CARE HOMES FOR OLDER PEOPLE
Woodland Grove Weston Park Bath Bath & N E Somerset BA1 4AS Lead Inspector
Jon Clarke Unannounced Inspection 09:30 29th November & 1 December 2006
st 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 DS0000008163.V321086.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. DS0000008163.V321086.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Woodland Grove Address Weston Park Bath Bath & N E Somerset BA1 4AS 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) 01225 464004 01225 426501 TinaDavis@anchor.org.uk susan.austin@anchor.org Anchor Trust Tina Alison Davis Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places DS0000008163.V321086.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. May accommodate up to 42 persons aged 65 years and over requiring personal care only. 26th January 2006 Date of last inspection Brief Description of the Service: Woodland Grove is a care home for older people owned and managed by Anchor Trust Foundation and provides accommodation for up to 42 residents. The home is a converted older property, which has been extended and adapted to provide residential care within individual flats. Each flat has a bed sitting room, small-integrated kitchen and en-suite bath or shower, basin and toilet. There is a large communal lounge, which can be divided into two rooms and a dining room with direct access to the patio seating area. There is lift access to all parts of the home. The home is set in extensive gardens and located in the Weston area of Bath within easy reach of the town centre and local amenities. Fees are £500 per week inclusive of all care and facilities in individual’s flats, not including community health services. DS0000008163.V321086.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an announced inspection was took place over two days. The inspection focused on areas which had been identified at previous inspection and arose from concerns as to the quality of service being offered in the home. Specifically there had been failings in maintaining care plans and the recording of information. In addition because of staff changes and vacancies along with low morale the care provided to residents was not of the standard required and residents had spoke of their unhappiness and lack of care being provided. Since the previous inspection a new manager has been appointed and action had been planned to address the failures identified. This inspection was to look at whether the level of care, staffing and other areas of practice had indeed been addressed and improvements made. As part of this inspection it was arranged with the manager that a residents meeting and staff meeting would be held so that the inspector could have a more formal opportunity to discuss with residents and staff their views of the quality of care and care practices in the home. Throughout the inspection there was opportunity to talk informally with residents and staff. A number of records were looked at including assessments, care plans, recruitment and selection, training and those relating to health and safety practice in the home. Pre-Inspection questionnaires “Have your Say” were sent to residents and Comment Cards were also sent to relatives and professionals. There was a poor response from residents with only 4 responses; however 17 responses were received from relatives and professionals. This inspection was also used to look at a number of specific areas as part of the Commission’s themed inspection arrangements. These were: information provided to residents specifically Service Users Guide, Complaints Procedure, Contracts and Pre-Admission assessments. Three residents were identified who were able to discuss the home’s practice in these areas. What the service does well:
It was evident throughout this inspection that there has been a significant effort to address the concerns raised from previous inspection. The appointment of a new manager along with deputy and recruitment of care staff to the point where there is now a full complement of staff other than one weekend vacancy has resulted in improved morale. As one resident said “the atmosphere is so much better”; another “its changed for the better” “its
DS0000008163.V321086.R01.S.doc Version 5.2 Page 6 happier here then it used to be”. Staff spoke of “more stable group”, “getting it right”, “learning to work as a team, bonding quite well”. Care practice is improving and there is now a sense that staff are informed about the needs of residents in a more thorough way and have a real sense of their needs. In observing the interaction between staff and residents it was noted that staff were sensitive to individuals behaviours, patient and attentive. Residents spoke of staff as being “very caring” “always helpful” and one resident though critical of “all the staff changes” also said “its better now then it used to be, not so many different staff all the time (this was in relation to the previous use of high number of agency staff). Relatives’ comments highlighted the positive change: “general improvements at the home over the last 8 months; prior to this (Jan 06) was not satisfied with number of staff on duty or care/attention offered/feedback. I am pleased to say that things have improved and the family are much more satisfied with level of care and attention provided.” “Recent changes to management and staff have been welcome”. One area of real improvement is that of activities with the appointment of a activities organiser. Residents spoke of “more to do” and how the organiser was “getting things going, more entertainers”. A relative commented “the improvements to the recreational activities will be a major advance if it can be sustained”. In looking at areas which were part of the themed inspection, it was noted that the residents who were asked about information they had when coming into the home were generally well informed. Contracts had been issued and these were of a high standard in giving the terms and conditions of living in the home. Assessments of need had been completed though this would benefit from improvement in providing more detail about the personal circumstances of the individual. What has improved since the last inspection?
In addition to the comments above a real improvement is the environment of the home. There has been major re-decoration of communal areas of the home resulting in a more warm, homely and inviting environment. A number of residents commented that they found the environment “much better” “not so dark, brighter”. The dining area has been improved with new carpeting and new furniture in lounge though residents commented that for some residents it was not suitable and this was recognised by the manager who is hoping to purchase further seating. DS0000008163.V321086.R01.S.doc Version 5.2 Page 7 Requirements from the previous inspection have to some extent been addressed with improved practice in care planning though there remain gaps in practice. The manager advised that new formats are being introduced and staff will be receiving training. The inspector felt that whilst there is a real commitment from the manager to improve practice in this area there was a reluctance to fully address the shortfalls with the new care plan due to be implemented. As noted in the previous section of this report a major improvement is that of staffing arrangements in the home. There is now an instruction from Anchor Housing that agency staff are not to be used. Whilst this is welcomed, and there were real difficulties when this was implemented, such instruction should not lead to a failure to have the necessary staff on duty. There were a number of comments received from residents and relatives about what was perceived as “staff shortages” “main problem lack of staff”. In the inspector’s view with the current level of occupancy and care needs there are adequate staff; however this must be continually reviewed. What they could do better:
Recognising the significant improvements there remain a number of practice areas identified from this inspection which must be addressed. Care Plans had a number of gaps: weight monitoring was not consistent, personal profiles were not always completed fully, reviewing of care plans was not undertaken on a regular basis and wishes on death of resident was not recorded. Medication administering records had not been completed on a number of occasions raising concerns about how rigorous staff are at ensuring residents receive the medication they have been prescribed. The management of medication stocks must be more effective so that medication is used at the appropriate time and risk of administering expired medication is removed. Staff would benefit from more specialised training about the needs of older people and specific conditions e.g. Parkinson Disease, Diabetes, Strokes, and Managing Continence. From looking at the home’s practice around complaints information, it would improve residents’ awareness of their right to make a complaint and how to do so if the complaints procedure was issued as separate document to the Service Users Guide and also displayed more prominently in the home. DS0000008163.V321086.R01.S.doc Version 5.2 Page 8 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. DS0000008163.V321086.R01.S.doc Version 5.2 Page 9 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 DS0000008163.V321086.R01.S.doc Version 5.2 Page 10 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): 1,2,3,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for admitting residents to the home are good so that individuals have all the information they need to make a choice about choosing Woodland Grove as their home. Pre-admission assessments are undertaken to provide information about care needs so that the home can make an informed decision about their ability to meet those needs. Contracts provide the necessary information to individuals or their representative so that they are fully aware of the terms and conditions of living at the home. DS0000008163.V321086.R01.S.doc Version 5.2 Page 11 EVIDENCE: Residents confirmed that they had all received a copy of the service users’ guide when they were admitted to the home. Included is information about the service residents can expect when living in the home such as meal arrangements, facilities available and the care and services they can expect to receive. Also included is how to make a complaint and how it will be responded to though timescales of response are not stated. Residents identified as part of the “themed” inspection were able to confirm they had all received and had a copy of the home’s contract. Residents’ files contained a signed copy of the contract. The contracts give clear and detailed information about the terms and conditions including: service information ie fee inclusive of all care, meals, laundry, maintaining of shared facilities and fitting and furnishing not owned by the individual. In addition how extra services such as hairdressing, chiropody can be arranged and what happens about fees if the individual is away from the home or on their death. Other information in residents’ contracts are about policies and procedures of the home ie Access to your room, Complaints, Fire regulations and smoking, Gifts and tips, medication, personal belongings and furniture. Payment arrangements are set out including how fees are reviewed and weekly charge. There is also information about how the individual or home can end the contract. It is to be commended that Anchor Trust has taken account of the guidance in the Office of Fair Trading report “Fair terms for Care in care homes for older people in the United Kingdom” (2004). This has resulted in a document which accurately and fairly states the terms and conditions of residency. Those pre-admission assessments of need sampled showed full and detailed information about the health and social care needs and personal care tasks required by the individual. Included is a section Social History providing information about the likes/dislikes/hobbies (past and present), personal care and physical well-being. Information about Medication, dietary requirement and financial situation of the individual is also included. In talking with residents about their experience of coming into the home they spoke positively of how they were given “all the information I needed”. One spoke of how a member of staff had visited her at home another how someone had spoken to them and her son about the “help I needed”. All confirmed they had visited the home before deciding to come into the home, one individual DS0000008163.V321086.R01.S.doc Version 5.2 Page 12 had been in the home on a previous occasion for respite this had given them “opportunity to see what it was like”. DS0000008163.V321086.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. Whilst there has been real improvement in care planning practice there remain areas which need addressing so that care plans accurately reflect the needs and situation of the individual and so that staff have the necessary information to provide the care and attention to residents of the home. The home has good arrangements for meeting the health needs of residents. Management of medication must be improved to make sure residents receive their prescribed medication and their health needs safeguarded. The practices of the home help to make sure that residents are treated with respect and their rights upheld. DS0000008163.V321086.R01.S.doc Version 5.2 Page 14 EVIDENCE: A number of care plans (5) were looked at and showed the care tasks required though reviewing of individual’s needs was not taken place on regular basis. Risks assessments had been completed as were moving and handling assessments. There were gaps in the recording of individual’s weight in two instances no record of weight on admission or since had been recorded. Not all had been signed by the resident to evidence their involvement. There is no information about the wishes of the individual on their death. Social history is included in care plans helping to provide a picture of the resident’s life, interests, occupation and important relationships. Health care needs are met through the providing of community-based services such as community nursing. Chiropody, optician and dental treatment are provided on a regular basis. Where there are concerns about an individual’s mental health the home contacts through the individuals G.P. mental health services. The administering and storage of medication was looked at and showed significant gaps in the administering records. There was no evidence that for a number of individuals their prescribed medication had been given. Storage arrangements are generally satisfactory with secure storage however stocks of some medication had been held resulting in some being close to expiry date. The home has a number of residents who manage their medication and risk assessments had been completed and their ability to continue had been reviewed. However in one instance no risk assessment had been completed. A pharmacist inspection of 27/09/06 had reported the need for “more attention in signing of administering records, improved stock rotation” and identified that expired insulin was being retained. In talking with residents they spoke of how they felt staff treated “me with respect” when asked in what way one responded “its just how they speak, their patience and understanding” another “they always understand and make me feel alright”. DS0000008163.V321086.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. The arrangements for meeting the social and recreational needs of residents are good and there are opportunities for residents to maintain links with family, friends and the local community. The home’s practice and routines are flexible and enable residents to exercise choice and have control over their lives. The home provides meals which are balanced and which meet the dietary needs of individuals in the home. EVIDENCE: With the appointment of an activities organiser there has been real improvement in the activities available to residents of the home. A questionnaire is being completed with each resident to help in identifying
DS0000008163.V321086.R01.S.doc Version 5.2 Page 16 individuals interests. Individual session of 45 minutes every fortnight will be held and three programmed activities a week. In talking with residents they spoke of how “much better” activities had been and in the resident’s meeting a number of residents spoke very positively about the new organiser and efforts she was making. During the Christmas period carol singing and Xmas fayre was being arranged. Religious services are held in the home. Activities arranged included gentle exercise and movement, clothes show, films. There is also a weekly coffee morning, which the manager attends. There is open visiting to the home and the appointment of a customer services manager it is hoped will address an area of concern raised by the questionnaire. This was that staff particularly seniors were not always available to visitors to the home including professionals. This new appointment will improve how visitors to the home are received. Residents said they their relatives were always they felt made to feel welcome by staff who one resident described as “warm and friendly”. Fourteen of the relatives responding to the questionnaire said they were welcomed in the home by staff. In talking to residents about the routines and flexibility of the home they said they felt there were few routines. One resident said they “could do as we wished” another “its up to me what I do staff understand and say this is your home” When asked about going to bed/getting up they said, “I chose” “its up to me”. One resident who needed assistance particularly in getting up said they “don’t make me feel I have to get up it suits me”. One of the issues discussed at the residents meeting was that of the food and meals provided in the home. There have been changes in catering staff and this had it was felt by some residents resulted in a deterioration in the meals provided. There has been an appointment of a new chef who is due to start before Christmas. However resident also spoke of how recently the meals and food generally had improved: “better then it was” “flavoursome” “always good choice” (on days of inspection there were 3 main choices for dinner) “definitely better, more variety” “very good” were some of the comments made. The inspector joined residents for dinner and the meal was appetising and well presented. Menu looked showed a good variety of meals on offer. DS0000008163.V321086.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. The home has procedures in place to enable individuals to make a complaint and voice their views about the service they receive and to know that they will be listened to and actions taken where necessary. The home makes sure that as far as possible residents are protected from harm by having policy and procedure about the Protection of Vulnerable Adults and providing training to all staff in this area. EVIDENCE: As part of the themed inspection the home’s complaint policy and practice was looked at and residents were spoken with about their understanding and information they had received about making a complaint. The home’s complaint policy is displayed in the home though it could be more prominent. It would also be more helpful if displayed in large print to make it more visible to those residents who have a visual impairment. The procedure fails to give timescales in responding to any formal complaints.
DS0000008163.V321086.R01.S.doc Version 5.2 Page 18 The complaints procedure is made available to residents as part of the service users guide and those residents spoken to about this were not aware of this though knew they could make a complaint. When asked how they would make a complaint responses were “I would speak to the manager” “I would go to the office”. In speaking to residents generally about what they would do if unhappy about something there was a real sense that they felt able to voice their views, this was evident at the resident’s meeting, and they would “be listened to”. The manager clearly makes an effort to encourage an atmosphere which enables resident to say how they feel about the service they receive. A relative in their comment card stated: “I have not had to make a complaint but I have had to express concerns. The home does now respond and you feel that something will be done”. The complaints log was looked at and 5 complaints had been made since the previous inspection. These had all been dealt with appropriately including in one instance the holding of a review where one resident had felt their care needs were not being met. This had resulted in changing the care plan to show more clearly the needs of that resident. Written responses had been made to other complainants to confirm the outcome of the complaint made. The home has a Adult Protection policy and staff have completed Adult Protection training. A member of staff was spoken with about their understanding of abuse and showed a good understanding they were also clear about what action they would take if a resident made an allegation of abuse. DS0000008163.V321086.R01.S.doc Version 5.2 Page 19 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. The home provides a safe and hygienic environment for the residents and staff. Improvements have been made so that the home is able to offer a more homely and welcoming environment. EVIDENCE: At the time of this inspection the home was clean and free from offensive odours. Resident spoke of the home as “always being clean” “I have no complaints my flat is always clean”.
DS0000008163.V321086.R01.S.doc Version 5.2 Page 20 Real improvements have been made with decoration of communal areas of the home that has resulted in these areas being much brighter and attractive. Residents spoke positively of the changes. New seating has been purchased for the lounge though some residents felt it was not really suitable for those residents who had difficulties with sitting and getting in and out of chairs “too low”. This was raised at the residents meeting and the manager recognised that this would need to be looked at and continued improvements are needed. It would also improve the environment if a hearing loop was installed in the lounge to help those with a hearing impairment. DS0000008163.V321086.R01.S.doc Version 5.2 Page 21 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): 27,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements in the home are generally satisfactory so that the needs of residents can be met in an efficient way with care being provided by skilled and competent staff. The recruitment and selection of staff is undertaken to make sure that as far as possible the health and welfare of residents is protected. EVIDENCE: A number of comments were made by relatives and professionals about the level of staffing in the home and concerns that “not enough staff and often seem harassed due to high demands” “staff are very good and do their best but they are under pressure due to staff shortages”. This was discussed with the manager at the time of this inspection who recognised that there had been significant staffing difficulties however there has been considerable improvement in the recruitment of staff with now a full complement of staff. A real improvement is that of not using agency staff. With the current numbers of residents and needs in the inspector’s view there are adequate staff on duty.
DS0000008163.V321086.R01.S.doc Version 5.2 Page 22 Staffing rotas were looked at for a period of 4 weeks and whilst there had been a number of occasions when staffing was not at the normal level overall staffing arrangements were good. Currently there are 4 staff am with team leader and 3 plus team leader pm with waking night staff. There is no change to numbers of staff on duty at the weekend. The manager recognised that if occupancy or needs of residents increase this may mean increasing staffing levels. In talking with residents about the availability of staff they spoke of staff “always there if we want them” “its better then it was”. Staff commented at the staff meeting that they felt “it has got easier” “there’s more staff available”. Recruitment and selection records showed that the necessary checks had taken place ie Criminal Record checks, two references being obtained and application forms provided full and detailed information about applicants including full employment history. Health questionnaires are also completed. Training records showed that staff had completed the required mandatory training: moving and handling, first aid, health and safety, fire. The home is also using BTEC Induction Intermediate Award. Whilst there are other opportunities for staff to undertake training such as NVQ and mental health awareness there are limited opportunities for staff to undertake more specialised training in relation to caring for older people. DS0000008163.V321086.R01.S.doc Version 5.2 Page 23 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): 31,33,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager of the home is making real efforts to encourage an open atmosphere and address the improvements needed so that residents and staff live and work in supportive and caring environment. There are opportunities for residents and others to express their views about the service they receive. The practices of the home help to make sure that the health, safety and welfare of residents and staff are protected. DS0000008163.V321086.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager Ms T.Davis has extensive experience of working in care home, previously working in a local authority home for older people. She has undertaken the Registered Manager’s Award in addition to Adult Protection training and other mandatory areas of training. Residents and staff spoke positively of the new manager: “she is someone we can talk too” described her as “approachable” “can always go to her” “listens to what we have to say”. Importantly she recognises that improvements have been essential in making sure that the quality of care provided in the home meets the required standard. Whilst residents meeting are held regularly and this provides an opportunity for residents to comment on the quality of the care they receive, there have been no formal quality surveys. This was discussed with the manager at the time of this inspection. The manager and deputy have spent considerable time since taking up their positions looking at the policies, procedures and practice in the home. This has entailed improvements being made in recording information, health and safety monitoring and other areas of practice and is to be welcomed. Health and Safety practice is improving with the appointment of a handyman who has taken some of the responsibilities in this area in that they fit with his day-to-day duties and responsibilities. Recording of checks such as emergency lighting, fire equipment, safety systems, environment safety checks and monitoring have all improved. The handyman would benefit from specific Health & Safety training to increase his knowledge and skills and this function should in the inspector’s view remain with this individual who clearly has made real efforts to improve this area of the home’s practice. Records looked at showed that equipment such as lifts, hoists, parker bath have been serviced, Gas Safety certificate issued. Fire risk assessments as well as general environment risk assessments have been undertaken. Fire alarms have been tested weekly and emergency lighting monthly as required by the fire service. Safety Data sheets are available to staff providing information about the safe use of potential harmful chemicals and risk assessments relating to their use have been completed. DS0000008163.V321086.R01.S.doc Version 5.2 Page 25 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 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X 3 DS0000008163.V321086.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. 2. Standard OP7 OP7 Regulation 15 (b) 12 (1) (a) Requirement Ensure Care Plans are kept under review. Ensure that where necessary residents weight is monitored and any appropriate action is taken to make proper provision for the health and welfare of residents. Ensure medication administering records are completed as required. (This refers to making sure that all medication administered is recorded and providing the required evidence that medication has indeed been given to individuals) Ensure safe administration and storage of medication stocks. (This is about the rotating of stocks to remove risk of out of date medication being given to individuals) Ensure the complaints procedure sets out timescale for responding. Ensure staff receive training appropriate to the work they are to perform. (This refers to specialised training about caring
DS0000008163.V321086.R01.S.doc Timescale for action 29/11/06 29/11/06 3. OP9 13 (2) 29/11/06 4 OP9 13 (2) 29/11/06 5 6 OP16 OP30 22 (4) 18 (1) (c)(i) 29/11/06 30/06/07 Version 5.2 Page 27 7 OP33 24 (1) (a) (2) for older people eg Physical conditions such as strokes, Parkinson’s. Health & safety) Undertake Quality assurance questionnaire and provide report to the CSCI of outcome and any actions taken as result of questionnaire. 30/06/07 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 OP16 Good Practice Recommendations Provide copy of complaints procedure as separate document to Service Users Guide. Display copies of complaints procedure in the home that is suitable for individuals who have visual impairment. DS0000008163.V321086.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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
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