CARE HOMES FOR OLDER PEOPLE
Upminster Nursing Home Clay Tye Road Upminster Essex RM14 3PL Lead Inspector
Ms Rhona Crosse Key Unannounced Inspection 11th August 2006 08:45 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 DS0000062200.V307470.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. DS0000062200.V307470.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Upminster Nursing Home Address Clay Tye Road Upminster Essex RM14 3PL 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) 01708 220201 01708 641420 Havering Care Homes Limited Mrs Mandy Patricia Davies Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (37), Physical disability over 65 years of age (1) of places DS0000062200.V307470.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 8th May 2006 Brief Description of the Service: Upminster care home is a home providing 24 hour nursing, currently for 34 older people (see previous page regarding conditions of registration). It is situated in a rural area between Upminster and North Ockendon. The accommodation is on three floors, the lower ground floor, the ground floor and the first floor. There are 34 single bedrooms and 2 shared bedrooms all rooms have an en-suite with a toilet and wash hand basin. The home has wheelchair access and a passenger lift is provided. DS0000062200.V307470.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that means that the home did not know the inspector was coming. The manager was not at the home. The nurse in charge assisted with the inspection until the manager arrived later in the morning. The inspection covered a tour of the premises, the inspection of all health and safety records and a random selection of service users records relating to their care. Discussions took place with service users, staff and the relatives that were visiting at the time of the inspection. The fees for the home range from £520.00 - £625.00 per week. Since the last inspection a new manager has been registered with the Commission. The new manager has made considerable improvements in the operation of the home in the short time she has been employed. Both the manager and the staff are to be congratulated for the efforts they have made that have benefited the service users accommodated. The main lounge was being prepared for re decoration and the walls had been stripped. Service uses were looking forward to this room being decorated. What the service does well:
There was evidence that the manager is monitoring the documentation in relation all service users care. Small ‘post it’ notes were observed on documents reminding staff to update documents and carryout checks and chase up referrals as necessary. It had been a failure in the past that previous managers were not appropriately monitoring the care records and the nursing care being provided. In discussion with relatives visiting at the time of the inspection stated that hey were happy with the care being provided. One of the comments made was ‘I could not fault the care my dad has been given here, they are marvellous’. An assessment of the needs of a new service user admitted to the home since the last inspection was thorough with many of the areas of the care plan completed in the four days he had been at the home. The remaining areas were identified and the named nurse was to complete these. The service user had been visited by the GP and was now on the GP’s list. The kitchen was clean and tidy. The environmental health officer visited whilst the unannounced inspection was taking place and was satisfied with the cleanliness of the kitchen. DS0000062200.V307470.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better:
Due to the improvement in the operation of the home there are very few areas were it has been necessary to make requirements. The named nurse had not updated the care plan for one service user since June 2006. Another nurse had updated 2 areas of the care plan where a change had occurred (weight and catheterisation). Odour control was poor in one bedroom and the odour of stale urine was strong (room 14). An inspection of beds was undertaken. A torn sheet had been used to make up the bed in room 14 this is poor practice. All other bedding was appropriate. The manager stated that new linen had been purchased. The kitchen cupboards require replacing these should be replaced with units suitable for industrial use. The timescale set at the last inspection for renewal to take place has not yet expired. Fridge and freezer temperatures are not always being recorded. This must be carried out on a daily basis. An inspection of the fridge and freezer found that sandwiches were not labelled or dated. The kitchen assistant then labelled and
DS0000062200.V307470.R01.S.doc Version 5.2 Page 7 dated the sandwiches. In the freezer a pudding ‘Artic roll’ was left open to frost damage. All food once opened should be appropriately wrapped before being put back into the freezer. As the home is built on three levels, rubble and bricks hold the level of soil to the rear of the grounds back. It has been a requirement that this is dealt with by planting within the rubble in the soil to cover the unsightly rubble and debris. The manager stated that some plants had been put into this area although there was little evidence that this had been at all successful. Tubs of colourful plants had been placed along the pathway in front of the rubble and went some way to brightening up this poorly maintained area. This does not satisfactorily disguise the fact that rubble and bricks hold back the soil. Dense ground cover planting should be provided to disguise the rubble. Alternatively a small retaining wall should be build to hold back the bank of soil, the rubble and building debris should then be removed. A further timescale will be given to ensure this is dealt with appropriately for the benefit of the service users. 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. DS0000062200.V307470.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 DS0000062200.V307470.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): 1, 2, 3, 4, & 5 standard 6 does not apply to this home. The quality in this outcome area is good therefore there are more strengths that weaknesses. The home endeavours to ensure that anyone wishing to live at the home has the appropriate information prior to admission and the length of the admission process is arranged around the needs of each individual. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose has been updated this year. This document holds the information about the service the home states it will provide for service users. The service Users Guide must have the analysis of the quality questionnaire added to it to form part of the guide. The quality assurance analysis should be reviewed annually. The home has an admissions policy and procedure and these are followed as part of the admission process. Prospective service users and relatives are able to visit the home prior to admission, however it is mostly relatives that view the home. At a previous inspection the inspector observed that a service user had come in for the afternoon to have lunch and view the home prior to admission.
DS0000062200.V307470.R01.S.doc Version 5.2 Page 10 A file of a service user who was recently admitted to the home held the appropriate documentation, as assessment carried out by the home and the placing authorities assessment along with the contract of terms and conditions of residence. DS0000062200.V307470.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 The quality in this outcome area is good therefore there are more strengths that weaknesses. Documentation was good in relation to healthcare needs and referrals to other health care professionals. Medication storage and administration was good ensuring the well being of service users. Greater attention should be paid when completing care plans to ensure that all are updated as required. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users care plans were picked at random by the inspector. Of the care plans inspected only one care plan had not been up dated, as it should have been by the named nurse. However another nurse had updated two of the areas of the care plan. Referrals to the GP, dietician, diabetic nurse, Tissue Viability Nurse, optician and Chiropodist visit were all documented clearly, evidencing that service users needs or any concerns about their health care is raised. Food charts, fluid balance charts blood sugar monitoring charts were all found to be appropriately completed. Three observation sheets were observed to have
DS0000062200.V307470.R01.S.doc Version 5.2 Page 12 gaps in the recordings on 17, 18, and 19/7/06. Wound management was well documented with support from the Tissue Viability Nurse documented and her advice acted upon with evidence of wounds healing. The inspector saw ‘post it’ notes on some files evidencing that the manager has been monitoring the paperwork and has raised issues with staff to be dealt with. Further examination of records showed that the concerns raised had been dealt with by the staff. Service users spoken with stated: ‘yes they call the doctor if I am not well and the doctor comes to see me’. ‘Staff are nice here they bath me and treat me with kindness and respect’. ‘Some staff are nicer than others you have your favourites, but they all take care when they are helping you and they treat us well here’. DS0000062200.V307470.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 The quality in this outcome area is good therefore there are more strengths that weaknesses. The quality and fulfilment of life depends greatly on what choices are made available to service users. Service users confirmed their contentment with life in general in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection there has been a food survey undertaken. Of the 24 questionnaires sent out 17 were returned. The results of this were positive, however some changes have been made to the menu as a result of this. The home has a 4-week rotating menu and there is a variety of food offered. Alternatives to the menu are also provided. Service users stated that ‘we get a choice of meal if you don’t like something they will do you what you want’. ‘I like my egg on toast, we had that this morning’. ‘The meals are good you get enough to eat’ you can have more if you want but I don’t eat so much now’. ‘I like Pat’s cooking best, she does good plain home cooking, I don’t like fancy things like the other man used to do’. Meal choices that service users make are recorded and these records are kept. Service users are encouraged to make choices in daily life and some choose to use their rooms all day, others go their rooms after lunch for a rest in the afternoon. Some service users retire to their rooms early in the evening. One
DS0000062200.V307470.R01.S.doc Version 5.2 Page 14 service users told the inspector ‘I like to go to my room after tea to watch my T.V. the girls come up later and help me get undressed’. ‘The girls ask me when I want a bath, I have mine on the same day but you can have one when you want, they come and ask you again if you refuse’. One service user stated: ‘I don’t go down stairs I like to stay in my room, I don’t go down for the entertainment either, I like being in my own room I like my T.V’. In discussion with staff they were able to demonstrate that they were aware of the needs and individual choices of service users. Activities have improved since the last inspection. Both the manager and the activities co-ordinator visited another home run by the same company that provides a wide range of activities to get some new ideas. New activities materials have been purchased. The activities co-ordinator make sure she visits the service users who like to stay in their bedrooms so that they are not isolated. On the afternoon of the inspection some of the service users were stripping the lavender flowers off the stalks to make lavender bags. A trip out to Southend is booked for the 1/9/06 and a group of entertainers is booked to come into the home on the 26/9/06. On the 20/10/06 another singer is booked ‘Sing–a-long with Hank’. This entertainer has not been to the home before but provided the home with a video of the type of music that he performs and the service users said they would like him to come to sing to them. Various arts and crafts also take place. A gardening club has also been started with service users helping to plant up flowers in tubs and one service user is growing ‘cherry’ tomatoes. There are no restrictions placed on visiting times. Relatives are able to come and go as they choose. Relatives visiting at the time of the inspection were spoken with to gage their views on the service the home provides. One relative stated ‘you can come at any time and you are always made welcome’. DS0000062200.V307470.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, 17 & 18 The quality in this outcome area is good therefore there are more strengths that weaknesses. The home has policies and procedures for the reporting of suspected abuse and staff have received appropriate training, which enhances the protection of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has policies and procedure for the protection of vulnerable adults. Most of the staff have attended training in the detection and reporting of abuse or the new POVA (protection of vulnerable adults) training. Two training dates for POVA training were recorded as taking place on 12/6/06 and the 27/6/06. New staff who have not taken this course will be placed on this course once they have completed their probationary period at the next training date available. The complaints book was inspected no new complaints had been recorded. No complaints have been made to the Commission. One relative stated: ‘you can’t fault the care here they are all marvellous, dad is well looked after I have no worries about that here not like some places you hear about’. Another relative said: ‘If you raise anything you are concerned about Mandy will deal with it, it is not left’. DS0000062200.V307470.R01.S.doc Version 5.2 Page 16 Information about Age Concern and advocacy services are displayed on the notice board in the hallway should anyone wish to use these services. DS0000062200.V307470.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, 20, 21, 22, 23, 24, 25 & 26 The quality in this outcome area is adequate therefore there are some strengths but areas of particular weaknesses. The home is well maintained and comfortable. Odour control in one bedroom was poor this needs to be addressed. Service users needs are being met by specialist equipment provided. The outlook to the rear of the building is poor with building rubble being used to hold back the soil to stop the erosion of the bank. This is an unattractive outlook and reflects on the well-being of service users who can see this from the lounge/dining room and downstairs bedrooms. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is an ongoing programme of refurbishment. The main lounge dining room had been prepared for decoration. The decoration is to take place at night when the room is not being used. The corridors upstairs had been decorated since the last inspection.
DS0000062200.V307470.R01.S.doc Version 5.2 Page 18 The bedrooms (with the exception of rooms 30, 21, 18 and 5 as service users were resting in bed or being assisted by staff) were inspected. All communal areas were also inspected. All of the bedrooms were clean and free from odours. Only one room number 14 had an odour of stale urine. This carpet requires appropriate cleaning (possibly daily) to ensure the odour is removed from the carpet. If the odour cannot be removed then the carpet will need to be replaced. The bedding in this room had a tear in the top sheet. The manager stated that new bed linen had been purchased. The bed was to be remade. Some of the extractor fans had been turned off in the en-suites; the switches are too high for service users to reach these. These fans should not be turned off as these provide ventilation to the en-suites when the light in the en-suite is turned on. These ventilation fans were turned on again by the manager. Bathrooms were clean and had aids and adaptations for frail service users. Specialist equipment and beds are provided to aid pressure relief. Locks must be fitted to the doors of bedrooms to provide privacy for service users. In service users files there are statements by relatives that they do not wish locks to be fitted. It is a requirement that appropriate locks be fitted to all bedroom doors. The choice is then whether service users wish to activate them or not. The locks must be suitable for the purpose and be operable with a turn knob from the inside and a master key from the outside, to enable staff to gain access in an emergency. The laundry was clean and tidy. A new washing machine had been provided since the last inspection. All clinical waste was appropriately stored awaiting collection. The refuse area outside the home was clean and tidy. As the home is built on three levels, rubble and bricks hold the level of soil to the rear of the grounds back. It has been a requirement that this ‘eye sore’ is dealt with by planting within the rubble in the soil to cover the unsightly rubble and debris. The manager stated that some plants had been put into this area although there was little evidence that this had been at all successful. Tubs of colourful plants had been placed along the pathway in front of the rubble and went some way to brightening up this poorly maintained area. This does not satisfactorily disguise the fact that rubble and bricks hold back the soil instead of a suitable retaining wall. This area requires attention with either soil and planting of dense ground covering plants or alternatively a small retaining wall should be built to hold back the bank of soil and the old rubble and brick debris then removed. A
DS0000062200.V307470.R01.S.doc Version 5.2 Page 19 further timescale will be given however if this are is not attend to then formal action will be taken to ensure this is dealt with appropriately for the benefit of the service users. DS0000062200.V307470.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The quality in this outcome area is good therefore there are more strengths that weaknesses. Staff training and good recruitment and selection procedures ensure the safety of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the unannounced inspection there was sufficient staff on duty for the needs of the service users. The home is aware that there must be 50 of the staff trained to NVQ level 2. At present 2 staff hold NVQ level 2 training and 3 are in the process of achieving this qualification. One staff member spoken with said she is to take her NVQ level 3 training in September. Training that has taken place this year is: Infection control on 25/5/06. Protection of Vulnerable Adults training took place, there were two training dates for this on the 12/6/06 and the 27/6/06, and food hygiene on the 27/6/06 and manual handling took place on the 25/7/06. Since the last inspection the manager has completed a training plan for staff. Training has been provided and further training has been booked for later this year. On the 15/8/06 management of medication training is being undertaken, care planning on 22/8/06, on the 25/8/06 food hygiene raining. Infection control training is to take place on the 29/9/06 and health and safety also on
DS0000062200.V307470.R01.S.doc Version 5.2 Page 21 the 29/9/06. Manual handling is booked for the 3/10/06 as well as further session of health and safety training. The home has a recruitment and selection policy and procedure. A random selection of staff files for newly employed staff since the last inspection was inspected. These files held the appropriate checks and documentation required by legislation. DS0000062200.V307470.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 The quality in this outcome area is good therefore there are more strengths that weaknesses. The home is being run in the best interests of service users taking into account their wishes and needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection a new manager has been employed and is now registered with the Commission. The manager has demonstrated that she can manage the home to a good standard with good monitoring procedures in place. This has benefited the service users and in turn has enabled the home to move forward as these improvements have been seen at this unannounced inspection. Induction programmes were observed to be held in the files of newly employed staff.
DS0000062200.V307470.R01.S.doc Version 5.2 Page 23 Service users money held in safekeeping was inspected. All money held corresponded with the receipts kept. Since the last inspection a food survey has taken place with a good response received from service users and relatives. Changes to the menu were made as a result of these findings. This survey is made available to anyone wishing to read this. A quality assurance questionnaire has been sent out by the home to relatives, this should also be sent to health professionals. Once the questionnaires have been returned and an analysis of the information has been made, this should form part of the Service Users Guide and be reviewed annually. It was a requirement at the last inspection that staff received formal written supervision. 15 members of the staff group have received formal written supervision sessions. The home is aware that all staff must have the minimum of 6 supervision sessions in any one ‘rolling’ year. Health and safety documentation that is required by legislation was inspected all information was appropriately recorded and all certificates were in date. The recording of fridge and freezer temperatures were not always being recorded when the ‘part time’ cook was on duty. This must be addressed. All fridge and freezer temperatures must be recorded daily. Food found in the freezer was open to frost damage, as it had not been resealed after use. All food must be suitable covered and sealed if part used and placed back in the freezer. Sandwiches in the fridge had not been labelled or dated. The kitchen assistant told the inspector that she had just prepared these. The sandwiches were then dated and labelled. The kitchen was clean and tidy. The kitchen cupboards require replacing with cupboards that are designed for industrial use. The requirement set at the last inspection to replace these is still within the timescale. The extractor fan in the kitchen is only working on one speed. The cook stated that this is to be replaced when the kitchen is refurbished. DS0000062200.V307470.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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 2 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 DS0000062200.V307470.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 5 (1) Requirement The analysis of the quality assurance questionnaire must be added to the Service Users Guide and be updated annually. All care plans must be reviewed as changes occur. This is a restated requirement. The grounds to the rear of the building where building rubble holds back the bank of soil should be planted with ground covering plants to screen this rubble. This is a restated requirement. Alternatively a small retaining wall could be built to hold back the bank of soil and the building rubble then removed. Fit appropriate locks to all bedroom doors commencing with vacant bedrooms. This is a restated requirement that has not been complied with. Torn bed linen must not be used. Odour control must be improved in bedroom 14. If the odour cannot be removed then the carpet will need to be replaced. 50 of the staff team must have
DS0000062200.V307470.R01.S.doc Timescale for action 30/12/06 2 3 OP7 OP19 15(1) & (2) 23(2)(o) 30/10/06 30/11/06 4 OP24 12(2)(4)( a) 30/12/06 5 6 OP24 OP26 16(2)(c) 13(3) 30/08/06 30/11/06 7 OP28 18(1)(c) 30/04/07
Page 26 Version 5.2 8 OP33 (i) 24(1)(a) &(b) 9 OP38 16(2)(j) 10 OP38 16(2)(j) 11 OP38 23(2)(b) NVQ level 2 qualifications. A quality assurance questionnaire should be sent to any health professionals or other professionals who visit the home to gage the standard of service being provided. (Questionnaire have been sent to relatives). This is a restated requirement. Ensure the fridge and freezer temperatures are taken and recorded daily. This is a restated requirement. All food should be labelled and dated if decanted from the original container. Food placed in the freezer after use should be appropriately wrapped and sealed. Replace the kitchen units with units suitable for industrial use. This timescale is still in date. 30/11/06 30/08/06 30/08/06 30/10/06 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 OP24 Good Practice Recommendations Ensure that the ventilation fans are not switched off in the en-suites. DS0000062200.V307470.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 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 DS0000062200.V307470.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!
