Inspection on 31/08/06 for Ampersand House

This inspection was carried out on 31st August 2006.

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 17/07/07

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 Unannounced Inspection 31st August 2006 10:00 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.V310310.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.V310310.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 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) 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.V310310.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 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, one of which is a designated no smoking area, there is also a conservatory and dining room for use by service users. The fee range for this home currently £300-388.00 per week. Ampersand House DS0000055868.V310310.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 31st August 2006, between 11am and 6.10pm. The Link Inspector was Sally Hall. On the day of the inspection the Registered Manager was on annual leave so the Inspector agreed and explained the inspection process with the Senior Carer on duty, and later two of the homes owners. Time was spent reading a sample of care plans, and other records kept within the home. Staff were spoken with and a full 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 a pre–inspection questionnaire, and to send out surveys to service users, friends/families and other professionals that are involved with the service users at the home, however no responses were received from family or health professionals survey. The survey for service users was completed with a member of staff, it was felt that service users might not have been as open as they may have if a family member had helped them, and as all the results were the same for every service user, on this occasion evidence from these surveys will not be included in this report. What the service does well: What has improved since the last inspection? The assessments of service users individual needs have improved since the last inspection. However, the findings of these assessments are not always being cross-referenced with detailed action for staff to take to minimise any risks identified. Staff are now receiving supervision at the required regularity. Ampersand House DS0000055868.V310310.R01.S.doc Version 5.2 Page 6 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. Ampersand House DS0000055868.V310310.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 Ampersand House DS0000055868.V310310.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): 1-5 The overall judgement for this section is good. Service users are given the information they need to make an informed choice about the admission to the home. Service users can be sure that only if the home can meet their needs will they be offered a place at the home on a permanent basis. EVIDENCE: During the tour of the building a copy of the Service Users Guide was seen in a pocket on the back of every service users door. Many of the contracts on the service users files dated back to the previous owners and needed to be up dated in light of the change in ownership and to ensure that all the information including the room number and fee is included. This information was seen on the files of new service users to the home. On the service users files sampled, the initial assessments and subsequent assessments were seen and these covered the areas required in the standard. Ampersand House DS0000055868.V310310.R01.S.doc Version 5.2 Page 9 Staff confirmed that all service users are assessed before they are offered a place at the home. The senior carer explained that a lot of training had occurred in the last year, this included a six-month course on dementia care, to ensure the staff have the skills to care for service users with differing needs. Almost half the staff at the home now have an NVQ level 2 or above. All prospective service users are invited to visit the home for the day, if possible, before deciding to come into the home for a 28-day trial stay. New service users spoken to confirmed this. Ampersand House DS0000055868.V310310.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): 7-10 The overall judgement for this section is poor The service users are not protected by robust medication procedure with in the home. The service users benefit from the assessment and care planning process, however staff need to ensure to fully cross-reference needs and to record out comes of the monthly review. EVIDENCE: The service users files were sampled and care plans had been rewritten since the last inspection and contained more detail. The plans are being reviewed but only a date to indicate this, the senior carer was advised that the outcome of the review also needs to be recorded. It was however noted that over the last two months service users are being asked to comment on the care they receive and whether they are happy with that care provision. The comments made by service users are then recorded, this was good to see and along with a recorded outcome to the care plan monthly will make for a very robust system of review in the future. Ampersand House DS0000055868.V310310.R01.S.doc Version 5.2 Page 11 The staff have now increased the type of assessments they do regarding each service user. This enables staff to have a more informed picture of the service user. However it was noted that not all the information gleaned is then being used to formulate parts of the care plan or result in a separate risk management plan. For example a high risk of falls was identified but nowhere in the file were there instructions on how staff should minimise that risk. Evidence was seen in the files that service users have access to health professionals and that out patients appointments are facilitated if the family are unable to take their relative for a planned appointment. The home also has opticians, dentist and chiropodist that visit the home, or the service user can arrange for their own to visit. Evidence was seen of GP and district nurse visits on file. Staff do weigh most of the service users monthly, unfortunately the scales used are not suitable for all the service users that now live at the home and they will need to supply a set of scales that are. The medication administration, recording and storage was checked. The Medication Record Sheet were sampled, most showed that medication had been signed in when received into the building, although it was noted that one service users who came in during the middle of the month had not had her medication accounted for. No gaps were seen on Medication Record Sheet in the recording of the medication and the information required re personal details had been completed fully. The audit of medication did not tally with the numbers of the pills taken and the amount recorded as being in the home. This problem was highlighted at the last inspection. The senior carer explained that she and the manager had been doing regular monthly audits and they to had found problems. The senior carer was advised to increase the audits to daily, if necessary, to find out the staff that are not recording or giving the medication out correctly. On the tour of building tablets were seen on the floor and left on furniture in the service users bedrooms. Also prescribed creams were seen in a large number of service users bedrooms, none of the names on the creams match the user of the bedroom, on checking the Medication Record Sheets only a couple of service users are prescribed these creams. The senior carer was ask to dispose of the creams and to speak to the service user’s GP’s if they needed these creams. The new medication that had been delivered was not stored appropriately in a locked room. Ampersand House DS0000055868.V310310.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 The overall judgement for this section is good The service users can be confident that there are activities and outings available for them to chose from throughout the week at the home. The service users can be confident that they will be offered a varied and nutritious diet. EVIDENCE: The home does have a varied activity programme and that was seen displayed on the homes notice board. The owner said that they had just interviewed for an activity co-ordinator, who was being specifically trained to organise activities suitable for service users with dementia, she starts soon. On the service users files sampled the activities service users have taken part in or declined were recorded. Service users spoken to said that they do enjoy some of the activities and the entertainers that come into the home. After the evening meal a sing-a-long took place and it was evident that many of the service users enjoyed this, this was impromptu but service users said this happens form time to time, another said “it a shame some people can’t sing! But at least they have a go.” Ampersand House DS0000055868.V310310.R01.S.doc Version 5.2 Page 13 Service users confirmed that they pretty much do what they want, if they want to go to their rooms during the day, it is not a problem, and they can have their meals in their bedrooms if they wish. Some said they like to have their own chair in the lounge and to sit with the same people who they have got to know well, another said she likes to have a change. A newsletter is produced monthly, and recently with the changes to registration there have been a number of consultation meetings with both service users and their families. Family and friends are encouraged to visit and there is no restriction on when they come or how long they stay. The daily menu is written on the notice board, and a choice is available. The home uses fresh ingredients most of the time and meals are home cooked to ensure what is offered is nutritious. This includes the cakes that are made daily. All service users spoken to say that they enjoyed the meals at the home. A record is kept of what the service users eat on a daily basis, and the daily notes monitored the amounts eaten. On the day of inspection the meal on offer at lunchtime was chicken casserole or pie, or salad, the owners were advised that this did not give enough difference between the hot choices. It was noted that in the homes own survey of service users the service users said that there was not enough choice at meal times. In the evening a hot snack is available or various sandwiches. Snacks are available throughout the day and staff will always get service users something to eat if they say they are hungry. Ampersand House DS0000055868.V310310.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 The overall judgement for this section is good. The service users are protected by the home complaints and adult protection protocols. EVIDENCE: According to the Pre-inspection questionnaire the home has not had any complaints since the last inspection. The complaints procedure was evident in the Service Users Guide in every service users bedroom. Service users spoken to knew who to speak to if they were not happy with anything at the home. Adult protection was inspected in January 2006 and met the standard at that time with a policy and procedure in place and staff have been trained. Ampersand House DS0000055868.V310310.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The overall judgement for this section is poor Service users cannot be confident that the building will be a safe, clean environment in which to live, however a maintenance programme is underway. EVIDENCE: A full tour of the building was undertaken during the inspection, with the senior carer and then two of the owners of the home. The home has been established for some years and retains some of it old features and charm. It is set in pleasant grounds and there is a small care parking area to the front of the home. The fount door is protected by a door entry system and is wheelchair accessible. The home is on three floors, which are accessible by stairs and a lift. The home has recently applied for and been granted some of its rooms to be registered for service users with dementia, therefore there has been some changes being made such as reducing the number of shared rooms with in the home, and a redecoration programme has begun, to make the décor more suitable for service users with dementia. Ampersand House DS0000055868.V310310.R01.S.doc Version 5.2 Page 16 The tour of the building did however highlight a number of shortfalls and problems. In general terms these were, not all bedrooms had a lockable facility for service users to keep valuables, medication etc. safe. Some bedrooms did not have bedside lights. New sink units have been installed in most bedrooms as the other were in a poor state of repair, unfortunately some of these new ones have not been sealed properly and already possibly an infection control risk and are in danger of rotting due to water getting in to the composite wood used in the construction. Some curtains in the bedrooms were hanging down and needed to be re-hung. All radiators in the home are covered but the paint has worn off and not only do they look unclean they pose an infection control hazard as they cannot be cleaned effectively. In a substantial number of rooms the radiators were found to be permanently on, the valves have become stuck, it was disappointing to learn that this has been a known problem for many months and service users have had hot radiators in bedrooms through what has been some of the hottest months for some years. The owners said that they have arranged for a plumber to come in and sort out the valves etc. he being due the next day. The home has sufficient bathrooms and toilets if they were all in use. One bathroom cannot be used as the hoist has not passed the LOLLER check as it has not been installed correctly. The shower room is not in use as the radiator was off the wall, this room was seen as a health and safety risk and the owners were asked that it be locked until the radiator can be re hung. One toilet was being used to store the hoist on the second floor so is not in use. Another health and safety issue seen in the bathrooms was the bottles of shampoo, bath foam and prescribed creams left on the sides of the bath and window ledges. The other toilets around the home were in need of redecoration, one had a very rusty radiator and is a infection control hazard, the flooring in many is in need of replacement. The home has had a sluice put in for the cleaning of commodes but evidence was seen that commode pots are still being put in the bathroom. The door to this sluice room was highlighted in the fire inspectors report, as needing to be one of self-closure in May 06 this change has still not been made. One service users room had an over powering smell of urine, the carpet shampooing machine is not fully operational, but this level of smell is unacceptable, and the owners were asked to remedy the problem straight away. The home can replace the flooring to a washable non slip surface if the service users has an ongoing problem and agrees. Some bedrooms seen were not as clean as they could be, with dust on windowsills and radiator covers. In one room the chair and floor required cleaning were the service users had possibly dropped food, in another room there was a dangerous amount of wires around which presented a trip hazard. During the tour there was also evidence of medication that had not been taken by the service users on the floor and furniture in bedrooms, also many rooms had prescribe creams, none of the labels on the creams matched the persons name who was in the room. On further investigation these were not prescribed for the service users that had been given them. The senior carer was asked to remove these and speak to the GP to get them prescribed if they are required. There is now more space for the laundry, however were the machines are situated there is restricted room and the owners are considering leaving a new Ampersand House DS0000055868.V310310.R01.S.doc Version 5.2 Page 17 machine that has just arrived in the room attached which is now part of the laundry. There was no soap or soap dispenser for the sink in the laundry. The laundry was cleaner than on previous occasions but it is still not as clean as it should be. The redecoration that is occurring is being done to a high standard and a lot of the patterns that would be a problem for service users with dementia are being replaced with lighter colours which is making the areas look lighter and brighter. Ampersand House DS0000055868.V310310.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 The overall judgement for this standard is poor There is not sufficient staff to meet the needs of the service users at all times. The service users are not protected by a robust recruitment procedure. EVIDENCE: The staffing levels were inadequate in the evening of the inspection, with just two members of staff on duty. Staff said that there are normally three staff during the week in the evening. On further investigation it appears that the staffing levels at the weekend are reduced on those during the week this is not acceptable, if during the week the service users needs indicate a certain level of staff this need does not change at the weekend. The staffing levels at the home are changing as the home admits more service users with dementia. With the levels of service users with dementia at this time three staff are required in the evening as a minimum. As the manager was on holiday it was not possible to see on this occasion the staffs training records, these are to be forwarded on her return but will not be reported on this time. The staff files were seen, not all the files contained the information required. The owners said that CRB’s for example may be in another file, they were advised to ensure that relevant information from the CRB be available in the file to show that it had been sent for and received. It was not possible to evidence that the POVA list had been searched with regard to new staff. It was Ampersand House DS0000055868.V310310.R01.S.doc Version 5.2 Page 19 also noted that the reference from the last employer was not always the one sent for, the owners were advised that this is the most important reference to receive. Also looking at the references it was noted that the dates the candidate had said they worked for a firm was different to those the firm said they worked for them this should have been queried. The Pre inspection questionnaire completed in June 06 stated that of the 18 care staff employed then that 8 had gained an NVQ level 2 or above. As the manager was on leave more up to date information was not available, but it would appear that they have not yet attained the 50 of care staff having gained the award but they are working towards this. Ampersand House DS0000055868.V310310.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): 36 37 38 The overall judgement for this section was adequate. Service users benefit from staff that have been regularly supervised. The service users benefit from the quality assurance systems within the home, as comments received are taken seriously. Service users are not protected by the homes health and safety approach in the home. EVIDENCE: There was evidence of staff supervision, the target of formal supervision six times per year is now being met. The supervision record is completed and given to the staff to read and then they are asked to make comments. The senior carer who takes staff supervision is awaiting training; the method currently used was discussed. Ampersand House DS0000055868.V310310.R01.S.doc Version 5.2 Page 21 The home has a formalised a quality assurance system, last sent out on the 26/06/2006 to visitors and 25/5/06 to service users. The home does have regular staff meetings. The home does produce a newsletter monthly, which informs service users and families of futures events etc. Residents meetings are also held several times a year. The home has secure storage for all confidential information, staff were aware of who had a right to see service users files for example, however it was noted that the staff supervision file was on a shelf not locked away. The manager completed a pre-inspection questionnaire; it did not give the dates for the homes maintenance certificates. The certificates were therefore viewed during the inspection, however there was not a certificate for the electrical hard wiring or a LOLER certificate for the passenger lift. Both of these need to be arranged and sent to Commission for Social Care Inspection once issued. The bath hoist on the second floor did not pass the last LOLER inspection and cannot be used; this too needs to be rectified as soon as possible, as this puts another bathroom out of use. The home had policies and procedures in place and these had recently been reviewed; these were not sampled during this visit the information was taken from the pre-inspection questionnaire. The policies and procedures were seen on the shelf in the office and were accessible to all staff. The fire log was seen and showed that regular tests are done on the fire alarm and emergency lighting systems. The fire risk assessments were in place for the building and fire procedures were available. The last visit form the fire office was in May 2006. During this visit to the home they were told to ensure the door on the new slice room had a self-closing fitting, this has not been done and this was brought to the attention of the owners. It was not possible to see if staff training was being kept current because as previously stated the training records were not available during the managers holiday absence. The home does have a maintenance person who has been given a plan of works to do. It is important that the handy person understands the risk of possible health and safety issues found during the visit to the home. A number of health and safety issues have been brought to the attention of the owners and staff during the inspection. Many have been highlighted during the report. One of the most dangerous was the use of wheelchairs without the use of the footplates. Any person who is in a wheelchair cannot be expected to hold their feet off the ground whilst being pushed. The fact that staff could not get this service user in and out of the lift on the top floor is not a reason to remove them. It was however noted that none of the wheelchairs had Ampersand House DS0000055868.V310310.R01.S.doc Version 5.2 Page 22 footplates attached. The owners have been asked to ensure that footplates are reattached and in good working order. Ampersand House DS0000055868.V310310.R01.S.doc Version 5.2 Page 23 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 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 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 2 x 2 2 X 2 2 2 STAFFING Standard No Score 27 1 28 2 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X 3 2 2 Ampersand House DS0000055868.V310310.R01.S.doc Version 5.2 Page 24 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 Sch 3.1(b) Requirement A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. Ensuring these are reviewed monthly with out comes being recorded. Timescale for action 31/10/06 2 OP8 12,13 3 OP9 13,17,Sch edhule 3 4 OP19 23,24 The registered person promotes 31/10/06 and maintains service users’ health and ensures access to health care services to meet assessed needs. The registered person ensures 30/09/06 that there is a policy, and staff adhere to the procedures, for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. The location and layout of the 31/10/06 home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users’ individual and DS0000055868.V310310.R01.S.doc Version 5.2 Page 25 Ampersand House 5 OP21 23 6 OP22 16,23 7 OP24 14,16,23 8 OP25 23,13 9. OP26 13,16,23 collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. Toilet, washing and bathing facilities are provided to meet the needs of service users by ensuring that these remain usable at all times. The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. The heating, lighting, water supply and ventilation of service users’ accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. The premises including the laundry are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. Records required by regulation for the protection of service users and for the effective and DS0000055868.V310310.R01.S.doc 31/10/06 30/11/06 31/12/06 30/09/06 28/01/07 10 OP37 17 30/09/06 Ampersand House Version 5.2 Page 26 11. OP38 23 efficient running of the business are maintained, up to date and accurate and stored securely. The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. ensure all staff understand health and safety issues in the home, ensure that wheelchairs all ways have the footplates attached when in use. That rooms undergoing maintenance are kept looked when they are unsafe to use. Complete a building risk assessment, ensure this dated and gives time scales for action 30/09/06 12. OP38 12, 13 31/10/06 13. OP38 16 Ensure that the electric 30/09/06 hardwiring certificate, and LOLER certificate for the passenger lift are available for inspection in the home. Please send a copy to the Commission for Social Care Inspection by 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 OP2 Good Practice Recommendations Ensure that all service users have a contract/terms and conditions from the current owners of the home. Ampersand House DS0000055868.V310310.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Ampersand House DS0000055868.V310310.R01.S.doc Version 5.2 Page 28 - 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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