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Inspection on 22/06/06 for Adeline House Nursing Home

Also see our care home review for Adeline House Nursing Home for more information

This inspection was carried out on 22nd June 2006.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There is a stable staff group who have worked at the home for a good length of time, and they spoke positively about their positions at the home. Staff have shown commitment to their own learning and should be commended for their efforts to obtaining NVQ qualifications, and retaining the `Investors in People` award which recognises a commitment to training and developing the workforce. The views of service users and visitors to the home during this inspection were positive. Visitors said the care provided was good, with staff who were caring and appeared to have the skills and knowledge needed in a caring environment. Relatives said they felt involved in the care of their relative and they were always kept informed about any important issues. Service users said although they would rather live in their own home, they were happy to live at the home.

What has improved since the last inspection?

The registered providers continue to improve the decoration and refurbishment of the building, to enhance the environment for service users. Service users said they were comfortable in their environment and enjoyed sitting in the lounge, as the seating was comfortable. The registered manager has recently completed the Registered Managers Award and the inspector congratulates her achievement. Service users and relatives spoke highly of the manager and said she was kind and they were confident in her ability to run the home well.

What the care home could do better:

Observations of medication being admitted to service users raised cause for concern, as the nurse left racks of medication on the table (in the dining area) as there is insufficient room in the current trolley used for storage. This potentially endangers service users safety. The registered manager did say that the kitchen assistant usually observes the dining area while the nurse is away from the area, but she also has responsibility for service users their breakfast and was seen to be in and out of the kitchen. The registered manager must review the medication administration arrangements at breakfast to ensure medication is not left unattended and stored safely. Residents meeting are used to gain the views of service users, including suggestions for menus and activity programme. Annual quality surveys are not used currently, although the organisation provides a leaflet that asks for comments about the service provided. The registered manager must ensure that an annual development plan is developed, based on a systematic cycle of planning, action, and reviewing to reflect the aims and outcomes for service users. Service users should be encouraged to serve themselves cups of tea and coffee at mealtimes, (if assessed to be safe) as the inspector observed service users having to wait to be served drinks during breakfast. This would encourage service users to be more independent.

CARE HOMES FOR OLDER PEOPLE Adeline House Nursing Home Queen Street Thorne Doncaster South Yorkshire DN8 5AQ Lead Inspector Valerie Hoyle Key Unannounced Inspection 22nd June 2006 08:30 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 Adeline House Nursing Home DS0000015848.V298908.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. Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Adeline House Nursing Home Address Queen Street Thorne Doncaster South Yorkshire DN8 5AQ 01405 815512 01405 813594 NONE 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) County Healthcare Ltd, a wholly owned subsidiary of Four Seasons Health Care Ltd Mrs Vivienne Jacqueline Castle Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability over 65 years of age of places (40) Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To enable up to five service users to reside at the home under the age of 65 years. 2nd February 2006 Date of last inspection Brief Description of the Service: Adeline is situated in the heart of Thorne village, and is in easy reach of local shops and amenities. Grounds are well maintained usually by the handyman and a gardener and the drive leading to the entrance is block paved leading to the conservatory entrance. A quadrangle in the centre of the home is easily accessed by a sloping ramp and is a popular location for service users, and visitors. The home has three lounge areas; one is designated as the smoking area. The main entrance is a conservatory area with domestic type seating including sofas and coffee tables. All lounges have comfortable chairs with a television and domestic type lighting in all communal areas. There is a reception leading to the main areas of the home. The home provides both nursing and residential care. Qualified nurses provide the necessary care to those with nursing needs, and trained care staff provides care to the residential service users. Information gained on the 22nd June 2006 indicates the current fees range from £395 - £420 for residential care and up to £460 ( top ups for nursing bands) for nursing care. Additional charges include hairdressing, newspapers and outings. The home provides information to service users and their relatives prior to admission into the home. Service Users Guides are available on request from the manager. The last published inspection report is available on request and a copy is available for visitors to read. Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 7 hours where a partial inspection of the buildings was undertaken. The inspector examined two service users care plans and supporting documentation. Ten service users and six staff and two nurses were spoken to during the visit. The inspector was able to speak to seven relatives, to gain their views on how the home is run. Staff was observed interacting with residents (service users) in a positive supportive manner, enabling them to participate in daily living skills. Occupancy remains high with 24 service users who are assessed as needing residential care and 15 who have nursing needs. The registered manager was present throughout this inspection and assisted with the inspection process. What the service does well: What has improved since the last inspection? The registered providers continue to improve the decoration and refurbishment of the building, to enhance the environment for service users. Service users said they were comfortable in their environment and enjoyed sitting in the lounge, as the seating was comfortable. The registered manager has recently completed the Registered Managers Award and the inspector congratulates her achievement. Service users and Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 Page 6 relatives spoke highly of the manager and said she was kind and they were confident in her ability to run the home well. 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. Adeline House Nursing Home DS0000015848.V298908.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 Adeline House Nursing Home DS0000015848.V298908.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. The registered manager undertakes an assessment of service users prior to them moving into the home, ensuring their needs can be met. EVIDENCE: Admissions are not made to the home until a full needs assessment has been undertaken. The manager was able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the statement of purpose. For people whom are self funding and without a social service assessment the assessment is always undertaken by a skilled and experienced member of staff. Evidence confirms that the assessment is conducted professionally and sensitively and has involved the family or representative of the resident. Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 Page 9 Two assessment documents were examined and provided sufficient information to ensure care needs can be met by the staff at the home. The inspector was able to speak to one service user who had only lived at the home for a short period of time, and he/she said the home was very nice and staff were kind, although he/she would prefer to live in his/her own home but realised he/she could not manage anymore. Other comments were received from visiting relatives who said the manager visited prior to the admission of their relative and explained all about the home, making them feel better. Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 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, 8, 9, 10 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to this service, including examination of documents and discussion with staff and visitors to the home. The care plans provides staff with sufficient information to ensure they can meet the needs of service users. Arrangements for dealing with service users health issues are adequately met by staff at the home, with support from health professionals. Medication policies and procedures are generally followed, however storage of medication poses risk to service users and affects the overall rating for this outcome group. EVIDENCE: Two care plans were examined during this visit, and included sufficient information to ensure staff understands the support needed by individuals. There is evidence that the care plan is regularly updated and reviewed. Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 Page 11 Risk assessments demonstrate service users are safe in the environment, whilst able to maintain their independence. Staff spoken to confirmed that they had a good understanding of the needs of service users, they said handovers also keep staff un-to-date with any changes to service users. Records examined and discussion with the staff confirmed service users healthcare needs are met. The qualified nurses are able to carry out nursing requirements for those service users who fall into the nursing category. District nurses also attend the home to carry out injections, take bloods and attend to dressing for service users who are residential. There is evidence within the records that service users are able to access dieticians and speech therapists, and one service user said she/he had been receiving regular physiotherapy, although this had now ceased. The registered manager told the inspector that the nurses had recently attended courses dealing with people who are terminally ill, to develop new skills and knowledge. An audit of medication and records was examined and were found to be correct ensuring the health and safety of service users. Qualified nurses have responsibility for administering medications and the local pharmacist is contracted to undertake periodic checks to ensure the stock levels are maintained and procedures are followed. The registered manager told the inspector that there is a new supplier of medication who also has responsibility for the safe disposal of waste medicines. The inspector observed medication being administered to service users. The nurse ensured medication was administered with a drink and service users were encouraged to take their medication promptly. The nurse did say that the volume of service users taking medication meant that the drug round takes a considerable length of time, completing the medication round at mid-day. The nurse had several racks of medication that was on a table at the side of the trolley. This could potentially be dangerous to service users, if left unattended. The registered manager must review this arrangement to ensure the medication is not left unsupervised. Throughout this visit staff were seen interacting with service users in a kind manner, they spent time talking to service users and were observed knocking on bedroom doors before entering. All service users were referred to by their first name and this was agreed in the care plans examined. Staff were able to understand the needs of service users who had communication difficulties. Adeline House Nursing Home DS0000015848.V298908.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service. Social activities are arranged by the home and service users are able to participate if they wish, to enhance their lifestyle experience. Mealtimes are well managed and the facilities promote a calm environment with dining areas to accommodate all service users. Service users are encouraged to make choices and control over their own lives. The home has clear visiting policies and procedures to ensure residents can maintain contact with their family and friends. EVIDENCE: There is a lively atmosphere at the home and service users choose where and with whom they want to spend their time. An activity co-ordinator has responsibility to organise entertainment for service users including shopping trips and craftwork. There is a notice board displaying some of the more recent paintings that service users had completed, and posters are also displayed for future social events at the home. Service users said they had really enjoyed a trip to the lakeside shopping centre and onto a pub for lunch. Further trips have been organised to go to Hornsea and picnics in Thorne Park. Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 Page 13 Service user are actively encouraged to keep in contact with family and friends living in the community. Visitors are welcome at any time and facilities are available for them to have a drink or a meal with the resident. Service users can choose to entertain visitors in their own rooms or perhaps a lounge or garden areas. Visitors spoken to during this visit made very positive comments about the home and the staff team. One visitor said she/he was always made to feel welcome and offered a drink. Another visitor said staff were always available to pass on any information about the care of their relative. The registered manager should risk assess where needed to ensure those who are able to serve themselves with tea and coffee, should be given teapots to enable them to help themselves. The food in the home is of good quality, well presented and meets the dietary needs of service users. The cook is experienced, consults with service users and tries to meet the preferences and suggested dishes when preparing the menu. Menus were examined and appear to be well balanced, although they were still operating a winter menu, and should consider changing to a summer menu to include seasonal fruits and vegetables. Staff are trained to help those service users who need help when eating and are sensitive in their approach. Breakfast and lunch was observed during this visit. Service users were brought to the dining room by staff and the kitchen assistant had responsibility to ensure meals were brought to the service user. Drinks were provided on request from the kitchen. This potentially restricts service users choice and ability to maintain independence. The registered manager should risk assess where needed to ensure those who are able to serve themselves with tea and coffee, should be given teapots to enable them to help themselves. Adeline House Nursing Home DS0000015848.V298908.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service, and examination of documents. Service users and their relatives are provided information to enable them the raise concerns about the home and their care. Adult protection Policies, procedures and training of staff ensure the protection of service users from abuse. EVIDENCE: The service has a complaints procedure that is up to date, very clearly written, and is easy to understand. It can be made available in a number of formats (on request) to enable anyone associated with the service to complain or make suggestions for improvement. The complaints procedure is widely distributed, and has a high profile within the service. Guests and others associated with the home demonstrate a good understanding of how to make a complaint and they are very clear of what can be expected to happen if a complaint is made. Unless there are exceptional circumstances the service always responds within the agreed timescale. The policies and procedures regarding protection of guests are of a high quality and are regularly reviewed and updated. The service is clear when incidents need external input and who to refer the incident to. Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 Page 15 Training of staff in the area of protection is regularly arranged by the home. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding when incidents should be reported. Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 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, 26 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service, including a tour of the building. The registered provider continues to improve the décor and furnishings at the home creating comfortable and safe environments for service users. The home is clean and free from odours and there is sufficient domestic staffs to maintain good hygiene standards. EVIDENCE: The home is located well within the community of Thorne and the single storey building ensures that service users have easy access to all parts of the building. Grounds are well maintained usually by the handyman and a gardener and the drive leading to the entrance is block paved leading to the conservatory entrance. Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 Page 17 A quadrangle in the centre of the home is easily accessed by a sloping ramp and is a popular location for service users, and visitors. Redecoration of bedrooms and the replacement of carpets continue to enhance the environment and there is also a rolling programme for the replacement of some bedroom furniture. The home was clean and free from offensive odours and service users said that their bedroom was always kept clean and tidy. The domestic staff are commended for their efforts in maintaining the cleanliness of the home. Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 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, 28, 29, 30 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service, and interviews with staff. Staff have the skills and knowledge to fulfil their roles within the home, and a stable staff group ensures continuity of care by staff that knows the service users. Recruitment policies are followed ensuring the safety and protection of service users. EVIDENCE: Staff rotas examined demonstrated there is sufficient nursing and care staff to meet the needs of service users. One member of staff said she did have some concerns about the staffing levels. She said it was difficult to cover shifts if staff telephone to say they are not coming to work at short notice. On occasion’s staff working as carers are asked to manage the teatime meal, as not all kitchen shifts are covered. The Inspector discussed these concerns and reassurances were given by the manager that every effort is made to maintain appropriate levels. The inspector joined staff during their meal break to gain their views on the care provided at the home. Staff spoke positively about the home and they said they wanted to ensure residents were well looked after. They said they had recently attended a number of training courses and felt supported by the manager, and the nurses. Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 Page 19 The staff at the home have achieved the required 50 NVQ level 2/3 and are commended for their efforts. The registered manager has demonstrated a continuing commitment to developing the workforce, including attaining ‘Investors in People award’ Several staff have completed a customer care course and are currently undertaking a distant learning course on health and safety, to ensure they continue to develop new skills. Two staff have completed a fire warden course and now have responsibility to undertake weekly and monthly fire checks and train staff in fire evacuation. One of the staff said she had enjoyed the course and had already started to take on her new role, and she said she liked the added responsibility. Discussion with the manager regarding the recruitment of staff demonstrates clear understanding of the procedures to ensure the safety and protection of service users. There is a stable staff group who have a clear understanding of the needs of service users. Examination of nurses PIN and qualifications confirmed that the nursing needs of service users are met. Two new staff have been employed at the home, and their recruitment files were examined and contained all the necessary employment checks including references and CRB checks. Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 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, 38 Quality in this outcome area is good. The judgement has been made using available evidence including a visit to this service, and interviews with staff. The registered manager is skilled and experienced to manage the home to ensure the safety and protection of the service users. The registered provider must develop method to actively seeks the views of service users. Procedures are in place to ensure the financial interests of service users are safeguarded. Staff and service users follow health and safety procedures and records provide evidence of servicing of essential equipment. Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager has the required qualifications and experience and is competent to run the home. She works to continuously improve services and provide an increased quality of life for service users. The manager has completed the Registered Managers Award and continues to develop her own knowledge by attending internal courses. There is a strong ethos of being open and transparent in all areas of running of the home. The manager is service user focused and leads and supports a strong staff team who have been recruited and trained to a high standard. The manager is aware of current developments both nationally and by CSCI and plans the service accordingly. Residents/relatives meetings are used to gain the views of service users, including suggestions for menus and activity programme. Annual quality surveys are not used currently, although the organisation provides a leaflet that asks for comments about the service provided. The manager said a number of surveys had been completed and these indicated service users were happy with the service provided. The manager said she intended to give out a few surveys each month, although this may not give an overall picture of satisfaction levels. An annual survey would give a clearer picture and identify any service areas that need to be developed. The registered manager must ensure that an annual development plan is developed, based on a systematic cycle of planning, action, and reviewing to reflect the aims and outcomes for service users, and stakeholders. Service users are able to manage their own finances, although most prefer the manager to assist with dealing with their personal allowances. A number of service users pocket money records were checked and these were accurate. Accident reports are analysed by the manager to ensure risk assessments are developed where required. Maintenance and service records examined were up to date and current to the services provided. The manager has the required Health and Safety policies and procedures and displays the relevant notices. Fire safety procedures are in place and service records were examined and were current, ensuring the safety of service users. Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 X X 3 Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 Page 23 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 Requirement Timescale for action 01/07/06 2. OP33 24 The registered manager must review the medication administration arrangements at breakfast to ensure medication is not left unattended and stored safely The registered manager must 01/10/06 develop a systematic approach to gain the views of service users 9timescale 1July 2006 not met 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 OP15 Good Practice Recommendations The registered manager should risk assess where needed to ensure those who are able to serve themselves with tea and coffee, should be given teapots to enable them to help themselves. Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Adeline House Nursing Home DS0000015848.V298908.R01.S.doc Version 5.2 Page 25 - 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. 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