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Inspection on 24/04/06 for Broome Park Nursing Home

Also see our care home review for Broome Park Nursing Home for more information

This inspection was carried out on 24th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

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

What the care home does well

The management and staff team strive to ensure that the home provides a pleasant and homely environment and atmosphere for the residents. The staff team demonstrated a good understanding of the residents care needs, which were well met on the day. Care plan documentation is comprehensive, with clear instructions for the care provided. The residents benefit from a stable staff group, who provide a consistent level of care. Staff training is given a high priority at this home, with many training courses offered on an ongoing basis. The home has recently been chosen as the winner of the Health Care Employer Supporting Learning and Progression Award.

What has improved since the last inspection?

All but one of the requirements made following the last inspection have been met. The home continues to improve the environment for the residents. Kitchen practices in respect cleaning and food safety regulations have improved. For example, the kitchen has been thoroughly cleaned, areas have been repainted and a cleaning schedule has been developed.Some of the residents bedrooms have been fitted with new vanity units. One bedroom has been completely refurbished. New armchairs and curtains have been ordered. A new security lighting system has been installed at the annex.

What the care home could do better:

A requirement made at the pharmacy inspection in December 2005 in respect of updating the homes medication policy and procedure has yet to be met. The home still has to address this area, which now must be a priority for attention. Failure to comply with these may result in CSCI seeking legal advice. The home is undertaking major works to one of the bedrooms. The CSCI were not notified of this, nor has the registered person(s) applied for an application in respect of a major variation. Whilst on the whole care planning documentation is good. It was noted that there were some shortfalls in one. In order for the staff to ensure that residents needs are properly met, a care plan in respect of a resident must be further developed to include managing risk and challenging behaviours. It was noted that procedures in respect of the homes medication policies were not being followed. These procedures must be followed in order to protect the health safety and wellbeing of the residents. The procedures in respect of the control of substances hazardous to health were not being followed. This could potentially lead to residents being put at risk. The annex at Broompark nursing home provides for respite care. It was noted that there were no photographs kept in respect of residents who are admitted to the home on respite care. Which could have the potential to lead to confusion in respect of medication and missing persons procedures. The clinical waste bins outside the main building were overflowing, and appeared not to have been emptied for some time. This could potentially be hazardous to residents, staff and visitors to the home.

CARE HOMES FOR OLDER PEOPLE Broome Park Nursing Home Station Road Betchworth Surrey RH3 7DF Lead Inspector Pauline Long & Vera Bulbeck Unannounced Inspection 24th April 2006 11:25 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 Broome Park Nursing Home DS0000013303.V291882.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 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. Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Broome Park Nursing Home Address Station Road Betchworth Surrey RH3 7DF 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) 01737 843333 01737 842444 Mr Michael Law Hing Choy Mrs Muriel Law Hing Choy Mr Michael Law Hing Choy Care Home 56 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (43), Learning disability (3), Learning disability of places over 65 years of age (3), Mental disorder, excluding learning disability or dementia (9), Mental Disorder, excluding learning disability or dementia - over 65 years of age (43), Physical disability (9), Physical disability over 65 years of age (12), Terminally ill over 65 years of age (4) Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. Age/age range - up to 9 (nine) service users within categories, dementia DE(E), learning disability LD(E), physical disability PD(E) over 65 years. Of the 56 service users accommodated up to 43 may fall within category of either mental disorder MD(E) or dementia DE(E) - over 65 years. Up to eight service users within all categories (except category TI(E)) may be accepted on a day care basis. One (1) terminally ill person over 65 years of age (TI(E)) within category (MD(E)) or (DE)(E)) may be admitted to the Annex Three (3) persons with physical disability over 65 years (PD(E)) within categories (MD(E)) od (DE(E)) may be admitted to the Annex. One person with Mental Disorder, excluding learning disability or dementia (MD) over 60 years of age may be admitted to the Annex One (1) person with Dementia (D) over 60 years of age may be admitted to the Annex 5th January 2006 Date of last inspection Brief Description of the Service: Broome Park Nursing Home is a private Care Home, which specialises in the care of older people with enduring mental health disorders and dementia. Service provision includes placements for residents with physical or learning disabilities. The home operates from a converted country manor house and stables, set in 10 acres of mature well maintained grounds. The accommodation consists of single and twin bedrooms, some with en-suite facilities, communal lounges, sitting rooms and separate dining rooms. Access to the upper floors is via stairs and a lift. The home is situated in a semi rural location and is accessible by major road and rail networks. It is convenient for Dorking and Reigate town. The home has its own vehicles and drivers who convey residents to appointments and other community resources. Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit as part of the key inspection year for this home, and was unannounced. The inspection was carried out by two inspectors and lasted for six hours. Discussions were had with some of the residents, the registered manager, registered provider, nursing and care staff. Documents sampled, included service users files, care plans, health and safety documentation, staff communication records and some policies and procedures. A full tour of the home’s two buildings took place. Verbal feedback from some of the resident’s on the day was limited, in view of the their communication difficulties. It was positive to note that residents were encouraged to take an active part in the inspection process, one resident sat in on the feedback session at the end of the inspection. CSCI would like to thank the residents, managers and staff for their hospitality and co-operation during the inspection. What the service does well: What has improved since the last inspection? All but one of the requirements made following the last inspection have been met. The home continues to improve the environment for the residents. Kitchen practices in respect cleaning and food safety regulations have improved. For example, the kitchen has been thoroughly cleaned, areas have been repainted and a cleaning schedule has been developed. Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 Page 6 Some of the residents bedrooms have been fitted with new vanity units. One bedroom has been completely refurbished. New armchairs and curtains have been ordered. A new security lighting system has been installed at the annex. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 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 Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Comprehensive needs assessments are routinely carried out by the home before a resident is admitted. The home does not provide for intermediate care. EVIDENCE: Three residents files were sampled as part of the inspection. These files contained various documents. For example: community care, mental health and social needs assessments, which were sought from social and health care teams prior to the home undertaking their own care needs assessment. The manager stated that a qualified nurse would carry out the needs assessments at a resident’s home or hospital and once admitted to Broompark the assessment would be ongoing and result in a comprehensive overview of a residents needs. At the present time the home does not provide for intermediate care. Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Holistic care plans are in place for the majority of the residents. Staff had not followed the homes medication procedures. Residents are not responsible for their own medication. Residents are treated respectfully and their privacy is upheld. EVIDENCE: Care plans were sampled, and on the whole were found to be well written, to include all daily living activities. The care plans gave clear and concise instructions to the reader about a residents care needs, demonstrating that the care staff would be aware of the residents needs. However one of the care plans sampled did not contain any guidelines in respect of managing a resident’s challenging behaviours, nor were there any documented risk assessments, or action plan to manage the associated risks. Medication practices were checked in the annex. It was noted that medication received had not been recorded correctly on the medication record sheet. This demonstrated that the homes procedures for dealing with medicines had not been followed. Resident’s commented that the staff were always polite and that they were always respectful towards them. Care staff were observed providing various Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 Page 11 personal care tasks in a respectful manner being mindful of a residents privacy. A requirement in respect of medication procedures has been made. Please refer to page 25 of this report. Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 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): 12,14,15 The home enables the residents to exercise choice and control over their lives helping them to maintain fulfilling lifestyles in the home. Feedback from residents regarding the meals was mainly positive however the area of menu choices could be promoted further. EVIDENCE: The home has an activity organiser who works across both buildings. On the day of inspection there was no up to date list/programme of activities. However staff and residents discussed various activities offered at the home for example: celebrations around St Patrick’s and St David’s day, church services, Easter bonnet parade, keep fit afternoons, sing-along mornings and music and movement exercise, beauty therapist sessions. The home also invites local schools in to perform shows. One resident commented that whilst the home offered many activities, there were not enough activities aimed at his age range. This was discussed with the manager. Families and friends are encouraged to visit the home, there are no restrictions on visiting times. Meal times and meals were discussed with some of the residents. Some residents commented that they were not asked what they would like to eat, however they also commented that the food was good. Staff stated that residents do have a choice of main meal, however the menu submitted on the day did not demonstrate this. This was discussed with the manager who stated Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 Page 13 that residents could choose to have an alternative main meal. He was advised to add an alternative to the daily menu to ensure that residents would be in a position to make a choice. The residents lunch time was observed, the food looked appetising and residents commented that the meal was very good. Some residents required help to eat their meal, and staff were observed providing help in a quiet and respectful manner. The home provides a comment book for residents and staff in order to give feed back to the chef. It was noted that there were several comments in the book and that the majority of the comments were positive, however it was not clear if the comments came from the residents or staff. It was positive to note that the head of care and the chef had discussed various comments dated 13/03/06 and that menus had been adjusted as a result of this feedback. Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 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 home has satisfactory policies and procedures and training in place for addressing concerns and complaints. Staff had a good understanding of adult protection issues. EVIDENCE: The CSCI have received no complaints since the last inspection. According to the pre-inspection documentation completed by the home, no complaints have been made directly to the home. On the day of inspection discussions were had with the manager and staff as to how complaints were being recorded. Minutes of a recent staff meeting demonstrated that this issue had been discussed. Various ideas were put forward for consultation. At present complaints are noted in a residents daily records and responded to directly by the manager or head of care. One resident commented that he would be more than happy to make a complaint if the need arose. He commented that he had complained and that it had been promptly dealt with. The home has recently amended the complaints policy to reflect the current management arrangements. The manager commented that, the procedure was under review and would be amended to reflect the outcome of the recent staff meeting. Various scenarios in respect of adult protection issues and the homes whistle blowing policies were discussed with staff. It was positive to note that in respect of the homes protection of vulnerable adults procedures the staff had a good understanding and clarity as to how the process worked. However one member of staff was not completely clear as to how the whistle blowing policy Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 Page 15 worked. This was discussed with the manager, who indicated that he would discuss this with the member of staff involved. He also indicated that the whistle blowing policy would be included in the next adult protection training course. Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,25,26 The home strives to provide a safe, well maintained, pleasant hygienic and comfortable environment for residents and staff. EVIDENCE: Broompark is an older property and therefore presents challenges for the providers in respect of the ongoing need for updating and refurbishment. There is an improvement plan in place, and since the last inspection various improvements have been made. For example; several of the bedrooms have had replacement vanity units installed, and have been redecorated. New furniture, carpets and curtains have been bought for various areas in the home. The home has identified various items for their “wish list” for example: new armchairs, re-painting the walls, replacing the carpets, replacing wheelchairs, landscaping the car park, rebuilding the wall, repairing the holes in the drive. On the day the home was clean, pleasant, hygienic and free from any malodour. The communal areas were decorated to a satisfactory standard and reflected the general wear and tear of a busy home. Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 Page 17 Major work had been undertaken in respect of adding a further bedroom to the home. This was being achieved by dividing a large room into two smaller rooms and by knocking down a wall to allow for a new door. There was considerable noise and dust generated, however the workman had taken some steps to ensure that the disruption was minimised and that the residents health and safety was considered. This was discussed with the manager and he was advised that CSCI should have been notified of this work. The home has also been advised to submit an application for a major variation to the homes registration. A requirement has been made in respect of the building work. Please refer to page 25 of this report. Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 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): 27,30 This home provides trained and competent staff in sufficient numbers providing a consistently good care service for the residents. EVIDENCE: The home benefits from a stable staff group. On the day staffing levels and skill mix were adequate for the dependency levels of the residents. The home maintains appropriate staffing levels across the two buildings and on the day were as follows: the morning shift staff team consists of 4 registered nurses and 9 care assistants, the afternoon shift, 2 registered nurses and 5 care assistants and 9 housekeeping staff. The manager, and responsible individual were on duty throughout the inspection. Staff training is given a high priority. The home has recently been chosen as the winner of the “The Health Care Employer Supporting Learning and Progression Award”. There is an ongoing training programme for both qualified and non qualified staff, which includes in house lectures covering mandatory training (Protection of Vulnerable Adults, Manual Handling, Food hygiene), clinic practice and NVQ programmes. The home also offers distance learning courses via Nescott. Ten candidates have been enrolled on an NVQ course and one is undertaking an NVQ Assessor award. Residents commented that the staff were always professional, and there was always help on hand if help was required. Telephone discussions were had with some relatives and they also commented that the staff at the home were Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 Page 19 always professional, well trained and that the level of care provided at the home was good. Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,38 Resident’s and staff benefit from a management team whose leadership, ethos and approach ensure that the home is run in the bests interests of the residents. On the day some health and safety practices need to be improved. EVIDENCE: The overall management arrangements at the home remain constant. The nurse manager at the annex has recently resigned, subsequently a new nurse manager has been appointed from the existing staff team. Residents and relatives spoken with commented that all of the management team were approachable, and that the home was well run. One resident commented that since he was admitted to the home he had met with the manager on several occasions, he stated that “the manager was always very helpful”. Staff commented that all of the management team were supportive and had a visible presence in the home. It was positive to note that residents were Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 Page 21 encouraged to take an active part in the inspection process, one resident sat in on the feedback session at the end of the inspection. As discussed earlier in this report, the manager had not informed the CSCI of major works being carried out at the home. The manager was advised that the home must notify the CSCI of any issues at the home which may affect the safety and wellbeing of the residents, he was also advised to apply to the CSCI office for a major variation of the homes registration category. Throughout the inspection residents were observed moving freely around the building. The only restrictions noted were the keypad to the front door, restricted keypad access to the kitchen, the clinical room and the duty office. A formal staff supervision programme has been implemented and one to one staff supervisions are taking place. The manager discussed the possibility of involving the senior nursing staff in the supervision of the non qualified staff. Regular staff meetings are held, the most recent one on the 20th April. Health and safety checks are routinely carried out at the home. It was positive to note that the main kitchen has undergone an in-depth programme of cleaning and some redecoration has been carried out. A daily cleaning schedule has been developed, the manager stated that the schedule will be implemented as soon as the staff have received their training. Kitchen records in respect of food hygiene regulations are well documented. Foodstuffs were stored appropriately. The water temperatures were checked in many of the bedrooms and communal bathrooms, all were satisfactory. Staff were observed transferring residents using the hoists provided, moving and handling practices were good. A bottle of bubble bath and a can of air-freshener were found to be stored in an unlocked bathroom cabinet in one of the annex’s bathroom, presenting a potential hazard to the residents. The nurse manger removed them whilst the inspector was there. Clinical waste bins stored out side the main building were overflowing. This was discussed with the manager and whilst he was able to give a satisfactory reason. He was advised that the situation must be dealt with as a matter of urgency. Requirements have been made in these areas. Please refer to pages 24 and 25 of this report. Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 Page 22 Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 X 29 X 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 X 2 Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? One remains unmet from the last pharmacy inspection. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The registered person(s) must ensure that the homes medication policies and procedures are reviewed and updated. Previous timescale of 02/12/05 not met The registered person(s) must ensure that a care plan in respect of an individual is further developed to include risk assessments and behavioural guidelines for a resident who displays challenging behaviours. The registered person(s) must ensure that all members of staff are aware of and have an understanding of the homes policies on restraint and restrictive practices. The registered person(s) must ensure that all staff adhere to the homes medication policies and procedures. All medication received into the home must be properly recorded on a resident’s medication record. The registered person(s) must ensure that all substances DS0000013303.V291882.R01.S.doc Timescale for action 24/05/06 2. OP4 12(1)(a) 13(4) (c 24/05/06 3. OP38 13(7) 24/05/06 4. OP9 13(2) 01/05/06 5. OP38 13(4)9a(b (c 25/05/06 Broome Park Nursing Home Version 5.1 Page 25 6 OP38 Schedule 3 hazardous to health including air fresheners and bubble bath solutions are stored according to the Control of Substances Hazderous to Health (COSHH) regulations. They must be locked away. It should be noted this requirement was met during the site visit. The registered person(s) must ensure that an up to date photograph is kept on file in respect of all of the respite residents. The registered person(s) must review all of the bedroom door locks. To ensure that if a resident wishes to lock their bedroom door they can do so. The registered person(s) must ensure that all clinical waste is disposed of correctly securely and in a timely manner. The bin must not be allowed to overflow. 24/07/06 7 OP24 12(1)(a) 4(a) 24/07/06 8 OP26 12(1)(a) 13(3) 16(2)(k) 02/05/06 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 3 4 Refer to Standard OP38 OP15 OP38 OP33 Good Practice Recommendations The registered person(s) should consider identifying the locked door on the first floor of the annex with a sign stating “Staff Use Only”. The registered person(s) should consider including on the daily menu sheet an alternative choice for the residents to consider. The registered person(s) should consider keeping all of the documentation relating to fire procedures in one folder including the fire risk assessment. The registered person(s) should consider reviewing the format of the minutes of meetings to include roles, DS0000013303.V291882.R01.S.doc Version 5.1 Page 26 Broome Park Nursing Home responsibilities and feedback. Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Broome Park Nursing Home DS0000013303.V291882.R01.S.doc Version 5.1 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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