Inspection on 27/10/05 for Valentine House

This inspection was carried out on 27th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Valentine House 12/08/09

Valentine House 03/10/08

Valentine House 15/05/07

Valentine House 03/05/06

Valentine House 05/05/05

Valentine House 19/10/04

Valentine House 12/05/04

Valentine House 06/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Valentine House Broadway Silver End Witham Essex CM8 3RF Lead Inspector Kathryn Moss Unannounced Inspection 27th October 2005 10:30 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 Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 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. Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Valentine House Address Broadway Silver End Witham Essex CM8 3RF 01376 585965 01376 585965 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) Atlantis Healthcare Limited Mr George Michael Botten Care Home 48 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (48) of places Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 48 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 12 persons) The total number of service users accommodated must not exceed 48 persons 5th May 2005 Date of last inspection Brief Description of the Service: Valentine House is a large detached house, situated opposite a small parade of shops in a village location. The home has three floors that are accessed by a through floor passenger lift, and residents are accommodated in single bedrooms, all with ensuite toilets. Facilities include lounge areas on all three floors, a large dining room, a number of bathrooms (some with assisted bathing facilities), and a secure garden area with seating available. The home is registered to provide 24 hour personal care and support for up to 48 older people (i.e. over the age of 65), including up to twelve people who suffer with dementia. The home provides both permanent accommodation and also short (respite) stays. The home is owned by Atlantis Healthcare, and the current registered manager is Mike Botten. Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 27/10/05, lasting nine and a half hours. On the day of the inspection there were 45 residents living at the home, including ten people with dementia. The inspection process included: discussions with the manager, two staff, eight residents and one relative; a feedback questionnaire from another relative/visitor; viewing of communal areas; and inspection of a sample of records. 17 standards were inspected, and 6 requirements and 7 recommendations have been made. Information on core standards not covered on this inspection can be seen in the previous report of the 5th May 2005. Not all previous recommendations were reviewed on this inspection. What the service does well: What has improved since the last inspection? There had been a number of good training initiatives in the home since the last inspection. Staff had attended several relevant training sessions, including sessions on diabetes and skin care, and on dealing with death and dying; the manager and deputy manager had attended a manual handling trainers course, and were updating staff manual handling training; and new induction materials (videos and workbook) had been obtained for use with new staff. There was also a good range of training being planned. Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 6 Other improvements included appropriate action taken to address a previous issue relating to promoting privacy and dignity in delivering personal care, and there was a noticeable improvement in the way medication administration records had been completed. What they could do better: 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. Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 7 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 Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 8 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): 4 and 5 Residents were confidant that the home could meet their needs. Prospective residents and their relatives had the opportunity to visit the home before admission. EVIDENCE: The home provides an environment that is suited to its purpose and to the needs of the people who it aims to accommodate. It has level access throughout and a through floor passenger lift, there is appropriate equipment available to assist people with poor mobility, and residents are accommodated in single rooms and have a variety of communal space available to them. Staff training is appropriate to residents’ needs, and there was evidence that the manager was progressing plans to provide ongoing training in dementia care for staff, as recommended at the last inspection. Residents spoken to were all confident that staff had the skills to meet their needs. A new resident confirmed that they had been able to visit the home before admission to check out its suitability and facilities, and had had a choice of room from those available at the time. Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 9 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 and 9 At the time of the inspection, residents’ personal and health care needs were being appropriately met; however, not all records satisfactorily reflected how these needs were being met. Residents were being treated in a manner that upheld their right to privacy and dignity. Practices relating to medication storage and administration were being satisfactorily maintained. EVIDENCE: Residents spoken to appeared well cared for, and reported being happy with the assistance staff gave them with their personal care. They were positive about the staff team, and felt that staff assisted them appropriately. Staff observed on the day of the inspection had a friendly and respectful manner when interacting with residents. An issue about respecting privacy noted at the last inspection had been addressed. From discussion with manager, staff and residents it was clear that medical support was promptly sought for health care needs, and that district nurses supported the home well. The manager and deputy manager had recently attended a two day core care skills training course, and had a training manual to use with new staff to provide guidance on all core care tasks (e.g. bed bathing, assisting with bed pan, wheelchair use, etc.). One resident reported that staff sometimes took a while to answer the Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 10 call buzzer, and the registered person should monitor this and ensure that there are always sufficient staff on duty to meet residents’ needs. The records for two residents were viewed on this inspection, for evidence of care plans and of how personal and healthcare needs were being met. In both cases there was good evidence of relevant assessments being completed and reviewed on a monthly basis (e.g. re nutrition and risk of pressure areas), and the care plans present covered a relevant range of needs. In both cases the pressure area risk assessment showed that the person was at high risk of pressure areas, but in only one file was there a care plan present detailing the preventative action required of staff. This contained clear details of the preventative action required. It was noted that this resident had recently returned from hospital with a pressure sore, and was currently bed bound. A review sheet briefly noted the changes since discharge (e.g. ‘bed bound, pressure sore’) and a night care plan and manual handling care plan had been revised to show their changed condition. However, care plans for ‘at risk of pressure sores’ and ‘feeding’ had not been updated to show the changed needs and additional action required by staff since the person returned to the home. It was noted on one person’s file that their weight was being regularly monitored and recorded. Records of meals eaten were being maintained for all residents, but issues identified at the last inspection had not been fully addressed. Many records still did not show what the meal was: staff had not completed the ‘menu week number’ details at the top of the form, so the records could not easily be cross-referenced with a menu to see what had been served; on some days staff had recorded actual details of the main meal served, which was good to see, but this was not consistently recorded. Where residents had chosen an alternative meal, what they ate was not recorded, and details of what was served for teatime meals were not generally recorded; on some days no record had been made for a meal. This needs to be addressed. The home’s administration of medication policy was not viewed on this occasion, but medication practices were inspected. Medication was dispensed to the home in a monitored dosage system, and was securely stored in a medication trolley that was seen to be clean and well ordered. Medication Administration Records (MAR) were printed by the pharmacist: medication received by the home was recorded on these forms, and records of medication administered were generally well-maintained, including reasons for nonadministration; most changes to medication details or instructions had been signed and dated by the person making the entry. The deputy manager stated that most staff administering medication had received training by the pharmacist this year (evidence not viewed on this occasion). A new staff member had yet to attend this training, but the deputy manager had assessed their competence by observing them on several medication rounds before they worked alone, and had recorded this. Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 11 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): 14 and 15 The home provided a well-balanced diet, served in pleasant surroundings; however, a choice of meals was not being actively promoted in the home. In other aspects of their lives, residents were encouraged and supported to exercise choice and control over their lives. EVIDENCE: One resident spoken to stated that they maintained their own bank account and independently obtained money from a local cash point when they needed to, but chose to give some to the manager for safe keeping in the office. They confirmed that they had facilities to keep their money safe, and that they had a key to their bedroom door to enable them to lock their room. On the inspection, residents who had money in the safe were noticed to initiate requests to access their money, and to sign to confirm receipt of it, thus maintaining control over their affairs. The manager confirmed that an advocate was involved with one resident. Residents spoken to felt they had control over day-to-day choices such as how and where to spend their day, when to get up and go to bed, etc. Activities were not specifically inspected on this occasion, but the activities co-ordinator was observed to have taken two residents for a walk in the local park before coffee time, and an outside entertainer attended the home later in the morning. Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 12 Menus were not specifically inspected on this occasion, but residents spoken to were generally happy with the quality and variety of meals provided to them at Valentine House. However, as noted at the last inspection, evidence still indicated that a choice of food was not actively offered to residents each day. Only one main dish was provided at lunch each day, and several residents spoken to, whilst saying that they ‘thought’ they could ask for something different, were not aware of there being specific choices available to them for the main meal each day. The notice board in the dining room contained information on the day’s menu, listed a range of set alternatives available, and requested that residents asked for alternatives at breakfast time. However, not all service users were aware of this, not all went to the dining room for breakfast, and on the day of the inspection the menu board was out-of-date and still showed the meal choices from several days before. Nutrition records viewed predominantly showed all residents eating the same meal, and rarely indicated that an alternative had been eaten. This evidence suggested that a choice of food, although available, is not actively offered and promoted within the home. The registered person should therefore review menu choices, and how choices are offered, to ensure that residents have a real choice of food. Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 13 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 and 18 Residents and their relatives were confident that any complaints would be listened to and acted on. The home has information and policies on responding to suspicion of abuse, but systems for raising staff awareness of abuse issues (e.g. through training) were not yet satisfactory. EVIDENCE: The home’s complaints procedure was seen, and noted to include timescales for response and the CSCI contact details. The home maintained a clear record of any complaints received: records showed five complaints recorded since April 2005, relating to appropriate issues and showing the action taken. Where the complaint had involved a written response to a complainant, the letters seen were sympathetic and open in the way they addressed the issue. Residents and a relative spoken to appeared confident to raise concerns. The home has a Protection of Vulnerable Adults (POVA) policy: this contained reference to referring concerns about suspicion or evidence of abuse to the police and /or social services, but stated that concerns should only be reported with the service user’s consent. This was discussed with the manager, and it was suggested that due to the potential risk to other residents, the responsibility of the home to make referrals under the Essex Vulnerable Adults protection procedures should not depend on the resident’s consent. The policy did not include the need to also notify the CSCI of any allegations of abuse. The manager stated that this policy was available in the office, but was not specifically gone through with new staff. It was therefore recommended that the policy be discussed with new staff. Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 14 At the time of this inspection, records showed that twelve staff had attended POVA training in February 2005; although no further training had taken place since then, the manager was in the process of booking training with an external training provider. The home was currently employing 29 care assistants and 4 domestic staff, therefore 21 staff still needed to attend this training. Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 15 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): None EVIDENCE: No premises standards were specifically inspected on this occasion. On the day of the inspection the home was clean and tidy, and appeared safe and well maintained. A relative spoken to confirmed that odour control in the home was always good, and residents reported that their rooms were kept clean and that the laundry service was good. Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 16 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, 29 and 30 At the time of this inspection it appeared that agreed staffing levels were generally being maintained, and that the number and skills of staff continued to meet residents’ needs. Documentary evidence of the recruitment of a new staff member did not meet regulatory requirements. Training provided is appropriate to the jobs staff are required to do. EVIDENCE: The rota for the week of the inspection was viewed, and it was noted that the home was generally managing to maintain agreed staffing levels of seven staff in the mornings and six staff in the afternoons; however, there were two days when the home had been one staff short for all or part of a shift. The manager explained that the home was currently short staffed as several staff were sick with flu, but that they had been accessing agency staff when required. It was good to see that the home used one agency that supplied regular carers, thus providing continuity of staffing. The manager obtained information from the agency to evidence that all required checks had been carried out: he was advised that the Regulation relating to information required on new staff had changed last year, and was provided with information on this. The home continued to employ an activities co-ordinator supernumerary to the care staff. Staffing levels were discussed with the manager and deputy manager in relation to the increased number of beds for dementia care that the home is registered for, and both felt that current staffing levels met residents’ needs. The manager stated that they did not aim to admit people who were high Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 17 dependency, and that over half of the current residents required minimal support. The registered provider and manager should review staffing on an ongoing basis, and increase staffing if residents’ needs change. The file of one new staff member was inspected for evidence that recruitment checks required by regulation had been carried out before the person started work. The file contained evidence of checks on identity (copies of birth certificate and passport), a health questionnaire, a criminal record declaration, and names of two referees (including the last employer). Other than the person’s most recent employment, there was no employment history recorded; there was no evidence that the registered person had checked the person’s UK employment status (re work permit, etc.). Two written references had been obtained, but one had not been received until several weeks after the carer started work. The CRB/POVA check was dated two months after the person started: the manager stated that one had been obtained earlier, but had not included a POVA check; they had therefore applied for a further check, but had not kept a copy of the original as evidence. The carer had signed a statement confirming that they had not been referred to the POVA list. Training records were not viewed on this occasion. From discussion with the manager it appeared that variety of training had been completed by staff this year, including fire safety training, sessions on diabetes, skin care and pressure area care, and a Funeral Director’s talk (re dealing with death and dying). Further training booked or planned included: first aid, fire safety, loss and bereavement, POVA, and health and safety (distance learning course through Braintree college). A staff member spoken to felt that a good level of training was provided at Valentine House. No additional dementia care training had been received by staff since the last inspection, but it was good to see that a senior carer had just been offered the opportunity to attend a Dementia Care trainer’s course. The home had recently obtained a formal TOPSS induction package, consisting of videos and workbooks for new staff to work though, and a training manual for managers. The manager and deputy manager were due to attend a workshop introducing the TOPSS induction standards. The manager was also booked to do a First Aid instructors course. Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 18 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 and 38 The registered manager has appropriate experience to manage a care home, but has not yet achieved the required management training. The home does not have sufficient systems for demonstrating that the home is run in the best interests of residents (i.e. quality assurance and quality monitoring systems). Residents’ financial interests are safeguarded through the practices and procedures in the home. The home operates appropriate practices to promote the health and safety of staff and service users. EVIDENCE: The registered manager has several years experience of managing a care home, and attends regular training to update his knowledge and skills. Although he had previously started the Registered Manager’s Award, he withdrew from this due to the course being unsatisfactory. On this inspection he confirmed that he was in the process of re-enrolling on the Registered Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 19 Manager’s Award (NVQ level 4 in management), and that he hoped that the work previously completed would enable this to be quickly completed. The home does not currently have formal quality assurance processes in place. The manager had recently sent out questionnaires to GPs and social workers, and had previously sent out questionnaires to relatives; however, no formal survey of residents’ views had taken place, and this must be developed. The home did not have an annual development plan (based on outcomes for residents) that could be reviewed to demonstrate goals being set and achieved, or a formal internal auditing system. However, the responsible individual carries out monthly visits when he speaks with staff and service users and audits a sample of records, and the activities organiser holds regular residents’ meetings. Additionally, the manager stated that medication records are regularly checked for omissions, the maintenance person completes regular room audits and checks hot tap temperatures, and kitchen food hygiene audits are recorded. However, these processes are not part of a co-ordinated quality assurance system, and the home does not currently produce any report on the review of care in the home. The manager was advised that internal quality assurance and quality monitoring processes therefore need to be developed. The home does not act as agent or appointee for any residents, but will look after small amounts of money on their behalf. The home has safe storage facilities for this, and operated secure systems with respect to recording and handling residents’ monies. Money was kept in individual envelopes, and each resident had their own record sheet: in a sample checked, the money, records and receipts all balanced. The manager stated that relatives are encouraged to view and check these records, and to countersign them. It was noted that money could potentially fall out of the individual envelopes if dropped, and recommended that more secure individual containers be used. The home’s policies and procedures included a health and safety policy statement, detailing employer, manager and employee responsibilities. The home also had procedures covering a variety of health and safety issues, including: hygiene in the kitchen, infection control, legionella procedures, missing persons, accidents and RIDDOR, risk assessments, and laundry practices. Staff training records on health and safety issues were not inspected on this occasion, but from discussion during the inspection it appeared that relevant health and safety training was made available to staff (e.g. first aid and fire safety training were booked; some distance learning health and safety training was being planned). The manager and deputy manager had recently trained as manual handling trainers, and were in the process of updating all staff. The home maintained clear evidence of appropriate servicing being carried out by external contractors, including the servicing of fire alarms, fire equipment, hoists and passenger lift, gas safety inspection and servicing, and electrical installation periodic check. Records also showed that routine checks were Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 20 being maintained, including: testing of hot tap water temperatures, portable electrical appliance testing, testing of fire alarms and emergency lighting, and fire drills. The manager confirmed that the central hot water storage temperature is also regularly checked from the thermostat on the boiler, but that this is not currently recorded. Appropriate health and safety records were maintained, including risk assessments on safe working practices, fire risk assessment and procedure, and accident records. Records of chemicals used in the home were not inspected on this occasion. Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 21 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 X 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The registered person must ensure that care plans are updated when a person’s needs change, to incorporate any different or additional action required by staff. The registered person must ensure that care plans detail the action required to meet needs relating to pressure area care and preventative care. This is a repeat requirement (previous timescale 30/6/05). The home must maintain records of food provided for service users in sufficient detail to enable any person inspecting the record to determine whether their diet is satisfactory. This relates to ensuring nutrition records accurately reflect what each individual has eaten. This is a repeat requirement for the second time (previous timescales 18/11/04 & 3/6/05). The registered person must ensure that residents are actively offered a choice of food at mealtimes. DS0000017989.V261373.R01.S.doc Timescale for action 30/11/05 2 OP8 12(1) & 15 30/11/05 3 OP8 12(1),16 (2)&17,Sc h4 30/11/05 3. OP15 16(2)(i) 31/12/05 Valentine House Version 5.0 Page 23 4. OP18 13 and 18 5 OP29 19 6 OP33 24 It is required that the registered 31/03/06 person ensure that all staff (including domestic staff) receive appropriate training in abuse awareness and in the home’s procedures for responding to suspicion of abuse. It is required that the registered 30/11/05 person ensure that information obtained on all new staff before they start work includes: 1. Evidence of employment history, including written explanation of any gaps; 2. CRB and POVA check (or POVA First check and evidence of the supervision of the person); 3. Two written references. 31/03/06 The registered person must establish a system for regularly reviewing the quality of care provided in the home. This should include the processes detailed in standard 33, and must include systems for seeking residents’ views. A report must be submitted to the CSCI regarding any review of the quality of care carried out in the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP3 OP18 Good Practice Recommendations The registered person should ensure that ongoing dementia care training is provided to staff, to develop their knowledge and skills with this client group. It is recommended that the home’s POVA policy be amended to reflect issues discussed on the inspection. DS0000017989.V261373.R01.S.doc Version 5.0 Page 24 Valentine House 3 4 5 OP18 OP27 OP29 6 7 OP31 OP38 It is recommended that the home’s POVA policy is discussed with all new staff. The registered person should keep staffing levels under ongoing review, to ensure that they satisfactorily meet the changing care needs within the home. The registered person should ensure that appropriate checks are carried out to ascertain the employment status of any non-UK nationals employed to work in the home (i.e. work permit/visa, etc.). The registered manager should ensure that action is progressed to obtain NVQ level 4 in care and in management as soon as possible. The registered person should ensure that routine checks on the central hot water storage temperature are recorded, as evidence of the systems in place to reduce risk from Legionella. Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Valentine House DS0000017989.V261373.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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