Inspection on 29/06/05 for Weston House

This inspection was carried out on 29th June 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.

Other inspections for this house

Weston House 01/05/07

Weston House 06/06/06

Weston House 25/01/06

Weston House 16/11/04

Weston House 27/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Weston House Green End Whitchurch Shropshire SY13 1AJ Lead Inspector Janet Adams Announced 29 June 2005 09.30 th 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. Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Weston House Address Green End Whitchurch Shropshire SY13 1AJ 01948 663052 01829 731800 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) Golbourne Healthcare Ltd. Care Home 38 Category(ies) of 32 Old Age registration, with number 4 Dementia of places 1 Learning Disability - over 65 1 Learning Disability Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th November 2004 Brief Description of the Service: Weston House is registered to provide personal care to 38 older people. The home has been converted from a large three-storey building situated in the centre of Whitchurch and it is within easy walking distance of the local shops and other amenities. Accommodation is in either shared or single rooms a number of which have en-suite facilities. There are 3 communal lounges a conservatory and a dining room. The upper floors may be accessed via a shaft lift and there is a small garden to the rear of the property for the use of residents. Weston House is owned by Golbourne Healthcare Ltd, a company that operates a number of care homes both in the local area and nationally. Due to the relocation of the home manager to another home within the company, a new manager, Alison Sumner has recently been recruited to this role. and is being supported by an area manger for the company. The company has commenced refurbishing the building to update facilities. Care is provided by a team of carers, some of whom have completed NVQ training, and there is also a team of ancillary staff. Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Since the last inspection the home has undergone organisational changes and is no longer registered to provide nursing care. This inspection was announced and commenced at 9.30am lasting seven hours. It included observing activity within the home, inspecting the premises, looking at records, ‘case tracking’, talking and listening to residents their visitors and staff working at the home in a variety of roles. The staff on duty were welcoming and helpful throughout the inspection. The newly appointed manager Alison Sumner was in attendance for the inspection, supported by her area manager, and Weston House’s deputy manager. It was obvious a lot of preparation had been undertaken to make sure all information needed was available, and the details the home provided to CSCI (Commission for Social Care Inspection) before the inspection was most worthwhile. A variety of information provided for CSCI confirmed what was seen at the inspection, including the results of a survey where some visiting professionals gave information about their impression of life at Weston House. No written comments were received from residents or relatives on this occasion. As the home is in the middle of a major refurbishment, the focus of the inspection was on the environment to monitor progress with the work, and the safety and well being of people living working and visiting there during this time of change. 22 people were reported to be living at the home at the time of the inspection. Resident accommodation on the top floor has been vacated so that the refurbishment work could continue with minimum disruption to the people living there. On this occasion a total of 24 out of 38 National Minimum Standards were assessed. What the service does well: It was impressive to see that the home had more than met National Minimum Standards for several parts of the service and support it provides for its residents. The home meets the individual personal and health care needs of the elderly people living at Weston House in a desirable manner. This reflects that the staff team have worked together following its company policies to provide a good quality of life for its residents. Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 6 The home offers a wide variety of activities that are suitable for the varying capabilities of residents. Comments received from residents on the day of the inspection were unanimous that the outings in the home’s minibus were popular – there had been four trips organised for the month of June. It was also positive to hear that alternative activities for people who wished to stay in were also planned by the home’s activity organiser, for the care team to be involved in. What has improved since the last inspection? What they could do better: Discussion with the area manger regarding improving medication systems in the home confirmed although many actions had been carried out, there had been a delay in liasion with the GP to carry out some of the issues raised by the CSCI Pharmacy Inspector. This needs to be addressed . Although considerable progress has been made with the refurbishment, the timescales have been a lot slower than were originally planned. CSCI have not been updated with the ongoing progress of the refurbishment lately, and priority must be given to getting refurbishment of bathrooms completed. It is also advisable to ensure that a safety audit of areas where refurbishment has been completed is carried out, to make sure safety features such as radiator guards, call bells etc have been replaced. Attention to the passenger lift also needs to be carried out to ensure residents who are mobile can use this facility safely. There has not been a problem to date with the infection control procedures within the home. But, to improve the level of health and safety for service users and staff and to fully meet the national minimum standard for hygiene and control of infection, the home needs to prioritise several issues with regard Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 7 to storage of clean linen, systems for managing re- usable continence aids, clinical waste and safe management of chemicals in the laundry. As Bedrails were seen in use in the home, employers should ensure that all employees who are responsible for selecting, fitting and checking bed rails have received appropriate training. Other staff, such as care assistants who make beds and help service users in and out of bed, also may remove and replace bed rails. These employees should be given information and instruction in the correct fitting and adjustment of bed rails. This was discussed at the end of the inspection. 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. Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,and4 The home has an admission procedure that is effective in ensuring that individuals moving into Weston House know that the home will meet their needs. Staff individually and collectively have the skills and experience to deliver the care, which the home offers to provide. EVIDENCE: Discussion with a lady who had recently moved into the home confirmed that the home team had got to know what her needs and preferences were before she moved into the home. This involved her coming for a look around, and having a cup of tea and a chat with some people already living there as well as the staff. Her records and those of another three residents looked at showed that all necessary professional assessments had been routinely carried out. Observations and discussions with residents, staff, and home management team indicated that the home meets the individual needs of the elderly people living at Weston House in a satisfactory manner. Several comments received from residents confirmed this. One gentleman who invited the inspector into his bedroom for a private chat said that the home was the third he had been admitted to and he had finally settled at Weston Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 10 House “ because it is smashing in all respects, good food, kind carers, nice room, - the lot”‘. Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,&9 There is a good, consistent care planning system in place, which confirms residents get the care they need and expect. The staff are sensitive to the individual needs of each service user and meet these in a professional manner. Continued improvements in systems for the management of medication demonstrate the Weston House’s efforts to make sure most arrangements are in place to meet all residents’ medication needs. EVIDENCE: The care plans of three residents at the home were looked at, including one of a resident who had recently been admitted to the home. Residents health, personal and social care needs were seen to be set out in appropriate detail in their records to give a full picture of the way the person prefers them to be carried out. Some very easy to understand forms were seen to be in use to enable the residents to be fully involved with their care plans if they made the choice to do so. The records were maintained to a very professional standard and were full of information which was cross referenced to make sure anyone reading it knew Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 12 exactly how to safely care for that person. It was noteworthy to comment that all of the care plans looked at had good examples of care plans for mouth care. In the way the information was laid out, it was clear to see when people were referred to see any health care professionals such as the doctor or a specialist. At the inspection in November 2004, a CSCI specialist pharmacy inspector had an in depth look at how the medication systems in the home were managed. As a result 16 statutory requirements were made for this issue. It was positive to see the staff have worked hard to meet the requirements, and as a result 10 of these had been fully met, and the home was already taking action to completely meet the others, including the repair of a faulty thermometer on the drug fridge. Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13,14 &15 Full involvement with individuals living at the home raises staff awareness to promote choice and control over their lives wherever possible. Meals at the home are of a good homely type offering both choice and variety and cater for special dietary needs EVIDENCE: It was seen that individuals were encouraged and empowered as far as it was practical to maximise their independence and be involved in choices about all daily activities in the home. Weston house has its own minibus and employs a full time activity organiser, who ensures peoples needs and interests are explored. A notice board details up to date information about the range of activities that are available for residents to take part in if they choose. All activities listed appeared appropriate for the residents within the home. Discussion with residents confirmed that the outings were very popular, and there had been four trips out in June, including a visit to Endmondely Gardens. It was positive to hear that there were always alternative activities laid on for residents who did not want to go on the trips out. This shows the home has a team approach to keep people involved and stimulated in pastimes appropriate to their wishes. Three residents spoken to said that the choice and meal quality was of a good standard. Cloths seen on trays used to serve meals enhanced their Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 14 presentation. The menus provided for inspection were seen in use in the home, and were user friendly with their colour co-ordinated layout. The clear wording made sure residents knew what choices were available for breakfast, lunch, evening meal and supper. A resident commented that one of the reasons they enjoyed the food was because a lot of it was freshly home made. Dining facilities had been reallocated to part of a lounge area whilst the dining room is being upgraded, and residents spoken to do not find this an inconvenience as a short term arrangement. Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: The details to assess this part of the inspection were not collated on the occasion of this inspection. Please see the Inspection reports of 7th June and 16th November 2004 when the standards were met. Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25, &26. Progress with the ongoing refurbishment continues to improve the living environment within the home. All necessary works have been identified and are in hand. Interim measures until its completion ensures residents have a clean, safe, comfortable and homely place to live. EVIDENCE: On the day of the inspection it was seen that workmen from a variety of trades were engaged in the home upgrade. A lot of equipment was seen already delivered on site awaiting installation. Although progress has been a lot slower than anticipated, and the Area Manager described many of the challenges encountered which were out of the home’s control, the home management plans have made sure that disruption has been kept to a minimum for the people living there. The top floor accommodation has been completely vacated in order to progress with the interior refurbishment. It was seen that one of the bathrooms had been upgraded, however, the deterioration in the condition of a bathroom that was still in use was no longer acceptable to continue to use. Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 17 It was agreed by the area manager and home manager that the use of this bathroom would cease with immediate effect. Good progress was seen to improve the lighting in the home. Although a written programme of the maintenance works was not available, knowledgeable staff pointed out these changes during the home tour, and it was confirmed that the dining room lights remained to be renewed. As the refurbishment project had not been completed, it was seen that the provision of all necessary hand washing facilities and the laundry had not yet been carried out. A lot of the residents bedrooms were seen to be completely refurbished and many residents expressed their satisfaction in the décor, new carpets and furniture. However, it was seen that in a bedroom on the ground floor which was reported to have been upgraded, that its radiator guard had not been replaced. Another bedroom seen did not have a call bell attachment plugged into the wall. Discussion with one lady who had recently moved into the home gave the inspector the impression that the staff had welcomed her and made sure her room was the way she wanted it, and that one of her favourite chairs from home was located in the communal lounge as she had requested. She was not able to recall if she was offered a key for her room. During the tour of the home it was agreed that linen cupboards needed to be relocated in order to promote infection control standards, especially the one located within a toilet area. It was also agreed that a communal stock of continence pants be disposed of, and for clinical waste bins to be foot operated and located away from clean storage areas such as linen cupboards. Upon visiting the laundry, it was seen that there was an excessive stock of chemicals, which needed to be relocated for safe storage. Furthermore, two food freezers were seen to be located in the cupboard allocated for chemical storage. Although gloves and aprons were provided for staff to use, a container labelled with the name of a liquid soap did not contain it. These issues were discussed in depth with the area manager at the time of the inspection and she took immediate action to make sure immediate permanent changes were carried out. When the passenger lift was used it was seen that the carpet had worn and posed as a trip risk, and that there was no handrail for residents to hold onto whilst it was in motion. The home was last visited by the Environmental Health Department in September 2004 which was satisfactory. Throughout the extensive tour of the home, it was seen that despite the ongoing building works, the home was spotlessly clean. This shows that thorough day to day systems are taken seriously by the staff at Weston house to keep it clean, tidy and safe in all areas that the residents have access to. Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 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 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 , 29 and 30. Residents are supported by a well trained and committed staff group who are meeting the needs of each individual in a sensitive and professional manner. EVIDENCE: The staff rotas on display and staff on duty at the time of this inspection indicated that adequate numbers and skill mix of staff are on duty at all times. The rotas were very clearly presented and easy to understand to show the roles and responsibilities of who was on duty for 24 hours a day. It was commendable to hear that the home did not use agency staff, and despite the major upheaval of the refurbishment, and organisational changes within the home there had been a relatively low turnover of staff. Five sets of staff records looked at confirmed that the home has a robust recruitment process. The home employs some overseas staff via an agency, however, it was pleasing to see that personnel checks are fully validated by Golbourne Care themselves to ensure they employ appropriate people. Information provided by the home and records seen whilst at Weston house confirmed that there has been a great improvement in the way staff training is carried out. The appointment of a training officer for the company earlier in the year has resulted in a more effective system to make sure the staff get the training they need to look after the residents currently living at Weston house. This is monitored by the use of a training matrix. Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 19 Over 80 of the care team are qualified up to NVQ level 2. A detailed workbook designed and researched by the area manager to fully comply with training recommended by Skills For Care UK is issued to all new employees to make sure they get off to a good start to working at Weston House. Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 20 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, 36, 37 and 38 The home has a competent provider who has ensured the staff team have been properly managed and supervised during recent management changes. Health, safety and welfare of residents, staff and visitors continue to be maintained, improved and adjusted to make sure safe working systems already in place meet the changing needs as they arise during the ongoing refurbishment project. EVIDENCE: Although the home has been subject to a lot of reorganisation, and some concerns were expressed about this by a social worker, it was seen that the monitoring and support of the area manger during the times of change had made sure the home was managed satisfactorily. After discussions with staff and looking at their records, it was seen that all levels of the care team are appropriately supervised on a regular basis. Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 21 Discussions with the newly appointed manager confirmed her awareness of responsibilities in order to effectively manage Weston house through the ongoing months of change. However, the efforts and hard work by the previous manger have already established good systems within the home. All records and service certificates to make sure the home fully complied with health and safety legislation were seen to be satisfactory. It was obvious that a lot of effort had been made by the previous manager at the home to ensure regular necessary recordkeeping had been carried out. It was noteworthy to comment that the safe working practices in the home were enhanced by the use of excellent accident statistic monitoring which was the manager’s responsibility. This made sure the staff had the awareness to make as many accidents preventable as possible. It was reported that as a result of such monitoring, more staff were now rostered on duty in the early evenings to offer more support to the current residents of Weston House. It was confirmed that a visit from the fire officer was due, as the home was awaiting advice regarding building changes as a result of the refurbishment. When the issue of residents own furnishings being placed in communal areas was discussed, it was confirmed that the home needed to ensure a system was needed to risk assess this issue. Shortfalls reported about the storage of chemicals earlier in the report confirm that further staff awareness of these needs to be reinforced. Although standard 37 was not assessed fully, some shortfalls regarding recordkeeping will be met when other standards including those for medication have been met. As Bedrails and protective padding was seen in use in the home, it is also recommended to include maintenance of bed rails in the records for routine checks of equipment and health and safety audits. This was discussed at the end of the inspection. CSCI look forward to reviewing future records to confirm successful completion of all works identified at previous inspections have been carried out once the refurbishment of the home is complete. Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 22 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 x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 2 1 2 3 3 2 2 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x 3 x x x x 2 2 Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 23 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 OP9 Regulation 13(2) Requirement When amendments to individual entries on the MAR charts need to be made, the existing entry must be discontinued and a new accurate entry added. (With immediate effect timescale of 5th January 2005 not met) Products that have a short shelf life when opened must be dated upon opening and discarded at the appropriate time. (With immediate effect timescale of 5th January 2005 not met) Service users medication once finished with must be discarded and not kept for general use for other service users. (With immediate effect timescale of 5th January 2005 not met) All medication must only be administered to the service-user it was prescribed for. (With immediate effect timescale of 5th January 2005 not met) Timescale for action With immediate effect 2. OP9 13(2) With immediate effect 3. OP9 13(2) With immediate effect 4. OP9 13(2) With immediate effect Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 24 5. OP9 13(2) 6. OP9 13(2) 7. OP19 16 (1) 23 (2)(b) 8. OP19 23 (4) 9. OP19 16 (1) 23 (2)(b) 10. OP21 16 (1), 23 (2) (j) 11. OP21 23 (2)(j) The maximum and minimum temperature of the fridge must be recorded on a daily basis to ensure that the fridge temperature is maintained at between 2 and 8 degrees centigrade.The fridge thermometer must be operational at all times. (With immediate effect timescale of 5th January 2005 not met) Any verbal requests by GP’s to alter service users medication must be confirmed in writing before the request is undertaken. (With immediate effect timescale of 5th January 2005 not met) A programme of routine maintenance and refurbishment must be available for inspection at all times. (Previous timescale of 20/12/04 not met) With regard to interconnecting doors, the home must consult with the Fire and Rescue Service to ensure that fire safety measures and evacuation procedures are in line with current requirements. (Previous timescale of 28/2/05 not met) The homes planned refurbishment and redecoration must be expedited and timescales forwarded to the CSCI. (Previous timescale of 20/12/04 not met) All of the bathrooms in the home must be refurbished and redecorated as a priority. (Previous timescale of 31/1/05 not met) The use of the ground floor bathroom must cease until it has been fully refurbished and the bath and its aids are readily cleanable. With immediate effect With immediate effect 31/12/05 30/11/05 30/11/05 31/12/05 With immediate effect Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 25 12. OP25 23(2)(p) 13. OP25 23 (2)(a,c) 14. 15. 16. OP26 OP26 OP26 13 (3) 13 (3) 16 (2)(k) Lighting throughout the home must be domestic in character. (Previous timescale of 31/1/05 not met) The home must adopt a system to ensure safety audit of each bedroom as it is refurbished to ensure all safety features such as radiator guards have been replaced. The use of communal continence pants must cease. Clean linen stock must be stored in designated clean areas. Clinical waste bins in use in the home must be foot operated and located in designated areas to minimise cross infection. Staff must be provided with suitable hand washing facilities in the close vicinity of any sluices. (Previous timescale of 31/1/05 not met) The home must ensure that the plastic coated surfaces of assisted bathing equipment remain intact to facilitate adequate cleaning. (Previous timescale of 31/1/05 not met) The home’s laundry must have wall and floor coverings which are readily cleanable (Timescale of 28/2/05 not met) The flooring of the passenger lift must be made safe from trip risks. A handrail must be provided to maximise safety for service users. Staff awareness must be raised to ensure all chemicals are used and stored in accordance with COSHH legislation. Freezers for food storage must not be located in chemical storage areas. 31/01/06 30/11/05 With Immediate effect 30/11/05 31/12/05 17. OP 26 13 (3) 31/12/05 18. OP26 13 (3) With immediate effect 19. OP26 13 (3)23 (2)(b,c) 23 (2)(,c) 23 (2)(,c) 18 (1)(c ) 31/12/05 20. 21. 22. OP38 OP38 OP38 With immediate effect 31/12/05 31/12/05 23. OP38 13 (6) 30/11/05 Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP22 Good Practice Recommendations It is recommended that the refurbishment of the home includes a re-evaluation of the ergonomics of some ensuite facilities, to ensure safe access by individuals using mobility aids and equipment. It is recommended that written authorisation for the administration of Homely Remedies, which is specific to each service user, be obtained from the service users General Practitioner. It is recommended that the GP be asked to carry out medication reviews as recommended by the National Service Framework for Older People. It is also recommended that the details of the review be recorded in the service users care plan. It is recommended to be mindful of Regulation 18(1)(a). Provide training appropriate for staff who who are responsible for selecting, fitting/using and checking bed rails. It is recommended to include maintenance of bed rails in the records for routine checks of equipment and health and safety audits. 2. OP9 3. OP9 4. OP38 5. OP38 Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn SHREWSBURY SY2 5DE 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 Weston House E56 S59419 Weston House AI V207366 290605 Stage 4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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