Inspection on 18/08/08 for Ealing Manor Nursing Home

This is the latest available inspection report for this service, carried out on 18th August 2008.

CSCI found this care home to be providing an Good service.

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

Other inspections for this house

Ealing Manor Nursing Home 05/12/05

Ealing Manor Nursing Home 21/06/05

Ealing Manor Nursing Home 17/01/05

Ealing Manor Nursing Home 19/07/04

Ealing Manor Nursing Home 12/08/03

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Ealing Manor Nursing Home 5-6 Grange Park Ealing London W5 3PL Lead Inspector Mrs Rekha Bhardwa Unannounced Inspection 12:50 18 and 19 August 2008 th th 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 Ealing Manor Nursing Home DS0000010963.V367946.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. Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ealing Manor Nursing Home Address 5-6 Grange Park Ealing London W5 3PL 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) 020 8840 3490 020 8579 4595 mittal_uk@msn.com Mr Narain Mittal Mr Rajesh Mittal Mrs Lydia Ngusoron Kur Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0), Physical disability of places over 65 years of age (0), Terminally ill (0) Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users to include up to 6 TI and up to 35 in total All Service Users to be over the age of 40 Date of last inspection 9th October 2006 Brief Description of the Service: Ealing Manor Nursing Home is a converted detached house in a residential area of Ealing. It can be accessed by bus, underground and main line train services. The accommodation consists of 27 single and 2 double bedrooms. The main day room has three areas for residents to utilise, plus there is a separate quiet lounge available. There are local shops within 10 minutes walk and the Ealing Broadway Shopping Centre is accessible by bus or a longer walk. Local transport facilities are available in the form of buses and Ealing Broadway underground and mainline station. The home has a designated information board for visitors and this information is comprehensive. At the time of the inspection there were 31 residents accommodated at the home. The fees charged range from £550 to £650, dependent on the assessed needs. Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection carried out as part of the regulatory process. A total of 15 hours was spent on the inspection process, and was carried out by 1 Inspector. We carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 10 residents, 6 staff and 3 visitors were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from residents, staff and health & social care professionals have also been used to inform this report. What the service does well: The home is being effectively managed and the management style promotes an atmosphere of openness and communication. Prospective residents are fully assessed prior to admission to ensure the home are able to meet their needs. Service user plans are well completed and accurately reflect the needs of each individual and how these are to be met. Staff were seen caring for and communicating with residents in a gentle, caring and professional manner. There is excellent interaction between staff and residents and a happy, homely atmosphere throughout the home. End of life care needs and wishes are discussed and recorded to ensure the wishes of the residents and their representatives are respected. There is an ongoing activities programme and evidence of group and individual activities taking place. The home has an open visiting policy and visitors are made welcome. Information regarding advocacy services is available. The food provision at the home is good and offers variety and choice to meet the preferences of each resident. The home has a complaints procedure and residents and relatives were aware of how to make a complaint. The home has procedures in place for safeguarding adults and staff have a good knowledge of these, thus safeguarding residents. The home is being well maintained and provides a clean, homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, minimising the risk of infection. The home was appropriately staffed to meet the needs of the residents and the overall needs of the home. There is a training programme in place, which includes induction training and training relevant to the needs of the residents. Monies held on behalf of residents are well managed. Overall health and safety is being well managed. Some shortfalls identified at this inspection should be easy to address. Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 6 Overall the comments received via the CSCI comment cards were positive. Examples of these are: ‘All the staff are very friendly, kind and great fun.’ ‘Great homely atmosphere.’ ‘I am very happy at the nursing home. I have no complaints.’ ‘Very good home it’s like happy families.’ ‘There are no minuses only pluses here.’ What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. EVIDENCE: The home has a comprehensive pre-admission assessment document that provides a good picture of the resident and their needs. This is completed for all prospective residents in order to ascertain if the home is able to fully meet their needs. Completed assessments were viewed and had been well completed. The home also obtains a copy of the assessment undertaken by social services. We were informed that the assessment where possible is discussed with the resident and their representative. Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 9 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 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service user plan documentation is well completed to provide staff with the information to meet each resident’s needs. Overall Medications are being well managed at the home, however shortfalls identified at this inspection should be easy to address. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The home provides good end of life care, thus ensuring that residents and their families have their wishes and needs fully discussed, recorded and met. EVIDENCE: 3 service user plans were sampled. Overall had been well completed to provide staff with information about each residents needs and how these are to be met. The service user plan documentation had been reviewed monthly and when a residents’ condition had changed. We noted that staff were continuing to Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 10 record very little information within the monthly reviews and this was discussed with the Registered Manager who had already identified this in the service user plan audits. There was some evidence of input from the residents and/or their representatives we suggested that this area be further developed to include all residents. Risk assessments for falls and other identified areas of risk had been completed. Wound care documentation was viewed. Care plans were in place and body charts and photographs of wounds were available plus wound treatment, assessment and dressing record documentation had been completed. Pressure sore risk assessments were in place for all residents and the specific pressure relieving equipment in use for each resident had been identified. Care plans were available on pain management and appropriate analgesia had been prescribed. Moving & handling assessments were in place and the specific equipment to be used for each move had been documented in the moving and handling care plan. Nutritional assessments had been carried out and there was evidence of regular weight monitoring, depending on the residents identified needs. Continence assessments are carried out. There was evidence of input from healthcare professionals to include GP, tissue viability nurse, dietician, chiropodist, optician and dentist. We viewed the medication management for the home. The recording of receipts, administration and disposal was checked and medication audited against the stock held. A list of specimen signatures and initials for staff administering medications was available on each floor. We noted that medicines were being checked when received into the home. There were however inconsistent practices of recording the date of receipts of medication and balances carried forward, and it was therefore not possible to always reconcile the stock held. These shortfalls had been identified in the medication audit undertaken by the Registered Manager. Several of the medication administration records (MAR) were viewed and all those viewed had been appropriately signed for when medication had been administered. Registered Nurses were using the appropriate coding for when residents had refused medication. We noted that some liquid medications did not have the dates of opening recorded. Controlled drugs records were up to date and the register was being completed correctly. Medications are being securely stored in the home. Professional single use lancets are in use for blood glucose monitoring. Records for the disposal of medication were being correctly maintained. Since the last inspection air conditioning has been installed in the clinic room. The medication fridge and room temperatures were within safe range. The clinic room was clean, tidy and well organised. The home has policies and procedures in place for the management of medications and copies are available on the medication trolleys. Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 11 Staff were seen caring for residents in a gentle, caring and professional manner and excellent interaction between residents, relatives and staff was observed on both days of the inspection. Bedrooms had been personalised and there was a very homely feel throughout. Personal clothing is labelled with either the residents name or room number and residents were dressed to reflect individuality. On the first day of the inspection all bedrooms were being installed with a telephone for the use of the resident. The home has attained accreditation in the Gold Standard Framework for palliative care. Care plans viewed for end of life care were personalised and reflected the wishes of residents and their families, so that these can be respected. The Palliative Care Team in Ealing are providing training for the registered nurses in medication management and other topics relevant to palliative care needs. It was clear that staff understood the wishes of the residents and the recent training had developed their skills, knowledge and confidence in this sensitive area of care. One Registered Nurse had also completed her Marie Curie palliative care training. Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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 activities provision is good and varied, and each resident’s right to choose to join in is respected, thus meeting his or her individual needs and wishes. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the residents’ right to independent representation is respected. The food provision in the home is good, offering variety and choice, with resident’s choices being respected. EVIDENCE: The home employs a part-time activities co-ordinator who works from Tuesday to Saturday. A variety of activities are undertaken, these include reading, puzzles, games, gardening, shopping and outdoor activities. For some residents the mobile library undertakes visits to the home. All the residents at the home are registered with Dial-a-ride, giving them access to transport for personal or group outings. Records are kept of activities that are undertaken by the residents. Where residents choose not to participate in activities this is respected. Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 13 The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made welcome at the home and representatives are kept up to date with any issues. Residents can choose to receive visitors in one of the communal rooms or in their bedrooms, as they so wish. Information regarding advocacy services was available and on display in the main entrance of the home. We viewed the kitchen and it was clean and tidy, with all the records being up to date. The home has attained a 4 star rating for food hygiene from the Environmental Health Services. Residents are offered a choice of meal and their preferences are recorded. Mealtimes are flexible and several residents had chosen to have their lunch late in the afternoon. All residents spoken with confirmed that they liked the food provided. Staff were available to assist residents with their meals and did so in a discreet and professional manner. Drinks and snacks are available throughout the 24-hour period. We also viewed the lunch and suppertime serving and meals to include liquidised meals were well presented. Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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 clear complaints procedures in place to address any concerns raised by residents and their visitors. There is a robust system in place for the safeguarding of residents from abuse. EVIDENCE: The home has a clear complaints procedure and this is available in the Statement of Purpose and the service user Guide. The Registered Manager has an ‘open door’ policy for residents, visitors and staff, and responds to any concerns raised. Relatives and residents spoken with confirmed that they were aware of the complaints procedure and any concerns raised had been addressed by the Registered Manager. The home has had no complaints since the last inspection. The home has safeguarding adult’s policies and procedures in place that dovetail with the Ealing Safeguarding Adults documentation. Staff spoken with said that they had received POVA training and were clear to report any concerns. One concern raised with Ealing Safeguarding team had been investigated and addressed. The Registered Manager was clear to report any issues that might have a POVA element to them to the Ealing Safeguarding Adults Team, as well as informing CSCI. Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. 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 is being well maintained, thus providing a clean, homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: Since the last inspection a new quiet room has been created for residents and their families. All bedrooms have been redecorated and new carpets have been installed. There is an ongoing programme of routine maintenance, redecoration and refurbishment and the Registered Manager carries out a regular buildings audit of the home. New chairs and a plasma screen television have been purchased for the lounge. The garden is well maintained and since the last inspection a covered seating area has been provided for the residents to use along with some raised flowerbeds. Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 16 Since the last inspection the home has purchased 5 profiling beds with more in the process of being purchased. There are rails in the corridors and in the toilet and bathing facilities. We viewed the laundry and this was clean and tidy. Good practice notices and laundering guidelines were on display. The washing machines have sluice programmes for infection control and there are 2 washing and 2 drying machines, all industrial standard. Protective clothing to include gloves and aprons was available throughout the home. Infection control procedures are in place and were being followed. The home was clean, bright and fresh throughout. Some of the bedrooms were malodorous and the possibility of alternative flooring being used to assist with continence care needs was discussed with the Registered Manager. There was evidence of regular infection control training. Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed to ensure that the needs of the residents are met. Systems for vetting and recruitment practices are in place, however shortfalls identified potentially do not safeguard residents. There is a comprehensive ongoing training programme, providing staff with the skills to meet the needs of residents, to include specialist care needs. EVIDENCE: At the time of inspection the home was being staffed appropriately to meet the needs of the residents. The Registered Manager was clear that staffing is based on the dependency levels of the residents and not the number of residents living at the home. No comments were received in relation to any staff shortages. The home has a stable staff team with several staff having worked at the home for several years. Since the last inspection the home has introduced internal rotation for all nursing staff. The home is being well maintained and the numbers of kitchen, domestic and maintenance staff are appropriate to meet the needs of the home. The Annual Quality Assurance Assessment completed by the home detailed that 75 of care staff are qualified to NVQ in care level 2 or 3 or the Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 18 equivalent, with several care staff who are qualified nurses in their country of origin. We viewed 3 sets of staff employment records. Two of the employment records only contained one reference. The need to ensure that two references area available prior to employment was discussed. All other information required under the Care Homes Regulations 2001 was available. The home has an induction programme based on Skills for Care Common Induction Standards. Staff spoken with said that they have 3 days induction, one of which is watching various care and health & safety videos and then 2 days working shifts alongside experienced staff. Staff spoken with commented that they have access to training courses and that in-house training is also available. Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the skills and experience to manage the home effectively and has an open approach to management, encouraging good communication. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Resident’s monies are well managed. Systems for the management of health and safety throughout the home are in place, however shortfalls could present a risk to residents, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse and has completed the Registered Managers Award, NVQ level 4 in management. She has been in post for several years and has extensive experience of working with older people. The Registered Manager has attended various training sessions and courses relevant to her role and to the diagnoses of the residents. She is also a Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 20 moving and handling instructor. The home also has a Deputy Manager and it was clear that there is a good management team for the home. Residents, visitors and staff spoken with said that the Registered Manager is very approachable and works hard to address any issues promptly and effectively. Comments were also received that the Registered Manager is supportive to the relatives and friends of residents living at the home. Regular staff meetings are held. Residents and relatives can discuss any issues with the Registered Manager on an individual basis at any time. Surveys for residents and relatives had been carried out in March 2008 and results were displayed on the notice board. A full audit of the home was undertaken in June 2008 in line with the homes quality assurance system and details were available of shortfalls and action to be taken. The Registered Manager undertakes regular medication audits, care plan audits, wound care audits, building audits and accident audits. We discussed that where a shortfall is identified that a system is implemented to ensure that the shortfall has been addressed within a specific timescale. Small amounts of personal monies are managed by the home. Clear records of income and expenditure with receipts are maintained. Samples of servicing and maintenance records were viewed and these were up to date. The home employs a full time maintenance person. The training matrix was viewed and staff were up to date with their mandatory training. We noted that staff that had undertaken their First Aid training previously required to be updated. We were informed by the Responsible Individual following the inspection that this training had been booked for the 8/09/08. Regular fire drills were being undertaken for day and night staff with the details of time and staff attending the drills being recorded. We noted during the tour of the home that several of the bedroom doors were being propped open with wedges. The importance of ensuring that where a resident wishes to have their bedroom door kept open this must be done so with a self-closing door mechanism. We were contacted by the Responsible Individual following the inspection informing us that 8 Dorgards had been delivered on the 21/08/08 and would be fitted to those bedroom doors that were to be kept open. New carpeting has been fitted throughout the home to include corridor areas. We noted that several carpets were fraying at the join areas and could be a potential hazard. We were informed following the inspection that these would be repaired week beginning 25/08/09. Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 3 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 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 22 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. Standard OP9 Regulation 13(2) Requirement Timescale for action 08/09/08 2. 3. OP9 OP29 13(2) 19(1) Schedule 2 24 4. OP33 Records of all receipts of medication must be kept in order to provide a clear trail of each residents medication. All liquid medications must have 08/09/08 their date of opening recorded. All required staff employment 12/09/08 checks and records must be in place before staff work at the home in order to safeguard the residents. Where shortfalls have been 12/09/08 identified in the audits undertaken by the Registered Manager, the quality assurance system must be developed to ensure that the shortfalls are addressed in a timely fashion. Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 23 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 OP7 Good Practice Recommendations Where a review is carried out on a service user plan the review information should be completed in detail. Ealing Manor Nursing Home DS0000010963.V367946.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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