Inspection on 29/01/07 for Tralee Rest Home

This inspection was carried out on 29th January 2007.

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

Tralee Rest Home 26/06/08

Tralee Rest Home 26/07/07

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

CARE HOMES FOR OLDER PEOPLE Tralee Rest Home 38-40 Tankerton Road Whitstable Kent CT5 2AB Lead Inspector Mark Hemmings Key Unannounced Inspection 29th January 2007 09:00 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 Tralee Rest Home DS0000067902.V326123.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. Tralee Rest Home DS0000067902.V326123.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tralee Rest Home Address 38-40 Tankerton Road Whitstable Kent CT5 2AB 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) 01227 276307 01227 264598 Baldev Krishan Sohal Mrs Alison Farmer Care Home 25 Category(ies) of Dementia - over 65 years of age (25) registration, with number of places Tralee Rest Home DS0000067902.V326123.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Not applicable because the Service is newly registered. Brief Description of the Service: Tralee (the Service) is registered to provide accommodation and personal care for 25 older people (service users) who have special mental health needs. This means that they experience a reduced ability to recall events and to organise their thoughts. The premises are two older two-storey properties, which have been joined together and extended. There is a total of 23 bedrooms which means that if full, two of the bedrooms would have to be used for shared occupancy. In practice, all of the service users have their own bedroom. Each bedroom has a private wash hand basin and 11 of them also have a private toilet. There is a stair lift which runs up to the first floor and which means that service users have step free access to all parts of the internal accommodation. The premises are fitted with a call bell system which is designed to help service users call for assistance should it be needed. The Service is set back a little from one of the main roads into Whitstable. To the rear of the property, there is an enclosed garden. The nearest shops are about one half of one mile away. The Registered Provider is understood to supply information to prospective service users through a variety of routes. These include the provision of a Service Users’ Guide. This is a brochure which outlines the principal features of the facilities and services available in the Service. There is a document called a Statement of Purpose available for review in the Service. This gives a more detailed account than does the Guide. Also, the Registered Provider ensures that a copy of the most recent Inspection Report from the Commission, is available for reference in the Service if requested. The range of fees charged currently for residence in Tralee, runs from £367.82 to £450.00 per week. Tralee Rest Home DS0000067902.V326123.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Report is based upon a number of sources of evidence. These include a review of the correspondence in relation to the Service received by the Commission since the Registered Provider’s registration in September 2006. Another source of evidence, involves any written information received from service users and from their relatives. Also, the Inspector completed an unannounced inspection visit to the Service. This took about six hours to complete. During this time, the Inspector spoke in some detail and/or spent time with four of the 15 service users in residence. Some of these discussions/periods of time were in private. The Inspector spoke with the Registered Manager and with the daughter of the Registered Provider. Also, he spoke with the Senior Care Worker, with three care workers, with the laundry organiser, with one of the two housekeepers and with the cook. The Inspector examined various parts of the accommodation and he reviewed a selection of the key records and documents. The Registered Provider in general operates the Service in a suitable manner. This means that the service users in residence are able to receive the support and assistance they need. There are 19 Required Developments at the end of this Report. The Registered Provider should give these matters focused attention. This is so that the steps necessary can be taken in order to enable them to be completed within the relevant timescales. What the service does well: Service users are provided with a generally pleasant setting in which to make their home. Service users say that the care workers are kind in their manner. Also, they consider that they receive the assistance they need. Tralee Rest Home DS0000067902.V326123.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Various records which the Inspector needed to see in relation to the resolution of a complaint, were not available. Either they had not been retained in the Service, or they could not be found. The calendar of social activities should be more closely reviewed. This is so that its adequacy can be established. There are some obvious defects in the premises and in the level of the amenity they provide for the service users and for their guests. Some of the security checks which should be completed in relation to care workers, are outstanding. The internal quality assurance system is not adequate. Elements of the fire safety regime are not adequate. Elements of the health and safety arrangements need to be strengthened further. Tralee Rest Home DS0000067902.V326123.R01.S.doc Version 5.2 Page 7 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. Tralee Rest Home DS0000067902.V326123.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 Tralee Rest Home DS0000067902.V326123.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): Standards 1, 2, 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this Service. Prospective service users have access to the information they need in order to establish if the Service will meet their requirements. Prospective service users have their needs assessed. EVIDENCE: Prospective service users are provided with a range of written information about the facilities and services available in Tralee. The Registered Manager complements this by answering questions about points of detail. Tralee Rest Home DS0000067902.V326123.R01.S.doc Version 5.2 Page 10 The Registered Manager completes an assessment of each prospective service user’s needs for assistance. This is done before a decision is made about whether or not the Service is a suitable place for the person’s residence. The information then is used to brief care workers, so that they know what assistance needs to be provided from the point at which someone moves into the Service. Nearly all admissions are for longer periods of time. However, some may be for shorter periods. In relation to the latter, the Registered Manager is aware of the need to help service to return to their own homes. Tralee Rest Home DS0000067902.V326123.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): Standards 7, 8 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this Service. The health and personal care which service users receive, is based upon their individual needs. Suitable arrangements are in place to manage service users’ medication. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Service users say that the care workers offer them all the assistance they need and that this is provided in a reliable and consistent manner. There is a written plan of care for each service user. These are important documents because they form one of the means by service users can be informed about and can agree to, the assistance they will receive. Also, the plans constitute a source of reference information for care workers. Tralee Rest Home DS0000067902.V326123.R01.S.doc Version 5.2 Page 12 Service users are assisted to maintain their physical health. This includes care workers keeping a tactful eye open, so that medical attention can be sought promptly should the need arise. Suitable arrangements are in place to enable service users’ medication to be stored securely and to be administered in accordance with the doctors’ instructions. Service users say that the care workers are kind and considerate. Service users are relaxed in the company of the care workers and there is a family atmosphere in the Service. The Commission has received a complaint about several aspects of the personal and health care provided for a service user who is no longer in residence in the Service. The Inspector was not able to complete a suitably detailed review of the matters in hand. This was because the individual written plan of care and various related documents, either had not been retained in the Service, or could not be found. This is not satisfactory. In future all records such as this must be archived carefully. This is so that they can be accessed by the Commission should the need arise. Tralee Rest Home DS0000067902.V326123.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): Standards 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this Service. Service users are able to choose their life style. There are some social activities taking place. Service users are assisted to keep in touch with family and friends. Service users receive a normally varied diet according to their requirements and choice. EVIDENCE: Service users say or indicate that they are able to choose what to do each day. The pace of daily life is relaxed. There are no unnecessary rules or routines to disrupt the experience of a normal domestic setting. There is a calendar of social events held in the Service. However, it is difficult to be sure about the adequacy of this provision. This is because the records of the events held and of the people who take part, are not up to date. The Tralee Rest Home DS0000067902.V326123.R01.S.doc Version 5.2 Page 14 Registered Manager is going to address this oversight. Also, she is going to use the information to consider further the adequacy of the range of activities available currently. This will include the advisability of assisting service users more frequently to go out into the neighbourhood and further afield. This development should be completed within the timescale established in the relevant Required Development listed at the end of this Report. Service users are assisted to keep in touch with family and friends. Service users can receive visitors at any reasonable hour. They can meet with their visitors in the privacy of their bedroom if they wish to do so. Service users say that they receive good quality meals and they always have enough to eat. The menu indicates that service users are provided with a normally varied diet. As necessary, service users are provided discreetly with assistance to dine. Tralee Rest Home DS0000067902.V326123.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): Standards 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this Service. Service users have access to an organised complaints procedure. Service users’ day to day wellbeing is safeguarded. EVIDENCE: The Registered Provider is aware of the need to ensure that complaints about the Service are investigated thoroughly and resolved promptly. There is a written complaints procedure which explains how someone can go about making a complaint. The Registered Provider has not received any complaints so far. Therefore, the Inspector is not able to determine how well this procedure will work in practice. There is an adult protection alert in place. This involves a multi-agency committee investigating a series of concerns about aspects of the arrangements used by the Registered Provider to support the operation of Service. Some of the matters at hand, have been confirmed by the Commission to remain outstanding. However, others have been addressed. Tralee Rest Home DS0000067902.V326123.R01.S.doc Version 5.2 Page 16 The care workers have a sound understanding of what constitutes good care practice. As part of this, they are aware of the need to be alert to instances in which the well being of a service user might become jeopardised. Service users say or indicate by their relaxed manner, that they feel safe living in Tralee. Tralee Rest Home DS0000067902.V326123.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 24 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this Service. There are various defects in aspects of the accommodation. These detract from the general level of amenity available for the service users. EVIDENCE: Service users say that they are comfortable living in Tralee. They consider the accommodation to be homely and welcoming. Tralee Rest Home DS0000067902.V326123.R01.S.doc Version 5.2 Page 18 There is a number of obvious defects. In the visitor’s bathroom, the toilet does not flush properly and the shower enclosure is very dirty indeed. In one of the bathrooms used by the service users, there are no curtains at the windows. In the garden, the fish pond has begun to overflow and it looks most unsightly. At one point, there is quite a drop to the side of the pathway which is not protected by a handrail or fence. The Registered Provider should address these matters within the timescales established in the relevant Required Developments listed at the end of this Report. The Registered Providers have completed an organised assessment of the adequacy of the fire safety measures in use in the Service. This assessment now should be forwarded to the Kent Fire and Rescue Service. This is so that this Agency can use the information in question to update its evaluation of the adequacy of the fire safety regime operated in the Service. The Registered Provider should address this matter within the timescale established in the relevant Required Development listed at the end of this Report. It is understood that the premises comply with the principal requirements of the local Department of Environmental Health. However, the Inspector cannot be sure about this matter because the paperwork in question was not to hand. There is evidence of damp penetration in the medication cupboard. The Registered Provider will need to review this matter to see what repairs might be needed. Just inside the cupboard, there is a long length of electrical cable which is coiled up and taped over at the end. This needs to be removed within the timescale established in the relevant Required Development listed at the end of this Report. The kitchen is equipped adequately. One of the ceramic floor tiles has become loose. This defect now needs to be addressed within the timescale established in the relevant Required Development listed at the end of this Report. There are various defects in the laundry. There is no hot water supplied to the sink. The arrangements used to drain water from the washing machine and to vent the dryer, mean that the window cannot be closed. Also, they look very unsightly. These matters should be addressed within the timescales established in the relevant Required Development listed at the end of this Report. In the absence of the relevant records, the Inspector cannot establish if the Service complies with current regulations relating to the maintenance of water purity. These are designed to ensure that used water does not leak back into the main pipe-work from appliances such as the dishwasher. The Registered Provider should address this matter within the timescale established at the end of this Report. Tralee Rest Home DS0000067902.V326123.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this Service. Members of staff are available in suitable numbers. There are omissions in the system used to complete security checks in relation to care workers. Care workers have the competencies they need. EVIDENCE: There are four care workers on duty to respond to service users’ needs for assistance from early in the morning until later in the evening when the night staff arrive. The care workers are supported in their work by other people, who undertake catering and housekeeping tasks. There are enough staff on duty to enable service users’ practical needs to be met in a timely and reliable manner. This provision might need to be increased in the future, if the review of the calendar of social events indicates the need for its further development. Of the 16 care workers employed in the Service, nine have acquired or are about to acquire, a National Vocational Qualification (NVQ) in health and social care. This Award is useful because it provides care workers with a range of Tralee Rest Home DS0000067902.V326123.R01.S.doc Version 5.2 Page 20 opportunities to confirm elements of good care practice and to extend their range of skills. The Registered Provider completes a number of security-related checks. These are designed to ensure that all members of staff employed in the Service are suitable to be entrusted with access to service users who may be vulnerable. There are different omissions in relation to Care Worker A and in relation to Care Workers B, C and D. The Registered Provider needs to address this matter within the timescale established in the relevant Required Development listed at the end of this Report. There are arrangements in place to ensure that all new care workers receive introductory training. This is intended to ensure that they have the basic competencies they need in order to be able to work without direct supervision. This is important because the quality of care service users can expect to receive, depends largely upon the adequacy of the knowledge and skills care workers can invest in the completion of their duties. Given the absence of any new appointments recently, the Inspector was not able to check how well these arrangements work in practice. In addition to the introductory training, existing care workers undertake a number of training courses. These are designed to enhance their capacity to deliver care. The Registered Manager has complemented this provision, by completing an organised review of the adequacy of the skills and knowledge of each of the existing care workers. This is an important example of good management practice, because it double-checks that each care worker has the competencies they need. Tralee Rest Home DS0000067902.V326123.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this Service. The day to day management of the Service is effective. The quality assurance system is not sufficiently developed. There are omissions in aspects of the health and safety arrangements. EVIDENCE: The Registered Manager has not yet acquired either of National Vocational Qualifications which are recommended for people who manage residential care Tralee Rest Home DS0000067902.V326123.R01.S.doc Version 5.2 Page 22 services. The qualifications are designed to consolidate and to develop those management skills which support the development of good quality residential care provision. The Registered Manager, the Head of Care and the Senior Care Worker have a detailed knowledge of the how the Service operates. There is a relatively small staff team and there are suitable arrangements in place to ensure that service users receive a consistent response to their needs. The Registered Provider does not operate a suitably organised quality assurance system. In particular, there is no organised system in place to enable service users (and other relevant stakeholders) to say what they think about the Service. This is important because the service users are the experts on what it is like to live in Tralee. Also, there is no system by means of which the Registered Provider can inform service users (and other stakeholders) about what is going to be done to implement any suggested improvements. The Registered Provider should address this matter within the timescale established in the relevant Required Development listed at the end of this Report. The Registered Provider should be completing monthly evaluations of the adequacy of the provision available in the Service. Also, he should be submitting a report of his findings to the Commission. He has not done this for most months. This is not satisfactory. It should now be addressed in the manner described in the relevant Required Development listed at the end of this Report. The Registered Provider disburses some of the service users’ personal spending allowance. This entails purchasing items such as toiletries on their behalf and then billing their representatives for the amounts involved. The Inspector could not examine how well this arrangement works in practice. This was because the Registered Provider had not brought the relevant records to the Service. In future all such records should be available for review in the Service. The Registered Manager says that all items of equipment in use in the Service remain in good working order. However, there is no current certification to confirm both the continued serviceability of the gas appliances in use in the Service and of the electrical wiring installation. The Registered Provider should address these omissions within the timescales established in the relevant Required Development listed at the end of this Report. The Registered Provider is completing a number of ongoing checks which are designed to ensure that the Service’s fire safety equipment remains in good working order. However, the programme of unannounced fire drills is overdue. These are intended to check that members of staff know what to do if the fire alarm sounds. The Registered Provider should address this matter within the Tralee Rest Home DS0000067902.V326123.R01.S.doc Version 5.2 Page 23 timescale established in the relevant Required Development listed at the end of this Report. This programme should now be complemented with a further system which is designed specifically to ensure that all members of staff are able to operate reliably the Service’s fire safety arrangements. Also, that they know how best to avoid the occurrence of a fire safety emergency in the first place. This is important because the actions taken by members of staff, determine largely the level of fire safety protection provided in the Service. The Registered Provider should address this matter within the timescale established in the relevant Required Development listed at the end of this Report. The Registered Manager monitors the premises and the accommodation so that potential hazards to health and safety can be identified and resolved. The Registered Manager says that there are no significant hazards waiting to be addressed, other than those identified already by the Inspector in this Report. Tralee Rest Home DS0000067902.V326123.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 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 1 3 2 3 X 3 X 1 STAFFING Standard No Score 27 3 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X X X X 1 Tralee Rest Home DS0000067902.V326123.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Not applicable. 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 OP12 Regulation 12 Requirement The Registered Provider should ensure that a suitably detailed review is completed of the activities included within the social calendar. This should be based in part upon a consideration of which service users are electing to participate in which of the activities that are available currently. The Registered Provider should repair the fish pond which is beginning to leak badly and which looks to be very unsightly. The Registered Provider should install a suitable handrail at the point in the garden path where there is a steep slope to one side. The Registered Provider should remove the long length of electrical cable stored inside the medication cupboard. The Registered Provider should repair the damaged area of flooring in the kitchen. The Registered Provider should repair the water closet in the visitors’ bathroom. DS0000067902.V326123.R01.S.doc Timescale for action 01/05/07 2. OP19 23 01/04/07 3. OP19 23 01/06/07 4. OP19 23 01/03/07 5. 6. OP19 OP19 23 23 01/03/07 01/03/07 Tralee Rest Home Version 5.2 Page 26 7. OP19 23 8. OP21 23 9. OP19 23 10. OP26 23 11. OP26 23 12. OP26 23 13. OP29 19 14. OP33 24 The Registered Provider should return to a normal standard of cleanliness, the shower enclosure in the visitors’ bathroom. The Registered Provider should enable the window in the ground floor bathroom to be obscured suitably. The Registered Provider should submit to the Kent Fire and Rescue Service a copy of the current assessment of the adequacy fire safety regime operated in the Service. The Registered Provider should reinstate a suitable supply of hot water to the sink located in the laundry. The Registered Provider should establish a normal through-thewall system to carry used water and to vent hot air from the laundry. The Registered Provider should ensure that the Service complies with the regulations relating to the maintenance of suitable standard of the purity of the drinking water delivered in the Service. The Registered Provider should in relation to Care Worker A, ensure that a suitably detailed employment history is obtained. In relation to Care Workers B, C and D, he should ensure that suitable personal references are obtained. The Registered Provider should introduce a suitable internal quality assurance programme. This should include provision for all of the service users (and other necessary stakeholders) to be consulted about the operation of the Service. Also, there should be provision for service users DS0000067902.V326123.R01.S.doc 01/03/07 01/03/07 01/03/07 01/04/07 01/04/07 01/07/07 01/03/07 01/07/07 Tralee Rest Home Version 5.2 Page 27 15. OP31 26 16. OP38 23 17. OP38 23 18. OP38 23 19. OP38 23 (and other stakeholders) to be informed about the Registered Provider’s intentions to progress any suggested improvements. The Registered Provider should submit to the Commission at least once each month, a report of his quality review of the Service. The Registered Provider should reinstate a suitably periodic programme of unannounced fire drills. The Registered Provider should reinstate a suitably periodic programme of fire safety competency appraisal which includes all members of staff. The Registered Provider should ensure that the continued serviceability of all gas fired appliances used in the Service (including in the laundry), has been certified in accordance with the relevant British Standard. The Registered Provider should ensure that the continued serviceability of the Service’s wiring installation, has been certified in accordance with the relevant British Standard. 01/03/07 29/01/07 01/03/07 01/03/07 01/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Tralee Rest Home DS0000067902.V326123.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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