FOR OLDER PEOPLE The Limes High Street Henlow Bedfordshire SG16 6AB Lead Inspector Leonorah Milton Unannounced Inspection 3rd February 2006 09:00 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 Limes DS0000014929.V281847.R01.S.doc Version 5.1 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 Limes DS0000014929.V281847.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Limes Address High Street Henlow Bedfordshire SG16 6AB 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) 01462 811028 01462 811028 Mr Michael Wilkinson Mrs Joan Wilkinson Mrs Joan Wilkinson Care Home 22 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (22), Mental disorder, excluding learning of places disability or dementia (3), Old age, not falling within any other category (22) The Limes DS0000014929.V281847.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users must not exceed 22. The home shall accommodate persons of either sex. No one falling into the category of MD (age range over 65 years) may be admitted into the home where there are already 3 persons of category MD (age range - over the age of 65 years) accommodated within the home. No person aged under 45 years of age who falls within the category of DE may be admitted to the home. 3rd October 2005 4. Date of last inspection Brief Description of the Service: The Limes is a privately owned residential care home, providing care for 22 residents over 65 years of age with physical and mental disorders. The property is situated in Henlow, High street. It was built in 1840 and had been sympathetically converted by the proprietors to retain much of its original character and charm. In 2001 a further large extension was added to increase the registered accommodation to its present occupancy. Bedrooms located on the upper floor of the original house are accessed via staircases and a chair lift. Bedrooms in the extension are accessible via a shaft lift. The Limes DS0000014929.V281847.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of the statutory two inspections that the Commission for Social Care Inspection (CSCI) is required to carry out each year. This inspection was carried out in accordance with the CSCI’s procedures to assess core care standards within the two inspections as detailed on this report. This inspection therefore focussed the core standards not assessed at the first visit and reviewed the progress on requirements from that inspection. During this inspection the arrangements for the care of two service users were assessed. Their case files were reviewed, as were their private bedrooms. Conversations took place with these service users, one other service user and four members of staff. The manager who is also a co-owner attended the home for most of the inspection. A partial tour of the building took place and sundry other records were assessed. Conversations took place with the service users in a dining room and case files were reviewed in a lounge where it was possible to assess service users’ lifestyle and their interactions with members of the staff. The concerns arising from this inspection about the failures to meet legal requirements for the operation of a care home were such that the manager/proprietor was subsequently asked to attend a meeting with the CSCI. It is recommended that this report be read in conjunction with the report of the inspection carried out in October 2005 for a complete overview of the standard of the operation between these dates. What the service does well: The building provided a well-adapted, comfortable and clean environment that was suitable for the care of frail older people. Accommodation was spacious. Bedrooms seen at this inspection were roomy, well decorated and furnished. Two lounges and two dining rooms provided plenty of space for dining, relaxation and recreation. It was noted that one lounge was used for those who preferred or would benefit from a quieter environment. The home provided a friendly and informal atmosphere. The members of staff on duty were observed to treat service users with respect. Those service users spoken to were complimentary about the personnel in the home, describing them as “nice, ok and kind.” One service user stated that she was treated well The Limes DS0000014929.V281847.R01.S.doc Version 5.1 Page 6 and that the food was “ok”. She stated that she had no complaints about her care in the home. Another said that she was, “a satisfied customer” but whilst she accepted the restriction of smoking only in the designated area, she didn’t know her cigarettes were held by the home. What has improved since the last inspection? What they could do better: The home had been without consistent management since November 2005, the manager for personal reasons, only having attended the home throughout this period 3 or 4 times each week for 3 to 4 hours each time. It was evident from discussions with the two seniors in charge at this inspection that they were knowledgeable about service users’ needs, appropriate ways to care for them and the day-to-day routines of the home. However, it was also apparent that there were risks to service users’ welfare because the records for the assessment of their needs and those that showed how these would be met were not sufficiently detailed. The manager was not aware of some aspects of service users needs, and her practice showed that she had not carried out some aspects of the legal requirements for the operation of a care home: Recruitment practice must include the obtaining of relevant references and checks via the Criminal Records Bureau before employment commences to ensure that service users are protected from abuse and cared for by persons of the right calibre. There must be sufficient written guidance for personnel to show how the home intends to protect service users from abuse. This omission had been highlighted at the two previous inspections. Records of purchases made on behalf of service users must be accurately maintained and a receipt obtained to substantiate transactions. The reasons for restrictions to service users’ lifestyle such as the inability to hold their cigarerettes or manage their personal monies must be documented. Rotas must accurately show all persons employed in the care home. Sufficient personnel must be rostered throughout the day to care for service users. A named person must be left in charge during the manager’s absence under the current circumstances. This person must have sufficient time that is additional to the care staff rosta to enable them time to carry out management duties. The Limes DS0000014929.V281847.R01.S.doc Version 5.1 Page 7 The CSCI must be notified about changes to management arrangements as were seen at this inspection. It was also concerning to note that a service user was scheduled for admission on the day of the inspection for a brief weekend respite stay. This admission meant that the home would be accommodating more people than it’s legal registration allowed. 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 Limes DS0000014929.V281847.R01.S.doc Version 5.1 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 Limes DS0000014929.V281847.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 Insufficient information about a service user’s needs had been obtained before she moved into the home. As a result there was a risk that some needs would not be met. The home was not meeting its registered conditions of registration and the numbers of persons for care identified on its Statement of Purpose. EVIDENCE: The case file for a service user who had moved recently into the home was assessed. The manager initially stated that her family had referred the service user. It later transpired that this was not the case and that the service user had been referred and was funded by the local authority. As such the home should have been provided with a pre-admission assessment under the care management procedures of the local authority. The assessment on file carried out by the home was brief and had not taken account of needs such as continence or recorded that the service user smoked. On the reverse of one document was briefly noted, “Parkinsons and epilepsy”. There was no other mention of these The Limes DS0000014929.V281847.R01.S.doc Version 5.1 Page 10 conditions or the implications for care of someone with these throughout the case file. The manager located a piece of paper that had been stored elsewhere. It contained rough notes that were presumably made at the initial referral. These notes mentioned that the service user had double incontinence, depression and also liver problems for which she was undergoing tests. There was no further mention of these issues on the assessment document or the resulting care plan. A service user for respite care was scheduled for admission on the day of this inspection into a room that was already occupied by another service user on a permanent basis. At this admission the numbers of service users accommodated in the home would be 23, which is 1 above the permitted registered numbers. The manager contended that the actual number of persons in the home would be 22 as one service user was in hospital. The CSCI holds to the view that the home must not accommodate additional persons whilst service users are temporarily absent from the home, as in this case, and whilst the home is still in receipt of the funding for the care of the absent service user. There were no contractual arrangements in place to show that the permanent service user had agreed to share her bedroom. Indeed it remains unclear why a bedroom for single accommodation contained two beds. The Limes DS0000014929.V281847.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,10 The home relied on the knowledge that personnel had about service users’ needs rather than the written guidance to the same. There was a risk therefore that needs would remain unmet and that restrictive practice would happen as a matter of course rather than as a result of individual risk assessment. Service users’ dignity and privacy had been compromised. EVIDENCE: Care planning documentation had been reviewed in response to a requirement from the previous inspection. It is acknowledged that the member of staff responsible for this task had made a good effort but the process however was incomplete. In some respects there was less information about service users’ physical and mental health needs than had been seen at previous inspections. In addition to the reference on the previous section about omissions to care planning guidance there were no mention on either case files assessed at this inspection to the smoking habit that both service users had and to explain why neither person was allowed to hold their cigarettes. The Limes DS0000014929.V281847.R01.S.doc Version 5.1 Page 12 One person had previous alcohol related problems that had resulted in a detrimental effect on her physical and mental health. There was no risk assessment on her care plan in relation to the withholding of alcohol. It was noted that one service user was given a box of cigarettes to take out to a social centre. The service user stated that she would prefer to hold her cigarettes and that she had waited too long that morning for a cigarette. Two other service users were each handed a cigarette rather than being offered the choice of taking one from a box that that in fact belonged to them. A service user was scheduled for admission later on the day of the inspection. There were no screens for privacy in the bedroom that was due to shared by two people. The care plan for the current occupant indicated that she needed the full support of staff for her personal care needs. The Limes DS0000014929.V281847.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Service users had been provided with a range of recreational activities and supported to retain contact with their families. There was insufficient evidence to show that the home’s control of service users’ personal monies was appropriate. Nutritional needs had been met in most part that there was risk that those served liquidised meals might suffer loss of appetite because of the unappealing appearance of their meals. EVIDENCE: Service users confirmed that they had opportunities to take part in board games and similar. Books, music and videos were also used for relaxation and recreation. Occasional parties and trips out on a one-to-one basis were mentioned. Staff explained that there was a monthly religious service for those who wished to take part. One service user had continued to attend a specialist social centre and stated that she went out with her family to attend church services each month. Hand massage was provided on a frequent basis. There were additional charges for this service. The Limes DS0000014929.V281847.R01.S.doc Version 5.1 Page 14 Service users confirmed that their families came to see them regularly and that there were no restrictions to visiting. The manager was holding personal monies and making purchases on behalf of several service users. There were no assessments to show the level of ability in money management that service users had or to show whether the practice of managing money on their behalf was necessary. The person carrying out the cooking duties on the day of the inspection showed an understanding of her role and individual service user’s nutritional needs. It was evident that she took a personal interest in the appetite and welfare of each service user. She was observed to talk to service users about the menu and to have established a good rapport with them. Menus were written up on a weekly basis in a bound book and showed a nutritious and varied diet. It is recommended that the daily menus be advertised for service users’ information. Meals were served in two sittings to enable staff sufficient time to properly assist service users. A member of staff was observed to feed a service user in a lounge. Her practice was appropriate. The service user was helped to take his meal in an unhurried fashion. Unfortunately the meal served to him looked unappealing, as it had been liquidised all together rather than in separate portions. The Limes DS0000014929.V281847.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Complaints had been appropriately dealt with. The complaints procedure required updating, so that those who wished to refer complaints to the regulatory body were correctly informed about that authority. There were risks that service users might be at risk of abuse because the home had failed to follow robust recruitment procedures and also to provide staff with sufficient written guidance about protection procedures. EVIDENCE: Records indicated that complaints had been investigated and complainants had been responded to. The records however were a little disorganised. The manager was advised that records must be held on individual case files. Two personnel files were assessed. There was no evidence that CRB checks had been carried out for either person or that a check had been sought about the most recent employment from the POVA First register. The manager stated that she thought she had obtained a CRB check for the one of these employees but was unable to locate it at this inspection. The application for employment made by one of the above had been poorly completed. The sections for previous employment and referees were mostly incomplete. Further in the file was a used envelope, on the reverse of which were the names and addresses for two referees. Records indicated that these were obtained 6.5 months after the employee had commenced work in the The Limes DS0000014929.V281847.R01.S.doc Version 5.1 Page 16 home. Neither reference clarified the relationship of the referee to the applicant. A notification requiring urgent action was issued to the manager/proprietor at this inspection in respect of recruitment practice. The Limes DS0000014929.V281847.R01.S.doc Version 5.1 Page 17 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 the following standard(s): 19,23 The environment was mostly suitable for the needs of the service users. The privacy and safety of one person assessed at the inspection had been compromised. EVIDENCE: As noted in the summary of this report the building provided a good standard of accommodation that was homely in appearance inside and provided a large well-tended garden outside. The accommodation was distributed on its ground floor over several levels that were accessed via short staircases and a lift. On the upper floor there were also some steps to sections of a corridor and also a bedroom. The bedroom for one service user that was located in the purpose built extension to the building was assessed and found to provide spacious, well The Limes DS0000014929.V281847.R01.S.doc Version 5.1 Page 18 appointed accommodation. The service user’s personal belongings had given the room a unique appearance. A bedroom in the original section of the building was accessed via a step up. The service user who occupied this room walked with the aid of a zimmer frame. There was no assessment on her file to show that the trip hazard had been assessed. Her bedroom could also accessed via a door that led directly from another bedroom. This arrangement had been required for fire safety purposes. The door had to remain unlocked. There was no assessment of any risk/inconvenience that might result from this arrangement. The service user was scheduled to share her room with another over the coming weekend. There were no screens for privacy in this room, or a second wardrobe. The integral wardrobe was full of the service users’ belongings. It was explained that some space would be made in this wardrobe to accommodate the belongings of the new comer. Each drawer of a chest of drawers in this bedroom was labelled to indicate storage of items of clothing. On enquiry the inspector was told that this arrangement had been for the convenience of the previous occupant of this room and was not applicable to the current occupant. The Limes DS0000014929.V281847.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 The members of staff on duty presented as knowledgeable and caring. However, the shortfall in staffing numbers meant that there was a risk that staff would have insufficient time to care for service users properly. Recruitment practices were inadequate and had not ensured before employment commenced that service users would be cared for persons of the right calibre. EVIDENCE: Whilst the staff were knowledgeable about their roles, responsibilities and service users’ needs, rotas identified that insufficient numbers of staff had been rostered to meet service users’ needs: There had been no hours, additional to the care staff rota, allocated to the person/persons in charge during the manager’s absence. Given that there was evidence that they were carrying out assessment of needs, care planning and arrangements for the staffing rota in addition to their supervision of staff and caring duties each day, this was not acceptable. Rotas identified that the home was not complying with the staffing levels during the day that had been set down by the previous regulatory authority, which must be at a ratio of 1carer to 6 service users or part thereof. The rota for the week during which the inspection took place showed that 4 care staff were rostered throughout the midweek days until 14.30 hours. One member of staff explained that her duties on 2 of these days were to mainly to carry The Limes DS0000014929.V281847.R01.S.doc Version 5.1 Page 20 out hand massages and beauty therapies, for which there was an additional charge. The ratio of staff in the afternoons was reduced to 3 carers until the night staff commenced duties at 21.00 hours. Three care staff only were rostered throughout the day and evening at weekends. Two members of staff were rostered for waking night shifts. The manager explained that a third person was on call on sleep in duties. This person was not identified in the staffing rota; neither was the person carrying out the cook’s duties on the day of the inspection. The inspector was informed that the health of the person on call prevented her from carrying out moving and handling tasks. There was no risk assessment on her personal file with regard to this. Concerns about recruitment practice have been identified on the section commenting on standard 18 for the protection of service users. The Limes DS0000014929.V281847.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,35,37,38 The recent inconsistencies in the management of the home had resulted in risks that service users needs had not been properly assessed and met and that staff had not received the required level of guidance. The fire safety risk assessment was outdated and there was a risk that some safety aspects had not been taken into consideration. EVIDENCE: The manager held a qualification in nursing and stated at this inspection that she had maintained her registration. She also informed the inspector that she had commenced work towards the Registered Manager’s qualification. As the inspection commenced the inspector was informed that the manager was absent through ill health and that the two senior carers on duty were in charge of the home. The manager, being available for advice by telephone. The Limes DS0000014929.V281847.R01.S.doc Version 5.1 Page 22 The manager arrived at the home sometime later and also stated that she had been absent from full time management since November 2005. The CSCI had not been informed about the change in management arrangements as is required under Regulation 38(1)(2)(3)(5) in emergency circumstances. The outcomes of this inspection were concerning and demonstrated the need for consistent management and a review of the service provision against the legal requirements and standards for the operation of a care home. The records for monies held on behalf of two service users were assessed. The manager had been given responsibility by one service user to make withdrawals from his building society account. It was not possible to cross reference building society transactions, there being only one statement on file. The manager stated that the service user held others. Signed permission was seen on both case files to allow the home to administer service users’ personal monies. The records for both persons for income and expenditure had not been properly maintained, the date of such transactions being shown monthly rather than the actual day, month and year on which they had occurred. In one instance a record showed a withdrawal with no date against it and another withdrawal had the note “lost receipt” alongside it. Purchases made on behalf of one service user that totalled £1392.98 were not substantiated by receipt, there being only one on file for a small purchase. The most recent entry on the record was dated January 2006 and showed expenditure for hat, gloves, socks cigarettes and tobacco. There were no receipts for these purchases and no sum/sums of money had been entered in the expenditure section of the record. Record keeping in the home did not meet required standards, there being evidence already noted in this report in relation to care assessment and planning, staff rotas and service users’ personal monies. The home employed the services on an external assessor to oversee the safety of the environment. The service was of a good standard but had not reviewed the home’s fire risk assessment. The document shown to the inspector had been in place before the addition of the extension and the registration of additional beds and therefore was not reflective of the current fire safety arrangements. The Limes DS0000014929.V281847.R01.S.doc Version 5.1 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 1 2 1 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 x 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 3 x x x x 2 x x STAFFING Standard No Score 27 2 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x 1 x 1 1 The Limes DS0000014929.V281847.R01.S.doc Version 5.1 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 OP1 Regulation 4 Requirement Timescale for action 31/12/05 2 3 OP1 OP2 4 OP3 5 OP7 The Registered Person must ensure that the Statement of Purpose and the Service Users Guide contain all the details as required in schedule 1 of the Care Standards, including the arrangements for service users inclusion in running the home, the admission assessment criteria, and the latest Inspection report in Service Users Guide. (Not assessed at this inspection) CSA 2000 The home must not admit more Part 11.24 than 22 service users. 5(1)(c), Contractual arrangements must 12(2) show that the decision to share a bedroom has been a positive choice. 14(1) The home must not admit any service user to the home unless a comprehensive of need has been carried out by the home or obtained in respect of that person under care management procedures. 14.2 The Registered Manager must 15.2(b) ensure there is a robust system in place for assessing and DS0000014929.V281847.R01.S.doc 28/02/06 31/03/06 28/02/06 30/04/06 The Limes Version 5.1 Page 25 6 OP16 22(7) 7 8 OP16 OP35OP18 17(1)(a) Sch 3 13(6) 9 O10P27 18(1)(a) 10 OP35 17(2) Schedule 4 planning the Service Users needs in relation to their physical health, personal and social needs Previous timescale of 31/12/05 had not been met) The Registered Person must change the complaints procedure so that it includes reference to the CSCI and not the NCSC. Records of complaints should be maintained on individual case files. The Registered Manager must revise the home’s protection procedures to include the circumstances under which urgent referral would be made to a service user’s GP and the Service Users consent. (Previous timescale of 01/12/05 had not been met in full) From this inspection: The homes protection procedures must be reviewed in line with the “No Secrets” guidance issued by the Department of Health to include definitions of abusive practice and signs of such. Sufficient staff must be rostered at all times to meet service users’ needs and to assist with the management function: The care staff ratio must be 1:6 or part thereof throughout the day and evening. Personnel carrying out management duties must be given time supernumerary to the care staff roster to complete such tasks. The Registered Manager must carry out the following with regard to service users’ personal monies that are held by the home: Maintain a record of all DS0000014929.V281847.R01.S.doc 31/03/06 31/03/06 31/05/06 28/02/05 28/02/06 The Limes Version 5.1 Page 26 transactions to show the actual date on which they occurred. Obtain receipts to substantiate purchases made on behalf of service users. Records should be signed by two persons, one of which should, where possible be the service user. Records must be audited on a regular basis. 18.2 The Registered Manager must implement formal staff supervision sessions at least 6 times per year, to ensure the provision of support for staff and the implementation of safe practice. ( Not assessed at this inspection. 7,9,17,19. The Registered Person must maintain records in connection with service users’ case files, personnel records and staff rotas as detailed by Schedules 2,3,4 18(1)(a) The Registered Manager must (c) provide support and supervision to ensure the training carried out for safe moving and handling of Service Users is implemented in practice. (Not assessed in full at this inspection) 13(4)(c) The Registered Person must carry out a risk assessment in respect of the member of staff whose health prevents her from carrying out moving and handling tasks. 13(4)(c) The Registered Person must review the home’s fire safety risk assessment. 11 OP36 31/01/06 12 OP37 31/03/06 13 OP38 01/12/05 14 OP38 28/02/06 14 OP38 31/03/06 The Limes DS0000014929.V281847.R01.S.doc Version 5.1 Page 27 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 2 Refer to Standard OP15 OP24 OP10 Good Practice Recommendations Each portion of a liquidised meal should be prepared separately to ensure that the meal is not served as an unappealing mix. Spare beds should not be stored in service users’ bedrooms. Service users’ dignity must be upheld. In this instance those who smoke must be given the opportunity to take a cigarette from a box rather than handed one cigarette. If bedrooms are to be shared, screens must be provided for privacy. The Limes DS0000014929.V281847.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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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