Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 10/07/07 for Vishram Ghar

Also see our care home review for Vishram Ghar for more information

This inspection was carried out on 10th July 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 Responsible Individual provides an Asian style environment, which meets the needs of the majority of the current resident group. The health care of residents continues to be well managed, with current improvements also being made to the "surgery" in the home. Staff were seen to be asking residents if they required their pain relief. Privacy and dignity for residents is good with appropriately fitting bathroom and toilet doors, and staff who respect residents` private space. Activities are provided for the majority of residents in the home. The resident and relative meetings have good outcomes for residents with a positive effect on meal choices offered. The physical improvements to the building have greatly enhanced the environment for residents in the home. The management team ensure that all checks are made on staff prior to employment in the home. Staff training is established in the home. Accident reports are completed appropriately.

What has improved since the last inspection?

The Responsible Individual has put in place a significant programme of refurbishment, this has been planned to cover certain areas of the building, so lessening the disruptive effect on residents and staff.

What the care home could do better:

The assessment information gathered by staff of residents moving into the home must give full health, personal and social care information. Paperwork such as the Statement of Purpose, Service User Guide and contracts must be updated giving prospective residents definite information regarding their stay. Care plan detail must be increased, and medication procedures tightened considerably to increase levels of safety in the home. Care plan reviews must be increased; this would then inform staff of the appropriate levels of care offered to individual residents. Medication outcomes still show some dangerous practices, and though medication training has been offered to a number of staff, little improvement has been shown since the last visit. Periodic checks must be built in to the medication regime. Activities for residents with Dementia must be researched and offered to residents in consideration with their abilities. There was no evidence of the staff on duty at the time of the visit having undertaken training in adult protection; issues exist of individual residents being placed in situations where abuses could take place. Numbers of care staff should be regularly reviewed and thought given to the impact of low staffing levels at peak times to residents` satisfaction, and staff morale. Quality assurance has yet to be implemented and used effectively to inform prospective residents of details on the home. Staff supervision should be increased to allow personal development and detailed discussion regarding residents` care in the home. Periodic safety tests must be completed regularly to increase the safety of residents and staff in the home.

CARE HOMES FOR OLDER PEOPLE Vishram Ghar 120 Armadale Drive Netherhall Leicester Leicestershire LE5 1HF Lead Inspector Keith Williamson Key Unannounced Inspection 10th July 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Vishram Ghar DS0000063114.V340896.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. Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Vishram Ghar Address 120 Armadale Drive Netherhall Leicester Leicestershire LE5 1HF 0116 2419584 0116 2432745 mahesh@pattani.plus.com 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) BestCare Limited Ms Kusum Vala Care Home 40 Category(ies) of Dementia (40), Mental disorder, excluding registration, with number learning disability or dementia (40), Old age, of places not falling within any other category (40), Physical disability (40) Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are: Old age, not falling within any other category - Code OP Dementia - Code DE Mental Disorder - Code MD Physical Disability - Code PD The maximum number of service users who can be accommodated is 40 21st June 2006 2. Date of last inspection Brief Description of the Service: Vishram Ghar care home is registered to care for up to forty older persons who may have Dementia, Physical Disabilities or Mental Health issues in an Asian lifestyle environment. The property is purpose built and is situated in the residential area of Netherhall close to shops and other facilities. The home is easily accessible for private and public transport. The premise consists of two floors accessible by use of the stairs and passenger lift. There are a variety of facilities in the home including dining and lounge space. The home comprises thirty-eight single bedrooms two with en suite facilities and one double bedroom without en suite facility. A garden is situated to the rear of the premises. At the time of this visit, the range of fees was between £297 and £440 per week. Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections is on outcomes for residents and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting a sample number of clients and tracking the care they received through looking at their records, talking with them where possible, and looking at their accommodation, in this case four residents were chosen. This inspection took place over one day, commencing at 9.00am and took seven and one half hours to complete. One inspector conducted the inspection (or site visit). An opportunity was taken to look around the home, view records, policies and care plans and to talk to residents and staff. Information was gathered prior to the site visit from sources such as residents, their relatives and staff comment cards; the pre inspection questionnaire from the acting manager and in some cases complaint information. Twelve of the residents were seen and three spoken with during the inspection process, though due to the frailty of the resident group, few comments were made. An interpreter was used at the inspection. What the service does well: The Responsible Individual provides an Asian style environment, which meets the needs of the majority of the current resident group. The health care of residents continues to be well managed, with current improvements also being made to the “surgery” in the home. Staff were seen to be asking residents if they required their pain relief. Privacy and dignity for residents is good with appropriately fitting bathroom and toilet doors, and staff who respect residents’ private space. Activities are provided for the majority of residents in the home. The resident and relative meetings have good outcomes for residents with a positive effect on meal choices offered. The physical improvements to the building have greatly enhanced the environment for residents in the home. The management team ensure that all checks are made on staff prior to employment in the home. Staff training is established in the home. Accident reports are completed appropriately. Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The assessment information gathered by staff of residents moving into the home must give full health, personal and social care information. Paperwork such as the Statement of Purpose, Service User Guide and contracts must be updated giving prospective residents definite information regarding their stay. Care plan detail must be increased, and medication procedures tightened considerably to increase levels of safety in the home. Care plan reviews must be increased; this would then inform staff of the appropriate levels of care offered to individual residents. Medication outcomes still show some dangerous practices, and though medication training has been offered to a number of staff, little improvement has been shown since the last visit. Periodic checks must be built in to the medication regime. Activities for residents with Dementia must be researched and offered to residents in consideration with their abilities. There was no evidence of the staff on duty at the time of the visit having undertaken training in adult protection; issues exist of individual residents being placed in situations where abuses could take place. Numbers of care staff should be regularly reviewed and thought given to the impact of low staffing levels at peak times to residents’ satisfaction, and staff morale. Quality assurance has yet to be implemented and used effectively to inform prospective residents of details on the home. Staff supervision should be increased to allow personal development and detailed discussion regarding residents’ care in the home. Periodic safety tests must be completed regularly to increase the safety of residents and staff in the home. Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Vishram Ghar DS0000063114.V340896.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 Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The assessment process for residents is still not detailed or effective; resulting in a lack of accurate and detailed information for staff to ensure care needs shall be met. The information in the Statement of Purpose, Service User Guide and Contract is not reproduced in a language appropriate for all residents in the home; resulting in a lack of information for residents being admitted to the home. EVIDENCE: The Statement of Purpose, which sets out the latest aims, objectives and philosophy of the home, about its services, facilities, and current staffing, was available for inspection on this occasion. This document has been updated to include the new registration details and reflects the current residents being admitted to the home. The Statement of Purpose, Service User Guide and Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 10 Contract must be reproduced in a language or format understood by residents or their representatives. Of the residents’ files that were viewed on this occasion, none had an appropriate contract or statement of terms and conditions in place. Assessment information for the residents was viewed. The information gathered by the staff remains partially complete, and was not adequate in providing full information on the residents needs to ensure The home does not provide facilities for intermediate care. Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Residents are not looked after well in respect of their care planning and care plan reviews. Gaps and inaccuracies in the medication recording and information means that residents are at risk from medication errors. EVIDENCE: Care plans for the residents did not include enough detail for staff to enable them to undertake health, personal and social care needs, on a consistent basis. The plans are not reviewed regularly, the only evidence of which was on an annual basis. Health care monitoring is good, with records covering weight gain and loss kept in a file other than the main file. Care plans lacked specific detail regarding the assistance required for individual residents oral and foot care. Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 12 Access to the General Practitioner is good, with regular visits made to the home. The medication administration records (mar charts) had a few missing signatures, and where medication was prescribed, “as required” no code was used to explain the reason why medication had not been administered. Medication received from the chemist is recorded, however medication already in the home was not carried forward onto records. Records are in place for residents who self-administer medication, though no risk assessment is in place on the files viewed. No periodic checks are in place to ensure proper administration procedures are taking place. Policies and procedures are in place and have been recently reviewed, though these were not adequate in instructing the appropriate administration of ordering, and administering medication in the home. No homely remedy policy was seen on the day. A carer was observed administering medication they asked residents if they needed ‘when required’ medication and explained what the medication was for, administration records were then signed appropriately. Medication prescribed for short courses, was not being administered for appropriately, as a 15 capsule course had 18 signatures with 3 caps remaining in the container. The registered manager stated they had started a process of regular audits to ensure appropriate medication took place. The privacy and dignity of residents is good with toilet and bathroom door locks that fit appropriately. Staff were witnessed to knock and wait prior to entering residents bedrooms, and were heard to speak respectfully to residents. Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Most residents enjoy, experience and participate in activities and interests, and are supported to maintain their preferred individual daily routines and choice of lifestyle with the support of the staff. Lack of assessment, care planning and researched activities, leaves residents with Dementia lacking in stimulation. EVIDENCE: Activities are planned and provided for the majority of residents, religious events in the lounge, and one resident stated the outside speakers “were interesting”. There is a lack of detailed social care information for residents suffering with Dementia, little information is gathered at the point of assessment, and no enteries could be found in the care plans. Visiting is unrestricted with a number of relatives visiting on the day of the visit. Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 14 Choice is promoted by staff, where residents that are capable of making choices they do so, assisted by staff. One resident indicated she chose to clean her own bedroom “as it keeps me fit”. Meals and meal times are well organised, and the menu choices are discussed with residents and their families, and posted in advance. The cook produces meals in line with residents’ dietary preferences and information gathered at the resident and relative meetings. Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents’ are not protected by appropriate complaints and adult protection policies, and staffs’ lack of Adult protection knowledge. EVIDENCE: Residents who were spoken with stated that they feel comfortable discussing any concerns with the home’s manager or staff. The complaints procedures are available for residents and visitors, and are included in the Statement of Purpose and Service User Guide, though these documents require to be reviewed. The complaints procedure is not available in any language other that English (also see the comments in Section 1 Choice of Home). The Responsible Individual produced records for five complaints made since the last visit to the home. These were clearly recorded, investigated appropriately and had satisfactory outcomes for the complainants. The Commission for Social Care Inspection has received no complaints in the same period of time. Staff are not aware of, or been trained sufficiently in safeguarding adults; this places residents at risk of abuse in the home if staff do not recognise and respond appropriately to alleged abuse. Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A comfortable and safe standard of accommodation is provided for the residents. EVIDENCE: The home provides a relaxed and spacious environment that is appropriate to the specific needs of the people who live there. The building and grounds are well maintained, and specialist aids and equipment are provided to meet the needs of the people who use the service. A maintenance programme is in place, and projected work is in place to ensure the improvement in the home to date, is sustained for the future. Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 17 Staff when spoken with have a good knowledge of cross contamination and cross infection issues. A range of protective clothing is available to ensure residents safety in the home. Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Good staffing levels and a sound recruitment practices ensures residents and staff are safe within the home. EVIDENCE: Staff rotas viewed on the day, showed reasonable numbers of care staff are employed, and are backed up by cleaning, catering and other ancillary staff. Staff training has accomplished more than the minimum of care staff undertaking the National Vocational Qualification level two in care. The recruitment process is well managed and secure, with evidence of completed application forms, references, proofs of identification and the appropriate Criminal Records Bureau checks seen on staff files. Staff training is in place with a number of statutory training courses taking place since the last visit. There is currently no overall staff training matrix in place, this would assist the registered manager in planning staff training needs. Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The management approach does not promote effective care practice in the home for residents’ care and protection. EVIDENCE: The current registered manager is qualified having passed the Registered Managers award. Quality assurance questionnaires have been distributed to residents and their relatives, though these have not been collated, findings circulated to interested Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 20 parties, nor added to the Service User Guide, due to poor numbers returned in the past. The Responsible Individual stated that the latest quality assurance Resident finances are currently not held by the staff. Staff supervision is currently not undertaken in the home. The Responsible Individual indicated that staff appraisal is due to commence shortly. A sample of accident reports were completed appropriately, and there is accuracy between these and the residents’ individual daily records. Fire records were viewed and the weekly fire alarm tests and emergency lighting were found to be up to date, the fire risk assessment is not. There is no up to date gas certificate for the home. The annual portable appliance tests (pat tests) and five-year electrical safety test have not been completed. There are blending valves in place on taps in resident areas throughout the home, however these are not periodically tested to ensure they are working appropriately. The lack of effective safety systems / tests places service users, visitors and staff at risk of injury Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 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 1 1 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 1 X 1 Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 23 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 4 (1) Requirement The Statement of Purpose must be produced in a format or language accessible to the majority of residents in the home. This is to ensure the full information is available to the resident prior to any stay in the home commencing. The contract or terms and conditions of the residents stay, must be produced in a format or language accessible to the majority of residents in the home. This is to ensure the full information is available to the resident prior to any stay in the home commencing. A copy of the contract or terms and conditions of the residents stay, must be placed on the residents file. This is to ensure the full information is available to the resident prior to any stay in the home commencing. Residents’ assesments must be fully detailed to ensure the home and staff group can meet the residents’ needs prior to any stay commencing. All care plans must be sufficiently detailed to enable DS0000063114.V340896.R01.S.doc Timescale for action 24/08/07 2 OP2 17 (1) a 24/08/07 3 OP2 17 (1) a 24/08/07 4 OP3 14 (1) c 24/08/07 5 OP7 12 (1) 24/08/07 Vishram Ghar Version 5.2 Page 24 6 OP7 12 (1) 7 OP8 12 (1) a 8 OP9 13 (2) staff to fully care for individual residents personal, social, health and emotional care. This is in order to enable staff to understand the full care needs of the residents in the home. Care plans must be periodically 24/09/07 reviewed. This is to enable the staff group to have the up to date information to enable full care to take place. Nutritional assesments must be 24/08/07 undertaken at the point of admission. Monitoring records appropriate to the areas being overseen must also be kept. This is to ensure residents’ nutrition is monitored appropriately. There must be an accurate 24/08/07 record of all medication received, administered and disposed of by the service including: Defined codes for any nonadministration Quantity administered where a variable dose is prescribed Quantity and date of any medication given to residents for self administration Quantities received and balances carried forward from the previous month. All prescribed medication must be administered as prescribed. This would ensure safe dispensing and administration of medication to residents in the home. Homely remedies used must be included in the homely remedy policy and records of administration must be kept. This would ensure no interaction occurred with medication DS0000063114.V340896.R01.S.doc 9 OP9 13(2) 24/08/07 10 OP9 13(2) 24/08/07 Vishram Ghar Version 5.2 Page 25 11 OP12 12 OP15 13 OP16 14 OP18 15 OP33 16 OP33 17 OP36 prescribed by medical professionals. 12 (1 & 3) Information for residents’ pastimes must be researched and provided to meet the needs and wishes of residents. This shall ensure residents are offered activities at an appropriate level for their intellect. 12 (3) Residents must be informed of meal choices in a form acceptable to all levels of residents’ intellect. This would ensure all residents were offered appropriate meal choices in the home. 22 A complaints procedure, which is appropriate to the needs of residents, must be put in place. This would ensure anyone wishing to complain, has the correct information to do so. 18 (1) a Staff awareness of Adult protection issues, must be heightened. This is to enable residents’ to be protected in the home. 24 Effective quality monitoring systems must be put in place, to ensure the development of the home is continual, and is to the benefit of residents. This would ensure that residents could comment on, and influence the development of the home. 24 The outcome of any quality assurance exercise is used to inform any prospective residents to the home. This would provide prospective residents with the information to make an informed choice regarding a stay in the home. 18 (1) a Staff must be appropriately supervised, and aspects of practice, the philosophy of the home, and career development DS0000063114.V340896.R01.S.doc 24/09/07 24/08/07 24/08/07 24/10/07 24/09/07 24/09/07 24/09/07 Vishram Ghar Version 5.2 Page 26 18 OP38 17 (2) 19 OP38 17 (2) covered. This would ensure staff employment policies, induction and training were all put into practice in the home. Periodic reviews of the fire risk 24/08/07 assessment must be performed regularly. This is to ensure the safety of residents. The Responsible Individual must 24/08/07 ensure all health and safety checks are undertaken regularly, and certificates required to prove the validity of these tests, be available for inspection. This is to ensure a safe environment for the residents. 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 OP7 OP9 Good Practice Recommendations It is recommended that care plans be produced in a format or language appropriate for all staff to understand. It is recommended that a written record is maintained of all training, supervision and assessment provided to staff regarding the safe handling, storage and administration of medication and that further accredited training be provided. It is recommended that the Registered Manager has a full working knowledge of the vulnerable Adults Policy ‘No Secrets’ and that further training regarding the protection of vulnerable adults is provided to all care staff. 3. OP18 Vishram Ghar DS0000063114.V340896.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Vishram Ghar DS0000063114.V340896.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!