Inspection on 09/09/08 for Torkington House

This inspection was carried out on 9th September 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Torkington House 15/01/07

Torkington House 12/01/06

Torkington House 14/07/05

Torkington House 07/01/05

Torkington House 04/06/04

Torkington House 26/11/03

Torkington House 20/06/03

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 09/11/2008.

CARE HOMES FOR OLDER PEOPLE Torkington House Creswick Road Acton London W3 9HF Lead Inspector Robert Bond Unannounced Inspection 9th September 2008 09:50 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 Torkington House DS0000027744.V370726.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. Torkington House DS0000027744.V370726.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Torkington House Address Creswick Road Acton London W3 9HF 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) 0208 992 5187 0208 896 1196 torkington@greensleeves.org.uk www.greensleeves.org.uk Greensleeves Homes Trust Margaret Josephine Siriwardena Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Torkington House DS0000027744.V370726.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 32 15th January 2007 Date of last inspection Brief Description of the Service: Torkington House was established in 1947 as a residential club for older people. It was later registered as a residential care home. The home is situated on a quiet street in Acton. There are no shops or services in the immediate vicinity, however Acton High Street is accessible by bus or car. The property is a large attractive detached Edwardian house, dating from 1899. The home had an extension built in 2005 and a further extension in 2008. The accommodation provision throughout is of a good standard. The home is registered to provide personal care for thirty-two older people. Torkington House is owned and managed by Greensleeves Home Trust who are a London based not for profit charitable organisation with a total of 16 homes throughout England. The home has a Registered Manager and a Deputy Manager. The fees range from £540 to £610 per week according to the assessed needs of the resident. Torkington House DS0000027744.V370726.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was a key inspection that considered the key National Minimum Standards (NMS) as published by the Department of Health for Care Homes for Older People. The previous CSCI key inspection took place on 15th January 2007, with a CSCI Pharmacy inspection on 11th April 2007, and an Annual Service Review on 21st February 2008. The home submitted to us in advance of this current inspection, a completed Annual Quality Assurance Assessment (AQAA), which is referred to in the text below. On the day of the inspection we spent 6 hours at the home during which time we interviewed the Registered Manager (hereafter referred to as The Manager) and the Acting Deputy Manager, met other staff, talked to residents, toured the home, and examined a range of documents. We assessed the home’s performance for 23 of the NMS, and found that 12 outcomes were fully met, and 2 expected outcomes were exceeded, whereas 9 outcomes were only partly met. This led us to make 9 requirements and 7 recommendations. Throughout the inspection, we considered issues of equality and diversity. Although these aspects were met by the home’s actions in practice, cultural needs of the latest residents to move in were not being formally assessed and recorded within the home’s care records. On the day of the inspection the home was full, and there were two staff vacancies. Substantial building work was ongoing but with minimal disruption to residents. What the service does well: The home is being satisfactorily managed. Residents and their representatives are provided with information about the home and encouraged to visit prior to admission, allowing them to make an informed choice. Prospective residents are assessed prior to admission to ensure the home is able to meet their needs. Specialist care needs, including religious and cultural needs, are being met. Residents are involved in the review of the care plans and comprehensive review records are kept. Residents’ healthcare needs are met, and clear Torkington House DS0000027744.V370726.R01.S.doc Version 5.2 Page 6 records of input from healthcare professionals are kept. Staff care for residents in a courteous, gentle and professional manner, respecting their privacy and dignity. Residents spoken with praised the home for the good standard of care they receive. Procedures and health care professional input for residents’ end of life care are in place, and residents can stay at the home during their final days if they so wish. The activity provision at the home is good, and residents are consulted regularly about their interests and asked for suggestions for activities and outings. The home has an open visiting policy and visiting is encouraged. Information regarding advocacy services is available in the home. The food provision is of a very good standard, offering variety and choice and catering for individual dietary needs. Robust procedures are in place for the management of complaints and POVA. The home is clean and fresh and there are systems in place for infection control. The home is appropriately staffed to meet residents’ needs. Systems are in place and being adhered to for staff recruitment. Training provision in the home is good, including NVQ in care and induction training, plus topics relevant to the needs of the residents. There are good systems in place for quality assurance and for the management of resident’s monies. What has improved since the last inspection? What they could do better: The Statement of Purpose and Service Users’ Guide should be updated to include all the services offered by the home, such as respite care, and complementary therapies. The assessment of prospective residents should include their cultural and social needs so that these may be included within their care plans, and ways identified of meeting those aspects of need. Torkington House DS0000027744.V370726.R01.S.doc Version 5.2 Page 7 It is recommended that the use of medical or nursing abbreviations should be avoided in assessments, care plans or daily notes as non-nursing trained care workers may not understand their meaning. It is recommended that more detail should appear in the monthly weight records so that significant gain or loss in weight can be more easily spotted. It is also recommended that a new body chart should be used on every occasion that an entry becomes necessary. Records of medication returned to the pharmacist should show the strength of the medication. The home should maintain copies of investigations and response letters for all complaints received. It is recommended that domestic and administrative staff should receive basic awareness training in Safeguarding Adults issues. It is recommended that the room numbering system should be revised to accord with the actual number of residents present. Soiled and stretched corridor carpets must be replaced. All hand washing facilities must have hot water provided, for infection control purposes, and the facilities must not wet the floor, creating slip hazards for residents and staff. Evidence of interviews of new applicants for employment must be maintained for inspection, including an explanation of any gaps in previous employment. It is also recommended that when a reference request is sent out, the name and address of the referee should appear on the request letter so that when it is completed and returned, these details are known if the referee fails to apply their official stamp. The records of someone who has received respite care should be kept in good order for inspection, and in case they return for a further stay. Frozen food must always be stored at the correct temperature. 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. Torkington House DS0000027744.V370726.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 Torkington House DS0000027744.V370726.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 and 3. 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 offer intermediate care. The information provided to prospective residents and their representatives is not complete. Assessment information is mainly good but cultural needs are not always formally assessed since the pro-forma in use does not indicate the need to do so. EVIDENCE: The AQAA submitted to us by the home shows that during the previous 12 months 9 periods of short term care have been provided to residents. The Manager confirmed that this was respite care. We therefore examined the home’s Statement of Purpose and Service Users’ Guide and found that respite care was not a service that was mentioned in either document. Likewise, in these documents no mention is made of complementary therapies (aromatherapy, reflexology, head and hand massages) within the list of services that are available within the care home, but which must be paid for as ‘extras’. Torkington House DS0000027744.V370726.R01.S.doc Version 5.2 Page 10 We examined three care files in order to determine how well assessments had been done prior to residents moving in. Two files for permanent residents were beautifully maintained in ring binders with dividers. The other file was for a respite care recipient who had been to the home on four different occasions and had been assessed by the home prior to each one commencing. Assessments were also present in this case from the local authority who had made the referral, and who had paid the fees. The papers however were collected together ‘en masse’, making it difficult to find relevant documents. A recommendation concerning this is made under Record keeping (NMS 37). Both of the permanent residents were privately funded and hence no local authority assessment had been undertaken. However the home had undertaken their own assessment of needs to determine whether the needs could be met by the care home, and to determine the level of payment that it would be appropriate to charge. A recently devised Greensleeves Trust form is used for this purpose, and it is mostly a very good form but it fails to ask questions about the ‘culture’ of the resident, and to determine what their social and cultural care needs might be that will need to be considered within their care plan. A check of the AQAA information showed that only 17 out of 32 current residents of Torkington House are in the ‘white British’ ethnic category. One assessment form was seen to contain medical information on the prospective resident that used abbreviations that a non-nursing trained care worker is unlikely to understand. Assessments are reviewed six monthly. Torkington House DS0000027744.V370726.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ personal care and health needs are fully documented but their cultural and social needs are sometimes not. Some aspects of health recording should be improved, as should one aspect of medication recording. Residents are treated with great respect and dignity and their privacy is upheld. EVIDENCE: We examined in detail the care plans of three residents, one of whom had received respite care. The home now uses a purpose-designed pro-forma care plan from The Greensleeves Trust. This is a clear format where the entries are typed in and kept in computerised form. Details of personal care needs and how to meet them were seen to be clearly defined. The residents sign their care plans where possible, and express their views. One had written, “I am happy to be here.” The care plans are reviewed monthly. Unfortunately the new care plan format omits to include cultural needs and social needs as a category and hence no details of these aspects of care were contained within the care plans of the two permanent residents whose care files we examined. The care plan file contains details of health and medical or nursing interventions. For example one resident receives physiotherapy as a hospital Torkington House DS0000027744.V370726.R01.S.doc Version 5.2 Page 12 outpatient. Resident’s weight records are maintained monthly but the records do not show height or body mass index or how much weight is gained or lost during the month. Likewise, body charts are used to record any observed cut or bruise on a resident but one example we saw contained entries on four different dates on the one chart. We checked the home’s medication storage and administration recording systems in the presence of the Acting Deputy Manager. No errors or omissions were found except in the record of medication returned to the pharmacist. Here recent records generally did not show the strength of medication returned. We observed the residents of the home being treated with dignity and respect and having their privacy maintained. One resident said to us, “I have no complaints, and the staff are lovely.” One resident was observed having her meal in her room, as that was her choice. Dignity and respect are aspects that figure within the home’s induction training for new staff. Torkington House DS0000027744.V370726.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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a good range of activities and excellent food that reflect their own choices. Relatives are encouraged to visit and community links are maintained. EVIDENCE: As indicated in the outcome groups above, assessment and care planning of social care needs, particularly any identified cultural needs, must be improved. That said, the home does record residents’ hobbies or special interests and the home does employ an activity co-ordinator. However, she only works weekdays 9am to 1 pm and hence the advertised activity programme only covers these periods. Despite this, no residents complained to us about having nothing to do in the afternoons. The activity programme contains quizzes and exercise sessions, and is supplemented by additional facilities such as complementary therapies and hairdressing. An Age Concern volunteer takes a resident out, one resident goes out to church, and the Church of England, the Roman Catholic church, and the Pentecostal Church all send representatives to visit the home. Torkington House DS0000027744.V370726.R01.S.doc Version 5.2 Page 14 Relatives visit the home as evidenced by entries in the visitors’ book. No resident has an advocate at present but an advocacy scheme is advertised in the foyer of the home. Residents meetings are held quarterly at which residents’ views concerning outings and activities are discussed as well as food likes and dislikes. The home has a suggestions box, and there is a form for residents to tell the chef what they like to eat. Residents we spoke to praised the quality of the food. Suitable food choices are available, including Caribbean food, which is commended. The ambience of the dining room has been improved by the use of table clothes. Torkington House DS0000027744.V370726.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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives can be confident that complaints will be recorded and investigated; and that residents are being protected from abuse. EVIDENCE: The home has a good complaints procedure that is well advertised. Three complaints have been recorded in the home’s complaints folder in the last year. The NMS state that the home must also keep a record of any outcome or action taken following the investigation of a complaint. In one case, the home did not have on file a copy of the letter that had been written by the Head Office of The Greensleeves Trust to the complainant. Appropriate referrals as necessary have been made by the home to The London Borough of Ealing’s Safeguarding Adults Co-ordinator. The home has good protection policies and procedures in place. All the care staff have been trained in Adult Protection but not the non-care staff. Torkington House DS0000027744.V370726.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 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally clean, pleasant and hygienic but with certain exceptions. There are areas where the home is not sufficiently safe and well-maintained. EVIDENCE: At the time of this inspection, major building work was being undertaken that will ultimately create a new kitchen, servery, laundry, and staff room. In the meantime domestic staff are working in difficult conditions and are congratulated on what they are achieving. The Manager advised that the existing kitchen will have to be closed totally for a few days but that an alternative temporary source of hot food had been organised. There is a marked contract between the bedrooms, bathrooms and corridors in the old building, and those in the existing new wing. Once the present works are complete, the management must consider how to improve the old parts of the building. Specific issues noted were dirty corridor carpets on the ground floor next to the kitchen and on the top floor where the carpet was also rucked. We were confused by the bedroom numbering system that extended to Torkington House DS0000027744.V370726.R01.S.doc Version 5.2 Page 17 34 when there are only 32 residents. The present numbering system is likely to be contrary to Fire Service guidelines. The new wing is very attractive and additional pictures are now displayed on the walls of communal areas. We did however notice the lack of pictures on some bedroom walls in this wing. However, the Manager said residents were encouraged to bring their own possessions into their new home and to personalise their bedrooms as they wished. Each of the bathrooms and toilets within the new wing contains a small washhand basin with a single mixer tap. We were unable to obtain any hot water from these taps, only cold water, which came out at such pressure that it splashed onto the user and onto the floor, turning it into a slip hazard area. Two of these taps were also found to be loose. The garden and new summer-house however looked lovely. Torkington House DS0000027744.V370726.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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are well met by the staff group, who are sufficient in number and are well trained, but some improvements to the recruitment procedure are indicated. EVIDENCE: We examined the home’s current staff rota and observed that sufficient staff were on duty during the inspection. The rota however showed a lack of domestic staff scheduled to work at weekends. The Manager agreed and said this would be addressed when the current building work had been completed. The working hours of some care staff have just been changed. The Manager also reported that at present 49 care hours per week are vacant but that a 35 hour post had just be offered to an applicant, subject to a satisfactory Criminal Records Bureau (CRB) check. Temporary agency staff are occasionally used. The AQAA reports that 71 of the care staff have NVQ’s in care, a ratio which is commended. One additional member of staff is undertaking the award at present, and those with level 2 are going to proceed to level 3. We examined the recruitment files of three recently recruited staff members. Application forms had been completed, health questionnaires filled in, identity checks undertaken, references sought and CRB and POVA First disclosures obtained. However, some of the references received had not been stamped by the employer or college providing them, and hence the name and address of the institution providing the reference was not indicated. Also, the recruitment Torkington House DS0000027744.V370726.R01.S.doc Version 5.2 Page 19 files did not contain any evidence of interviews having taken place, that is no letters inviting applicants to attend, no notes to explain any gaps in applicants’ work history, and no interviewer notes. The Manager confirmed that interviews did take place, and that she would instigate a system for recording interview outcomes. All three applicants had undertaken substantial induction programmes. We noted the home’s comprehensive training plan, and saw records of training that had been booked for substantial numbers of staff in Health and Safety, Moving and Handling, and Infection Control. Residents we spoke to praised the kindness of the staff. Torkington House DS0000027744.V370726.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, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in a satisfactory manner, mostly in the best interests of residents, but with some lapses in health and safety matters. EVIDENCE: The Manager has obtained the Registered Managers’ Award and the Acting Deputy Manager intends to study for the same award. Both managers recently attended training in End of Life Care. The Manager has been successful in meeting all the requirements and recommendations of the previous CSCI inspection report. We saw evidence of quality assurance surveys being obtained from residents and relatives, and read resident meeting and staff meeting minutes. Residents are however restricted from putting pictures on their walls in some bedrooms. We checked the financial records and cash balances of two residents for whom the home continues to hold money. All was in order. An invoice system Torkington House DS0000027744.V370726.R01.S.doc Version 5.2 Page 21 operates for most residents and their relatives in order to reduce the amount of cash the home needs to keep on the premises. As indicated in the ‘choice of home’ outcome group section of this report, although the files of current residents were excellently maintained, the file of the person who had received several periods of respite care was not. A recommendation is therefore made. Under Health and Safety, we noted a Food Safety report from the London Borough of Ealing that rated the home as ‘good’ in this respect. However, we checked fridge and freezer temperatures and noted that a freezer thermometer indicated an operating temperature of minus 16/17 degrees, whereas the required temperature is minus 18 to 22. The Chef considered the thermometer was at fault. This will have to be investigated. The lack of hot water at the wash-hand basins in the bathrooms and toilets of the new wing, and the splashing onto the floor that happens when they are used, is reported in the ‘environment’ section of this report. This fault has infection control implications as well as creating a slip hazard. We measured the hot water temperature at a bath in the old part of the building to be 44.5 degrees Centigrade, which is slightly hotter than the maximum permitted. We found that the door between the occupied part of the home and that where building work was going on, was unlocked. This was corrected whilst we were still on site. A note on the home’s lift warned staff that the lift did not always stop directly level with the floor, thereby creating a trip hazard. We asked to see the home’s certificate of safety for the lift. One was produced but it was unclear what period it covered and whether it was still current. This will have to be clarified and any ongoing problem with the lift mechanism corrected. We did however see a certificate dated 19/08/08 that said the home’s water tanks were clear of micro-organisms. Torkington House DS0000027744.V370726.R01.S.doc Version 5.2 Page 22 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 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 2 x x x x x X 2 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x 3 2 Torkington House DS0000027744.V370726.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? no 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 and 5 Requirement The Statement of Purpose and Service Users’ Guide must be updated to include all the services offered by the home. The assessment of prospective residents must include their cultural needs. Assessed social and cultural needs must be included within each resident’s care plan. Records of medication returned to the pharmacist must show the strength of the medication. The home must maintain copies of investigations and response letters for all complaints received. Soiled and stretched corridor carpets must be replaced. The hand washing facilities must have hot water provided, for infection control purposes, and must not wet the floor, creating slip hazards for residents and staff. Evidence of interviews must be maintained for inspection, including an explanation of any gaps in employment. DS0000027744.V370726.R01.S.doc Timescale for action 01/11/08 2 3 4 5 OP3 OP7 OP9 OP16 14 15 13(2) 22 01/10/08 01/11/08 01/10/08 01/10/08 6 7 OP19 OP26 23(2)(d) 23(2)(j) 01/01/09 01/11/08 8 OP29 19 01/10/08 Torkington House Version 5.2 Page 24 9 OP38 13(4)© Frozen food must be stored at the correct temperature. 01/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations The use of medical or nursing abbreviations should be avoided in assessments , care plans or notes as nonnursing trained care workers may not understand their meaning. More detail should appear in the monthly weight records so that significant gain or loss in weight can be more easily spotted. A new body chart should be used on every occasion that an entry upon it becomes necessary. Domestic and administrative staff should receive basic awareness training in Safeguarding Adults issues. The room numbering system should be revised to accord with the actual number of residents. When a reference request is sent out, the name and address of the referee should appear on the request letter so that when it is completed and returned, these details are known if the referee fails to apply their official stamp to it. The records of someone who has received respite care should be kept in good order for inspection, and in case they return for a further stay. 2 3 4 5 6 OP8 OP8 OP18 OP19 OP29 7 OP37 Torkington House DS0000027744.V370726.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Torkington House DS0000027744.V370726.R01.S.doc Version 5.2 Page 26 - 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!