CARE HOMES FOR OLDER PEOPLE
Trafalgar Care Home 207 Dorchester Road Weymouth Dorset DT4 7LF Lead Inspector
Rosie Brown Key Unannounced Inspection 10:20 18 & 22nd May 2006
th 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 DS0000030316.V295727.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. DS0000030316.V295727.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Trafalgar Care Home Address 207 Dorchester Road Weymouth Dorset DT4 7LF 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) 01305 777567 01305 777567 Mr Derek Edwin Luckhurst Care Home 29 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (5) of places DS0000030316.V295727.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. That Denise Chrippes achieves NVQ4 in Care Management by January 2005 and that she undertakes periodic training to improve and update her knowledge of Mental Disorder 29th December 2005 Date of last inspection Brief Description of the Service: Trafalgar Care Home is registered to provide accommodation and personal care for up to 29 older people, five in the category of old age and 24 with dementia. The home is situated in a residential area of Weymouth about a mile from the sea front and the centre of town. It is set back from the main road and provides an area for parking at the front: the grounds are secured with fencing. Residents have access to the sheltered gardens at the front and rear of the home. Residents accommodation is provided on two floors with a passenger lift that enables residents’ level access to the first floor. The home has 23 single bedrooms and 3 double bedrooms. There are two communal lounges and a dining room with an activities area on the ground floor. A separate smaller lounge with a dining table is situated on the first floor: people who use this room tend to be more physically frail and live mainly on the first floor. DS0000030316.V295727.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection visit was unannounced and started at approximately 10:20am on 18th May 2006. It was the first of 2 key inspections of the home, 28 National Minimum Standards were assessed and the outstanding requirements from the previous inspection reviewed. Additionally, the situation regarding an allegation of abuse and a current adult protection investigation being undertaken by the local Social Services was clarified. The registered manager Mrs Denise Chrippes ceased working in the home last Autumn and Ms Pat McIntyre was appointed as the acting manager in October 2005:her application to become registered with the Commission is being progressed. Observation skills were used when viewing the communal areas and a selection of residents’ bedrooms. Residents’ care and medication records were examined and a selection of policies and procedures were reviewed. The inspector gained information from the manager, staff on duty, two visitors and three residents. Four comment cards supplied by the Commission were received from social care professionals; the views expressed within them have also been used to inform this inspection report. There are 13 requirements and 5 recommendation made as a result of this inspection. What the service does well:
The home has a comprehensive statement of purpose and service user guide that is supplied to prospective residents representatives. Before moving into the home the manager undertakes a pre-admission assessment of care needs for each resident to ensure that the home can meet the person’s needs prior to admission. The home provides a safe and pleasant environment for residents to live in: the grounds and gardens are secure and well tended. Staff on duty at the time of the visit were friendly, caring and patient with residents. The home has good systems in place regarding the servicing and maintenance of equipment used. Fire records indicated that routine servicing of the fire safety system and fire fighting equipment takes place. DS0000030316.V295727.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better:
Residents care plans must be reviewed each and at times of significant change. Staff must record daily care information about residents into their individual daily care records and not into a day-book: records should be clear and evidence how situations are resolved. The home must obtain and use an accident book that complies with Data Protection: the records must be properly completed with the date, name of the person concerned and the action taken to prevent recurrence. The manager must implement an auditing system in relation to accidents and incidents that occur in the home. A separate form for recording incidents should be developed and used in the home. All untoward incidents and accidents must be reported to the Commission. Two staff must sign the controlled drugs medication administration record as required by the Royal Pharmaceutical Society guidelines. All out of date or no longer used medicines must be returned to the pharmacy and surplus stocks of Paracetamol should not be kept. Each resident’s medication administration record (MAR) charts must be signed by staff to indicate if medicines have or have not been administered. Medication to be administered to residents when needed and not provided in the blister pack system must be dated when opened in order to establish and audit trail. An up to date record of food supplied to residents must be kept and include all variations to the menu that are provided. DS0000030316.V295727.R01.S.doc Version 5.2 Page 7 There is one bedroom in the home that needs redecorating (this was identified with the manager during the visit) and a way of protecting the central heating radiator in this bedroom identified for safety reasons. The home must obtain and keep a hard copy of the POVA guidance issued by the Department of Health in July 2004. The manager and deputy care manager must attend the local Social Services Protection of Vulnerable Adults 2 day awareness training course so that they are completely familiar with local processes and procedures. Although an immediate requirement was not issued in relation to the need for an adult protection issue to be referred through ‘No Secrets’ to Adult Services, the inspector remains concerned that appropriate referrals may not be made. The manager agreed to contact the Commission for advice and guidance in such matters in future. 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. DS0000030316.V295727.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 DS0000030316.V295727.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in the outcome area is good; this judgement has been made using available evidence including a visit to this service. Pre-admission assessment information concerning each resident is gained before new service users are admitted into the home. EVIDENCE: The care files for two residents were viewed and these demonstrated that the manager had completed a pre admission assessment form. In formation gained before admission included, personal details, personal care needs, mental health needs, a mental health diagnosis and a care plan written by the placing care manager for Social Services. Due to the mental frailty of most prospective residents placements are mainly decided by the professionals or relatives involved. However, residents are offered a 4-week trial stay in the home before their placement becomes permanent: this also allows time for the home to be sure they can meet a resident’s needs.
DS0000030316.V295727.R01.S.doc Version 5.2 Page 10 The files also had copies of letters sent to the resident’s representative prior to admission confirming that the home could meet the prospective resident’s needs. DS0000030316.V295727.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in the outcome area is poor; this judgement has been made using available evidence including a visit to this service. Although a care plan is in place for each resident they are not being routinely reviewed and updated each month. Residents’ care records show that other health care professionals are contacted for advice when necessary. The recording of some aspects of medicine administration must be improved to demonstrate that residents receive their medication correctly. Staff on duty were treating residents with respect and patience. EVIDENCE: The care plans and daily care records for three residents were sampled. The care plans reflected the assessed needs of residents and provided guidance for staff to follow to ensure each identified need is met. One care plan showed that they were reviewed in 1/06, 3/06 and 5/06. Care related risk-assessments are also drawn up for example with regard to the
DS0000030316.V295727.R01.S.doc Version 5.2 Page 12 management of MRSA, challenging behaviour and the use of bedrails. The riskassessment related to diabetic care and meals supplied should include more detail, for example about the supper snack supplied. The manager said she has now set up a system to ensure that care plans are updated each month and at other significant times. The daily care records written by care staff should be more factual and less general and note the time of the entry. The records demonstrate that the home contacts a resident’s doctor, the Community Psychiatric Nurse (CPN) or Community Nurse when identified as necessary. Although one comment card received highlighted that CPN’S get a lot of calls from the home regarding the use or withholding of sedatives or antipsychotic drugs. A relative also made a complaint to Social Services in February 2006 concerning the use of eye drops for one resident. While checking the home’s accident records it was noted that the book used does not comply with Data Protection. Additionally each accident must be accurately recorded and include the date, the name of the resident and the action taken to prevent recurrence. A number of incidents had been recorded as accidents and it recommended that an incident record sheet be developed and used. The home uses a lockable medicines cupboard, which is fitted with a lockable Controlled Drugs (CD) storage unit: medicines are transported safely around the home in a medicines trolley. Tablet medicines are mainly provided by a local pharmacy in a monitored dosage system while other medication is supplied in liquid form or are contained in packets, tubs or tubes. A refrigerator is available for the storage of eye drops and a record of the temperature kept when in use. An individual Medication Administration Record (MAR) chart is kept but when some charts were sampled it was noted that staff had not signed to indicate if the medicine had been administered or refused, e.g. for one resident taking tablet medication to control their diabetes. One bottle of tablets prescribed 28/11/05 and used as necessary was not dated when opened and therefore an audit trail of this medicine was not easily possible. The inspector requested that one out of date medicine be returned to the pharmacy and that smaller amounts of Paracetamol be kept for those residents who are prescribed this medication. A CD registered is used by the home to record the administration of Temazepam administered to three service users but this record is not being routinely signed by two staff: it was noted this mainly occurred at 22.00 hours or during the evening shift. Staff on duty were polite, caring and respectful in their interactions with residents. DS0000030316.V295727.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in the outcome area is adequate; this judgement has been made using available evidence including a visit to this service. The home endeavours to provide a good quality of life for residents who are encouraged to maintain contact with their friends and relatives and visiting is welcomed by the home. Through staff, relatives, friends and legal representatives service users are helped to exercise choice and control over their lives. A nutritious and varied diet is provided for residents. EVIDENCE: The home does not keep a visitors book as required but daily records do note when visitors call into the home as does a day-book. The home’s activities organiser has recently left the home so currently staff are providing afternoon activities. Staff were seen making jigsaw puzzles with residents in the dining room. Notes of activities are recorded into the home’s day book and this information is transferred into residents care records. DS0000030316.V295727.R01.S.doc Version 5.2 Page 14 The use of a collective book contravenes the Data Protection Act and information concerning each resident must be recorded separately and directly into individual care notes. The manager said she is hoping to employ another activities co-ordinator in the future. The mental frailty of residents means that the majority are not able to make informed choices. Relatives and friends are involved in care planning and are consulted about the lives and needs of residents. While viewing a selection of residents’ rooms it was evident that personal possessions and items of furniture are brought into the home: an inventory record is kept of these items. It was evident while talking with the home’s cook that she is familiar with residents’ likes and dislikes regarding the meals supplied. When people move into the home they and their families are asked about what residents’ like to eat and this information is recorded into their care records. Residents although not always able to say what they enjoy, are able to make their preferences clear. The record of food supplied is kept in the home’s kitchen but had no new entries since October 2005. The home must keep a record of all food provided to residents’ including special diets and all alternatives provided. The home operates a 4 weekly menu based both around the known likes and dislikes of the residents and on providing a good wholesome diet with seasonal variations. Drinks are available throughout the day and care staff that prepare or serve food and work in the kitchen when the cook is off duty have appropriate food hygiene training. DS0000030316.V295727.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in the outcome area is poor; this judgement has been made using available evidence including a visit to this service. The home has a complaints policy and procedure and this is supplied to residents’ representatives. A recent complaint however was initially referred to the local Social Services and not to the home’s manager for investigation. The home has guidance available on the proper response to be made following any suspicion or allegation of abuse to ensure residents are protected from harm. However, a recent allegation from a member of staff about care practice is being investigated by the local Adult Services under the ‘No Secrets’ process. EVIDENCE: The home has a complaints policy and procedure and this information is supplied to residents’ representatives in the home’s service user guide and is detailed within the terms and conditions of residency agreement. Information concerning complaints received by the home are kept in a file by the manager but there is no complaints record sheet available for recording and concluding the outcome of complaints or minor grumbles. In February 2006 a relative of a resident living in the home raised a complaint with Adult Services (also known as Social Services) and this matter became an Adult Protection investigation. The concerns related to a poorly resident who was admitted into hospital, the use of eye drops and some staff not having a good command of English. The complaint was unsubstantiated but some
DS0000030316.V295727.R01.S.doc Version 5.2 Page 16 shortfalls in record keeping were identified: these mainly concerned the monitoring of the resident’s deteriorating health. No in-house complaints have been received since the last inspection. In April 2006 an allegation of physical abuse toward a resident was raised with the manager of the home who suspended the staff member concerned. The incident was reported to the Commission and was then passed on for investigation by Adult Services through the ‘No Secrets’ process. The outcome has yet to be concluded. The home does not keep a copy of the ‘POVA’ guidance issued by the Department of Health in July 2004. Some time was spent considering a part in the guidance that requires an employer to report staff for consideration and inclusion onto the POVA list if misconduct is substantiated. The manager agreed to obtain and keep a copy of this guidance for reference. While examining the home’s accident record book it was noted that one incident concerning a resident being hit by another resident had been recorded: the same resident also hit a member of staff. The manager was advised to refer this incident to Adult Services for investigation as a matter of Adult Protection. A regulation 37 notification was sent to the Commission to inform them of this untoward incident. The home has policies and procedures related to the protection of vulnerable adults and the identification of abuse. There is also a Whistle Blowing procedure for staff protection and a copy of the local ‘No Secrets’ guidance is kept for reference purposes. The home’s policy concerning vulnerable adults should be updated to make reference to ‘No Secrets’ and ‘POVA’ guidance. It is also required that the manager and deputy attend the Social Services 2 day Adult Protection Awareness training course. DS0000030316.V295727.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in the outcome area is adequate; this judgement has been made using available evidence including a visit to this service. Residents live in a generally well maintained environment: the home is attractively decorated and comfortably furnished. The home is clean, pleasant and hygienic. EVIDENCE: Communal facilities and service user’s rooms were viewed and appeared clean, homely and safe with the majority of service user’s rooms being highly personalised. The home has a quiet front lounge and a separate lounge/dining room that provides access to and a view of the home’s back garden: this room is also used for many of the afternoon social activities. A smaller separate dining room/ lounge is available on the first floor for the more physically frail residents.
DS0000030316.V295727.R01.S.doc Version 5.2 Page 18 There are 23 single and three double bedrooms available for use: care records must evidence that those residents who share a room have agreed or chosen to do so. Bedrooms are centrally heated and radiators are protected in all but one resident’s room: a risk-assessment is documented in this regard. It was noted that this bedroom needs redecorating as the wallpaper is stained and coming away from the wall. The home has assisted bathing facilities ob both floors and some bedrooms have en-suite wc’s. Prior to the inspection a letter was received from the Fire Safety Officer following his inspection. The letter identified four issues to be addressed, these included: an air vent being fitted to the laundry door, the need to ensure that auto–closing swing free devices are connected to electrical power supply, that the bedroom located off the dining room has an alternative fire exit and that the closing device to the office door be reinstated. The manager took the time to show the inspector that these matters had been remedied. The Fire Safety Officer wrote to the Commission to confirm his satisfaction with the work on 7th June 2006. The home has a fenced front garden and the back garden is enclosed: garden furniture is available so that residents can sit outside and enjoy the warmer weather. The home’s laundry is situated in an extension to the main building at the back of the home and is accessed from the outside: it is properly equipped with a washing machine that has a sluice wash facility and disinfection programme. Cleaning products are kept safely in a lockable cupboard. DS0000030316.V295727.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in the outcome area is adequate; this judgement has been made using available evidence including a visit to this service. The home employs care and domestic staff but night staffing arrangements needs to be reviewed to ensure residents’ needs are routinely met. The manager follows proper recruitment procedures when employing new staff. The extended target of 50 staff with NVQ level 2 qualifications by 2006 has not yet been met. The home uses an induction and staff-training programme so that residents’ needs are met. EVIDENCE: The home employs a, deputy care manager, day care staff, wakeful night staff, a cook, and two cleaners to assist the manager with the day to day running of the home and care of residents. A copy of the home’s staff rota was supplied to the inspector and this demonstrates that there are five care staff on duty from 8am to 2pm, four from 2pm to 8pm and then two wakeful night carers from 8am to 8pm. A discussion took place concerning the need to reconsider the numbers of staff on duty at night. The residents’ accommodation is arranged over two floors
DS0000030316.V295727.R01.S.doc Version 5.2 Page 20 and given the layout of the home, the number of residents (a maximum of 29) cared for and their collective needs. When two staff are needed to assist one person at any time during the 12 hour night shift then potentially another resident requiring assistance would have to wait. It was evident from medication records that sedative medicines are often given to residents during the night shift: some have difficulty sleeping and at least one wanders about the home. Additionally one member of staff said that it is not easy to identify where a call for assistance has come without going to the call-board and the call bell rings until it is switched off at source. It is recommended that the social activities post is advertised and filled as soon as possible. The manager explained that the deputy care manager had recently been recruited. The recruitment and employment records for the deputy and one foreign care staff were examined. These demonstrated that application forms had been completed and interviews held with written records kept, two references were requested: one being from the person’s former employer. POVA first checks and CRB disclosures are undertaken. Staff training records evidenced that induction training is provided and mandatory health & safety training is supplied. Recent training provided for some staff includes, diabetic care, fire safety and the safe handling of medicines. The manager said that training had been booked in June for a course entitled, ‘Caring for Older Persons with Dementia’. Staff files showed that appraisals had been undertaken but that individual supervision sessions were not taking place: the manager is hopeful that this will be achieved once the deputy is working in the home. Of the 19 staff currently employed 15 are care staff, six are qualified at NVQ level 2 ( two of these have also completed NVQ3 training) while a further two are in the process of NVQ2 training through Weymouth college: further NVQ training is planned. A brief discussion took place with the manager regarding the home providing NVQ2 training for foreign staff. The manager was confident that the home will shortly meet the target of 50 of all care staff qualified to at least NVQ level 2. DS0000030316.V295727.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in the outcome area is adequate; this judgement has been made using available evidence including a visit to this service. The manager is experienced in management and residential care and is gradually improving recording systems in the home. Resident’s financial interests are safeguarded. The home generally follows practices that promote and safeguard the health, safety and welfare of service users. EVIDENCE: The home’s manager holds an NVQ 4 in management and is currently completing an NVQ 4 in care module to ensure that she has the appropriate qualification. She has relevant experience of working in a similar care setting for elderly people with Dementia.
DS0000030316.V295727.R01.S.doc Version 5.2 Page 22 She has applied to become the registered manager for the home and a date for her fitness interview has been agreed with the Commission. It became apparent that she does not have a job description but does have an updated terms and conditions of employment contract. There are clear lines of accountability within the home and the manager has recently recruited a deputy to assist her: it is hoped this will allow the manager more time to provide staff with individual supervision, update policies and procedures and to set up internal auditing of the home’s care records. The manager receives monthly support visits undertaken by another manager of a local home owned by Mr Luckhurst the Registered Individual (RI). Staff training records evidenced that induction training is provided and mandatory health & safety training is supplied: the manager has arranged for five members of staff to receive update training in first aid on 31 May 2006.Staff were supplied with moving & handling training in January 2006 and fire safety training from an external trainer is arranged for 6th June. The home’s maintenance records evidenced that a portable appliance testing (PAT) training certificate is held by the home’s shared maintenance worker: as this is dated 1993 it is recommended that update training be provided. Certificates for controlled waste transfer, gas boiler safety, electrical installations, lift servicing and manual hoist servicing were in place. The home’s fire records demonstrated that the fire safety system is regularly serviced by an engineering company and that in-house safety tests and checks of the fire precautionary system are routinely undertaken. The home’s last fire drill took place on 31st January 2006: this included residents and staff and a written record of the drill was documented. All staff received fire training on that day including two night staff who were supplied with training by the manager at 8pm. The manager updated the home’s fire safety risk-assessment in May 2006. DS0000030316.V295727.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 X X X X X X 3 STAFFING Standard No Score 27 1 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000030316.V295727.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? 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 14 & 15 Requirement Residents care plans must be reviewed each and at times of significant change. The home must obtain and use an accident record book that complies with Data Protection: staff must complete all accident records properly, e.g. with the date, name of the person concerned and any actions taken including how recurrence will be prevented. All untoward accidents and incidents must be reported to the Commission and other relevant agencies. All out of date or no longer used medicines must be returned to the pharmacy. The controlled drugs (CD) administration record book must be signed by 2 members of staff. Each resident’s medication administration record (MAR) charts must be signed by staff to indicate if medicines have or have not been administered. Medication to be administered when needed and not in the blister pack system must be dated when opened in order to establish and audit trail.
DS0000030316.V295727.R01.S.doc Timescale for action 31/07/06 2. OP8 13 (4) (c) 31/07/06 3. OP8 37 31/07/06 4. 5. OP9 OP9 13 (2) 13 (2) 31/07/06 31/07/06 6. OP9 13 (2) 31/07/06 7. OP9 13 (2) 31/07/06 Version 5.2 Page 25 8. OP15 Schedule 4 (13) 37 9. OP18 10. OP19 13 (4) (c) 11. OP19 13 (4) (c) 12. OP27 18 (1) 13. OP29 33 &34 A record of all food supplied to residents must be kept. The home must routinely report incidents of abuse through the ‘No Secrets’ process to the local Adult Services and the Commission. Where radiators do not have low temperature surfaces steps must be taken to ensure that each is securely guarded. This is necessary to ensure that risks to residents are eliminated. Previous timescale of 31/1/06 not met. Radiators in all rooms must be kept at sufficiently warm temperatures to ensure the safety and comforts of residents. The inspector was unable to review this requirement because the central heating was not on: assessment will take place during a future inspection. The night staffing arrangements for the home must be reviewed to ensure that sufficient staff are on duty to meet the residents collective needs. The home must obtain a copy of the ‘POVA’ guidance issued by the Department of Health in July 2004 for references purposes. 31/07/06 31/07/06 30/09/06 30/09/06 31/07/06 31/07/06 DS0000030316.V295727.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP7 Good Practice Recommendations Staff should record daily care information about residents into their individual daily care records and not into a day book (Data Protection): records should be clear and evidence how situations are resolved. The manager should set up an incident recording form to be used by staff to ensure that no untoward incidents are missed out of care records. These records should be regularly audited. The resident’s bedroom identified during the inspection should be redecorated as planned. Another activities organiser should be employed to work in the home. The home should continue to make provision regarding training for NVQ level 2 so that the target of 50 trained care staff is achieved by the extended date of 2006. 1. 2. 3. 4. 5. OP8 OP19 OP27 OP28 DS0000030316.V295727.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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