Inspection on 08/03/06 for Yercombe Lodge

This inspection was carried out on 8th March 2006.

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

Yercombe Lodge 01/10/08

Yercombe Lodge 04/10/06

Yercombe Lodge 06/06/05

Yercombe Lodge 12/01/05

Yercombe Lodge 29/07/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Yercombe Lodge Stinchcombe Dursley Glos GL11 6AS Lead Inspector Bernard McDonald Unannounced Inspection 8th March 2006 08:45 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 Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 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. Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Yercombe Lodge Address Stinchcombe Dursley Glos GL11 6AS 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) 01453 542513 yercombe@btopenworld.com Yercombe (Gloucestershire) Trust Mrs Angela Kathleen Turner Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11), Physical disability (11), Physical disability of places over 65 years of age (11) Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th June 2005 Brief Description of the Service: Yercombe Lodge is an Edwardian property that has been sympathetically adapted and extended to provide accommodation for long-term and respite care for older people over 65 years and for anyone over the age of 18 with a physical disability. The home does not provide nursing care. All bedrooms are pleasantly decorated and comfortably furnished; four have en-suite facilities. The home is equipped with three assisted bathrooms and one of these includes a shower. The home provides additional aids to assist service users and a shaft lift provides access to the first floor. Comfortable and spacious communal areas are located on the ground floor, all of which have the benefit of extensive and attractive views over the surrounding countryside. A small kitchen has been provided on the first floor for service users to prepare their own breakfast if they choose. The home has large landscaped gardens that may be enjoyed by the service users in good weather. Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven and a half hours. The inspector viewed all communal areas and all service users bedrooms that were resident at the time of the inspection. The inspector met with five service users some in private and some in small groups to obtain their views of the care they receive. The inspector met five support staff in private and spoke to one visitor. Other support staff were spoken to more informally during the course of the inspection. The inspector also spent time with the manager and deputy. The inspector examined all care plans and risk assessments and a sample of records relating to the recruitment of staff. In addition policies and procedure to ensure the safety of service users were examined. Feedback was given to the manager on the preliminary findings of the inspection. What the service does well: What has improved since the last inspection? Improvements have been made to the décor in the corridors and bedrooms of the respite unit. In addition new double-glazed doors and windows have also been fitted in this area. These improvements have been made to ensure service users have a comfortable environment for their stay. The manager reported the windows needed replacing to stop the draughts in service users bedrooms. Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 Page 6 Improvements been noted to the recording of meals served at the home. This ensures any alternative meals provided to service users are recorded and demonstrates the service user is receiving a balanced and nutritious diet. What they could do better: This inspection report has identified eleven requirements and ten recommendations on areas that could be improved at the home. The home needs to improve service users care plans to ensure they fully reflect their needs. Care plans were brief and did not clearly specify the action required by staff to meet the needs of service users. In addition the inspector found care plans were not being reviewed as regularly as they should. Risk associated with the care of service users were not being reviewed. The inspector found some service users had risk assessments completed while others had none. The inspector was concerned to find that following a fall the service users risk assessments had not been reviewed. The purpose of such a review would have enabled the home to identify any action that could be taken to reduce the risk of the service user from falling again. The recording of medication given to service users was poor. There were a number of gaps in the recording of medication given to service users, which could not be explained. The inspector could not determine whether service users had received their medication. Written entries in the medication administration sheets did not specify the time and dose of the medication or how it should be administered. This practice puts service users at risk. The home needs to urgently improve the recruitment procedures and ensure a satisfactory Criminal Records Bureau check is obtained by the home prior to any new staff commencing work. Failure to complete these checks puts service users at risk. Since the last inspection the home has reduced the number of staff on duty in the morning. This has impacted on the quality of care provided to service users. Service users commented that staff are always busy. Staff also confirmed they now have less time to spend interacting with service users. Consideration should be given to returning to the previous staffing arrangement for the benefit of service users. The Commission is concerned to find the home has failed to meet two requirements from the last inspection. Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 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. Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 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 Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 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 the following standard(s): 3, 6. The manager ensures no service users are admitted to the home without first having their needs assessed. EVIDENCE: No long-term service users have been admitted since the last inspection. Previous inspections have found the manager is aware of the need to obtain an assessment on the needs of service users prior to admission to ensure the home can safely meet their needs. The manager confirmed all service users are invited to visit the home before making a decision to move in. The home does offer short-term care for a maximum of six service users, however no intermediate care is provided. The inspector examined a recent referral to the home for short-term care. Documentation confirmed an application form and care planning information has been obtained. Copies of the terms and conditions of service users stay in the home were held on individual files. Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9. The home is failing to ensure service users care plans fully reflect the care they need. Risks associated with the care of service users are not being considered as part of the care plan and puts service users at unnecessary risk. Significant improvements are required in the recording of medication administered to service users. EVIDENCE: The inspector examined the care plans of five service users who are permanently resident at the home. Records show that not all care plans are being reviewed as frequently as they should. Care plans provided brief information on areas of personal care and what action was required by staff to meet the needs of service users. A requirement was made at the last inspection regarding the need to personalise care plans to clearly specify what action was required by staff to meet the needs of service users. The inspector found this requirement had not been met. Care plans still contained statements such as “bathing, assistance needed” or “dressing, supervision required”. This information is not sufficient to ensure the needs of service users are consistently met in the home. Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 Page 11 Fluid and food charts had been started for three service users. Care plans and daily notes contained no reference to the chart and care plan reviews that had been conducted stated “no change”. Discussion with the manager confirmed the charts were implemented at the request of the district nurse. Information for staff on the implementation of the charts was recorded in the staff message book. Discussion with staff demonstrated a commitment and understanding of the needs of service users. It is evident they raise concerns regarding the welfare of service users but these are not recorded as part of the care plan. A recent example is where one service user is wandering and becoming increasingly confused. The inspector found that no risk assessments had been completed or their care plan updated to ensure the service users safety. The inspector found one service user who had a recent fall had no risk assessment completed following the incident to ensure steps are taken to reduce the risk of this happening again. The inspector found some service uses had risk assessments while others did not. Service users were however very complimentary about the care provided. One service user stated, “ They (staff) are very good”. Another service user stated, “The care is excellent”. Service users also commented on how busy staff are. One service user commented they “felt sorry for the staff” because they were so busy. Discussion with staff confirmed since the reduction in the number of staff on duty in the morning they are having difficulty in meeting the needs of service users. This can result in service users being left on their own for long periods when two staff are required to assist one service user with washing and dressing. Staff did comment that the manager would assist at peak times when asked. There is evidence to demonstrate service users are supported to manage their medication. Two service users currently self-administer their medication. Risk assessments have been completed to ensure their safety but these had not been reviewed in the past year. Secure facilities are provided in service users rooms to safely store their medication. Discussion with staff confirmed training has been provided in the safe handling of medication. However records examined showed gaps in the records of medication administered to service users. The inspector could not determine what medication had been administered or whether medication had been refused. There were written entries on the medication records that did not specify the time or frequency medication should be administered. For example one service user had a cream prescribed and recorded on the medication sheet. There were no entries to demonstrate whether this medication had been given. Discussion with the manager confirmed the service user did not use the medication and it should not have been recorded. Another medication record had recorded eye drops required but there was no indication over the frequency, amount or which eye required the drops. These errors were brought Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 Page 12 to the attention of the manager so that immediate action could be taken to improve the handling of medication at the home. A separate record is kept of medication received at the home, which is checked and signed by two staff. Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 15. The home is providing opportunities for service users to satisfy their social and recreational interest though the frequency is dependent on the availability of staff. Every effort is being made to support service users in maintaining contact with people who are important them. The home is striving to ensure service users are provided with a wholesome and nutritious diet. EVIDENCE: Information on weekly activities is on display at the entrance to the home. Discussion with service users confirmed activities do take place but not always. On the day of the inspection staff were observed engaging service users in a memory game. However staff stated that when there are more service users at the home they do not always have time to organise activities. One service user who was attending on a day care basis stated, “ I sit here like a sack of potatoes with nothing to do, there is just not enough staff now”. There were no records to show if service users have been consulted about the choice of activities in the home and it is recommended this is done to ensure activities on offer are suited to the needs of service users. On the day of the inspection a “pet therapy” dog was visiting the home. This was a service residents appeared to enjoy. Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 Page 14 The manager stated there is an open door policy for visitors to the home. The relative of one service user confirmed this practice and stated they can “drop in” at anytime. Service users can meet with visitors in one of the communal living areas or in their private bedroom. The inspector observed part of the lunchtime meal. The meal time was relaxed, unhurried and was more of social occasion where everyone including staff sat down for the meal. Where services users required assistance with their meal this was provided in a discreet and sensitive manner. Staff were observed offering choices to service users over what they wanted to eat. The records of alternative meals provided to service users have been improved since the last inspection Service users were very complimentary about the standard and quality of meals proved in the home. One service users stated the “food was wonderful”. Another service user stated the “food is good”. Discussion with the cook confirmed service users likes and dislikes are recorded. Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 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 the following standard(s): 16,18. The home is making every effort to ensure service users concerns are listened to and they are protected from abuse. EVIDENCE: The home has complaints procedure, which includes the name and address of the Commissions office in Gloucester. An abbreviated version of the complaints procedures is held in the service users guide. The procedure specifies that any complaint will be responded to in writing within fourteen days. The manager confirmed no complaints have been received since the last inspection. Discussion with service users confirmed they would speak to the staff or their relatives if they were unhappy or had a complaint. One service user confirmed they, “felt safe” in the home. Another service user commented they had, “nothing to complain about”. The home has an adult protection policy and a copy of the Department of Health “no secrets” guidance. Discussion with staff demonstrated a good awareness of the action they would take to raise concerns about the welfare of service users. The manager stated that the majority of staff have completed “in house” training on abuse awareness. A whistle blowing policy is in place to support staff should they raise concerns about the care of service users. Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 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 the following standard(s): 19, 24, 26. The home provides service users with a comfortable, clean and wellmaintained living environment. EVIDENCE: The inspector viewed all communal living areas and the bedrooms of all service users who are permanent residents. In addition a sample of bedrooms used for respite care were looked at. Following a requirement made at the last inspection the home has fitted a number of fire safety self closure devices on service users bedroom doors and communal areas. The manager stated the remaining work on the four doors leading from the communal areas should be completed soon. Discussion with staff confirmed they are now finding it much easier when passing through with wheelchairs and hoists. Service users are able to move more freely through these areas, which enables service users to access areas independently. Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 Page 17 Service users and a visitor spoken to at the inspection were very complimentary about the standard of accommodation. The inspector found the home was clean, tidy and free from any offensive odour. The home has recently decorated the main lounge and dining area. In addition new double-glazed windows and doors have been fitted to all respite areas on the ground floor. All service users benefit from single bedroom accommodation. One service user commented they had been able to bring a lot of their personal furniture for their room. Bedroom doors have been fitted with suitable locks to allow access to staff in the event of an emergency. Discussion with service users confirmed these locks are very seldom used. To ensure service users are protected from the risk of burning, radiators have been guarded and hot water is regulated close to 43c. The laundry room is situated on the ground floor well away from any food preparation area. Service users were complimentary about the laundry service and reported their laundry is promptly returned after being washed. The home has a commercial washer and dryer and there is a separate sluice area adjacent to the laundry room. Staff confirmed they have received training in infection control. Staff confirmed soiled linen is separated from the main wash, however to further reduce the risk of infection it is recommended that the home purchase “red alginate” bags, so soiled or infected laundry can be placed directly into the washer. Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29. The reduction in staff numbers is impacting on the quality of care provided to service users. The home is failing to ensure safe recruitment practices are followed. EVIDENCE: Since the last inspection the Trustees have reduced the number of staff on duty in the morning from 4 to 3. This has clearly impacted on the quality of service provided at the home. Service user comments such as, “staff are always busy”, and, “ I feel sorry for the staff,” is an indicator that there is insufficient staff on duty. Discussion with staff confirmed there is limited time to spend with service users when more dependent service users are admitted for respite. The staff confirmed that the manager would help out when asked but they try to manage. The manager stated that more consideration is being given to the needs of service users admitted for respite but there appears to have been no consideration given to the deteriorating needs of the permanent residents who increasingly need two staff to assist with personal care. Consideration should be given to returning to the previous staff levels. One member of staff has been appointed since the last inspection. Examination of the staffing records show the home had not completed a Criminal Records Bureau (CRB) check prior to the member of staff commencing work. The manager stated she was not aware CRB’s were no longer transferable as they had obtained a copy of a CRB from the staff members previous employment. Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 Page 19 The manager was advised to urgently apply for a CRB and request a POVA first check. The manager was informed the member of staff must not provide any personal care to service users without first receiving a satisfactory CRB and POVA check. Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. The registered manager is struggling to balance the responsibilities of managing the home with the need to provide “hands on care”. The supervision of staff needs to be improved. The home is seeking the views of users of the service but has yet to produce an action plan to address any issues raised. . EVIDENCE: The manager has extensive experience of working with older people having been the manager of the service for over nine years. The manager has successfully completed the registered manager award and has continued to update her professional development by attending a number of mandatory training courses. Since the change to the staff rota the manager stated she has needed to work in a more “hands on” capacity. This has impacted on the time spent on managing the service, which is reflected in the number of requirements made in this inspection report. Consideration should be given to Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 Page 21 ensuring the manager has sufficient time “off rota” to manage the home, provide supervision to staff and ensure the needs of service users are being safely met. At the present time the home was not holding any money on behalf of service users, though facilities are available should this service be required. Following a requirement made at the last inspection the manager has taken steps to review the questionnaires sent out to residents following their stay. The inspector found there was a high level of satisfaction regarding the quality of care they received. A copy of service users completed questionnaires was available for inspection. The manager confirmed there are plans to seek the views of stakeholders over the coming months. A copy of the CSCI last inspection report was available at the home and one visitor confirmed they were aware of the findings of the last inspection. It was a requirement at the last inspection that staff are appropriately supervised. This requirement has not been met. Staff stated they do not receive regular supervision. The manager stated there appears to be reluctance on the part of staff to engage in formal supervision meetings. However in view of the changes to the staff rota and the impact on staff moral the lack of supervision means there is no formal mechanism for staff to share their views on the effect of this change and to discuss the impact on the care to service users. The manager is to implement an annual appraisal system over the coming months and it is hoped this will kick start regular supervision meetings. In view of some progress being made to implement staff supervision the Commission has agreed to extend the timescale for compliance with this requirement. Health and safety records were examined which demonstrated fire safety checks were being completed at the required intervals. Control of substances hazardous to health risk assessments and product information sheets were available at the home. In addition risk assessments on the safety of the environment had been completed and reviewed in the past year. Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 2 STAFFING Standard No Score 27 2 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 X 3 Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The Registered Person must ensure that service users care plans are individualised to meet their needs. This was a requirement at the last inspection. The timescale for compliance was 01/09/05 The Registered Person must ensure that service users care plans fully reflect the care they need. The Registered Person must ensure service users care plans are reviewed each month or earlier if the needs of the service user change. The Registered Person must ensure service users risk assessments are reviewed a minimum of once a year or earlier if the risk to the service users changes. The Registered Person must ensure any risk to service users is identified and a risk assessment completed on the action required to reduce the risk to the service user. DS0000016660.V281896.R01.S.doc Timescale for action 01/05/06 2. OP7 15 01/05/06 3. OP7 15(1)(b) 01/05/06 4 OP7 13(4)(c) 01/05/06 5 OP7 13(4)(c) 01/05/06 Yercombe Lodge Version 5.1 Page 24 6. OP7 13(4)(c) 7 OP9 13(4)(c) 8. OP9 13(2) 9. OP9 13(2) 10 OP29 19(1)(a) (b)(i) 18(2) 11. OP36 The registered Person must ensure that following a fall the service users risk assessment is reviewed. The Registered Person must ensure service users medication risk assessments are reviewed at least annually or earlier if the needs of the service user change. The Registered Person must ensure medication is accurately recorded when it is administered to service users. The Registered Person must ensure medication records clearly specify the time, dose and frequency of medication administered to service users. The registered person must ensure all staff have a CRB and POVA check undertaken by the home before commencing work. The Registered Person must ensure that staff are appropriately supervised. This was a requirement at the last inspection. The timescale for compliance was 10/09/05 01/04/06 01/05/06 09/03/06 09/03/06 09/03/06 01/05/06 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 OP7 Good Practice Recommendations The home should record in service users care plans for example, if one carer is needed for personal care. The tasks the carer needs to perform must be listed. The home should give consideration to reviewing the service users care plan to include information on the service users mental health. DS0000016660.V281896.R01.S.doc Version 5.1 Page 25 Yercombe Lodge 3. 4. 5. 6. 7. 8. 9. OP9 OP9 OP12 YA26 OP27 OP31 OP33 10. OP36 The Registered Person should ensure two staff sign any written amendments to the service users medication records. The Registered Person should provide a refresher course on the safe handling of medication for all staff responsible for administering medication. The Registered Person should seek the views of service users regarding the provision and choice of activities in the home. The Registered Person should consider purchasing red alginate bags for soiled or infected linen. The Registered Person should urgently review the staffing levels at the home. The Registered Person should ensure the manager has sufficient time “off rota” to effectively manage the home. The home should collate the results of service users questionnaires and produce an action plan to address any issues. These should be used as part of the homes quality assurance systems as evidence the home is taking into account service users views. Staff should receive 6 supervision sessions a year. Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Yercombe Lodge DS0000016660.V281896.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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