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Inspection on 05/05/05 for Valentine House

Also see our care home review for Valentine House for more information

This inspection was carried out on 5th May 2005.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has good facilities: all residents have single rooms with ensuite toilets and there are a range of different communal spaces available. The location allows easy access to local village services, and the home has built up positive links with the local community. The home has a dedicated activities coordinator, who arranges a variety of activities and outings. Residents were positive about the staff team, saying that they were kind and helpful. Staff were observed to be caring and patient in the way they helped residents. There was a good level of training provided for staff, and staff spoken to were enthusiastic about some of the training they had recently done.

What has improved since the last inspection?

The home is now fully staffed, which has enabled staffing levels to be maintained and a more consistent and settled staff team to be developed. This was reflected in the positive and relaxed atmosphere in the home, and staff spoken to felt that they now worked together better. Since the last inspection, a high proportion of staff had attended a dementia workshop, including some of the domestic staff. Although staff will need further and ongoing dementia training, this represents a good start at developing knowledge and skills in this subject, and staff were positive about the training.

What the care home could do better:

The home should explore ways of actively offering residents a choice of main meal at lunch times, and need to ensure that records reflect the choices of food eaten. Some other areas of recording also need further development (e.g. for people with dementia, the recording of their communication abilities, likes and dislikes, etc.). The service should also explore ways of involving care staff in a more planned way in initiating activities and interaction with residents, particularly with those individuals who have dementia and are less able to occupy themselves.

CARE HOMES FOR OLDER PEOPLE Valentine House Broadway Silver End Witham CM8 3RF Lead Inspector Kathryn Moss Unannounced 5th May 2005 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 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 I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Valentine House Address Broadway, Silver End, Witham, CM8 3RF Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01376 585965 01376 585965 Atlantis Healthcare Limited George Michael Botten Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (OP) 48 of places Dementia - over 65 years of age (DE(E)) 8 Valentine House I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 48 persons) 2. Persons of either sex, aged 65 and over, who require care by reason of dementia (not to exceed 8 persons) 3. Three named persons of either sex, aged 65 years and over, who require care by reason of dementia, whose names were made known to the Commission in May 2004. 4. The total number of service users accommodated must not exceed 48. 5. Staffing levels should be reviewed with the Commission within 6 months from 19 July 2004. Date of last inspection 19/10/04 Brief Description of the Service: Valentine House is a large detached house, situated oppposite 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 acommodated 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). Included in this number, the homes conditions of registration allow the provider to admit up to eight people with dementia, and to continue to accommodate and care for a further three named individuals who have developed dementia since coming to live in the home. 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 I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 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 5/5/05, lasting nine hours. On the day of the inspection there were 46 residents living at the home (one of whom was in hospital), including ten people with dementia. The inspection process included: discussions with the manager, six staff, and seven residents; viewing of communal areas; and inspection of a sample of records (including any records of notifications or complaints sent to the CSCI since the last inspection). Eighteen standards were covered, and six requirements and eight recommendations have been made. What the service does well: What has improved since the last inspection? The home is now fully staffed, which has enabled staffing levels to be maintained and a more consistent and settled staff team to be developed. This was reflected in the positive and relaxed atmosphere in the home, and staff spoken to felt that they now worked together better. Since the last inspection, a high proportion of staff had attended a dementia workshop, including some of the domestic staff. Although staff will need further and ongoing dementia training, this represents a good start at developing knowledge and skills in this subject, and staff were positive about the training. Valentine House I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 Page 6 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 I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Valentine House I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 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 standard(s) 3 and 4 and 5. Standard 6 is not applicable at Valentine House. There were appropriate procedures in place to assess new residents’ needs before admission, to ensure that the home can meet their needs. The property is suitable for accommodating people with the range of needs that the home aims to meet, and has appropriate arrangements in place for meeting these needs (e.g. equipment, staff training, etc.). Residents and their relatives are able to visit the home prior to admission. EVIDENCE: The file of a person who had come to live in the home since the last inspection was seen to contain an assessment of the person’s needs carried out by the home prior to their admission, and also a care management assessment provided by social services. The pre-admission assessment covered an appropriate range of needs, including physical and mental health needs, and social and spiritual/cultural needs. Prospective residents and/or their relatives are able to visit the home prior to admission. Valentine House I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 Page 9 It was noted that there had been several occasions over the previous year when a resident had died soon after coming to live in the home. The manager confirmed that sometimes individuals admitted from hospital to the home’s ‘interim care’ beds (i.e. contracted by the health authority to enable hospital discharge whilst other care arrangements were being finalised) had been found to have ongoing health issues, and should have remained in hospital. The home subsequently ceased to have any interim care beds from April 2005. Residents spoken to were all positive about the care provided to them by staff at Valentine House, and expressed no concerns about the way care is delivered or the competence of staff. Staff spoken to showed a good understanding of residents’ needs, and appropriate training was being provided to ensure that staff have the skills to meet individuals’ needs. Following the last inspection the home had been required to make sure that staff received training in dementia care. It was noted that 21 staff had recently attended a half-day workshop on dementia: a carer spoken to during the inspection was positive about what they had learnt from this training, and it was good to learn that ancillary staff (e.g. domestic staff) had also been included in this training. Valentine House I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 Page 10 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 standard(s) 7, 8 and 10 Residents’ health and personal care needs were set out in their care plans. Although health care needs appeared to be well met, records did not adequately demonstrate some specific issues (e.g. pressure area care, nutrition, etc.). Staff treated residents with dignity and respect, but there were some practical issues affecting the promotion of privacy in the home that were unsatisfactory. EVIDENCE: Residents’ files contained a range of assessments completed after admission (e.g. moving and handling, nutrition, continence, pressure areas, risks etc.). Each resident had a ‘care plan’, which provided details of their main needs and of the action required of staff to meet these needs. Those inspected were generally well completed: they were typed (therefore easy to read) and covered relevant needs, including mental health and social needs. There was evidence that care plans and assessments were being reviewed regularly. Residents looked well cared for; care plans reflected the support they needed with their personal care, and health care needs were appropriately referred to healthcare professionals. One care plan clearly described the care being given to prevent pressure sores, including pressure relief equipment use by that Valentine House I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 Page 11 person. However, care plans for three other people identified as being at risk of developing pressure areas did not describe the care required, although staff reported that pressure relief equipment was in use. One resident was reported to have a small pressure sore, but this was not indicated on their assessments or care plans. Staff were seen actively encouraging a resident to mobilise, and showed care and patience when doing this. The home had established good links with a nurse employed by the local Care Trust to monitor and advise on falls in care homes. Staff spoken to had a good understanding of one resident’s mental health needs: their care plan described appropriate action to address challenging behaviour, but there was no system in place for recording and monitoring incidents of challenging behaviour. Another resident with dementia had no verbal communication: staff spoken to showed good knowledge of how that individual communicated their likes and dislikes, what foods they particularly liked, etc., however this was not recorded on their file. Residents’ files contained nutrition assessment forms and care plans, and records showed that residents’ weights were monitored. Although daily records of food eaten by each person were being maintained, these did not adequately illustrate nutritional intake: records of breakfasts and teas used codes for choices (e.g. A or B), but the foods represented by these codes was not shown and records did not cross-reference to which menu this related to. Details of the main meal served at lunchtime were shown, but the same meal was entered for every resident, with no variations: for example, on the day of the inspection it was noted that two people had asked for a sandwich for lunch, but the records showed them as having eaten the cooked meal. Medication practices were not fully inspected on this occasion. A sample of medication administration records (MAR) were viewed: these were generally well maintained, but it was noted that where a quantity of medication was carried over onto a new MAR sheet, the entry was not signed and dated. Additionally, on one resident’s records there were some discrepancies between codes entered for the non-administration of certain drugs, and the recorded explanations of these codes. It is important that records are accurate. Staff were observed discretely assisting residents, and treated them with care and dignity; care records showed the name a resident preferred to be called by. Some staff expressed concern at having to go into bathrooms to obtain disposable gloves and wipes, and showed appropriate awareness of this being intrusive if a resident was using the bathroom at the time. They felt it would be better if these items were available in ensuite toilets. One resident commented that they did not find it easy to use the pay phone, as this was on the first floor and they did not like using the lift. They could receive incoming calls on the portable office phone, but felt conscious of staff waiting to retrieve the phone. Valentine House I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 Page 12 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 standard(s) 12, 13 and 15 The home provides flexibility in daily routines. Activities are available to meet a range of recreational, social and religious needs: however, with the changing care needs in the home, care staff need to be more actively involved in initiating activities. Residents are able to maintain contact with family and friends, and are supported to access the local community. Dietary needs are met through the provision of appropriate meals, but a choice of main meal is not actively promoted. EVIDENCE: From observation and from discussion with staff and residents, daily routines in the home were flexible. Residents could get up and go to bed when they wanted, could chose where they took meals (e.g. lounge, bedroom, etc.), could join in with activities or not, etc. Assessment forms contained space for information on interests/hobbies, social contacts, likes and dislikes, and religious and cultural needs. One file contained a good ‘life history’, but three other files viewed all stated that life history information could not be obtained, despite there being contact details for relatives on the file. Staff showed that they had a good knowledge of one person’s likes and dislikes, but this was not currently recorded (see Health and Personal Care section). The home has an activities co-ordinator, who was on leave the week of the inspection: residents spoke highly of this person’s input, and clearly missed Valentine House I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 Page 13 them when they were off for any length of time. Care staff related well to residents, and it was good to hear them chatting to residents during the course of their work. One staff member organised a small group of residents to sit in the garden during the afternoon, but no other activities were seen taking place, and two residents commented that there was ‘not much going on’! In view of the number of residents and changes to the needs that the home aims to meet (i.e. now that the home is registered to care for a number of people with dementia), the need to ensure that ‘activities’ are not just the remit of the activities co-ordinator was discussed. One staff member expressed concern about residents ‘getting bored’, and had ideas about an activity for a specific individual. This should be encouraged. Residents confirmed that they could receive visitors at any time. It was noted on previous inspections that the home has good contact with the local community, with residents attending a local community coffee morning each week, monthly church services held within the home, and trips out during the summer. Meals seen looked and smelt appetising, and all residents spoken to said that the food was generally good. Menus provided only one choice of main meal at lunchtimes, but a range of standard alternatives were available (e.g. baked potato, omelette, etc.). Although residents spoken to said that they were generally happy with the meal served to them, most of them did not seem aware of alternatives being available. Only one person stated that other options were written at the bottom of the menu board in the dining room, and that they had to order any alternative at breakfast time. Staff confirmed that this choice is not verbally offered to residents each day; other residents spoken to said that they ‘supposed’ they would be given something else if they asked, and two were seen to have asked for a sandwich at lunchtime. The sample of nutrition records viewed did not provide evidence of any alternatives being eaten. It was good to see that residents could choose where to have their meals served, and that cold drinks were available in lounges. Valentine House I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 Page 14 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 standard(s) 17 The home supports and promotes residents’ legal rights. EVIDENCE: This inspection took place on an election day. A couple of residents spoken to said that they didn’t want to vote, but were clear that this was their choice. The Manager confirmed that several residents had made postal votes, and said that one resident would go to the local polling station. At the last inspection it was noted that the home had information on advocacy services, and that an advocate had been accessed for several residents at that time. This was not discussed on this occasion. Standard 18 was not fully inspected on this occasion, but it was noted that five staff had attended training on the Protection of Vulnerable Adults in February 2005, and that quite a number of staff had attended this training last year, although this did not cover the whole staff team. Valentine House I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 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 standard(s) 19, 20, 23 and 26 Valentine House is warm and homely; areas of the home viewed on this inspection were safe and well-maintained. Bedrooms and communal areas are suitable for the needs of residents. On the day of the inspection the home was clean, tidy and free from unpleasant odours. EVIDENCE: Records of maintenance and decoration were not inspected on this occasion, but areas of the home viewed were safe and in a satisfactory state of decoration. The home is suited to its purpose both in location and design, and is accessible to residents. All residents are accommodated in single rooms that meet the minimum standard regarding space, and have ensuite toilets. The home has four lounges available to residents: at the last inspection it was noted that only the two ground floor lounges were generally used by residents, resulting in them becoming overcrowded. On this occasion, two residents were seen to spend some time in the first floor lounge, which was good to see: the need to continue promoting a wider use of these facilities was discussed. The Valentine House I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 Page 16 hairdresser’s sink and equipment had been relocated into a larger room that provided better working facilities, and which had space for several chairs for ‘customers’, enabling a visit to the hairdresser to become a social event. This is to be commended. Staff were pleased that new linen cupboards had been installed on each floor, and cupboards had also been fitted in two bathrooms to enable towels to be stored more hygienically and out of sight. The home was clean and tidy on the day of the inspection, and there were several domestic staff on duty. Domestic staff had clear routines and had been included in appropriate training; those spoken to showed an interest in residents, and a caring manner towards them. Infection control policies were not inspected on this occasion, but it was noted that several senior staff had recently completed an in-depth infection control course through a local college. Laundry facilities were not inspected on this occasion, but are located outside of the main building, and away from areas where food is prepared or served. Valentine House I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 30 At the time of this inspection, staffing levels and skills were appropriate to the needs the home aims to meet. In view of the changing care emphasis within the home (re dementia care), this needs to be kept under review. Staff are provided with appropriate training to do their jobs. EVIDENCE: Rotas for the week of the inspection showed that the agreed staffing levels of 7 staff in the mornings and 6 staff in the afternoons were generally being maintained. There were two days when the rota only showed six staff on in the morning: the manager and deputy manager’s hours were shown on a separate rota, and if either of them were part of the care shift on these occasions this should be clearly indicated on the rota. It was good to see that the home was now fully staffed, and that no agency staff were being used. There were appropriate levels of ancillary staff on duty. Staff spoken to felt that current staffing levels generally enabled them to meet residents’ needs satisfactorily. However, they highlighted that it can often take much longer to communicate with, support and assist someone who has dementia, and stated that there are therefore occasions when current staffing is not sufficient. The manager reported that, of 30 care staff currently employed, six staff have completed NVQ level 2 and four more are currently doing NVQ level 2; a further four are about to start, and three 18-21 year olds are due to start a modern apprenticeship (which includes NVQ 2). Six staff would like to go on to Valentine House I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 Page 18 do NVQ level 3, and it was good to see that the manager was exploring ways of supporting them to do this. Staff reported that a good range of training was available to them: they were positive about this, and showed a good knowledge and understanding of care issues. Core training attended this year to date included: fire safety (23 staff), dementia workshop (22 staff), Moving and Handling training (11 staff), Medication training (18 staff) and POVA training (5 staff). Individual training records were maintained, but at present there was no overall staff training record/database to enable the manager to easily monitor which staff need to attend core training. Recruitment records were not inspected on this occasion, but the manager stated that the home is now registered with the Criminal Records Bureau, and hoped that this will reduce the previous delays in obtaining CRB checks. Valentine House I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 Improvements in the home suggested a positive management approach, with service users benefiting from a more stable and developed staff team. EVIDENCE: There was a positive and relaxed atmosphere in the home on this inspection. Residents spoken to were happy with the staff and with the way the home is run; regular residents meetings take place. Staff spoken to identified several improvements in the home, including better staffing, a more dependable staff team, and training opportunities. Staff felt able to approach the manager and deputy manager with any concerns. However, some staff also observed that office work seemed to be taking over much of the manager and deputy manager’s time, and felt that the managers needed to spend more time around the home with staff and residents. Several senior staff commented that they would like to have two seniors on duty at times when the manager or deputy manager were not present in the home. This suggests that senior staff might benefit from more support with their responsibilities. Valentine House I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 3 x x 3 x x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 3 x x 2 x x x x x x Valentine House I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 8 Regulation 12(1) and 15 Requirement The registered person must ensure that care plans detail the action required to meet needs relating to pressure area care and preventative care. 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. Timescale for action 30/6/05 2. 8 12(1), 16(2) and 17, Schedule 4 3/6/05 3. 9 13(2) 4. 10 12(4) This relates to ensuring nutrition records accurately reflect what each individual has eaten. This is a repeat requirement (previous timescale 18/11/04) The registered person must 3/6/05 ensure that all entries on medication records are signed and dated, and that reasons for any non-administration are clearly recorded. 30/6/05 The registered person must ensure that service users privacy and dignity are maintained when personal care is being provided. This relates to staff entering bathrooms to obtain gloves and wipes, whilst the bathroom is in use. Version 1.30 Page 22 Valentine House I56-I05 s17989 Valentine House v226061 050505 stage 4.doc 5. 27 17, Schedule 4 18 6. 27 The registered person must ensure that rotas clearly indicate if the manager or deputy manager are part of a care shift. The registered person must keep staffing levels under ongoing review, to ensure that they satisfactorily meet the changing care needs within the home. 3/6/05 30/6/05 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. 3. 4. 5. 6. Refer to Standard 3 8 8 10 12 12 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. The registered person should ensure that care plans describe the communication skills and needs of residents with dementia. It is recommended that the home records and monitors incidents of challenging behaviour, in order to analyse any causes and consequence of this. It is recommended that the registered person reviews with service users whether current telephone facilities meet their needs. It is recommended that the registered person explores ways of involving care staff more actively in initiating activities with residents. It is recommended that staff make every effort to seek information on service users past life histories and interests. This is particularly with respect to asking relatives for information, where servcie users are unable to provide this themselves. It is recommended that the registered person ensures that choices of main meal are actively promoted and explained to residents. It is recommended that the registered person ensures that managers have sufficient time to spend with staff and service users in the home, and reviews the support required by senior staff to enable them to confidantly carry out their duties. I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 Page 23 7. 8. 15 32 Valentine House Commission for Social Care Inspection Fairfax House Causton Road Colchester 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 I56-I05 s17989 Valentine House v226061 050505 stage 4.doc Version 1.30 Page 24 - 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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