Inspection on 17/07/07 for Ampersand House

This inspection was carried out on 17th July 2007.

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

Ampersand House 31/08/06

Ampersand House 17/01/06

Ampersand House 22/07/05

Ampersand House 19/01/05

Ampersand House 30/09/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Ampersand House 164/166 Frindsbury Road Frindsbury Rochester Kent ME2 4HP Lead Inspector Sally Hall Key Unannounced Inspection 17th July 2007 09:30 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 Ampersand House DS0000055868.V343229.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. Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ampersand House Address 164/166 Frindsbury Road Frindsbury Rochester Kent ME2 4HP 01634 724113 01634 724113 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered Manager and two of the owners (if applicable) Type of registration No. of places registered (if applicable) Mr Thuraisamy Ravichandran Mr Nallanathan Suganthakumaran, Mrs Radha Ravichandran, Mrs Suganthini Suganthakumaran Antionette Lawrence Care Home 27 Category(ies) of Dementia (15), Old age, not falling within any registration, with number other category (27) of places Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2007 Brief Description of the Service: Ampersand House is a care home registered to provide residential care and accommodation for a maximum of thirty-one older people. The home is a large detached property set in pleasant grounds. It is situated in the residential area of Frindsbury and is approximately one mile from Strood town centre. Motorway links are close by. The home is near a bus route and Strood mainline railway station is approximately one mile away. The accommodation is set out over three floors and has a passenger lift serving the upper floors. There are two lounges and a conservatory leading off the dining room for use by residents. The home is now no smoking throughout. The fee range for this home currently £331-408.00 per week; this does not include the costs of hairdressing, chiropody or new papers. Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key Inspection at Ampersand House took place on Tuesday 17th July 2007 between 7.30am and 3.30 pm, the link inspector was Sally Hall On the day of the inspection the Inspector agreed and explained the inspection process with the Registered Manager and two of the owners. Time was spent reading a sample of care plans, written policies and procedures and records kept within the home. Staff were spoken with and a tour of premises was undertaken. The focus of the inspection was to assess Ampersand House in accordance with the National Minimum Standards for Older People. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. The home was ask to complete an AQAA (Annual Quality Assurance Assessment) and evidence from this document is also included in this report. Unfortunately there was not time to send out surveys to residents, their families and other health professionals before this inspection. However, two relatives were spoken during the inspection process. What the service does well: What has improved since the last inspection? Parts of the home have had a face-lift, mainly on the first and second floors. These areas have been decorated and some new furniture has been purchased. There are plans to redecorate and replace the flooring in the lounge, dining room and conservatory. Residents are being asked to choose the colour scheme and wallpaper. The home has had installed as part of the fire alarm system magnetic catches so that bedroom doors can be left open safely. The bedroom doors will now close if the fire alarms sound. Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 6 Many more staff have now received training in health and safety core courses and adult protection, more training has been booked to meet training shortfalls. The chemicals in the home are now being stored safely, as are the prescribed creams used by some residents. The home is now undertaking medication audits daily to ensure residents are receiving the medication they a prescribed. What they could do better: Despite the requirement at the last inspection residents are still being woken up and either sat up in bed or washed and dressed and taken to the dining room for breakfast from six o’clock onwards. Breakfast for the whole home, except for one resident, being finished and cleared away by 7.30am. This is regarded as being poor practice since it impinges on the ability of residents to make their own choices as to when they would prefer to have breakfast. This matter was discussed with the manager and the owners and they have agreed to review their practice in this area. The staff rota should show staffing numbers and skills relevant to the needs of the resident during the course of the day. The home does not have a robust recruitment procedure and staff have been employed before all the checks have been returned. New staff should only be confirmed in post following completion of a satisfactory police check, and satisfactory check of the Protection of Vulnerable Adults. All policies and procedures should be reviewed annually or before if there is a change in any legalisation that may affect the home’s practice. The home have been using a resident’s room which is used by a visiting hairdresser. This was considered to be poor practice which needed to be addressed. Please contact the provider for advice of actions taken in response to this Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 7 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. Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good, This judgement has been made using available evidence including a visit to this service. Residents’ needs are fully assessed prior to admission to ensure that the home can meet their needs. EVIDENCE: The files of the most recently admitted residents were sampled. The preadmission assessments had been completed with all the information required under Standard 3.3. The assessment tools used by the home are comprehensive and cover all aspects of the residents’ lives. Some further assessments are completed during residents’ trial stays at the home and the information is used to determine if the home can meet the long-term care needs of prospective residents. Care plan were seen for the newest residents to the home. These highlighted the initial care needs of the residents and it was evidenced that these are reviewed at the end of the first 28 days of their admission . Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 10 The home does not provide intermediate care. Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents can be confident that their health and care needs will be provided in a way that preserves their dignity relevant documentation could be improved. Residents can be confident that they will receive their proper medication because of improved practices that have been introduced by the manager and senior staff of the home. EVIDENCE: The residents’ files sampled showed that each residents’ assessment is ongoing. These assessments cover a wide range of residents’ needs and include for example cognitive assessment, communication and moving and handling. The information from these is then used to formulate the care plan in partnership with each resident. This was considered to be an improvement in practice since the last inspection visit. The plans also detailed how the staff can promote residents’ independence. As well as a monthly review of the care plan with the resident, the Manager and two of the owners also arrange a 6 monthly review with all relevant Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 12 parties such as each relative’s family and care manager. The outcome of these reviews is recorded and indicates where a change in care is required. The daily log does generally cross reference with the care plans. It was evident however that whilst staff are fulfilling the residents’ needs but they are not recording this sufficiently. It was also noted that staff are writing up the record before the tasks have been undertaken. The staff at the home call in the GP when a residents is not well. Visits are recorded on a separate sheet from the daily log but the daily log still needs to reflect the visit so that staff know to look at the completed health sheet. Residents are also visited at the home by chiropodists, opticians and dentists. Each resident or family member can arrange medical appointments through the home or privately. The home weighs the residents on a regular basis and the records are kept in each resident’s file. The home has recently purchased a weighing chair so that residents who find it hard to stand can be weighed. If a resident is losing weight then the GP is called and the staff keep a more detailed record of how much food and drink is being consumed by particular residents causing concern throughout the day. It is added to their care plans and staff are asked to encourage them to eat and drink more frequently. District nurses are also visitors to the home as are CPN’s (Community psychiatric nurses) for advice and guidance for the care of residents with dementia. Visitors spoken to said that residents are well cared for and are treated with dignity and respect. Residents spoken to said that staff treat them with respect, and “nothing is too much trouble, but they do get very busy at times”. Observation of the staff interacting with the residents also confirmed that staff approach residents in a respectful manor and staff preserved residents’ dignity. Some files also had risk assessments with agreed strategies aimed at minimising the risks to residents. However, the identified strategies were sometimes embedded in the actual risk assessments and this could cause confusion for staff. The Manager agreed to look at this issue. There were ‘likes and dislikes’ sheets in some files.These were detailed and explained more clearly each resident’s expectations. Whilst there were fluid charts in some files which showed what residents had drunk, the actual amount of fluid drunk was not recorded. The Manager informed the inspector that fluid charts were in all of the residents’ files. It was suggested to the manager thatthis is not necessary and such charts should only be available for residents who have identified problems in this area. The Manager explained that only staff trained to do so carry out the administration of medication and they ensure that trained staff are on every shift. There is a list of the staff members who are considered competent to Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 13 give out medication in the home, along with their signatures, for easy recognition if there are any queries. A check of the medication records indicated that staff are administering and recording medication correctly. The Medication Record Sheets were completed correctly in almost all cases. Medication is checked in when received by the staff and the record is signed. However, two staff are not signing the medication record sheet when it is necessary to add new medication. In some cases the resident’s diagnosis is being written where ‘any known allergies’ should be recorded. These issues were raised with the manager. The home has no controlled medication at this time. The home has had a pharmacy random inspection since the last key inspection and the requirements made at that time are to be found at the end of this report. There has been an improvement in practice and the manager has arranged for an audit of medication to take place daily. It was noted that all medication is being counted, including tablets in bottles. It was noted that staff were handling tablets. The Manager and two of the owners agreed to purchase a pill counter to address this matter. Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The residents can be confident that they will be offered a programme of activities some days during the week, and have trips out available occasionally. Resident can be confident that they will be offered a choice of home cooked nutritious meals. However they cannot be sure that they will be helped to exercise choice or maintain control of their lives. EVIDENCE: The activity co-ordinator has devised an activity care plan and the activities taken part in are recorded. There is a wide range of activities and they include for example Bingo, quiz, nail painting, sing-a-long and craftwork. The Manager and two of the owners said that outings are being arranged; next month a large number of residents will be attending a barbecue in Allhallows a village nearby. The home has arranged a cream tea for August when families will be invited to join their relative for the afternoon. The residents in the home do not fully exercise choice or maintain control of their lives. Unfortunately many past practices, which suit the staff more than the residents, remains. For example, residents are sat up in bed as early as 6am ready for breakfast. A small number are got up and dressed in order to Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 15 have their breakfast in the dining room. Breakfast for the whole home was over and cleared away before 7.30am. The inspector started the inspection at 7.30 am, and all but two residents were asleep, showing that they were not ready to get up or eat breakfast. During a previous random inspection of the home the Manager and the owners were asked to change this practice. The manager said that she thought the staff were now doing it differently and the breakfast is being served later with some residents eating in dining room. Evidently this is not the case. The manager informed the inspector that she was waiting the employment of a breakfast cook before the times were changed radically. The inspector challenged this practice in that residents should be allowed to wake naturally or choose if they wished to be woken up early. The Manager was advised that routines within the home need to be flexible and every effort should be made to follow the resident’s wishes on a day to day basis and that the staffing of the breakfast period should be reviewed until a cook is employed. The meals served are home cooked the majority of the time. Residents questioned said they enjoyed the meals offered and that there was a daily choice of meals. What the residents eat is recorded by the kitchen staff and in the daily record. The meal times are staggered, as a number of residents now need assistance. These residents have their meals first. Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents cannot feel confident that their complaints will be taken seriously. Residents cannot feel totally confident that they will be protected from abuse. EVIDENCE: The Manager and two of the owners confirmed there were no complaints had been received since the last inspection. However, one complaint was received on the day of inspection, which had been reported previously and should have been treated as a complaint under the home’s complaints procedure. The Manager and two of the owners were asked to record the complaint and follow it through as per the home’s procedures. All residents have a copy of the Statement of Purpose and Resident Guide in a pocket on the back of the doors in their bedrooms and these document contain the complaints procedure. The Adult Protection protocols had not been kept to up date and were two years out of date. The home did have its own policy which had not been recently reviewed. The home had a whistle blowing policy however the policy Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 17 and procedures were out date. Not all staff had completed their Adult Protection training but with the courses seen booked all staff should have received training by the end July 2007. Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 18 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 adequate This judgement has been made using available evidence including a visit to this service. Whilst the residents benefit from living in clean and safe environment, some areas of the home are in need of redecoration. EVIDENCE: Much improved since the last visit in May. The bathrooms and toilets around the home were clean and free from all chemicals. The residents’ rooms that were seen had not visible prescribed creams on show. Magnetic door holders that close when the alarms sound had been installed. It was noted that two doors did not fully close. This appeared to be due to old faulty catches operated by the door handles. The Manager and two of the owners explained that there is to be new decoration of the communal areas on the ground floor the home when the Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 19 residents have chosen the colour scheme. The home has been given a grant to finance this work. The first and second floor are in a generally good state of repair and decoration and it is the ground floor that needs attention. A relative of a resident complained to the inspector that the bedroom their relative occupied looked shabby. The handy man on the day of inspection was decorating parts of the corridor on the first floor. The grant will also cover the replacement of flooring in the communal areas and the corridor. At the time of the inspection the Manager and two of the owners were trying to decide the best materials to use. The laundry looked untidy and in places not very clean but it had improved since the last visit. The Manager and two of the owners and staff confirmed that they do use the red sack system, which enable staff to handle the soiled laundry as little as possible. During the inspection the inspector was informed that there is nowhere for the visiting hair dresser to use so all hair dressing takes place in one resident’s room. This issue was referred to the Manager as being poor practice, which needed to be addressed. The home appeared cleaner than at the last inspection with no unpleasant odours. During the redecoration of the home over the last 12 months the home has been replacing old furniture in the home including twenty-four new armchairs and bedroom furniture in five bedrooms. Fourteen windows were replaced with double glazed units. Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Residents are not protected by the homes recruitment procedure. The residents wishes can ‘t always be enabled because of the homes routines and staffing levels. EVIDENCE: On the morning of the inspection staffing levels were concerning. On duty there had been two night staff plus a staff member who slept in to help out until the night staff went off at 8am. The day staff started at 8am, but only two arrived followed by the Manager because there was no senior member of staff on duty to take handover. The other staff due on were all coming in later; one arrived by 8.30am the other two by 9.00am. This arrangement appeared to suit the staff’s rather than the residents’ needs. As has been described previously in the report, the breakfast had been given to residents in their bedrooms and was all cleared away by 7.30 am before the day staff came on Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 21 duty. The night staff said that blood tests for diabetics were started at 5.00am and that they started getting people up, or sitting them up ready for breakfast by 6.00am. The home does not have a robust recruitment procedure. In the staff files inspected it was evidenced that staff had started work at the home before the security checks and some references had been received. In one file it appeared that a new member of staff had commenced their duties before a POVA First had even been applied for. It was also noted that gaps in employment histories had not been fully explored. The home has 5 staff with NVQ (National Vocational Qualification) Level 2, and a further 3 who have gained a Level 3. The home employs 22 care staff so the number of staff who hold NVQ qualifications is well under the 50 requirement. The manager explained that 7 staff are currently on NVQ courses and that another memberS of staff is due to start a course in the near future.. The rota was seen and it showed that there has been an increase in staff at the weekend. Previously weekend staffing levels had been less than during the week. The Manager and two of the owners were of the view that the home’s staffing levels were sufficient to cope with the residents’ needs at this time though staffing levels should be increased as residents’ care needs increase. There has also been an increase in the number of staff who have undertaken some of the core training, and evidence was seen of further courses that have been booked for July 2007. However, whilst this will address some of the shortfall there is still a number of staff that need to undertake POVA, infection control, health and safety, moving and handling. All of the recently recruited staff have not been sent on the recognised induction training. However, it was confirmed that they are all undertaking an NVQ Level 2. Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 22 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, 37, 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is not run in the best interests of the residents, however the residents personal finances are protected. EVIDENCE: The Manager has achieved and NVQ (National Vocational Qualification) in Care Level 4, plus she has gained her RMA (Registered Managers award). She has many years experience in the care of the elderly and was a former nurse. The home is not run in the best interests of the residents. The old routines which were formulated to suit the staff’s personal commitments means residents appear to have to fit in with them. It is of concern that although the Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 23 very early waking up of residents was highlighted back in the May 2007 inspection the Manager has not yet stopped this practice. The handyman completes the fire log; the residents’ bedroom doors now have magnetic devices so these can be left open, closing when the alarms sound. The closure of these doors at the weekly alarm testing needs to be check. The home has a COSHH (Chemicals or Substances Hazardous to Health) file which the manager said is up to date, with any new items the home uses being added. Most staff at the home have undertaken COSHH training. The owners explained that they have recently sent out a quality audit to families asking that they fill these in with their relative at the home. They have had a poor response so far but the two received so far made positive comments about the care received. The owner said that they will follow this up with families and once they have a good number returned they would do a feed back sheet showing where improvements are to be made. Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 24 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 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X 2 2 Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Schedule 3.1(b) Requirement That a resident’s plan of care is generated from a comprehensive assessment, which is drawn up with each resident and or family. That dDaily notes must show time events happened not the time they were written and that events shouldnot be recorded before they have happened. That the registered person promotes and maintains residents’ health in that residents are encouraged drink fluids with records being kept of what is drunk and the amounts consumed and the amounts passed. That the registered person conducts the home so as to maximise residents’ capacity to exercise personal autonomy and choice. That medicines must be administered according to the prescribers’ directions and the home’s policy on witnessing administration must be followed. DS0000055868.V343229.R01.S.doc Timescale for action 30/07/07 2. OP8 12,13 30/07/07 3. OP14 12,15, 16 30/07/07 4. OP9 13(2) 20/07/07 Ampersand House Version 5.2 Page 26 5. OP9 13(2) That medicines must be stored in 20/07/07 the temperature range stated by the manufacturer That the registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of residents by ensuring all necessary checks have been completed before any staff member is allowed to work with residents. That the registered person ensures that there is a simple, clear and accessible complaints procedure and when a complaint is received it is dealt with according to policy. Any concern raised by residents or family etc should be recorded as a complaint. That staff are rostered on the staffing rota at times to suit and meet the resident’s needs. That a minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) should is achieved by 2008. The registered person to systematically consider the quality of the service for its users for which they are responsible by ensuring the home is run in the best interests of the residents. 15/08/07 6 OP29 19 4c Schedule 2 7. OP16 17.2 15/08/07 8 9. OP27 OP28 18.1a 18.1 31/08/07 31/03/08 10 OP33 10 (1) (2) 15/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000055868.V343229.R01.S.doc Version 5.2 Page 27 Ampersand House 1. Standard OP9 When a change in medication or dose is handwritten on a MAR, care staff should cancel the original entry, write the new directions legibly in ink on a new line, record the name of the prescriber who gave the new instructions, date the entry and sign (including a witness if possible). Records should be kept of the observation and assessment process for staff being trained to administer medicines. For medicines prescribed to be taken ‘when required’, care plans should include the criteria for administration and take into consideration the resident’s needs and choices. The registered person ensures that residents receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. Make sure that the adult protection protocols and the homes policy remain in date. Ensure that the home reaches a good standard of decoration furnishings and this is maintained. Ensure that policies and procedures are reviewed annually Ensure all staff have the statutory training required for health and safety of both the staff and residents. 2. 3. OP9 OP9 4 OP15 5. 6. 7 8 OP18 OP19 OP37 OP38 Ampersand House DS0000055868.V343229.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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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