Inspection on 04/02/08 for The Riseborough Care Home

This inspection was carried out on 4th February 2008.

CSCI found this care home to be providing an Poor 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 Riseborough Care Home 30/10/07

The Riseborough Care Home 02/05/07

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Riseborough Care Home (The) 11-13 Branksome Wood Road Bournemouth Dorset BH2 6BT Lead Inspector Chris Gould Key Unannounced Inspection 4th February 2008 09:45 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 Riseborough Care Home (The) DS0000068327.V358669.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. Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Riseborough Care Home (The) Address 11-13 Branksome Wood Road Bournemouth Dorset BH2 6BT 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) 01202 318567 01202 318568 the.riseborough@fshc.co.uk Four Seasons (No 7) Limited Care Home 74 Category(ies) of Old age, not falling within any other category registration, with number (74) of places Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. No more than 43 service users in need of nursing care may be accommodated. The home may accommodate two service users for respite care in the age range of 40-64 years to receive either nursing or residential care. The home may accommodate two service users in the age range of 40-64 years to receive either nursing or residential care. 30th October 2007 Date of last inspection Brief Description of the Service: The Riseborough is situated in a pleasant residential area of Bournemouth not far from the town centre. At the top of the driveway, there is a parking area and to the side and rear of the home are mature gardens that are well maintained. The home is owned by Four Seasons (No 7) Limited. There is currently no registered manager of the service. Accommodation is provided over three floors, which are accessible, by either stairs or passenger lift. All rooms in the home have en suite facilities. There are several lounges and a pleasant dining room, a small chapel and hairdressing facilities. The fee range is £440 to £850. Fees are determined in relation to the prospective residents’ needs, as the home is able to accommodate both residential and nursing residents. See the following website for further guidance on fees and contracts: http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people_ choos.aspx Riseborough Care Home (The) DS0000068327.V358669.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 0 star. This means the people who use this service experience poor quality outcomes. Two inspectors carried out the unannounced key inspection over seven hours on one day in February 2008. This was a statutory inspection and was carried out to ensure that the residents who are living at The Riseborough are safe and properly cared for. Requirements and recommendations made as a result of the last inspection visit were also reviewed. The home has been without a registered manager for some time being managed by a number of peripatetic managers and for a time a proposed registered manager. The present peripatetic manager has been managing the home since November 2007. A new manager has been appointed and will commence in post on the 11th February 2008. There has therefore been a lot of change in terms of the management of the service. The clinical services director that has a base at the home was available throughout the inspection. The premises were inspected, records examined and the daily routine observed. Time was spent in discussion with seven residents living in the home and six staff members on duty. Completed survey forms were received from residents and relatives. Surveys were provided for staff members but at the time of writing the report no responses had been received. The home also returned an Annual Quality Assurance Assessment (AQAA). What the service does well: The home has policies and procedures in place to assess residents prior to moving into the home with care plans that support care giving, enabling residents’ needs to be met sensitively and compassionately. Residents and relatives spoken with said that the care received was good and ‘the staff are marvellous’ and ‘very polite’. The home has an open culture to responding to any issues of concern or complaints, so that residents can feel confident that they live in a home that will listen and view any issues raised positively to improve the quality of service. Two visitors to the home spoken with were very happy with the care and facilities. They knew who to speak with if they had any concerns and were full of praise for the staff. Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 6 Staff members are currently employed in sufficient numbers to meet the needs of residents living in the home. What has improved since the last inspection? What they could do better: Assessments should be signed and dated, providing clear details regarding the time that the assessment was carried out and the competency of the person completing the assessment. This is once again included as a recommendation in this report. It could not be reviewed, as the home has not had any admissions since the last inspection. The residents care plans must include sufficient detail to provide staff with clear guidance on the actions they need to take in order to fully meet the residents care needs. A detailed plan and record of the nursing care provided must be maintained in respect of the resident’s health care needs. Medicines must be stored at the correct temperature. The residents must be consulted about their social interests and facilities and resources provide to meet their needs. The registered person must ensure that all relevant checks are undertaken and maintained for all staff working at the home. There must be adequate information provided for agency staff working in the home, demonstrating that they are suitable and fit to meet the needs of the service. Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 7 Staff must receive the appropriate training to meet the needs of the residents at the home including structured induction training. Training must include moving and handling, first aid, health and safety and infection control. The manager appointed to the service must submit an application for registration with CSCI. This will enable the service to benefit from continuity in organisation and stability in the management of 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. Riseborough Care Home (The) DS0000068327.V358669.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 Riseborough Care Home (The) DS0000068327.V358669.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place to assess residents’ needs prior to moving into the home, so that they feel assured that the service can meet their needs. EVIDENCE: The Riseborough has not had any new admissions since the last key inspection. A recommendation was made in the last inspection report that assessments should be signed and dated, providing clear details regarding the time that the assessment was carried out and the competency of the person completing the assessment. This standard will, therefore, be properly reviewed at the home’s next inspection. Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 10 The home has confirmed in the AQAA returned to the Commission for Social Care Inspection that there are policies and procedures in place, including preadmission assessment forms, to enable the service to assess prospective residents needs prior to moving in. The AQAA also confirms that staff have received documentation training and that a key worker will be assigned to new residents when they are admitted to ensure that their needs are met and they feel welcome. Riseborough Care Home (The) DS0000068327.V358669.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 and 10 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The residents all have a care plan however shortfalls in detail and clarity means that there health, personal and care needs are at risk of not being fully met. EVIDENCE: Care documentation for five residents was reviewed. Each file contained a variety of assessments and care plans. Assessments included: • MUST – a tool used to assess the nutritional needs of residents. • Waterlow – a tool used to assess pressure risk. • Moving and handling • Oral needs • Continence • Risk of falls • Monthly weights, blood pressure and pulse. Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 12 Residents and relatives spoken with said that the care received was good and “the staff are marvellous.” Files contained information of other health professional visits including the resident’s own doctor, district nurse, dentist, dietician and chiropodist. Residents when visited appeared well nourished and hydrated and generally care files seen showed maintenance or increase in weight. There were good recordings of food and fluid intake. One care plan said that the resident needed a fluid intake of 2 litres but fluid charts indicated that the average fluid intake was 1200 ml. Therefore the goal was not realistic. One resident’s care file included a body map indicating that a pressure sore was decreasing in size and healing well. A second resident’s care file included very confusing information about wound care. It was not clear from reading it what the current dressing regime was. The same file contained a care plan, which stated “High risk of developing pressure sores” and gave instruction about sitting in a chair. This service user was on bed rest and already had pressure ulcers. Residents were provided with the appropriate pressure relieving equipment where necessary. Old information was not removed from the care plan. Therefore the reader had to read all previous instructions before getting to the relevant information. One file contained two care plans for nutrition and it was not clear which one was to be followed. The care records of one resident identified a diagnosis of dementia but there was no mental health assessment or care plan around this issue to ensure that the appropriate care was provided. Instruction in the care plans appeared to be general rather than specific, for example, “use minimal barrier creams because they may reduce absorbency”. It did not tell the reader which cream to use. Some care plans included information not directly related to the problem, for example, instruction about social activities was included in the care plan for constipation. One diabetic care plan indicated that the normal blood sugar level should be maintained between 8 and 12. It was consistently higher and no instruction was given as to what to do in this event. Two files contained charts to monitor pain and both were incomplete; one said “dull discomfort” but not where this was. Where one resident had refused analgesia regularly but still complained of pain there was no evidence to Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 13 suggest this had been discussed with the service user and GP or any alternatives offered. Care plans did not included immediate problems, for example, when one resident had a chest infection and one had a transient ischaemic attack, resulting in weakness in an arm. Daily statements mainly reflected the physical care provided and did not include information on mental well being. Key worker diaries were not kept up to date. The last entry for one resident was 18.10.07 another was completely blank. On the nursing wing a medication trolley is held securely on each floor. The temperature where each trolley is held and documentation indicated that this should not exceed 25°C. However the first floor trolley was held in an area that exceeded this temperature and no action had been taken. Medication Administration Records (MAR) indicated that medication was given as prescribed. Creams prescribed had been signed as given. There was a clear audit trail that showed how much medication was held. Temazepam was held securely and appropriately recorded. Staff were seen knocking on doors and waiting for an answer before entering residents’ rooms. Residents spoken with said that they were always addressed in the way they had requested and the staff are ‘very polite’. The admission document includes the resident’s preferred form of address. Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The flexibility of the home enables residents to retain control over their lives where feasible however the activities programme provided is not based on individual assessments and therefore does not consistently satisfy the needs of all the residents. EVIDENCE: Information on activities undertaken was included in care documentation. However there was no individual profiles available on which to base suitable activities for that particular resident. Further work is still required in this area as a full picture of the person’s past family, work and social history will assist with planning for their future care. An activities co-ordinator is employed and a programme of activities arranged. There were notice boards up in the home detailing events taking place. As it was the co-ordinators day off on the day of inspection there were no activities arranged for that day. This was discussed with the manager to ensure that the Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 15 provision of social activities is not dependant on the presence of the activities co-ordinator. One resident who is being nursed in bed said that carers do not come and chat to them at all as they do not have time. Outside of the times care is being delivered if it wasn’t for a regular visitor they would see no one else. One relative when asked in the survey how do you think the care home can improve commented ‘give patients some stimulation’. The home benefits from a number of different communal areas enabling residents to choose where they would like to be, the views they would like to enjoy, watching the television or perhaps having quiet time with a relative or friend. A record is maintained of all visitors to the home. Visiting arrangements are included in the Service Users Guide. Visitors spoken with confirmed that they were always made welcome by the staff and relatives that responded to the survey agreed that the home assists the resident to keep in touch with them. Those residents who were able to articulate a view confirmed that they were able to make choices about such matters as what they ate and when they got up in the mornings and went to bed at night. Residents are able to “personalise” their bedroom with additional items of their choice. This was confirmed when visiting residents’ bedrooms. The lunchtime menu offered on the day of inspection was soup or melon with Parma ham, beef stew and herby dumplings or poached Pollock and dill sauce, vegetables and creamed potatoes followed by stewed fruit and custard. Alternatives are always available. Pureed diets were supplemented with extra nourishing additions such as butter, full fat milk, condensed milk, sugar. The pureed diet at lunchtime was the beef and at suppertime on that day it would be the Pollock as the main menu was unsuitable to be pureed. The need to ensure a choice for residents requiring a pureed meal was discussed. Some residents were prescribed nutritional supplements, which were given appropriately. Full fat yogurts and mousse were given at teatime as a snack if the resident could not eat cake and biscuits. Generally residents spoken with were happy with the food available and confirmed that there was a good choice. However one resident remained dissatisfied. The dietician had reviewed several residents and instructions given to the staff appeared to have been followed. A visit was made to the dining room at lunchtime. Staff were available to help residents needing assistance and this was generally done sympathetically. However one member of staff was seen feeding two residents at the same time. Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The systems in place provide residents with the confidence that their complaints will be listened to and acted upon and they are protected from abuse. EVIDENCE: The home has a complaints procedure and maintains meticulous records of complaints received, reflecting that all concerns are taken seriously and acted upon. Two visitors to the home spoken with were very happy with the care and facilities. They knew who to speak with if they had any concerns and were full of praise for the staff. The records available evidenced that most of the staff members have received a video based training programme in adult protection and all staff are now working towards completing the very detailed Four Seasons workbook, which covers all aspects of adult protection including reference to looking at local guidelines. Since the last inspection the person delivering and supporting staff members with this training has attended training themselves so that they are able to fully support staff members engaged in the programme. Riseborough Care Home (The) DS0000068327.V358669.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): 19 and 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. When the refurbishment programme to improve the quality and fabric of the home is complete it will further enhance the appearance, comfort and safety of the home for the residents that live there. EVIDENCE: At the time of this inspection the Riseborough refurbishment programme was nearing completion. Since the last inspection with the agreement of the residents or their representative a number of residents have been moved to other rooms where they are less inconvenienced by the work that is taking place. One resident who has remained in the same room confirmed that this was their choice. Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 18 The laundry was well organised on the day of the visit and residents felt that generally the service was much improved with their own clothes being returned. One relative had concerns about the laundry commenting ‘from time to time items of clothing have disappeared never to be found. We often find clothing in her wardrobe and drawers that do not belong to her which we return’. The housekeeper confirmed that with the appointment of two new domestic staff there would be no need to continue using agency staff and a revised cleaning programme was being put into place. One new domestic worker was receiving induction on the day of the inspection. One relative felt that the care home ‘provides clean accommodation’ and another relative commenting on what the care home does well said ‘keeps the home clean and tidy’. On the day of the visit all areas of the home visited looked fresh and clean with no malodours noted. Riseborough Care Home (The) DS0000068327.V358669.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): 27, 28,29 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home employs sufficient staff members to meet the needs of the present number of residents at the home however shortfalls in recruitment, the use of agency staff and staff training does not ensure the protection and safety of residents at all times. EVIDENCE: An off duty roster is maintained identifying the member of staff their grade and the floor that they have been allocated to work on. The roster had not been updated to show that the expected agency care worker on that day had been changed. On the day of inspection the occupancy was 35 residents including 23 requiring nursing care. The home has recruited sufficient registered nurses to be able to stop the use of agency nurses. A high number of agency care workers are still required although the recruitment programme continues. On the day of inspection on the nursing wing four agency care workers were required with one on the residential wing. Relatives commented ‘it would be nice to see the same staff when visiting or even see them’, ‘my father finds the continual staff changes difficult’ and ‘the care staff they have now are lovely, caring and friendly’. Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 20 Five staff files contained an application form, proof of identity, a health questionnaire, a job description, two written references and a contract. A satisfactory Criminal Records Bureau or a POVA first check had been received prior to the member of staff commencing employment. There was no written evidence to demonstrate that the Personal Identification Number (PIN) of the registered nurse is confirmed with the Nursing and Midwifery Council (NMC). The checks were undertaken electronically on the day of the inspection. The recent audit undertaken by the home identified that these checks had been made. The home do not obtain adequate information regarding agency staff working in the home, to ensure that they have undergone the recruitment checks and have the skills that they need to support the service in meeting the needs of residents. This was also identified during the last inspection. For two staff there was no information. This was obtained during the day of inspection. There are twenty-one members of care staff working in the home. There is currently one member of staff with a National Vocational Qualification in Care (NVQ) at level 2, with six members of staff holding an equivalent qualification. Four Seasons has a detailed induction programme, which the manager confirmed, complies with Skills for Care (the National Training Organisation’s standards). The new member of staff is allocated a mentor and the induction is programmed to be completed within six weeks. A new member of staff that commenced in post nine weeks previously had their induction programme records with them. The records had very few elements completed and none including the orientation two days had been countersigned by the mentor. The available training matrix, training attendance sheets and certificates did not evidence that all staff are up to date with the home’ mandatory training including moving and handling, first aid, health and safety and infection control. The training matrix evidenced that ten members of staff have attended dementia care training and six staff have received recent diabetes training. There is no evidence to demonstrate that staff are receiving a programme of training to meet the specialist needs of people entering and living in the home. One registered nurse spoken with said that she had worked in the home for a year and in that time had received the mandatory training and further training in dementia and tissue viability. She was very happy and said the team worked well together and she felt supported. Riseborough Care Home (The) DS0000068327.V358669.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 and 38 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The absence of a permanent registered manager providing continuity places residents at risk due to lack of adequate, stable management to organise and manage the service. The health and safety of the residents is not consistently promoted and protected due to the shortfalls in staff training. EVIDENCE: The home has been without a registered manager for some time being managed by a number of peripatetic managers and for a time a proposed registered manager. The present peripatetic manager has been managing the home since November 2007. A new manager has been appointed and will Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 22 commence in post on the 11th February 2008. There has therefore been a lot of change in terms of the management of the service. The person responsible for the residential service remains in post and the clinical services director has a base at the home and spends some time each week at the home. Residents and relatives comments included ‘it will be good when there is someone in charge for longer than a few weeks’, ‘the manager seems very nice but we never get to really know any of them’ and ‘looking forward to meeting the new manager next week’. The home has introduced a team audit process that the manager said had been completed the previous week. The audit includes all aspects of the day to day living and working at the home including activities, environment, care documentation, human resources, training and infection control. The audit is undertaken by a member of staff relevant to the topic being assessed and then verified by the manager. The audit results are then fed into a computer programme and submitted to head office. The manager then has two weeks to complete an action plan detailing how shortfalls will be met. The completed audit forms were not dated and had not been consistently completed with the person that had verified the findings. The person verifying the audit had on a number of occasions altered the conclusions of the person undertaking the audit so improving the outcome. On one occasion the auditor had noted that there were malodours in the home but the verifier had changed this and in discussion said that it was wrong, as there are never any malodours at the home. Discussion took place regarding the audit reflecting a particular period in time. The home is asked to submit the results of the audit and the action plan to CSCI when complete. The home has efficient procedures in place for safeguarding residents’ financial interests, taking appropriate action when there are any concerns regarding the safe handling of residents’ monies. Since the last inspection the cleaners now remove the tray containing chemicals from their trolley and take them into the room they are working in so that they are not left unattended. This was evidenced when walking around the home. During the inspection in October it was recorded that ‘maintenance records seen showed that regular routine maintenance takes place of equipment and facilities in the home. Fire records viewed demonstrated that routine checks are undertaken of fire equipment. There were two separate records of drill practice; one list stated the date and recorded that all staff had attended; another was thorough and contained the required information, which included a list of all staff taking part in the drill’. As discussed in standard 30 the home are unable to evidence that all staff have received training in moving and handling, first aid and health and safety. Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 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 2 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 2 Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The registered person must ensure that residents care plans contain sufficient detail to provide clear guidance to staff on the actions to be taken to meet their care needs. The registered person must ensure that a detailed plan and record of nursing care provided is maintained in respect of the residents’ health care needs. The registered person must ensure that medicines are stored at the correct temperature. The registered person must consult residents about their social interests and provide facilities and resources to meet their needs. The registered person must ensure that all relevant checks are undertaken and maintained for all staff working at the home. Timescale for action 30/05/08 2. OP8 17(1)(a) sch 3 30/05/08 3. OP9 13 29/02/08 4. OP12 16(2)(n) 30/05/08 5. OP29 19 29/02/08 Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 25 6. OP29 19 There must be adequate information provided for agency staff working in the home, demonstrating that they are suitable and fit to meet the needs of the service. The previous timescale of 15/12/07 was not met The registered person must ensure that the staff have received the appropriate training to meet the needs of the residents at the home including structured induction training. The registered person must ensure that the manager appointed to the service submits an application for registration with CSCI within the timescale set. All staff must receive training in moving and handling, health and safety, infection control and first aid to promote and protect the health, safety and welfare of residents. 29/02/08 7. OP30 18 30/05/08 8. OP31 8 31/03/08 9. OP38 12 30/05/08 Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 26 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. Refer to Standard OP3 Good Practice Recommendations Assessments should be signed and dated, providing clear details regarding the time that the assessment was carried out and the competency of the person completing the assessment. This was not reviewed at this inspection. The home should ensure that residents’ clothing is always returned to the person to whom it belongs following laundering. 2. OP26 Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Riseborough Care Home (The) DS0000068327.V358669.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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