CARE HOMES FOR OLDER PEOPLE
The Whispers Care Home 30 Rambler Lane Langley Slough Berks SL3 7RR Lead Inspector
Elaine Green Unannounced Inspection 30th October 2007 12:30 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 DS0000047604.V348753.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. DS0000047604.V348753.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Whispers Care Home Address 30 Rambler Lane Langley Slough Berks SL3 7RR 01753 527300 F/P 01753 527300 hyaremoni@hotmail.com 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) Mrs Mohanjit K Hyare Mrs Mohanjit K Hyare Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places DS0000047604.V348753.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 11th May 2006 Brief Description of the Service: The Whispers is a small independently owned residential home for 19 service users situated in a quiet cul-de-sac off the A4 Bath Road linking Slough and Langley. This home is a converted domestic house, which still retains some of the original structural and décor embellishments when built and is set in a moderate sized garden encompassed by large residential properties. The fees charged range from £300 to £470 per week and include basic hotel costs of staffing, meals, drinks, laundry and accommodation. Additional charges are made for hairdressing and chiropody. DS0000047604.V348753.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. As part of the Unannounced Inspection of The Whispers a site visit took place over 6 hours on the 30th October 2007. On the day of the site visit we spoke with six people who live at the home and ate a midday meal. We also had a tour of the building and had discussions with the manager and one of the providers. A range of records and documentation relating to the running of the home were also examined and included some of the homes’ policies, procedures & guidelines, daily records, plans of care, medication records, recruitment, training and personnel records and records pertaining to the management of the health and safety of people who live and work in the home. In addition to the site visit we sent the home an Annual Quality Assurance Assessment to complete. This document provides us with statistical information related to the management and staffing of the home. Some of the information supplied by the Registered Manager in the Annual Quality Assurance Assessment document is referred to within this report. Comment cards were also sent to the home for the people who live there and their friends and relatives to complete. At the time of writing the report 3 such comment cards had been returned and feedback from them is also included in the report. What the service does well: What has improved since the last inspection?
At the last Key inspection on the 11th May 2006 two requirements were made. One of these was for a Quality Assurance monitoring system to be introduced.
DS0000047604.V348753.R01.S.doc Version 5.2 Page 6 This has been met and a recommendation has been made that the results of the survey conducted earlier this year is fed back to the stakeholders. On the19th July 2007 a Random Inspection took place due to concerns being raised with us in respect of the poor state of repair of the building. Six requirements were made as a result of that visit 3 of which have been met. The Parker bathroom has been cleared of extraneous items of equipment and the manager gave assurances that it is no longer being used as a sluice. The ceiling in one of the bedrooms has been dried out and redecorated following repair of the roof however further redecoration may be required to completely remove the stain. The windows throughout the home have been cleaned to improve the outlook for residents. The information supplied by the manger in the homes Annual Quality Assurance Assessment states that the communal areas and corridors have been updated with new carpets, furniture and fabrics. Armchairs, several new dining chairs, two electric profile beds and an electrical hoist have been purchased. A catering cooker, dishwasher and new laundry equipment have also been purchased. Some bedroom carpets have been replaced and the flooring in all toilet areas has been replaced with non-slip flooring. What they could do better:
Outstanding requirements from the previous Key and Random Inspections include ensuring that all areas of the home are kept clean, tidy hygienic and free from hazard, cleaning the carpet in one of the bedrooms and repairing or replacing the rotten window frame in the laundry. The manager must also continue to review the staffing levels in the home to ensure that there are sufficient numbers of staff on duty at all times to meet needs of the people who live there. In addition to those outstanding requirements a number of other shortfalls were identified. The homes Statement of Purpose needs amending to ensure it is a true reflection of the services provided in the home, this includes specifying whether the home can meet the needs of people suffering from Dementia. Pre admission assessments and individual plans of care need to be holistic and more robust. They should be written in consultation with the person, amended as and when changes occur and reviewed monthly. The lack of a holistic approach to the care provided in the home means peoples diverse cultural and religious needs are not being identified and consequently they are not being met. More must be done to ensure the health and social needs of all the people who live in the home are identified, documented planned for and supported. Where it is assessed as safe to do so people should be able to store and administer their own medication. All medication that is administered must be signed for and guidelines should be written in respect of when ‘as and when’ medication can be given. People who live in the home should be offered the opportunity to participate in social and recreational activities of their choice
DS0000047604.V348753.R01.S.doc Version 5.2 Page 7 inside and outside of the home and be supported to do so, this should be planned for and documented. The homes complaints procedure needs amending and the Adult Protection policies and procedures need reviewing and rewriting to ensure they are in line with local guidance. The providers must consult with the people living in the home in order to establish what can be done to minimise the disruption the building works are having on their quality of life. A programme of maintenance and renewal should be implemented and shared with the residents. The grounds should be made safe and accessible. Recruitment procedures must be robust and appropriate references sought. All staff must undertake the Skills for Care Induction and complete the mandatory training within the given timescales. The home must continue to work towards the target of 50 of the care staff they employ holding a National Vocational Qualification (NVQ) in Care at Level 2 or above. All staff must be appropriately supervised. The home must employ a manager who has the qualifications, competencies and experience needed to become the registered manager of the home. The health safety and welfare of the people who live and work at the home must be protected and promoted at all times. Fire safety equipment must be serviced as required and a fire evacuation plan should be implemented. 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. DS0000047604.V348753.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 DS0000047604.V348753.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): 1&3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all the information provided to people to enable them to make and informed decision about moving into the home is accurate. Pre admission assessments are not holistic and peoples’ diverse needs are not identified or planned for before they move in to the home. EVIDENCE: On the day of the site visit to the home the homes Statement of Purpose was examined. Many of the people who live at this home present as suffering with dementia and this is not specified. It was also found to have insufficient information in relation to staff, their qualifications, experience and training. The level of activities specified as being on offer in the home was not a true reflection of what actually takes place. The Statement of Purpose is a legal document and as such must be an accurate reflection of the services provided
DS0000047604.V348753.R01.S.doc Version 5.2 Page 10 at the home. It is required that this document is reviewed and amended accordingly and that the people living in the home are provided with an up to date copy. At the time of writing 3 people who lived at the home had completed and returned comment cards and they all stated that they felt they had received sufficient information about the home prior to moving in. Pre admission assessments were also examined at the site visit and had not been signed by the person considering moving into the home or their representative to show their agreement. There was no evidence to suggest that individuals’ preferences in relation to how they receive their care had been sought or that any of the assessments and preliminary plans of care had been completed in consultation with them. In addition to this the assessments were very brief and were not holistic. DS0000047604.V348753.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. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who live in the home are at risk from not receiving appropriate care as the plans of care for the people who live in this home do not accurately reflect their health and personal care needs. Some of the medication administration practices adopted by the home put people at risk of harm. EVIDENCE: On the day of the site visit the plans of care for 5 of the people who live there were examined and none of them had been signed by the individual they related to or their representative. On some of the plans of care it was impossible to recognise the person from their photograph because the photographs were too dark. Much of the information on the plans of care examined was outdated and confusing and the required monthly reviews had not taken place. One plan stated the person was mobile and then stated they needed 2 people to assist them and yet there were no specific guidelines for staff to follow in relation to how this support should be given.
DS0000047604.V348753.R01.S.doc Version 5.2 Page 12 One persons’ plan of care states that they have a bath once a week and yet they had requested to be bathed daily in line with their religious believes. On the day of the site visit there was no record of this person having a bath for 26 days. Three of the people whose plans of care were examined had experienced falls recently but their falls risk assessments and related care plans had not been reviewed or updated. The use of cot sides was specified in two care plans but consent for this had not been gained and relevant risk assessments were not in place. There was no record on any of the plans of care examined of peoples wishes on death and dying this was discussed with the manager who agreed to ensure peoples wishes were documented. We have since been informed that one persons’ plan of care recently examined, stated that they wished to be buried which is against their religious beliefs. Many of the people currently living at this home are presenting as suffering from confusion and or dementia. There was no mention of this in individual’s plans of care; consequently there is no guidance for staff to follow in relation to supporting these people appropriately. Medication administration records were examined and appeared to be in order. However staff communication books stated that on one evening a painkiller was given to one individual, a pain relieving cream to someone else and a laxative to another. Upon further examination of the medication administration records none of these had been signed as being administered and one had been signed as being refused. Two of these were prescribed as ‘as and when’ medication but there were no specific guidelines in place for staff to follow in relation to when they could be given. The other medication was not prescribed and there was nothing written on their plan of care to say this person can be given this sort of painkiller or under what circumstances. Clear guidance must be written for staff to follow in regard to in what circumstances PRN medication can be administered and all medications must be signed for when given. There was no evidence to suggest that people had been assessed in relation to them storing, administering or assisting to administer their own medication. Each person should be assessed for this on admission to the home. People who live here are referred to by their preferred term of address and staff knock on people’s bedroom doors before entering. People have the option to have a phone of their own in their room. A visiting health care professional stated that he was happy with the standard of care delivered at the home and that staff do not inappropriately contact the surgery. DS0000047604.V348753.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): 12,13,14&15. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home does not provide sufficient suitable entertainment and activities. Visitors are welcomed into the home. The food provided is of good quality, varied and wholesome. EVIDENCE: When people are admitted to the home their personal preferences, social cultural, religious and recreational interests and needs are not documented and a plan of care as to how these interests, preferences and needs can be met is not written or agreed with the individual. Although some peoples likes are recorded and the manager was able to say what some of the people who live there like to do, there is no provision for individuals interests to be facilitated and supported. On the afternoon of the site visit staff took each person in turn to their bedroom as soon as they had finished their meal. This appeared to be the usual routine as no one was asked if that was what they wanted to do. When asked about this the manager stated that people are taken to their room because they are tired and that is what they want to do. No activities were offered to anyone that afternoon.
DS0000047604.V348753.R01.S.doc Version 5.2 Page 14 Feedback from the people who live in the home about the activities they participate in indicates that although some people have regular visitors who are welcomed into the home and some enjoy watching the television others are not satisfied with the level of activities offered or with the opportunity for social interaction. An examination of daily records and communication book showed no evidence of any residents taking part in any activities. The home does have a hairdresser that visits the home and a mobile library also visits on a regular basis. The lounge area on the ground floor is furnished with a range of different chairs and has jigsaws, books, a DVD player, a video player and a TV. There is a menu on the dining room wall that specifies the days’ meal. On the day of the site visit 3 members of staff and the manager served the meal and they were all wearing appropriate protective clothing aprons etc. People were asked if they wanted more and when one person left their meal they were offered an alternative. The food served was hot and homemade and well presented. There was a selection of fresh vegetables and a choice of sweet available. After the meal hot drinks were served. A record is kept of what each person has eaten each day and the manager stated that although the menu is set, the cook speaks to each person each day, to establish whether they want the main meal or an alternative. DS0000047604.V348753.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): 16&18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are managed and investigated appropriately by the home. The homes policies and procedures in relation to Adult Protection do not ensure that the people who live at the home are protected from abuse at all times. EVIDENCE: The complaints log was examined and it appears that the home has investigated complaints appropriately. The homes complaints policy and procedure was examined and needs to be amended to specify the contact details of the local Commission for Social Care Inspection office in Oxford. The policies and procedures in relation to Adult Protection and making an Adult Protection alert are outdated and need to be amended so that they are in line with local guidance. The home does have a copy of the local guidance however, not all staff have had Adult Protection training and so would be unaware of the local protocol. DS0000047604.V348753.R01.S.doc Version 5.2 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,23,24, &26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Peoples own rooms suit their needs and are safe, clean and hygienic. The grounds are not safe and accessible and the building works are having a negative impact on the quality of life of the people living in the home. EVIDENCE: Extensive improvements and building works are currently underway at the home, including the provision of extra communal, space on the ground floor and additional bedrooms in the attic. Whilst the building works will in time bring benefits, they have been ongoing for many months and the noise and disruption is having a negative affect on the people who live there. It is important that the providers consult with the people living at the home in respect of the impact the building works are having on them, so they can minimise the disruption. People who live there should be kept informed of the
DS0000047604.V348753.R01.S.doc Version 5.2 Page 17 progress being made and of the expected completion dates for the different stages of the improvements. Several concerns in respect of the state of repair of the building were raised with us earlier this year and as a consequence a Random Inspection took place and 6 requirements were made, 3 have been met and 3 remain outstanding. The Parker bathroom has been cleared of extraneous items of equipment and the manager gave assurances that it is no longer being used as a sluice. The ceiling in one of the bedrooms has been dried out and redecorated following repair of the roof however further redecoration may be required to completely remove the stain. The windows throughout the home have been cleaned to improve the outlook for residents. Still outstanding, is the need for the laundry window frame to be replaced or repaired, a bedroom carpet needs replacing and all areas of the home must be kept clean and free from hazards. Peoples own rooms were bright, clean and hygienic. Dining chairs had dried food on the seats and skirting boards and light switches were dirty. The provider and manager gave assurances that this would be addressed immediately. The grounds of the home and the driveway are in a state of disrepair and as such are not safe for people to access. There are many signs for staff around the home printed on A4 paper in plastic pockets and there are staff certificates and a staff notice board in the hallway. This is not considered very homely and it is recommended that they be removed. DS0000047604.V348753.R01.S.doc Version 5.2 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29&30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff do not have the skills they require to competently and safely meet the needs of the service users. Recruitment practices are not robust and have the potential to place the people who live here at risk. EVIDENCE: A requirement was made at the last Key Inspection ‘To continue to review staffing levels to ensure they adequately meet the needs of service users.’ Whilst the manager was able to show her workings out to demonstrate she had sufficient staff on duty at all times, this was not based on the fact that many of the people who live at the home are confused, suffering from dementia and require additional support when anxious. On the afternoon of the site visit none of the people who live at the home were supported to take part in any activity and when one person was calling out they had to wait for 15 minutes until the manager attended to her needs. Another person was left sitting in the hallway on the first floor for the whole afternoon and was only observed when staff were in the corridor. For these reasons the requirement has not been met and a further review of the staffing levels is required. An examination of the staff personnel, induction and training files confirmed that staff have not had a Skills for Care Induction or received the mandatory
DS0000047604.V348753.R01.S.doc Version 5.2 Page 19 training required to be completed within the given timescales. Therefore, they do not possess the skills they need to support people competently and safely. The home has not managed to meet the target of 50 or more of the care staff employed holding a National Vocation Qualification (NVQ) in Care at Level 2 or above. None of the staff employed have had training in dementia care and the manager does not have a training matrix in place to show who has had training and when the updates are due. Feedback from people who live at the home indicates that at times there is a communication problem with some of the overseas staff due to their poor comprehension of the English language. However the manager has identified this as a problem and stated that she always ensures that there is an Englishspeaking member of staff on duty at all times. An examination of 4 staff recruitment files showed that not all the references have been obtained appropriately. References have been obtained from former colleagues instead of from the former employer and they had been sent to the referees home address not the employers address. DS0000047604.V348753.R01.S.doc Version 5.2 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37&38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The poor management of the home has the potential to place the health and safety of the people who live and work here at risk. EVIDENCE: On the day of the site visit the manager was very welcoming and open, feedback from residents and visitors alike in relation to the manager was very positive and she is obviously well liked. However throughout the site visit it became apparent that the manager does not have the underpinning knowledge of the Care Home Regulations and the Care Standards Act that is needed to ensure the home is run effectively and safely. For example; she was unaware of the need for plans of care to be written in consultation with the person it
DS0000047604.V348753.R01.S.doc Version 5.2 Page 21 refers to or of the need for them to be reviewed on a monthly basis or when needs change e.g. following a fall. An examination of the staff rota and information received indicates there is not always a relevantly qualified and experienced person in charge of the care home particularly at weekends and when the manager is on holiday. A qualified and experienced person must be in charge at the home at all times. As a matter of urgency a person with relevant experience and the qualifications needed to become the registered manager must be employed to manage the home. The home has failed to notify us of the details of any emergency admissions to hospital, instances when they have had to call the emergency services and of the deaths of people who lived at the home. In future all such notifications must be made within 24 hours and confirmed in writing. This is required by Regulation 37 of the Care Standards Act and a failure to do so is an offence. The manager has introduced a quality assurance system to he home. It is important that the providers now take this information and make the necessary changes to the services provided so that improvements are made. The results of the survey and the actions taken as a result of this should be fed back to all stakeholders. The finances of the people who live at the home are protected by the homes policies and procedures. An examination of staff personnel files shows that staff are not appropriately supervised and the manager does not receive supervision at all. All staff must receive formal documented supervision a minimum of 6 times a year. Not all records are stored securely. The staff workstation is on the ground floor where many of the files and records relating to the people who live in the home are on display and could be accessed by anyone. All records relating to people who live in the home must be stored securely, including daily records and communication books. The daily record keeping in the home is poor. Staff routinely record whether someone has slept well, eaten or used the call bell but there is no mention of their emotional well being, any visitors they may have had, or of what activities they have participated in. Staff do not sign to say they have read information in the communication book and there is no formal record of any staff handover. Throughout this report the fact that the health safety and welfare of the people who live here is not always protected and promoted has been highlighted. Further shortfalls were also identified as follows, not all portable electrical appliances have been tested including a telephone that the manager had brought from home, fire extinguishers have not been tested since April 2006 and the home does not have an up to date fire evacuation plan. Information has been received in relation to poor food safety procedures and although the local authority has awarded the home a 2 star award for hygiene a referral has since been made to the local Environmental Health Authority. Work practice
DS0000047604.V348753.R01.S.doc Version 5.2 Page 22 risk assessments that are in place are generic and were not individualised for this home in addition they were neither signed nor dated and there are no risk assessments in place for peoples’ safe access to the home and grounds. DS0000047604.V348753.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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 2 3 X X 3 2 x 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 x 3 1 2 1 DS0000047604.V348753.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 OP1 Regulation 4(1)(a)(b) (c) Timescale for action In order to ensure transparency 30/12/07 the homes statement of purpose must be amended to ensure it is an accurate reflection of the services provided and life in the home. Statistical information must be accurate. In order to ensure that the home 20/12/07 can safely meet peoples’ needs and that it does not inappropriately admit people to the home, pre admission assessments must be robust and cover all the areas as required. Assessments and preliminary plans must be written in consultation with the person or their representative and must be signed to show their agreement. In order to ensure that the home 30/12/07 can safely meet peoples needs plans of care must provide the guidance staff require enabling them to competently and confidently support people in all areas of their lives. Assessments and plans of care must be written in consultation with the person or their representative and must be signed to show
DS0000047604.V348753.R01.S.doc Version 5.2 Page 25 Requirement 2. OP3 14(1)(a) (b)(c)(d) (2)(a)(b) 3. OP7 15(1) (2)(a)(b) (c)(d) 4. OP9 13(2) (4)(b)(c) 5. OP9 13(2) 6. OP12 16(2)(m) (n)(3) 7. OP18 13(6) 8. OP19 23(1)(a)( their agreement and should be robust, holistic and include their wishes on death and dying. Plans of care must be reviewed monthly and as and when changes occur. In order to protect people from harm the home must ensure that all medication is administered safely. Guidance must be provided for staff to follow in relation to when PRN medication can be given and a person qualified to do so e.g. G.P must agree to this. In order to promote independence each person living at the home should be assessed on admission in relation to storing, administering or assisting to administer his or her own medication. In order to protect people from harm the home must ensure that all medication is administered safely. All medication administered must be signed for. In order that the lifestyle experienced by people who live in the home matches their expectations their routines of daily living should be individualised to them. People’s interests must be recorded and they must be given opportunity for stimulation through leisure and recreational activities in and outside the home, which suit their needs, preferences and capacities. A record must be kept of activities participated in. In order to protect people from harm and ensure that the homes adult protection policies and procedures are robust they must be amended to be in line with local guidance and staff must read them. In order to minimise the
DS0000047604.V348753.R01.S.doc 30/12/07 30/11/07 30/01/08 20/12/07 30/12/07
Page 26 Version 5.2 2)(a)(o) 9. OP24 16(2)(c) 10. OP27 18(1)(a) 11. OP28 18(1)(a) (b)(c) 12. OP29 19(1)(a) (b)(c) 13. OP30 18(1)(a) (b)(c) disruption to the people living in the home the providers must consult with them as to how this can be achieved. A programme of maintenance and renewal should be implemented and shared with the residents. The grounds should be made safe and accessible. The laundry window must be repaired or replaced. Timescale 19/08/07 not met The carpet should be cleaned or replaced in room 11 to provide a more comfortable and hygienic environment for the residents. Timescale 19/10/07 not met. In order to ensure that there are sufficient numbers of staff on duty at all times to enable staff to support people safely. The home must continue to review staffing levels. Timescale 01/08/06 not met. There must be a relevantly qualified and experienced person in charge of the home at all times. In order to ensure that people are in safe hands at all times the home must ensure that a minimum of 50 of the care staff that they employ are qualified to NVQ Level 2 in Care or above. In order to protect people from potential abuse the home must ensure that the recruitment procedures are robust. Appropriate references must be obtained one of which should be from the previous employer. In order to ensure that peoples health safety and welfare is protected and promoted at all times and that they are in safe hands all new staff must undertake a Skills for Care Induction and complete the
DS0000047604.V348753.R01.S.doc 30/12/07 20/12/07 30/03/08 30/11/07 30/11/07 Version 5.2 Page 27 14. OP31 9(1)(2)(a) (b)(i)(ii) (c) 15. OP36 18(2) 16. OP37 17(1)(a) (b)(2) (3)(a) 17. OP38 23(a)(b) (c)(d)(o) (4)(a)(b) (c)(i)(ii) (iii)(iv)(v) 18. OP38 37(1)(a) (b)(c)(d) mandatory training within the given timescales. In order to ensure that the home is managed effectively and safely. A person with relevant experience and appropriate qualifications to become the registered manager must be employed to manage the home. In order to ensure that the staff are aware of all aspects of practice, the philosophy of care in the home and can identify their career development needs all staff, including the manager must be appropriately supervised. In order to ensure peoples rights and best interests are safeguarded by the home’s record keeping policies and procedures all records should be stored securely. The content of the records should be accurate, relevant, legible and up to date. In order to protect peoples health safety and welfare the home must ensure that all areas of the home and grounds are assessed as to peoples safe access, fire extinguishers must be tested, all Portable Electrical Appliances should be tested prior to use in the home, following consultation with a person appropriately qualified, individual fire risk assessment should be completed and a fire evacuation plan implemented, risk assessments must be completed for all work practices, these must be individualised for the home signed and dated. The home should be kept clean and free from hazards. Timescale 19/10/07 not met. In order to protect and promote the health and safety of the
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Page 28 Version 5.2 (e)(f)(g) (2) people living in the home the CSCI must be notified of any death, serious injury or illness of any person living at the home and any event in the care home which adversely affects the wellbeing or safety of the people who live there, this includes all emergency admissions to hospital and calls to the emergency services. All notifications must be confirmed in writing. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP33 OP16 OP19 Good Practice Recommendations That the results of the quality assurance survey should be communicated to stakeholders. The complaints procedure should be amended to include the contact details of the Commission for Social Care Inspection Oxford office. That staff certificates, notice boards and other staff notices be removed from the communal areas of the home. DS0000047604.V348753.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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
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