Inspection on 18/05/06 for Betsham Road (84)

This inspection was carried out on 18th May 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Betsham Road (84) 13/09/07

Betsham Road (84) 29/09/05

Betsham Road (84) 20/04/05

Betsham Road (84) 28/10/04

Betsham Road (84) 22/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Betsham Road (84) 84 Betsham Road Erith Kent DA8 2BG Lead Inspector Ms Pauline Lambe Key Unannounced Inspection 18th May 2006 09:30 Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 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 Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Betsham Road (84) Address 84 Betsham Road Erith Kent DA8 2BG 01322 332699 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) MCCH Society Limited Mrs Christina Lesley Harris Care Home 9 Category(ies) of Learning disability (9), Learning disability over registration, with number 65 years of age (2) of places Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Management had variations to registration to enable them to provide care and accommodation to two residents over the age of 65 years. Date of last inspection 29th September 2005 Brief Description of the Service: Betsham Road is a Care Home managed by Maidstone Community Care Housing. The service provides 4 self-contained flats for adults of both genders, aged 18 to 65 years with moderate/severe learning difficulties. The flats are joined at a central point and are staffed at all times. The home accommodates 9 service users in total. Betsham Road is situated in a small cul-de-sac in a residential area close to Erith Town Centre. There are bus routes and local shops near by. Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this unannounced inspection was completed over 5.25 hours. The manager was not on duty and the support worker in charge and staff assisted with the inspection. One resident was at College, one had gone bowling, one was going to visit family for the day and the others were in the home. Nine residents were in occupancy, two female and seven male residents. Although the home was inspected against the younger adults standards three of the residents were over 65 years of age. From the evidence provided staff were meeting the needs of these older residents and none of them required specialist equipment to have their needs met. Following the manager informed the inspector that discussions had taken place with the older residents about a possible move to a new home in the organisation, which is registered to care for older people. The service was last inspected on the 29thSeptember 2005. Not all of the requirements made at the last inspection had been met. The inspection included a review of the service file, a pre-inspection questionnaire completed by the manager, a visit to the home which included a tour of the premises, inspection of records, talking to residents, relatives and members of staff team. Following the inspection contact was made with the manager, relatives and other interested parties to try and get their views of the service. Feedback from relatives contacted was very positive about the quality of care provided, the suitability of the resident’s lifestyles, staff communication and involvement with relatives and the ability of staff to meet the resident’s needs. What the service does well: What has improved since the last inspection? Records were kept as required by regulation and those seen were up to date and accessible with the exception of staff recruitment files. A system was in place to provide supervision to staff. Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 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. Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. Although no new residents had been admitted since the last inspection systems were in place to comply with this standard. EVIDENCE: No new residents had been admitted to the home since the last inspection. This standard was assessed as met at the last inspection and no changes had been made to the admission process. Management had applied for a variation to registration to provide care an accommodation to two residents over the age of 65 years. At this inspection the home had three residents over the age of 65 years. Following the inspection this issue was discussed with the manager who was advised that management must apply to the Commission for a variation to registration to accommodate this resident. Requirement 1. Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. Residents had care plans prepared to show how assessed needs were to be met and daily diaries to show that care plans were followed. It is important that staff date and sign these documents to show they are reviewed in line with the standards. EVIDENCE: The care plans for three residents were inspected. These showed that individual needs were assessed, risk assessments were completed and relevant care plans were prepared. The resident’s records also included a ‘care plan guide’ for staff to follow and a reference to the resident’s ‘strengths and weaknesses’. Residents had a daily diary completed to show how their assessed needs, including social needs, were met on a daily basis. There was no evidence in the care plans seen to show that residents or relatives were involved in preparing these. Some of the care plan documentation was not dated or signed. Residents were able to make limited decisions about their lives and were assisted with this by their key worker. Key workers played an important role in resident’s lives and were allocated to work with residents in their flats. Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 10 Staff seen during the inspection displayed a very good understanding of the residents and their needs. Staff communicated with residents in a variety of ways. For example with words and body language or using the residents ‘communication passport’, which were developed with the support of the speech and language therapist. Residents seen had some ability to indicate how they wanted to spend their day and what assistance they required from staff. Residents were supported to take risks. Care plans seen included risk assessments in relation to bathing, going out and smoking. Requirement 2. Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 to 17. Quality in this outcome area was excellent. This judgement has been made using available evidence including a visit to the service. Residents were supported to lead a lifestyle that suited their needs and ability. Staff supported residents to lead active social lives, maintain family and relationship contact and to have a balanced diet. EVIDENCE: From the evidence provided and records seen residents were supported to take part in appropriate activities and to be involved in the local community. None of the residents attended further education or had plans to seek employment. Three of the residents were over pension age. Residents were involved with various activities such as attending day centres, a local college, swimming pool, a pop in parlour and attending church. Staff organised in-house activities such as parties and bar-b-ques. Residents could invite friends and family to these functions. Residents also attended social events planed at sister homes in the organisation. All residents had the opportunity to go out with key workers on a one to one basis. Social activities were recorded in resident’s daily diaries. On the day of the inspection one resident was at College, one Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 12 had gone bowling, one was going to visit their family for the day, one was at the day centre and the others were at home. Staff supported residents to maintain contact with family, to develop friendships and to make visits home. Two residents had no next of kin and the inspector discussed referring them to the advocacy service. Two residents were supported to maintain their friendships with members of the opposite sex outside the home. Relatives contacted said staff kept them informed about the resident’s well-being, made them feel welcome when they visited and felt that staff supported the residents to have a life style that suited them. Resident’s rights were respected. As a means of communication/consultation, each resident was assisted to complete a list of ‘things I like most’ and ‘things I don’t like’. Copies of these were seen in resident files. Staff interacted appropriately with residents and took time to understand them and respond to their needs. Residents indicated staff were responsive to their needs and respectful to them. Residents seen looked relaxed and comfortable in the home and when communicating with staff. Meals were prepared and eaten in each flat however residents could visit other flats for meals if they choose and all residents had a roast dinner together on Sundays. Each flat had its own kitchen. Residents were not able to cook meals but could help themselves to drinks. Staff said they incorporated resident choice into the menu. Menus seen indicated residents were given a varied and balanced diet. Food was stored properly and adequate food stock was available. Staff sat and ate with residents at lunchtime and offered them assistance as needed. Special cutlery was provided for residents to help them maintain independence. Recommendation 1. Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. Residents had their physical and emotional needs met and care provided as identified by assessment. Medication management and practice could pose a risk to residents and must be improved. EVIDENCE: From the records seen residents received personal care in private and at times to accommodate their schedules. Residents indicated they were happy with how they were care for. As mentioned the role of the key worker was very important to residents and to how their needs were met. All bedrooms in the flats were for single occupancy. Staff were observed providing care in private to residents and knocking on doors before entering rooms and flats. All residents were registered with a local G.P. Staff supported residents to access other medical services such as dental, optical, chiropody and to keep hospital appointments. Residents had a six monthly individual review, which included the resident, the key worker, the key worker from the day centre, relatives and other interested parties. Relatives contacted said that they were supported to attend these reviews. Some relatives were provided with transport to the home to enable them to attend the review and one relative said that the review was held in his home to meet his needs and ensure his Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 14 involvement. Staff worked with hospital consultants, speech and language therapists and the community learning disability team to ensure residents physical and emotional needs were met. Residents had an annual medicine review. At the time of writing this report feedback comments had been received from one outside professional. Policies and procedures were in place relevant to medicine management. Medicine management was assessed in two flats. None of the residents had the ability to manage their own medicines. Medicines were stored in locked filing cabinets in each flat. The pharmacist provided printed medicine administration charts and most medicines were provided in blister packs. Two members of staff had not signed hand written entries on medicine administration charts. Staff had added medications to the administration charts and it was unclear when these had been prescribed by the GP. An example of this was on one resident’s chart Paracetamol and a topical medicine had been added. Administration charts were otherwise well maintained. Internal and external medicines were stored together and in flat A the medicine storage drawer needed cleaning. Some medicines in stock had been supplied several months ago, for example topical applications and these items were no longer on the resident’s administration chart. The home did not have a homely remedy medicine list agreed with the GP yet some homely remedies were in stock and no records were seen for receipt or administration of these. Incident records showed that a medicine error had occurred in the home but this had not been reported to the Commission under regulation 37. As medicines were stored in the lounge area of the flats the temperature of the rooms must be monitored to ensure medicines are stored at the correct temperature. Requirement 3. Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. Procedures were in place to manage complaints and to provide protection for the residents. EVIDENCE: A policy and procedure in relation to complaint management was provided and was included in the statement of purpose. Records were kept of complaints received about the service and to show how these had been managed. Since the last inspection two complaints had been made to the staff. Records showed these had been appropriately managed. The Commission had not received any complaints in relation to the service. Relatives contacted knew the home had a complaints procedure however none of them had ever had to make a complaint. Policies and procedures were provided in relation to adult protection. These were generally satisfactory but did not state clearly that allegations or suspicions of abuse must be referred to the host local authority for investigation. Staff who spoke to the inspector displayed a good awareness of adult protection and how they would manage such a situation. Training records showed that some staff had access to adult protection training since the last inspection and since then no allegations or suspicions of abuse had been made to the provider or the Commission. Recommendation 2. Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27 and 30 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. The environment was homely, clean and generally suited to the lifestyle of the residents. Some repairs were noted and have been addressed through requirements. EVIDENCE: The layout of the home into four self contained flats made the environment homely and welcoming. Furnishings, fittings and equipment were domestic in character. Residents looked relaxed and comfortable in their surroundings. No risks to the health and safety of resident were noted. All residents had their own bedrooms. Bedrooms were comfortable and personalised to suit the occupant. Some residents were seen reading the paper or watching TV in their rooms and others were seen sitting in the lounge or in the garden. Residents indicated they were satisfied with their personal space. Each flat had its own bathroom and toilet. All flats were clean and tidy and there were no unpleasant odours. Relatives contacted agreed that the home was always clean and tidy when they visited. In flat A the bathroom needed some repairs as there was some damage to the boxing behind the toilet pan Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 17 and the flooring was coming away from the wall. In flat C a requirement made at the last inspection had not been met. This was in relation to the kitchen and in particular with the unsafe placing of the cooker. Following the inspection the manager confirmed verbally that work to refurbish this kitchen was almost completed. In flat D the seal round the bath must be renewed. Since the inspection the manager also confirmed verbally to the inspector that plans were in place to refurbish the bathroom in flat A to include having a shower unit fitted, which she felt would better meet the needs of the current occupants. Requirements 4 and 5. Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to the service. Adequate staffing levels were maintained and staff had access to relevant training and supervision. The information kept in relation to recruitment procedures must be more comprehensive. EVIDENCE: Staff rotas seen showed adequate staffing levels were maintained including providing one to one care for a resident from 21.00 – 24.00 hours. Relatives contacted made very positive about the staff and the care they provided to residents. Comments made included ‘ the staff are very good’, ‘staff look after residents very well’, ‘ residents get out a lot and go on holidays’ and ‘I could not praise the staff enough’. Staff recruitment files were not held on the premises. A form had been completed for each employee to indicate what recruitment procedures had been followed. The forms for three employees were inspected. All forms indicated that the employee had a CRB check completed. As the recruitment files were not in the home the registered person must ensure the information held in the home shows that staff were recruited as required by regulation 19. For example the forms did not indicate that an application form had been obtained or if there were any gaps in employment that needed to be explained. The form indicated that references were attached but one file did not have Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 19 these. It was not clear that a reference had been obtained from the last employer, if in that role the prospective employee had been working with vulnerable people and the form did not show that references received were verified as authentic. One form did not have a photo of the employee. The manager was provided with information on training planed by the organisation. Since the last inspection staff had access to training such as first aid, epilepsy care, autism, health & safety, food hygiene and infection control. A programme of training was seen for 2006. Staff who spoke to the inspector confirmed this and said they received adequate training and support to enable them to fulfil their role. Nine care staff had achieved NVQ level 2 and a further two had completed this and were waiting verification. This meant that over 50 of care staff had achieved NVQ 2 qualifications or above. Staff files contained records of supervision. Staff seen said they received supervision and said they benefited from these sessions. Systems were in place to provide supervision for staff every four to six weeks. Requirement 6 Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to the service. Although the home was managed satisfactorily other issues required the attention of the registered person. This included sending regulation 26 reports to the Commission and ensuring a quality assurance system was provided. Attention was given to providing a safe environment for residents and others. EVIDENCE: The registered manager had the skills and experience needed to manage the service. Relatives contacted indicated the manager included them in the lives of the residents. A number of residents were unable to make comments about the service and to say whether it met their needs satisfactorily. Relatives contacted said they were kept involved with resident care and had the opportunity to speak for the resident at the six monthly reviews. Relatives also indicated they had confidence in the manager and staff to understand the residents and ensure their had a lifestyle that suited them. Reports on regulation 26 visits were not Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 21 sent to the Commission. Following the inspection the manager said the visits did take place and reports were kept in the home. These reports were not seen at the time of the inspection, as the manager was not on duty. The manager informed the inspector that there was no quality assurance system in place. No major health and safety issues were noted. Some safety records were viewed including fire safety, gas and electricity. All records seen were up to date and showed safety systems were serviced and maintained regularly. Staff did a weekly ‘health & safety walkabout’ of the home to identify any issues that needed attention. Records seen showed staff had access to fire safety training and that fire drills were held for staff and residents. Only one fire drill a year was held to include night staff. Requirements 7, 8 and 9. Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 2 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 2 X X 2 X Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 23 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 YA3 Regulation 14 Requirement Timescale for action 14/07/06 2. YA6 15 3. YA20 13 The registered person must not admit residents outside the home’s category of registration. An application for a variation to registration must be made to the Commission to enable the third resident over the age of 65 years to be cared for and accommodated in the home. The registered person must 14/07/06 ensure staff sign and date care documents and risk assessments to ensure these are reviewed in line with standards. The registered person must 14/07/06 ensure arrangements are in place for the safe management of medicines in the home. • Hand written entries on medicine administration charts must accurately reflect the information on the label provided by the pharmacist and must be signed by two members of staff. • Only medicines currently prescribed by the GP must be included on the administration chart. DS0000037836.V289639.R01.S.doc Version 5.1 Betsham Road (84) Page 24 4. YA24 23 5. 6. YA27 YA34 23 19 7. YA39 26 Homely remedy medicines must only be administered with the agreement of the GP and records must be kept for receipt and administration of these. • Internal and external medicines must be stored separately. • Medicines no longer in use must be returned to the pharmacist. • Medicine storage areas must be kept clean and hygienic. • The temperature of the room where medicines are stored must be monitored to ensure medicines are stored correctly. • Medication errors must be reported to the Commission under regulation 37. The registered person must ensure that refurbishments or modifications regarding the cooker in Flat C are given priority. (Timescale of 31/12/05 was not met). The Commission must be informed in writing when this work has been completed. The registered person must ensure repairs identified in each flat are completed. The registered person must ensure recruitment information kept in the home provides evidence to show staff are recruited in line with the requirements of this regulation. The registered provider must ensure that Regulation 26 visits are carried out and reports sent to the Commission monthly. (Timescale of 30/11/05 was not met) DS0000037836.V289639.R01.S.doc • 14/07/06 14/07/06 14/07/06 14/07/06 Betsham Road (84) Version 5.1 Page 25 8. YA39 24 9. YA42 23 The registered person must ensure a quality assurance system is in place to review and improve the quality of care provided. The registered person must ensure all staff including night staff have the opportunity to practice fire drills in line with the frequency advised by the fire safety department. 14/07/06 14/07/06 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. 2. Refer to Standard YA15 YA23 Good Practice Recommendations The registered person should refer residents who do not have any next of kin to the advocacy service. The registered person should ensure the policy and procedure in relation to adult protection clearly states that all allegations or suspicions of abuse are referred to the host local authority for investigation. Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Betsham Road (84) DS0000037836.V289639.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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