Inspection on 30/10/07 for Tolson Grange

This inspection was carried out on 30th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Tolson Grange 21/10/08

Tolson Grange 21/11/06

Tolson Grange 23/01/06

Tolson Grange 03/10/05

Tolson Grange 11/02/05

Tolson Grange 08/07/04

Tolson Grange 09/03/04

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

CARE HOMES FOR OLDER PEOPLE Tolson Grange 12 Coach House Drive Dalton Huddersfield West Yorkshire HD5 8EG Lead Inspector Tracey South Key Unannounced Inspection 30th October 2007 09:10 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 Tolson Grange DS0000026339.V353543.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. Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tolson Grange Address 12 Coach House Drive Dalton Huddersfield West Yorkshire HD5 8EG 01484 432626 01484 519126 karen.wilson@anchor.org.uk www.anchor.org.uk Anchor Trust 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) vacant post Care Home 38 Category(ies) of Dementia - over 65 years of age (38) registration, with number of places Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2006 Brief Description of the Service: Tolson Grange is a residential home providing personal care and accommodation for up to thirty-eight older people with dementia. Anchor Trust, a national housing association and organisation providing residential care, own the home. Tolson Grange is located on the outskirts of Dalton, a residential suburb of Huddersfield. It is near to local shops and public transport and there is car parking to the front of the property. Tolson Grange recently increased the number of rooms available by incorporating an attached former sheltered housing complex. The original home was purpose built for the current client group. The home has twentyfour large, single en-suite bedrooms and 14 large single suites with bedroom, lounge and a walk-in shower room with toilet facilities. All rooms are fitted with privacy locks and an emergency call system. There are good communal facilities over three floors. Stairs and a shaft lift are available to allow access to the upper and lower floors. Security at the home is ensured through the provision of coded door locks. The home has enclosed sloping gardens. The Commission for Social Care Inspection was informed that, as at 5.11.07, the fees ranged from £508 to £575 per week. Additional charges are made for hairdressing, chiropody, personal toiletries, magazines, etc. Information about the home in the form of a Statement of Purpose, Service User Guide and the latest Commission for Social Care Inspection report are available from the home. Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out to the home by two inspectors on 30 October 2007. The visit began at 09.10 am and the inspectors had left the home by 3.30 pm. During the visit, the inspectors spoke with some of the people who live at the home, care staff, the activities co-ordinator, the home’s manager and deputy manager. Care records were examined and the inspectors audited a sample of medications, reviewed staff recruitment records, and looked around the home. One of the inspectors spent two hours sitting in the lounge with the people who live at Tolson Grange. The purpose of this was try and get a picture of what it’s like for people living at the home and to see first-hand the types of activities they get involved in. The staff at the home also completed an annual quality assurance assessment that was requested by CSCI (Commission for Social Care Inspection) about people who live at the home, the staff that work there, the service provided and any incidents or accidents that have occurred. Prior to this visit, surveys were sent out to obtain the views of people who live at the home, their relatives and people’s doctors. Ten surveys were sent out to people living at the home, none were returned. The reason for the nil return could be attributed to people’s frailty. Ten surveys were sent out to relatives, 4 were returned. Surveys were also sent to people’s doctors but none were returned. The inspector would like to take this opportunity to thank everyone who participated in the inspection process. What the service does well: Relatives’ surveys asked, “What do you feel the care home does well?” Responses include, “Care for the people to the very best of their ability. I have nothing but praise for them all.” “Everything, no complaints at all.” Looks after X for all his needs. He always seems very happy there when we visit him once a week.” People wishing to live at Tolson Grange are assessed by the management staff prior to them moving in to make sure that this is the right home for them and that their needs will be met. Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 6 People living at the home looked well cared for and the interaction between themselves and staff was very positive. A wide range of activities are provided to people in both group settings or on a one-to-one basis. The activities coordinator is a motivated person who enjoys spending time with people who live at the home. People living at the home are offered a choice of meals and the feedback about the quality of meals was good. The atmosphere at the home is relaxed and friendly. The environment is spacious, homely and comfortable and people are able to walk around the home freely and safely. What has improved since the last inspection? What they could do better: More emphasis must be made on ensuring that each person’s care plan clearly outlines their needs and the care and support they require from staff. Daily reports should clearly reflect delivery of the care plan including information about how the person has spent their day. The registered person should ensure that a minimum ratio of 50 trained members of care staff (NVQ level 2 or equivalent) is achieved. Qualified staff will have a better understanding of the needs of people in their care. The organisation needs to be able to demonstrate its commitment regarding continuous improvement and produce action plans, as a result of feedback from relatives and those receiving a care service, on how they intend to improve services. Please contact the provider for advice of actions taken in response to this Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 7 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. Tolson Grange DS0000026339.V353543.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 Tolson Grange DS0000026339.V353543.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 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are properly assessed prior to moving into the home to ensure that their needs can be met. EVIDENCE: To ensure people receive the right care service, pre-admission assessments need to be carried out to establish people’s needs. This is important in terms of assisting prospective residents and/or their relatives in choosing a care home that will meet their needs. Evidence confirming that thorough assessments are carried out was seen whilst examining the care documents relating to one person who had recently moved into the home. The home’s quality assurance assessment acknowledges that improvements are needed in respect of inviting prospective residents to spend time at the home to help them reach a decision about the home and if it’s right for them. Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 10 The manager explained that she plans to encourage people to visit for lunch or tea, when they will get the chance to meet other people living at the home, the staff and see for themselves what the home has to offer. Relatives confirmed that they received enough information about the home prior to their relative moving in. Tolson Grange DS0000026339.V353543.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. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. In order to give the exact care and support people need, care plans need to improve. People are protected by medication systems and people’s rights to privacy and dignity are supported by caring staff. EVIDENCE: Surveys sent to relatives asked if they felt that the care home meets the needs of their relative/friend, all four responded, ‘always’. The manager explained that new care documentation is currently being implemented and this includes the introduction of new care plans. With this in mind, the inspectors looked at new care plans only, as it is envisaged that each person will have a new care plan by the end of December 2007. Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 12 Two people’s care documentation was examined in detail. Both care plans were very similar in content and this is because a generic approach to the writing of care plans had been adopted. The care plans contained details about procedural matters rather than the level of support the person required. Further work is required to make sure that each person’s care plan is about them as an individual that clearly outlines their needs and the care and support they require. Daily reports do not describe in enough detail the level of care and support people receive. The majority of daily reports are repetitive and say very little about how the person is and how they have spent their day. The manager acknowledged this and explained that the new care documentation has been designed to improve this, although they had not been completed in the new care records examined. There was a number of spelling mistakes throughout the care documentation and, although correct spelling is not paramount in respect of outcomes for people, it is important that people’s medical conditions are spelt correctly as it could be very misleading. Staff had also used the term “is on palliative care”; when this was put to the Manager she could not understand why this term had been used as it bore no relevance to needs of the named person. Risk assessments have been carried out to identify any risks to the individual, for example, when a person is at risk of falling. Where a risk has been identified, a care plan is produced to minimise the risk. Plans used to identify the support people require with their mobility describe in detail the assistance required so staff are clear about what is expected from them and people are helped in a safe manner. During the time when the inspector was observing in the lounge, movement and handling practices were observed. Whilst movement and handling techniques were carried out properly, staff did not reassure or talk to the person they were assisting to help reassure them. There was good evidence in people’s care records that they are able to access health care services, such as the dentist, chiropodist, optician and everyone living at the home is registered with a doctor. For those people who are prone to developing pressure sores, an assessment known as “Waterlow Assessment” is carried out to assess the level of care they require in terms of prevention and treatment of pressure sores. This may include the use of specialist equipment such as a mattress or a cushion when sitting in an easy chair. Although Waterlow assessments had been implemented in respect of two people, the assessments had not been reviewed since June and July 07 despite a deterioration in health. Assessments need to be up to date in order to protect and support people correctly. Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 13 A sample of three people’s medication was checked during the visit. The majority of medication was correct although there were some discrepancies suggesting that medication had not been given even though it had been signed for. Codes used to explain why medication has not been given had not always been used correctly so it was not clear as to why a person had not had their medication. The list of authorised signatures should be updated to include all staff who are currently responsible for administering medication so that it is possible to easily identify who has given what medicines Tolson Grange DS0000026339.V353543.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are offered a range of activities and are able to make their own choices about how they spend their time. Meals provided are good, varied and served in a pleasant environment. EVIDENCE: The home’s quality assurance assessment indicates that staff encourage people to participate in activities and entertainment in the home on a daily basis. The home employs an activities co-ordinator who works 30 hours per week (Monday-Friday). The activities co-ordinator spoke with the inspectors and explained the types of activities she provides. These include, baking, bingo, hoopla, skittles, memory cards, reminiscence, dominoes and outings. She explained how she gets to know what people like to do by completing a ‘personal memory notebook’; family members are invited to contribute to this. Not everyone at the home wishes to join in activities so time is spent with people on an individual basis, this usually takes place in the privacy of people’s own rooms. Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 15 Themed events take place throughout the year and the activities co-ordinator is already planning Christmas events. The inspector who spent time observing staff interacting with people say how the activities coordinator was skilled at encouraging people to become involved in a variety of activities. Everyone was treated with respect and referred to by name. Although it was not possible to get direct feedback from people living at the home as to whether they are able to make their own choices about how they spend their time, it was clear through observing care practice that people are free to walk around the home and people were seen coming down for breakfast at different times throughout the morning. When asked if they felt that the care home supports people to live the life they choose, two relatives responded ‘always’ and two said ‘usually’. Relatives are welcome to visit the home at any reasonable time and the visitors’ book shows that a number of people visit on a daily basis. Taking into consideration people’s frailty, a new system has been introduced to improve meal times. People at the home are no longer asked in advance for their choice of meal, they are now able to choose at the time the meal is being served. Care staff were observed showing people a choice of two meals to help them decide what they might like to eat. The manager said that this new approach has proved successful in terms of people making their own choice based on what they see at the time as many used to forget what they had ordered which created a lot of confusion. Staff were observed serving lunches to people and supporting those who need help with their meals in an appropriate manner. The atmosphere at lunchtime was relaxed. The meals on offer looked appealing and one lady said she was enjoying her meal. Table settings were sparse and there was no evidence of any condiments on offer and this should be addressed. Tolson Grange DS0000026339.V353543.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home are protected from abuse and they can be confident that their complaints will be listened to and acted upon. EVIDENCE: Relatives said that they are aware of how to make a complaint. One person wrote, “I can ring up if there is a problem.” The complaints procedure is displayed in the reception area and on various notice boards within the home. It is also available in the home’s Statement of Purpose. The manager keeps a log of any complaints received and there was good evidence that people’s concerns had been taken seriously and the appropriate action had been taken to resolve the matter wherever possible. The home has received four complaints within the last twelve months. There was evidence that the complaints had been dealt with in accordance with the home’s procedures in terms of timescales and reporting the outcome. Staff who spoke with the inspectors demonstrated a clear understanding of how and why they should report any incidents of abuse. Policies and procedures are in place to guide staff about who they should alert when an allegation of abuse is made. The majority of staff have received safeguarding Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 17 (adult protection) training within the last twelve months. The manager explained that those staff who have not had the training will be put forward on the next available training date. Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 18 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home offers people a homely, comfortable and clean environment. EVIDENCE: The atmosphere on the day of the visit was warm and friendly and people looked comfortable whilst sitting in various parts of the home. The standard of cleanliness in the home is good although there was a trace of an unpleasant odour in one of the bedrooms. The manager explained the difficulties in maintaining an odour free environment and the bedroom in question is due to be redecorated; this will include new flooring. Odour neutralisers are used daily and the carpets are shampooed on a regular basis. Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 19 The home’s outdoor space is attractive and there are enclosed areas where people are safe to sit out during warmer weather. Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 20 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are met by trained staff who have undergone a thorough recruitment process before they are allowed to work in the home. EVIDENCE: When asked if the care staff have the right skills and experience to look after people properly, four relatives replied ‘always’. Care practice observed during this visit, and the relationship between staff and people being cared for, was very positive. The atmosphere at the home is warm and friendly. The manager explained there are eight staff on duty between the hours of 7.15 am and 2.45 pm and from 2.45 pm until 9.45 there are seven staff on duty. Four staff work during the night. Care staff are supported by domestic, laundry and kitchen staff. Seven of the 31 staff employed at the home (22 ) have completed NVQ (National Vocational Qualification) level 2 qualification in Care and a further 6 staff are working towards their award. The organisation must continue to Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 21 working towards achieving at least 50 of the workforce is qualified to a minimum of NVQ level 2. The recruitment files of three members of staff were audited in detail and contained the required information and recruitment checks. These checks are necessary to help protect people from potentially unsuitable staff. The manager was advised to ensure that all staff files contain a recent photograph of the person as proof of identification. New staff undertake induction training in accordance with Skills for Care, the National Training Organisation for care staff. There was evidence that this had taken place when examining the staff files of newly appointed staff. It was evident from records and discussion with staff that a range of suitable training is provided. Training records indicate that staff have received fire training, movement and handling, oral health, dementia care, safeguarding and health and safety. However, there was little evidence of staff receiving food hygiene, first aid and COSHH (Control of Substances Hazardous to Health) training and this needs to be addressed in order to maintain the health and safety of people living and working in the home. Staff were positive about their role and said they enjoyed working at Tolson Grange. They felt that they work well as a team in achieving good quality care for the people who live there. Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 22 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and the health, safety and welfare of people living at the home and staff is promoted and protected. EVIDENCE: Ms Karen Wilson is the acting manager at Tolson Grange. An application has been submitted to the CSCI for Ms Wilson to become the registered manager. She has a number of years’ experience of working with vulnerable people in other care settings. Ms Wilson has a BTEC National Diploma, which is equivalent to NVQ level 3 qualification and is currently undertaking the Registered Manager’s Award. Ms Wilson is hoping to take part in a five-day Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 23 dementia training course in December this year to give her more insight and knowledge of dementia related illnesses. Staff gave positive feedback about the manager saying she is approachable and supportive. The manager explained how satisfaction surveys are sent out to people twice a year. The results of the surveys are displayed on the notice board in the home. The results do not include an action plan so it wasn’t clear how the home intends to act on feedback on how the home can improve. The organisation needs to be able to demonstrate its commitment regarding continuous improvement and produce results that are more meaningful that result in better outcomes for people. Some people have small amounts of personal money that is held safely at the home. Records are available to show when money is deposited on behalf of people. The records show the individual cash balance for each person and how their money is used on their behalf, including receipts for goods and items purchased. Three people’s finances were checked during the visit and were found to be correct. The home’s quality assurance assessment indicates that routine maintenance and servicing of equipment takes place. The home carries out weekly fire safety checks and these are recorded. The manager needs to ensure that all staff take part in at least two fire drills per year. From examining the fire records, this does not appear to have been happening and the manager needs to ensure that this is addressed promptly. As already mentioned in the previous section, staff should receive training in respect of COSHH, food hygiene and first aid in order to maintain the health and safety of people living and working in the home. Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 2 Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement Each person’s care plan must clearly outline their needs and the care and support they require. Timescale for action 30/12/07 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 4 Refer to Standard OP7 OP7 OP8 OP9 Good Practice Recommendations Daily reports should clearly reflect delivery of the care plan and the outcomes to that care. Staff should take greater care when recording people’s medical diagnosis and other important information and ensure the correct spelling is used. Waterlow assessments should be kept under regular review to ensure people’s health care needs are met. Staff should ensure that codes used to explain why medication is not given is recorded as appropriate. The temperature of the medication fridge should be recorded on a daily basis, which should read between 2-8°C. (Recommendation carried forward) The registered person should ensure that a minimum ratio of 50 trained members of care staff (NVQ level 2 or DS0000026339.V353543.R01.S.doc Version 5.2 Page 26 5 OP28 Tolson Grange 6 7 8 OP29 OP30 OP38 OP33 9 OP38 equivalent) is achieved. (Recommendation carried forward). Staff files should include a recent photograph as proof of identity. Staff should receive training in accordance with their job requirements that includes, first aid, food hygiene and COSHH awareness. The organisation needs to be able to demonstrate its commitment regarding continuous improvement and produce action plans on how they intend to improve services. The manager needs to ensure that all staff are involved in a fire drill at least twice a year to ensure they are clear what to do if the fire alarm is activated. Tolson Grange DS0000026339.V353543.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Tolson Grange DS0000026339.V353543.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. 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