Inspection on 25/07/06 for The Shaw

This inspection was carried out on 25th July 2006.

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

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

Other inspections for this house

The Shaw 29/10/07

The Shaw 13/01/06

The Shaw 12/09/05

The Shaw 21/03/05

The Shaw 12/07/04

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 Shaw 169 Tollers Lane Old Coulsdon Surrey CR5 1BJ Lead Inspector Claire Taylor KeyUnannounced Inspection 25th July 2006 11:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Shaw Address 169 Tollers Lane Old Coulsdon Surrey CR5 1BJ 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) 01737 556 577 01737 556 386 Central & Cecil Housing Trust Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th January 2006 Brief Description of the Service: The Shaw, located in a semi rural residential area of Old Coulsdon, is a detached property situated in its own grounds and within easy reach of the local village. It is registered as a care home for older people with the Commission for Social Care Inspection to provide care and accommodation for up to 25 service users. Central and Cecil Housing Trust own the home and is a registered charitable organisation. There are 25 single rooms, some of which have en suite facilities. Accommodation is set out over three floors with a lift to service each. Communal areas consist of three dining rooms and two lounges. A loop system has been installed for the benefit of those residents who have hearing impairments. There is a large well-maintained garden planted with mature shrubs and trees, flowerbeds and hanging baskets / window boxes and a water feature. There is a large well-equipped kitchen and adequate laundry area. Ample space for parking vehicles is available at the front of the property and the home is situated within easy reach of nearby transport links such as buses. Fees charged range from £470.00 to £525.00 per week and were accurate at the time of this inspection. Additional charges may be payable for some extras such as hairdressing, newspapers and chiropody but would be discussed prior to admission. The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that began at 11.15am and lasted six hours. The visit was mainly facilitated by one of the home’s senior carers until the home manager arrived at the home towards the end of the inspection. In accordance with the Commission’s “Inspecting for Better Lives” programme, all of those standards considered to be key to the inspection process were assessed. On the day, there were 19 residents in the home and 6vacanct beds. Time was spent meeting with residents to discuss what it is like to live at the Shaw and a tour of the premises was carried out. Various records were looked at in relation to care planning, staffing and the general operation of the home. Some information was taken from the questionnaire that the manager had filled in prior to the inspection. Three written comment cards, completed by residents’ relatives or representatives, were received in respect of the service. “Have your say” questionnaires completed by three residents were also received. All those who took part in the inspection are thanked for their time to share their views about the home. What the service does well: Good standards of care continue to be maintained in this home and residents remain supported by a stable and well-trained staff team. Care staff have worked in the home for a number of years resulting in stability and familiarity for the people who live there. They have a variety of skills and knowledge relevant to meeting the needs of older people. Planning and review of care is thorough and shows that the home continues to meet the residents’ assessed needs. Care plans set out well the individual needs of the resident and how staff members should meet these needs. Healthcare needs are well monitored through close links between the home and other relevant professionals. Staff appear to take the time to help settle new residents into the home and maintain individual lifestyle choices for the remaining residents. A wide range of activities are arranged to suit the needs of the residents and provide interest and stimulation both within the home and out in the local community. Meals are nutritious and nicely presented and residents can choose what they eat and at times convenient to them. Residents are treated with respect and dignity that promotes their individuality and values their personal preferences. The home actively seeks the views of residents and their supporters to monitor satisfaction with the service provided. Residents and relatives were once again complimentary about the home. One relative wrote “I feel The Shaw provides a friendly and caring environment. I am very pleased with the care my mother has been given”. A resident wrote “The care and support at this home are excellent. The staff are very sympathetic listeners.” The décor, furnishings and fittings are well maintained and offer homely and comfortable surroundings for the people who live there. The premises and The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 6 facilities are kept safe and clean so that the health, safety and well being of residents are protected. What has improved since the last inspection? What they could do better: 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 Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 is not applicable to this home as it does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. The home provides good clear written information about the facilities offered at the home and introduction opportunities for prospective service users and their families to make an informed choice about whether to live there. Residents’ needs are fully assessed prior to admission to ensure that residents are appropriately placed, that the home can meet their needs and that staff are aware of how to support them. EVIDENCE: A detailed Statement of purpose and guide is in place, which sets out in detail the home’s aims and objectives, and the services and facilities provided. The documents had been recently updated to reflect the change in management at the home. Since the last January 2006 inspection there has been one new admission to the Shaw. Including this one, needs assessments for five residents were sampled and detailed information was available to staff to ensure they could The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 9 meet their social, emotional and care needs. One of the newest residents felt that they were fully involved in the process leading up to admission and likewise, were given the opportunity to view the suitability of the home. The manager or a senior staff undertakes the pre-admission assessment. This is usually completed with the resident, his/her relative or representative and if appropriate, any other relevant professional associated with the referral. Written admission documentation includes a questionnaire to establish any personal preferences of the new resident as well as a personal history profile that covers key areas of a person’s childhood, adulthood and retirement. One minor shortfall however was that the home did not complete a check on one resident’s property or valuables that were brought into the home and this must be addressed. Discussion with residents and care records indicated that the home was meeting their assessed needs. At the time of this inspection, the owning organisation had applied to the Commission for a variation to register the top floor of the home as a unit for people with dementia. Records showed that both residents and families have been consulted about the proposed changes. Progress regarding the application will be looked at during the next inspection. The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Care planning is well organised and regular informal reviews ensure that staff are aware of each residents’ current needs. Residents are able to access care from additional services so that their healthcare needs continue to be met and medication practices are well managed to ensure good health. Residents can be confident that they will be treated respect and in a way that respects their privacy and dignity. EVIDENCE: The records for six residents who live at the home were sampled. They each contained a detailed care plan that was initially based on the pre-admission assessment and addresses the health, personal and social care needs of each resident. There were details about how staff should support them, and about where the person was independent in meeting their needs. Records showed that residents’ care plans are reviewed each month so that any changing needs are identified and appropriate amendments can be made. One example included changes to a nighttime care plan for one resident who required extra reassurance due to some episodes of disturbed sleep. The care plans had been The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 11 signed by either the resident or their close relative to ensure that the details are a true record, which is good practice. Likewise, daily care records indicated that individuals are consulted about the care that they receive. Residents are in regular contact with General Practitioners, District Nurses and other health care professionals as required. E.g. hospital clinics, chiropody and optician. Records showed that staff monitor the care and psychological health needs to ensure that residents continue receiving the correct treatment or medication. Clearly, this assists in maximising each resident’s health and well-being. Risk assessments, that seek to protect resident’s health and safety were also recorded and reviewed three monthly in respect of residents’ mobility, skin care and nutrition (including weight monitoring) and other relevant areas. Individual mobility risk plans could be written in a more understandable format for which a recommendation is made. Risk levels were identified through a score type summary and it was not always clear what support they require with any mobility needs or preventing the risk of a fall. More details are needed so that staff have full information on supporting a resident. The recording, storage and disposal of medication was checked and in good order. Medication is reviewed at regular intervals and according to changing needs of residents. Adequate staff are trained to administer medication and records were accurate and in accordance with the residents’ individual prescriptions. The home uses a monitored dosage system, supplied by “Boots” chemist. In response to the last inspection, the pharmacist visited in February 2006 to complete an audit of the procedures and medication practices. Some areas were identified for attention and the home had addressed the necessary recommendations. As good practice, one of the senior staff carries out an in house medication audit each week to ensure safe practice is maximised. The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Activities are well managed with a variety of group and individual interests available for residents that satisfy their social, cultural and religious needs. Residents are fully supported to maintain contact with family and friends and visitors are welcomed to the home. Wherever possible, residents are able to exercise choice and control in their day-to-day routines, and receive appropriate support from staff to achieve this. Meals are nutritiously balanced and offer a healthy and varied diet for the people who live there. EVIDENCE: Once again, the home continues to provide a very good range of recreational activities for the residents that offer stimulation and interest for individuals. Residents spoken to commented favourably about things to do in the home including quizzes, sing a long sessions with a pianist and organised community outings. Recent trips have included visits to a local garden centre and “Beaver World” aquatic centre. A hall notice board is used to display up to date information about activities and social events/ functions. There are activities arranged according to residents’ specific needs. A mobile library visits the home to provide “talking books” for those with visual impairment. One resident The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 13 also has input from the RNIB. Reminiscence sessions are held regularly for individuals who have memory difficulties and there is a loop system in the home to assist people with hearing impairment. A widescreen TV has recently been purchased for the home and several residents said they appreciated the larger screen. Representatives from a local church regularly visit and residents are supported to follow their chosen religion or beliefs. The manager and staff maintain good communication links with relatives, friends and visitors. This was reflected within the returned comment cards and relatives feel very involved with the home as well as being able to contribute to its operation. Two relatives were visiting the home during the inspection. Both gave complimentary views about the way things are run and that staff are friendly and welcoming. Adequate areas are available for people to meet in private. Residents are provided with three meals a day including a cooked lunch as well as regular snacks and drinks. Breakfast can be served in bedrooms if individuals so wish and other meals may be taken outside of mealtimes according to choice. The daily menu is written on the home’s notice board and alternatives are offered. Staff served and assisted residents appropriately and sensitively, as well as ensure a relaxed and unhurried atmosphere during the lunchtime meal. Any dietary needs are clearly recorded in the care plans and residents’ weights are monitored monthly. The home employs cooks from a contracted catering firm and menus are planned in consultation with the residents. Residents spoke very positively in respect of the food provided, flexibility of meal times and choice of meals. One comment was “the meals are of a very high standard”. Themed type meals are arranged such as a recent summer lunch based upon “Wimbledon” tennis with strawberries and cream. The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Arrangements for complaints and protection from abuse are well managed and ensure that residents feel listened to and safe. EVIDENCE: The complaints procedure had recently been reviewed by the manager and is readily available to the people who live there, their relatives and other visitors. Copies of the procedure were available in the main entrance hall as well as a suggestions box. The complaints book was examined – two complaints had been recorded since the last inspection visit and outcomes showed that both were suitably dealt with by the home. In response to a previous requirement, details of all complaints are now kept logged in the book. Residents and relatives expressed confidence that any concerns would be dealt with appropriately and there were no negative remarks in the comment cards received by the Commission. Policies and procedures relating to residents’ protection were clearly written and up to date. i.e. on recognition and prevention of abuse, staff recruitment and safeguarding residents financial affairs. Staff receive training on abuse awareness as part of their induction and the majority have attended a course on the protection of vulnerable adults. The senior staff explained that the home was also awaiting an in house training day run by the coordinator for Croydon’s adult protection team. The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 15 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 and 26 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. Once again, the Shaw appears well maintained, decorated and furnished to high standards enabling residents to live in clean, safe and comfortable surroundings. EVIDENCE: The Shaw remains well kept and furnished to high standards. Since the last inspection, various home improvements have taken place including the provision of new armchairs in the lounge, new carpets to the rear staircase and installation of magnetic fire door closures where required. New flooring has been fitted in the corridors and the lounges, corridors and one bedroom have been redecorated. A new dishwasher, hot water urn and various crockery items had also been purchased. Residents were complimentary about the décor and furnishings in the home and also their bedrooms. There are well-maintained gardens for residents to access via the lounge areas. During this visit, the weather was particularly warm and the home had taken appropriate action to The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 16 deal with the recent heat wave. E.g. portable fans had been purchased for communal areas and individual residents. Staff were observed offering extra drinks to residents and the published Department of Health guidance on coping with the heat wave was available for people to read. As consistently highlighted at previous inspections, the premises appeared very clean, tidy and free from offensive odours. Good hygiene practices are observed and systems in place and well managed to control the spread of infection. Residents also confirmed that the home was kept clean and that their bedrooms were regularly attended to. The manager reported that the home was still awaiting an inspection from the Environmental Health Department despite contacting them on several occasions to arrange a visit. The previous requirement therefore still stands although it is acknowledged that efforts have been made to address the issue. As mentioned earlier in the report, the registered providers plan to register the second floor as a dementia unit for thirteen beds. This will involve some necessary environmental changes and adaptations which were discussed during the inspection. The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 17 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, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. There is a stable and competent staff team who receive ongoing training to meet the needs of the elderly people living there. Robust recruitment procedures are in place to ensure that residents are cared for and protected. EVIDENCE: Duty rotas seen indicated that sufficient staffing levels are maintained for the current resident group with three staff on each shift and two on waking nights. Ancillary staff consist of two contracted cooks and part time cleaners. Valuably, staff turnover remains low and most of the staff have worked in the home for many years. This means that residents benefit from a stability and consistency of care. Only two new staff have been appointed since the last inspection. Inspection of their personnel files contained all the required documentation including a Criminal Records Bureau / ‘POVA first’ check as well as evidence of induction training. Residents commented positively about several long-standing care staff and the new manager. The home holds regular staff team meetings, which are recorded. Staff members spoken to expressed positive comments on their experience of working at the home. Personal development plans are also used to identify training needs and the home continues to demonstrate efficiency in the area of staff training and development. Sampled files contained good evidence that staff had undergone relevant training. E.g. areas such as moving and handling; food hygiene; first aid; fire; elder care issues and dementia. A comprehensive training The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 18 programme is available that offers a variety of opportunities for staff to update their skills and knowledge along with recognition of mandatory courses that they must attend. In addition, there are nine staff who have achieved the NVQ level 2 qualification. The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 19 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, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using all the available evidence including a site visit to this service. There is a new manager who has relevant qualifications and a good leadership approach to continue to run the home in the best interests of the residents. The home’s financial procedures are thorough and protect the interests of the residents. Good systems are in place to promote and protect the health, safety and welfare of people living and working in the home. EVIDENCE: A new manager has been in post since January 2006 and has completed the necessary application to register with the Commission. The manager is currently studying for the required NVQ level 4 qualification. Staff spoke positively about the manager’s leadership style and felt the team works well together. The home is good at monitoring the quality of care provision and The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 20 there are many systems used to achieve this. A ‘satisfaction survey’ is offered to service users on an annual basis and the inspector read a selection of questionnaires completed in March 2006. Feedback indicated positive views about the home and the care provided. The manager also completes quarterly audits which are then analysed by the owning organisation so that any appropriate action can be taken. The manager welcomes feedback from visitors and ensures that regular residents meetings take place to ensure they feel part of the home they live in. Three monthly meetings are also held for relatives and representatives to share their views. Minutes of these meetings were sampled and confirmed that residents and relatives are consulted about the way the home is run. Residents have a lockable facility in their own bedroom in which to safely hold their own valuables if they wish. Full records and receipts are kept for any transactions that are made for residents who have personal finances kept by the home. These accounts are checked randomly as a part of the monthly visits that occur as required by Regulation 26. The home operates a comprehensive supervision programme for the staff and sessions are held approximately every two months. Annual appraisals were also completed for the staff files sampled. Individual training needs are addressed through supervision and appraisal. The home was once again found to be well maintained and promote a safe environment for the safety and well being of residents and people working in the home. A sample of health and safety practices and procedures were checked including fire records, accidents and incident records, staff training, risk assessments and infection control which were all satisfactory. Maintenance and servicing records were also sampled and up to date. The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes-1 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 OP3 Regulation 17(2) sch 4 9&10 16(2)(j)2 3(5) Requirement Timescale for action 30/09/06 2. OP19 The manager / staff must complete a property list of each resident’s furniture and valuables as appropriate when they are admitted to the home. The registered provider is 30/09/06 required to submit a copy of the Environmental Health Department report and any findings to the Commission. (Outstanding from 2005 although it is acknowledged that the home has made efforts to arrange a visit) 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 OP7 Good Practice Recommendations Individual mobility risk plans could be written in a more understandable format. More details are needed so that staff have full information on supporting a resident as it was not always clear what support they require with any mobility needs or preventing the risk of a fall. DS0000025855.V304810.R01.S.doc Version 5.2 Page 23 The Shaw The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. Extracts may not be used or reproduced without the express permission of CSCI The Shaw DS0000025855.V304810.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!