Inspection on 14/01/08 for The Mayfield

This inspection was carried out on 14th January 2008.

CSCI found this care home to be providing an Adequate service.

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 Mayfield 12/04/06

The Mayfield 03/11/05

The Mayfield 14/06/05

The Mayfield 03/12/04

The Mayfield 14/04/04

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 Mayfield 6 Alicia Avenue, Kenton Harrow Middlesex HA3 8AL Lead Inspector Andreas Schwarz Key Unannounced Inspection 14 January 2008 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 DS0000017548.V354796.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. DS0000017548.V354796.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Mayfield Address 6 Alicia Avenue, Kenton Harrow Middlesex HA3 8AL 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) 020 8907 7908 020 8907 5777 Mr Kiran Nathwani Mr Paren Nathwani *Vacant* Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places DS0000017548.V354796.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th April 2007 Brief Description of the Service: The Mayfield is a care home providing personal care and accommodation for up to 23 older people. The group of people living at the home at the time of the inspection were mixed gender. There were no vacancies at the time of the inspection. The home is owned by Messrs Nathwani of Farrington Care Homes Ltd. The organization owns two other homes in the local London region, and is expanding nationally. The home is located in a residential area of Kenton; fifteen minutes walk from an underground station. Nearby on the main Kenton Road there is a parade of small shops, with a hairdresser, cafes, pubs, churches, and a temple. There is a bus route close by. There is unrestricted parking outside of the home. The home is a large converted and extended house. Accommodation for people using the service is provided on the ground and first floor. Upstairs can be accessed by stair-lift or stairs. All of the bedrooms, except one, are single occupancy. Most of the bedrooms have en-suite facilities and are fully furnished. Communal toilets are located close to the two separate lounge areas. The home has one bathroom upstairs and a shower room downstairs. At the rear of the house is a patio and a large garden. The current scale of charges, as of 01/04/07, is £505 to £526 a week. Additional charges include for the hairdresser, and private chiropody and dentistry. The home did not have a registered manager at the time of this key inspection. A new manager, Ms Tolentino, has been employed since November 2007. DS0000017548.V354796.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This is the second key inspection for this inspection year 2007/08. I have also undertaken a random inspection on the 16th August 2007. During this inspection I have seen major improvements since the last key inspection. The home has met 44 of the 58 requirements during the random inspection in August 2007. The newly appointed manager Ms Tolentino was available during the whole day of this key inspection. I spoke to a number of people using the service, two visitors, interviewed four members of staff and spoke to both directors during this key inspection. I assessed six staff files; eight care plan files and other records such as menus, rotas, policies, etc. I have left ten service users and ten staff surveys, but none have been returned to me since this inspection. The home forwarded a completed Annual Quality Assurance Assessment to the Commission for Social Care Inspection on the 30/05/07. I would like to take this opportunity thanking everybody involved in this 2nd annual key inspection. What the service does well: People using the service interviewed gave very positive feedback about the care received and the new manager; visitors confirmed this. A visitor told me that her relative has improved since living in The Mayfield and staff is very caring. Care plans are regularly reviewed and are of good standard. The home is providing a varied and culturally appropriate diet to people using the service. DS0000017548.V354796.R01.S.doc Version 5.2 Page 6 The home is providing an activity programme, which meets the needs of people using the service. What has improved since the last inspection? What they could do better: I have made ten new requirements during this unannounced key inspection. The responsible individual must ensure that all people using the service who are at risk of falling have a falls assessment in place. All care plan files must include a current picture of the person. All staff must hold a valid manual handling certificate and must be assessed as competent by a qualified person. The responsible individual must ensure that a competent person assesses all people with pressure sores, and guidelines are in place of what actions to be taken to treat them. The registered provider must ensure that the outside food storage is cleaned at least monthly to ensure peoples Health and Safety. The home must purchase a new fridge to replace the one, which is not closing properly, and food is stored above the legal limit. The manager must ensure that rotting woodwork in windows is investigated and repaired. DS0000017548.V354796.R01.S.doc Version 5.2 Page 7 The manager must find safer ways to open the ground floor disabled toilet door. The registered person must ensure that at least 50 of care staff have National Vocational Qualification in Care level 2 or above. The registered person must ensure to register the manager with the Commission for Social Care Inspection. The manager must obtain relevant qualifications in Care and Management. The manager must ensure that a report, that summarises audited people’s views about the care provided in the home, is produced and circulated following each quality assurance audit. The responsible individual must ensure that all monies held on behalf of people using the service must be audited and records must be balanced. The responsible individual must ensure that all staff receives a minimum of six planned supervisions per year. The responsible individual must ensure that regular team meetings are arranged for staff to discuss issues relating to the home and people using the service. 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. DS0000017548.V354796.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 DS0000017548.V354796.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): 3 and 6 People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken by a skilled and experienced member of staff. EVIDENCE: I viewed four assessments of people recently admitted to The Mayfield. The Area Manager Annette Anderson has undertaken all assessments. I spoke to two of the people who have been assessed informing me that they have been involved in the process and have seen the assessment once completed. Information obtained during the assessment is included in care plans. The home is also providing care for Asian elders and staff informed me that assessments could be made available in Gujarati if required. DS0000017548.V354796.R01.S.doc Version 5.2 Page 10 The home is not providing intermediate care. DS0000017548.V354796.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 People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Health needs are monitored and appropriate action and intervention taken. There is evidence in the care plan of health care treatment and intervention, and a record of general health care information. There are some gaps in information but staff are able to think in a person centred way and are able to give a verbal update. The home has a good record of compliance with the receipt, administration, safekeeping, and disposal of controlled drugs. Staff have completed and passed an appropriate medication course. EVIDENCE: I viewed eight care plans during this key inspection, all of this care plans have been reviewed and up dated. People using the service and visitors confirmed DS0000017548.V354796.R01.S.doc Version 5.2 Page 12 that they know about the care plans and are asked if they want to take part in the review process. The home is reviewing care plans monthly. People at risk of falling, have falls assessments in place with the exception of one of the care plans assessed during this inspection. Falls are recorded and monitored; I noted however that on one occasion the date of the fall was given without any explanation. I discussed this with the manager and recommend that detailed records of falls are provided. Not all care plans viewed had a picture of the person using the service on file; this is required to ensure files can be clearly identified. The home is recording personal and oral hygiene separately. Records show that this is done to good standard. Manual Handling risk assessments are done by the homes manual handling trainer, all files viewed had an up to date manual handling risk assessment in place. Out of the four assessed staffing files only two had evidence of manual handling training. One of the staff interviewed told me that she never received any manual handling training. This was discussed with the manager and it is required to provide manual handling training to all staff, ensuring peoples safety. Three people using the service have pressure sores, no clear assessments and what action to be taken was in place; this is required. The manager told me that the community nurse who visits the home every second day treats pressure sores. People using the service told me that the have regular exercise sessions, activity plans confirmed this. People using the service are registered with a local General Practitioner. A chiropodist visits the home and staff support people accessing dentists and to any other clinical appointments. I sampled Medication Administration Sheet of all the people case tracked during this key inspection; all records were of good standard and had no gaps. The home is recording medication received and returned to the pharmacist. The medication cabinet is locked and the trolley is fixed to the wall, the key is kept with the shift leader. The home is providing clear guidelines for staff, which are displayed on the medication folder. Medication bottles were signed and dated once opened. The home has a medication fridge, which is located in the staffroom, temperature is recoded daily. Controlled drugs are stored in a separate cabinet fixed to the wall and records were of good standard. Staff has received medication training; only competent staff administer medication. People using the service told me that staff treats them with dignity and their privacy was respected. One person who recently moved in requested a personal phone line, which was provided by the home. People using the service informed me that clothes are laundered at the home and very rarely get mixed up. Staff observed demonstrated respect and understanding of peoples needs. The home has one shared room and appropriate screening is provided. DS0000017548.V354796.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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service are involved in meaningful daytime activities of their own choice and according to their individual interests, diverse needs and capabilities. The service is committed to the principles of inclusion and promotes and fosters good relationships with neighbours and other members of the community. The meals are balanced and nutritious and cater for the varying cultural and dietary needs of individuals. EVIDENCE: The homes activity co-ordinator left employment shortly before this key inspection. I viewed the homes activity plan. The home is providing a range of activities such as Movement, Arts & Craft, Entertainment, Bingo and Harrow School visit. During the day of this key inspection an entertainer visited the home and I observed people using the service participating and enjoying DS0000017548.V354796.R01.S.doc Version 5.2 Page 14 themselves. The home had a Barbeque during the summer, which was attended by people using the service, families, and staff and outside professionals. People using the service informed me that the home celebrated Halloween and Diwali. A mobile library visits the home regularly. The activity co-ordinator assessed all people using the service likes and dislikes and abilities of taking part in activities. People’s participation is clearly recorded. During the day of this inspection I observed family members visiting their relatives. One visitor informed me that she could come and visit her mother whenever she wants and the home is communicating well if there are any changes to her mother’s condition. As mentioned earlier the home is visited by Harrow Schools and people using the service told me that they are very happy seeing the school children. The person’s family, advocate or Court of Protection handles finances. The home does not handle people’s benefits. The manager informed me that she has some money, which was given to her for safe keeping on behalf of people using the service. I viewed the records of this and noted that none of these were correct. The home has a record keeping policy and records a safely stored in the managers office, and in a lockable cabinet in the staff room. People using the service invited me to their rooms. Rooms were nicely decorated; ornaments, pictures and personal possessions were displayed. I observed people using the service having lunch. Lunchtime was unrushed and the meal was nicely presented. The home has an English and Asian menu. Both menus are varied, healthy and nutritious. People liquid and food intake is recorded and people are weighed monthly. Drinks and snacks are available if requested. I observed staff asking people using the service if they are happy with the lunch and offering alternatives if they have changed their mind since choosing their lunch. Records of people’s dietary needs are in the kitchen. Cooks and kitchen staff have valid Food Hygiene certificates. The home is using the food management plan introduced by the Food Safety Agency. I noted that the outside food storage has not been cleaned since week commencing 12/11/07, this is judged as not frequent enough. The outside food storage must be cleaned at least monthly to ensure peoples Health and Safety. One of the fridges was not closing properly and a new fridge must be provided. DS0000017548.V354796.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): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand. It is available on request in a number of formats. People using the service and others involved with the home understand how to make a complaint The home understands the procedures for safeguarding adults and will attend meetings or provide information to external agencies when requested. EVIDENCE: The home has received three complaints since the last key inspection. Complaints are well documented and recorded. The home has a complaints policy. People using the service informed me that they know who to complain to. The manager or area manager has investigated all complaints. The home is recording compliments. Feedback in regards to care and staff is very positive. The complaints procedure is available in Gujarati and Hindi. The home did not have an adult protection referral since the last key inspection. Staff employed at the home has received Protection of Vulnerable Adults training. The home has an adult abuse policy and procedure in place. I have found them in different folders and suggest having them put together in DS0000017548.V354796.R01.S.doc Version 5.2 Page 16 one adult protection folder. Staff interviewed demonstrated good knowledge of referring and recording of adult abuse allegations. DS0000017548.V354796.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a well-maintained physical environment that is appropriate to the specific needs of the people who live there. The home is well lit, clean and tidy and smells fresh. EVIDENCE: The home has replaced all carpets in communal areas. The upstairs hallway has been repainted and a handy man was in the process of decorating the ground floor hallway during this key inspection. The drive way has been repaved and is now even, to prevent people using the service from tripping. The home continued the ongoing refurbishment of people’s bedrooms. During the day of this key inspection a CORGI registered gas engineer replaced the DS0000017548.V354796.R01.S.doc Version 5.2 Page 18 old boiler. The home looks homely and welcoming and people using the service told me that they are happy living at the home. The utility room is located on the ground floor and one member of staff is responsible for laundering people’s clothes. The home has sluice facilities and a semi professional washing machine, which has a wash cycle above 65° Celsius to control infection. Domestic staff is responsible for the cleaning of home. DS0000017548.V354796.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Rotas show thought out ways of making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the people who use the service. Staff receives relevant training that is focussed on delivering improved outcomes for people using the service. There is a good recruitment procedure that clearly defines the process to be followed, this procedure is followed in practice EVIDENCE: I viewed the staffing rota during this key inspection. The following staffing is provided 3 carers and one senior carer during the morning, 2 sometimes 3 carers and one senior carer during the afternoon and two carers during the night. This numbers seems sufficient and people using the service informed me that staff responds quickly to their demands. I noted however that the manager Mrs Tolentino was rostered in for a number of occasions. It is good to see the manager being hands on, but I noted during this key inspection that the manager had to deal with phone calls and other managerial issues. This reduced the number of staff supporting people using the service. I discussed this with directors and area manager who informed me that this is only a temporary measure until another senior carer has been recruited. DS0000017548.V354796.R01.S.doc Version 5.2 Page 20 Currently four staff hold National Vocational Qualification in Care, 3 staff have recently enrolled to obtain this qualification. This does not fully meet National Minimum Standards, but the manager told me this process is ongoing. I informed the manager that the home must continue providing National Vocational Qualification in Care until the minimum requirement of 50 is met. The home has a recruitment policy in place, which is followed and complied with. I sampled four staffing files during this key inspection, all files included a Criminal Records Bureau check, 2 references, passport photo, application form, birth certificate and work permit where required. Staff interviewed informed me that they have been issued with General Social Care Councils Code of Conduct and a contract. The four staffing files sampled showed that staff has different levels of training and qualification. Training recorded in files: Induction training, Protection of Vulnerable Adults, Diabetes, Infection control, Food Hygiene, Fire safety, Manual Handling, Medication. As mentioned earlier not all staff hold a current and valid manual-handling certificate, which is required. DS0000017548.V354796.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31; 33; 35; 36 and 38 People using the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager has the necessary experience to run the home. She is aware of and works to the basic processes set out in the National Minimum Standards. The manager is improving and developing systems that monitor practice and compliance with the plans, policies and procedures of the home. More work is needed in this area. The manager is aware of the need to promote safeguarding and the health and safety policy requirements and legislation. The service provider takes responsibility for the home’s accounts and business development. DS0000017548.V354796.R01.S.doc Version 5.2 Page 22 EVIDENCE: There is currently no registered manager in post. The previous manager has left and a new manager Mrs Tolentino has been appointed in November 2008. I have received very positive feedback from people using the service, staff and visitors about the support and capabilities of the new manager. Mrs Tolentino is a nurse, without United Kingdom registration. Mrs Tolentino informed me that she does not hold management qualification, but has worked as manager abroad. The home has undertaken users surveys in July and August 2007, but only three have been returned. The manager told me that she is planning to repeat this exercise and hopefully obtains more completed surveys. A quality assurance policy is in place, but no annual development plan was available for inspection. The home does not hold any residents meetings, which is strongly recommended to ensure people using the service are involved in the care and the running of the home. The home has forwarded records of provider visits for the past two months to the Commission for Social Care Inspection. The home is not acting as an appointee or agent for any of the people living at the home. Families, solicitors or appointees manage finances and the home is invoicing expenses. As mentioned previously the home is safekeeping some money for people using the service, and records viewed where not of good standard. Amounts in tins did not tally with written records. The manager informed me that she was not able to audit the accounts since taking over from the previous manager. The manager informed me that since taking up her new post she did not provide any supervision to staff, this was confirmed by staff interviewed. Records viewed showed that previous manager undertook the last planned supervisions. None of the viewed records does show a minimum of six planned supervisions per year. Staff interviewed informed me that they would like to participate in regular team meetings; this is required. I have viewed a general Health and Safety risk assessment, which has been reviewed in September 2007. The home is doing monthly Health and Safety inspections, the last one was done in September 2007, it is recommended to resume this practice. The fire alarm was last checked on 14/01/08, and a fire risk assessment is in place and of good standard. The emergency lighting was last serviced on 14/09/07; the last recorded drill was on 09/11/07. The electrical installation certificate is expiring in March 2010, the Landlords Gas Safety Certificate is expiring on 06/07/08, The home is undertaken annual in house Portable Appliances Tests. All hoists have been serviced in October 2007 and the lift has been serviced on 13/08/07. The home has an up to date Legionella test certificate in place. DS0000017548.V354796.R01.S.doc Version 5.2 Page 23 DS0000017548.V354796.R01.S.doc Version 5.2 Page 24 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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 1 X 3 DS0000017548.V354796.R01.S.doc Version 5.2 Page 25 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 13(4)(c) Requirement The responsible individual must ensure that all people using the service who are at risk of falling have a falls assessment in place. All care plan files must include a current picture of the person. All staff must hold a valid manual handling certificate and must be assessed as competent by a qualified person. (Previous timescale of 01/10/07 not met) 4. OP8 12(1)(b) The responsible individual must 01/03/08 ensure that a competent person assesses all people with pressure sores, and guidelines are in place of what actions to be taken to treat them. The registered provider must ensure that the outside food storage is cleaned at least monthly to ensure peoples Health and Safety. DS0000017548.V354796.R01.S.doc Timescale for action 01/03/08 2. 3. OP7 OP8 17(1)(a) Schedule3 (2) 18(1)(c)(i ) 01/03/08 01/03/08 5. OP15 16(2)(j) 15/02/08 Version 5.2 Page 26 6. OP15 23(2)(c) The home must purchase a new fridge to replace the one, which is not closing properly, and food is stored above the legal limit. The manager must ensure that rotting woodwork in windows is investigated and repaired. (Partially met) 15/02/08 7. OP19 23(2)(b) 01/03/08 8. OP19 13(4)(c) The manager must find safer ways to open the ground floor disabled toilet door. (Partially met) 01/03/08 9. OP28 18(1)(c) The registered person must ensure that at least 50 of care staff have National Vocational Qualification in Care level 2 or above. (Partially met) 01/04/08 10. OP31 9, 10 The registered person must ensure to register the manager with the Commission for Social Care Inspection. The manager must obtain relevant qualifications in Care and Management. The manager must ensure that a report, that summarises audited people’s views about the care provided in the home, is produced and circulated following each quality assurance audit. DS0000017548.V354796.R01.S.doc 01/04/08 11. OP31 9(2)(b)(i) 01/04/08 12. OP33 24 01/04/08 Version 5.2 Page 27 (Previous timescale of 1/9/06, 01/02/07 & 01/10/07 not met.) 13. OP35 16(2)(l) The responsible individual must ensure that all monies held on behalf of people using the service must be audited and records must be balanced. The responsible individual must ensure that all staff receives a minimum of six planned supervisions per year. The responsible individual must ensure that regular team meetings are arranged for staff to discuss issues relating to the home and people using the service. 01/03/08 14. OP36 18(2) 01/03/08 15. OP36 21(2) 01/03/08 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. Refer to Standard OP7 OP18 Good Practice Recommendations Falls records should include more detailed information to help staff to see if there is any pattern to the falls. Protection of Vulnerable Adults guidelines and procedures, and the abuse policy should be put in one folder to provide easier access for staff, people using the service and others. The home does not hold any residents meetings, this is strongly recommended to ensure people using the service are involved in the care and the running of the home. 3. OP33 DS0000017548.V354796.R01.S.doc Version 5.2 Page 28 4. OP38 It is recommended to resume the monthly Health and Safety checks by the manager to ensure the safety of people in the home. 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