Inspection on 26/09/05 for 87 Rectory Road

This inspection was carried out on 26th September 2005.

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

87 Rectory Road 14/07/09

87 Rectory Road 07/08/08

87 Rectory Road 14/11/07

87 Rectory Road 03/10/06

87 Rectory Road 23/03/06

87 Rectory Road 31/01/05

87 Rectory Road 15/06/04

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Rectory Road (87) 87 Rectory Road Pitsea Essex SS13 2AF Lead Inspector Mr Trevor Davey & Nicola Dowling Unannounced Inspection 26th September 2005 09:30 X10029.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 Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 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 and Care Homes for Adults 18 – 65*. 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. Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Rectory Road (87) Address 87 Rectory Road Pitsea Essex SS13 2AF 01268 583634 01268 584347 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) MCCH Society Limited Mr Francis Anthony Winn Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (7) Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To accommodate the five service users under the age of 65 years who have a diagnosed mental disorder (excluding learning disability or dementia). To accommodate the seven service users over the age of 65 years, who have a diagnosed mental disorder (excluding learning disability or dementia). 31/01/05 Date of last inspection Brief Description of the Service: 87, Rectory Road provides accommodation, nursing care and support for twelve residents who have severe and enduring mental health illness. The home is a purpose built property on two floors in a mainly residential area of Pitsea, within close proximity of local shops and has transport links to Basildon and Southend–on-Sea. All bedrooms are single with en-suite facilities and a passenger lift is provided to all levels. There is a communal bathroom on both floors and a large lounge/dining room on the ground floor with a separate activities room. Residents are able to access a large garden/patio area and on site car parking is available. The home has the use of a vehicle for transporting residents. Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which took place on 26 September 2005 lasting 7.5 hours. As there were two Inspectors, this equated to 15 hours input. The inspection process included discussions with the manager and deputy manager of the home, six staff and eight residents. A tour of the premises took place and a sample of policies and records were inspected. Eighteen standards were covered and requirements and recommendations are listed in the report. As the age range of the majority of residents falls within the older person category, the Older Person National Minimum Standards have been used for the basis of this inspection. What the service does well: What has improved since the last inspection? Since the last inspection, the majority of requirements and recommendations have been implemented. This includes changing some of the routines in the home in accordance with suggestions made by residents and including extra information in care plans relating to personal care and hygiene. All the residents were originally long-term patients in an institutional hospital environment. Since being cared for in the home, the staff team have managed to enable residents to be more assured as well as exercising choice and enjoying an increasing fulfilled lifestyle. The staff team have also considered ways in which the quality of services provided in the home can be further improved. The management are actively looking for another similar type of Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 6 establishment where dialogue can take place and information exchanged in comparing good care practices and procedures. 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. Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 Existing contracts terms/conditions do not specify clearly the breakdown of costings in respect of the responsibility of the South Essex Partnership Trust and other items which are the responsibility of the resident. The care programme approach information supplied by the S.E.P.T. does not include operational information for a pre-admission assessment prior to people moving into the service. Without this, there is no assurance that care needs will be met. EVIDENCE: The inspectors were advised that the Registered Provider was in the process of updating contracts and was in discussion with the South Essex Partnership Trust. The present contract together with terms and conditions, does not give a breakdown of costs to clearly indicate what services are provided by the Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 9 Funding Authority and extra items which are the responsibility of the resident. All residents have £16.50 personal allowance each week plus family contributions and other additional items are funded by the Registered Provider. Although the manager visits the hospital as part of the pre- assessment procedure, and prospective residents have trial days and overnight stays, the care plan submitted by the Funding Authority was brief and not descriptive of the care required. There was very little indication of the background and social needs of residents and other operational information had not been disclosed to the home prior to admission. Normally there is a three-month assessment period but it is understood that the South Essex Partnership Trust still holds the role of care co-ordinator indefinitely. As a registered care home providing nursing to mentally ill people in the community, the Registered Provider must have detailed information regarding the background, psychiatric needs and social history of prospective residents to ensure that placements are suitable and do not pose a risk to other residents in the home, staff and the community. Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are 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, 8 & 9 Care plans and risk assessments are well documented, regularly reviewed and contain necessary information to meet personal, health and social needs. Policies and procedures for the administration of medication were in place although some entries on record sheets had been omitted. EVIDENCE: A sample check of care plans was made and information recorded was clear, up-to-date and descriptive including the goals/aims, objectives and expected outcomes. Separate care plans included health and personal hygiene needs, mental state and behaviour, and medication were all addressed in assessment Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 11 documentation. Risk assessments were in place for mobilising, manual handling and these had been reviewed on a monthly basis. Daily and nightly log sheets were detailed and up-to-date. Some of the residents were able to confirm that any care issues were discussed with them and where possible, residents had signed reviews and agreed care plans. Detailed instructions for managing challenging behaviour had been recorded and staff had received training in these techniques. Specialist training is being arranged to enable staff to meet particularly difficult or challenging behaviour as it relates to individual residents. The qualified nurses in the home are responsible for completing care plans but this is done in conjunction with support workers who are to receive training so they can also be involved in these recording procedures. It was suggested by the Inspectors that after psychiatric assessments have taken place, reference be made in the care plans regarding any advice received regarding psychotic and deluded thought patterns and how staff should respond to these. Sample checks were made of the administration procedures for medication and overall, these had been completed in accordance with accepted guidelines. No tablets were out of date and stocks were reviewed monthly. Two gaps were found in the medication administrative records where entries had been omitted without reasons why medication had not been administered and signatures of staff were missing. Although R.M.N. nursing staff are responsible for administering medication, it was recommended by the Inspectors that protocols be drawn up for the benefit of agency staff, relating to any medication or clinical procedures which are in place particularly for epilepsy. It was noted that the medication cabinet had not been made secure to the wall. Staff commented that the service received by some local doctors was not as responsive as they would like, given the mental health needs of residents. Arrangements were in place for psychiatrists to visit as required to attend to clinical needs of residents. Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the 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, 14 & 15 Lifestyle experience in the home and social activities take into account wishes and expectations of residents. Meals are nutritious, balanced and offer a healthy and varied diet for residents. EVIDENCE: Some of the residents spoken to were positive of how their key workers and the staff team interacted with them on a daily basis for social and recreational activities. Some of the residents said how they had enjoyed their trip with staff to Paris and that they regularly visited the local shops and markets in the local community. Some of the residents showed inspectors their rooms which included personal possessions and other items which had been purchased. Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 13 Residents also confirmed that they receive their own personal mail which they open themselves although staff will help when assistance is required. Although social activities are arranged, some of the residents prefer to sit quietly and are free to choose their own preferred routines for the day. Comments were made by residents who felt that a second lounge area was needed as when residents argued, there was nowhere else to go for peace and quiet, (This issue has been referred to under standard O.P.20 of the Environment section of the report). Residents were generally positive regarding the standard of meals provided and nutrition records were available for residents which showed details of individual meals served. All staff have food hygiene certificates and are involved in some meal preparation when the cook is not available. Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) 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 There is an established complaints procedure which is made known to residents or their representatives. Up to date policies and procedures for the protection of vulnerable adults were in place. EVIDENCE: No official complaints had been recorded since the last inspection. Records were available of meetings and conversations with residents which take place on a regular basis. Where concerns are expressed, these are dealt with sensitively and professionally by the staff team. Policies and whistle blowing procedures were in place for staff to know the correct reporting procedures and agencies to be contacted should incidents be suspected or discovered. A record was also available to show that staff had attended P.O.V.A. training on the 15th of September 2005. Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) 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, 20 & 26 The premises are purpose built, suitably equipped, clean and hygienic to meet the needs of residents. There is some delay in the ongoing maintenance of services and equipment. Additional communal space needs to be created for the benefit of residents. EVIDENCE: Overall, the facilities provided, internal decoration and bedroom accommodation, is of a high standard giving residents a safe and comfortable environment to live in. The majority of residents have previously lived together Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 16 in an institutional nursing environment and they tend to congregate and sit in the main lounge/ dining area of the home. There is no second lounge and the atmosphere can become boisterous at times but many of the residents are reluctant to spend time in their bedrooms or to make use of alternative quiet areas. A conservatory or other suitable extension to the main community area would give more space to residents and the opportunity to interact in small groups, without feeling isolated from the other residents. It was noted that the gas safety certificate for the premises expired on the 29th April 2005 and had not been renewed. The sluice facility had not been working since December 2004 and in spite of the management reporting this to the Registered Provider on a regular basis, this was still out of action. It is understood that funding was to be available in April 2005 but it is unacceptable that these delays have occurred when the health and hygiene of residents and staff could be put at risk. The Inspectors are satisfied that the home have made suitable alternative temporary arrangements whereby an outside contractor is being paid to provide this service. Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the 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 deployment and number of staff available at the time of inspection, was sufficient to meet the needs of residents. The procedures adopted by the Registered Provider for the recruitment of staff were not sufficiently robust to ensure people in the home are protected. EVIDENCE: A staff rota was available for inspection which showed the R.M.N. staff cover who were on duty on a 24-hour basis, to act as shift leader and to provide supervision. In addition, there were four support workers rostered for the early shift and three for the late shift. There is also one support worker on awake duty at night. Managerial cover is also available on site during the waking day. Other staff include an activities co-ordinator who works five half days per week and also domestic and cooking staff. There is very little staff turnover in the home and where extra cover is required because of vacancies, one agency is used to provide a good and consistent service. Staff spoken to, did not feel they were asked to work excessive hours and felt the rota arrangements generally worked well. A sample check was made of the Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 18 recruitment records and these were only partly in place and included some references, confirmation of Criminal Record Bureau checks, proof of identity and other information. The head office of the Register Provider had still not completed all the procedures for sending confirmation and copies of recruitment checks which had been carried out on staff. This is of concern to the Commission for Social care Inspection as this has been a requirement from the previous three inspections. Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 & 38 The home is managed and run in the best interests of residents with good support, supervision and training provided for staff. Health and safety issues on behalf of residents are identified and appropriate measures are put in place. Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 20 EVIDENCE: Some of the residents spoken to, confirmed that they attended meetings with staff to talk about care and life in the home. They have the opportunity of asking questions and wherever possible, resident’s individual aspirations regarding daily routines, outings and leisure activities are arranged in their interests, with the support of staff. This included a recent trip to Disneyland by three residents accompanied by staff. The deputy manager spoke about how the arrangement for having separate meal sittings in order to minimise the noise level, came as a result of a suggestion made by residents at one of their meetings. The home is seeking to find another similar care home whereby comparisons can be made in order to discover ways of improving good care practice and the quality of life for residents. Health and safety policies were in place and staff spoken to confirmed that they had attended first aid courses, responding to challenging behaviour and other relevant courses, which all helped to increase the confidence and skills of staff. Staff also confirmed that regular supervision takes place with management and this was seen as a positive experience. Reference has already been made in this report, under standard O.P.19, in relation to the Registered Providers responsibility to ensure ongoing servicing and maintenance is carried out to protect the health and safety of residents as well as the staff team. A record of fire drills, checks and procedures was available including, a fire risk assessment, which had been carried out by the manager. Risk assessments were also in place in respect of service users who smoked. Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 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 X 2 2 3 2 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 X 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 ENVIRONMENT Standard No Score 19 2 20 2 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No Score 31 X 32 X 33 3 34 X 35 X 36 X 37 X 38 3 Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 22 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 OP2 Regulation 5(1) Requirement The Registered Provider must produce a contract terms/conditions which identifies the costs of services provided by the Funding Authority and other items which are the responsibility of the service user. (Previous timescale of 31/10/05 not met). The Registered Provider shall not provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so, the needs of the service user have been assessed by a suitably qualified or suitably trained person. The Registered Person must have obtained a copy of the assessment from the Placing Authority and be involved in any appropriate consultation to ensure that the home is able to meet the prospective service user’s needs. The Registered Provider shall make arrangements for the recording, handling, safekeeping DS0000036721.V255915.R01.S.doc Timescale for action 01/12/05 2 OP3 14(1) 30/11/05 3 OP9 13(2) 31/10/05 Rectory Road (87) Version 5.0 Page 23 and administration of medicines received into the care home. This includes ensuring entries are up to date on the M.A.R. sheets to show the reasons why medication has not been given. The medication cabinet must be made secure to the wall. 4 OP38OP19 23(2) The Registered Provider shall ensure that equipment provided in the care home is maintained in good working order and services are safe. This includes the provision of sluice facilities and renewal of the gas safety certificate which expired in April 2005. 30/11/05 5 OP20 23(2) The Registered Provider shall 31/03/06 having regard to the number and needs of the service, ensure that the physical design and layout of the premises to be used as the care home meet the resident’s needs. This is in reference to the need to create an extended area to the lounge/dining room to give more space to residents. The Registered Provider shall not employ a person to work at the care home unless all recruitment checks have been carried out and are available for inspection in the care home as required by regulation. (Previous timescale of 31/03/05 not met). 30/11/05 6 OP29 19 (Schedule 2). Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 24 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 OP8 Good Practice Recommendations Arrangements should be made to draw up protocols for any clinical procedure, particularly epilepsy, which might be helpful for agency staff. Arrangements should be made for a drink dispenser to be made available for the use of residents. 2 OP15 Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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. Rectory Road (87) DS0000036721.V255915.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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