Inspection on 29/11/05 for Cecil Court

This inspection was carried out on 29th November 2005.

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

Cecil Court 23/05/07

Cecil Court 22/11/06

Cecil Court 07/06/06

Cecil Court 15/06/05

Cecil Court 16/12/04

Cecil Court 01/07/04

Cecil Court 19/02/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Cecil Court 2-4 Priory Road Kew Richmond Surrey TW9 3DG Lead Inspector Sandy Patrick Unannounced Inspection 29th November 2005 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 Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 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. Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cecil Court Address 2-4 Priory Road Kew Richmond Surrey TW9 3DG 020 8940 5242 020 8332 1044 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) Central & Cecil Housing Trust Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45), Physical disability over 65 years of age of places (45) Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th June 2005 Brief Description of the Service: Cecil Court is a residential care home providing accommodation and personal care for up to forty-five service users. The home is managed by Central & Cecil Housing Trust. The Trust is a non-profit making organisation providing accommodation and support to vulnerable adults throughout London and the Home Counties. The house is situated in pleasant grounds in Kew, close to local shops, public transport links and local facilities. The home is also close to Kew Gardens and the River Thames. Accommodation is provided on three floors, all accessed by a passenger lift. The home is divided into four units, accommodating between 6 – 19 people. Each unit is equipped with its own facilities and communal space. All bedrooms have en suite facilities. The Registered Persons have produced a Service User Guide, which includes information on the aims and objectives of the service. Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 29th November 2005 and was unannounced. The Inspection Team included a Pharmacy Inspector, who also visited the home on 13th December 2006 to check compliance with immediate requirements made. The Pharmacy Inspector’s report is included within Section 2 (Standard 9) of this report. At the time of the inspection forty-one service users were living at the home. The Inspection Team met with the Acting Manager, other staff on duty, service users and visitors. There was a pleasant atmosphere at the home and staff treated service users with kindness and respect. The Lead Inspector was invited to share the midday meal with service users from one unit. This was well prepared and was a pleasant social occasion. Service users who spoke with the Inspectors said that they were happy living at the home and that staff were kind and caring. One service user told the Lead Inspector that they were free to do as they liked. What the service does well: What has improved since the last inspection? There is evidence that work has taken place to meet the majority of requirements made at the last inspection. Improvements have been made to service user plans and risk assessments. Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 6 Improvements have been made to the environment and health and safety, including equipping windows with restricting devices and extending one of the lounges. The Deputy Manager has been acting as Manager since February 2005 and has worked hard to maintain and improve standards throughout the home. Service users report that that are happy and well cared for. 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. Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 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 Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 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, 2, 3, 4 & 5 There is a range of information for service users about the home. Copies of the Statement of Purpose and Service User Guide are issued to potential service users and copies are available at the home, allowing service users to make informed choices regarding admission to the home. Procedures allow for service users to visit the home prior to admission and there is a period of trial stay. This gives service users the opportunity to assess the quality, facilities and suitability of the home. Individual license agreements are issued to all service users, detailing the terms and conditions for residency. EVIDENCE: The Registered Person has produced a comprehensive Statement of Purpose and Service User Guide for the home. These cover the required areas, including information on admission criteria, the complaints procedure and review of service user plans. There have minor changes to these documents to reflect changes in staffing and management. There is an appropriate procedure for the assessment of service users. This includes a visit to the home by the service user. Assessments for three service Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 9 users were examined. These indicated that the service user, their family and other representatives had been consulted. Medical information from health care professionals was included within assessments. All service users are admitted on a six week trail stay. At the end of this period a review meeting is held, where the service user, their representatives, the placing authority and representatives of the home make a decision about whether the service can continue to meet that person’s needs. The Acting Manager showed the Lead Inspector a collection of letters, cards and compliments which had been sent to the home from service users and their relatives. These letters included praise of staff, the atmosphere and activity provision. One service user told the Lead Inspector that they had visited the home for a day, including a meal, prior to making a decision about whether to move to the home. They said that this had been a really helpful experience. Individual licence agreements detailing the terms and conditions of residency are issued to all service users. Signed copies of the agreement were seen for three service users. Agreements included fees and room numbers. The home does not provide intermediate care. Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 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 Service user plans and risk assessments are in place. Improvements have been made to these and to daily recording. Further improvements are needed in some areas. Service users have access to a range of health care services. Although the home has arrangements for the ordering, storage, recording and auditing of medication and has access to a pharmacist for advice errors and omissions in administration, storage and recording of medication were found that question whether these arrangements protect the health and welfare of residents. EVIDENCE: Individual service user plans are in place for all service users. These included information on a range of needs. There was a focus on maintaining choice and promoting independence. Service users plans are subject to recorded monthly checks. Assessments of risk are in place and are reviewed regularly. The majority of service user plans had been signed by the service user or their representative and risk assessments included their view point. However, some Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 11 service user plans and risk assessments still needed to be signed by service users as a record of their agreement. The Manager should make sure this happens. Service user plans included some information on individual histories and social interests. In some plans this section was more detailed than in others. The staff should seek more in depth information on individual social needs and life histories. Some of the information within service user plans was inaccurate through spelling and other minor mistakes. In some cases this actually altered the meaning of the service user plan. The Manager must make sure that mistakes do not change the meaning of plans and that all information is clear and easy to understand. Daily care notes are made by staff. The Acting Manager told the Inspector that a new computerised system of care planning was going to be introduced to the home. She said that staff were receiving training and support in the use of this. Daily care notes will continue to be written by hand so that staff do not have to leave the units they work on to complete these. All service users are registered with local GPs and staff reported that other health care professionals are consulted as required. Service users who spoke with the Inspector said that they were able to take baths whenever they wanted and that they received a good service from the visiting hairdresser. However, some service user plans indicated that there were long periods of time between baths for some service users. This may be a recording issue. The Manager should make sure that all baths and hair washing are recorded. All medications administered by staff along with the records relating to receipt, storage, administration and disposal of medication were examined. The person in charge of each unit was interviewed, all medication not supplied in the monitored dosage system was counted and compared with the record of receipt and administration, five residents’ rooms were checked and the audit records for the previous month seen. From these observations and discussions residents are encouraged to selfmedicate. Risk assessments were seen for service users who were selfmedicating. These are reviewed regularly. Each resident has a medication profile that details allergies, medication on admission and any changes to medication. Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 12 Creams were found on the shelf in all rooms and denture cleaning materials under the sink in one room. These were not stored securely. No risk assessment was seen for the storage of these items in residents’ rooms. In one instance the cream in the room did not match the cream that had been recorded as being applied. In another instance the medication profile indicated that the cream that was found in the room had been discontinued in May 2005. Staff said the cream was being applied but no record had been made of the administration. There was a further instance where no record of application had been made of a cream found in the room. In one instance the application of a patch had not been recorded. Three residents had not been given medication on various dates over the last month as the medication was out of stock. The medication was out of stock on the day of inspection for two of these residents. In four instances the amount of medication in stock did not agree with the amount there should be from the records of receipt and administration for medication that was not supplied in the monitored dosage system. This indicated that the medication had not been given as prescribed. The receipt of the current monthly medication had not been recorded fully for three of the units. Temazepam was not stored in the controlled drugs cupboard. All other records had been completed accurately and only designated and trained staff administer medication. Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 13 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 & 15 There is a range of planned activities which service users are able to participate in. Service users reported that activities were generally well organised and fun. Service users are able to maintain independence both at the home and within the community according to wishes and risk assessment. There is a varied menu offering choice and service users are regularly consulted about food at the home. EVIDENCE: There is a daily programme of organised activities which service users can chose to join in with. Many of the service users at the home organise their own activities and go out shopping or to use local facilities as they chose. There is an activities room on the ground floor, which is used for large group activities. Service users reported that they participated in small group and individual activities within the units. There is a wide range of equipment to support activities, including craft work. Service users were seen to pursue a variety of activities and were supported by staff to read newspapers and socialise as well as participating in formal Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 14 activities. A video was shown in one of the lounges during the afternoon of the inspection. Service users are able to access the community according to risk assessment. Assessments of risk relating to this were seen within the service user plans examined. Over the summer a fete was held at the home. The Deputy Manager reported that this was enjoyed by service users and staff and acted as a fundraiser for the home. A Christmas Party and other festive activities were being organised during December. The Lead Inspector was invited to share lunch with the service users of one unit. The meal was well prepared. Vegetables were served in separate dishes so that service users could help themselves. Service users who ate with the Inspector said that they usually liked the food. During the meal staff were attentive to needs and offered support to those who needed in a kind and unobtrusive manner. Food is distributed to the units in heated trolleys and served by staff. One service user said that the food was sometimes cold when they were served. The Inspector passed this comment to the Acting Manager. The Chef meets with service users regularly to discuss their views and wishes with regards to the menu and quality of food. During the Inspection the Chef visited individual units and spoke with service users. There was no menu on display in one of the units. Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 15 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 Service users are able to access the community according to risk assessment. Assessments of risk relating to this were seen within the service user plans examined. EVIDENCE: There is an appropriate complaints procedure, which includes timescales and reference to the Commission for Social Care Inspection. There have been no complaints since the last inspection. The home has adopted the London Borough of Richmond Protection of Vulnerable Adults Procedure and the organisation has its own procedures on abuse and whistle blowing. There is a programme to make sure all staff are trained in the protection of vulnerable adults. Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 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, 20, 21, 22, 23, 24, 25 & 26 The environment is generally safe, well maintained and comfortable. Service users have unrestricted access to communal areas and report that they are happy with the environment. Improvements are being made to some communal areas. Further improvements are needed in other areas. EVIDENCE: The building is situated in pleasant and well-kept grounds, with level access areas and raised beds. The home is generally well decorated and maintained. Pictures, plants and ornaments were seen throughout communal areas. The home is generally well maintained. Building work in some areas will improve the environment. Maintenance needs identified at this inspection included a badly stained carpet in one of the corridors and worn flooring in the ground floor dining room. Consideration should be given to the replacement of these. At the time of the inspection building work to extend the first floor lounge and refurbish the kitchen in this unit were taking place. Refurbishment of the Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 17 second floor kitchen was due to take place once the work on the first floor was completed. Appropriate safety measures had been taken to protect service users whilst building works were taking place. The Deputy Manager stated that kitchenettes on other units would be refurbished during 2006. At the last inspection it was noted that, in one unit, accommodating seventeen service users, there are only twelve dining chairs within the dining room. The remaining five service users dine in the unit’s lounge away from other service users. The staff on duty within this unit stated that this was not their choice. In addition staff reported that service users preferred dining chairs with arms because this allowed them to stand more easily. Some service users need this kind of chair. There are not enough of these chairs for all service users within this unit. The existing chairs and tables within this unit are old and some are worn and need replacement. The Deputy Manager reported that she hoped that replacement furniture would be purchased in 2006. The Deputy Manager reported that the majority of windows had been equipped with restricting devices. Risk assessments are in place for windows which have not been equipped with these devices. These assessments must be reviewed on a regular basis and if a new service user moves into these rooms. All bedrooms have en suite facilities and have TV aerial points. Service users can organise for their own telephone line if they wish. Trolley telephones are available for service users within each unit. Each of the units at the home has a lounge and dining area. There is also a large activities room on the ground floor. The premises are suitably equipped with adaptations and equipment throughout. A passenger lift accesses all floors accommodating service users. All rooms are equipped with call alarm systems. The home was clean throughout and there are appropriate procedures for the laundering of clothes, Control of Substances Hazardous to Health, disposal of clinical waste and infection control. Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The home employs sufficient staff to meet the needs of service users. Staff are appropriately trained, supervised and their work appraised. Staff recruitment records did not all evidence thorough pre employment checks and service users may be at risk from unsuitable appointments. EVIDENCE: Staff, including senior staff, are allocated to each unit. Rotas indicate that sufficient staff are employed to meet the needs of service users in each unit. Senior staff demonstrated that the organised staffing on their units appropriately. Waking staff are employed at night. Volunteers offer additional support with certain activities, but do not support service users with personal care and must not do so. There is an extensive range of information for all staff on their roles and responsibilities. There was one part time care assistant and a domestic staff vacancy at the time of the inspection. Interviews for the care assistant vacancy were being conducted by the Acting Manager on the day of the inspection. The recruitment and selection process includes a formal interview, a written test and observations whilst the potential staff members meet with service users. Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 19 The Lead Inspector saw examples of questions asked at interview, these included scenario questions. The Lead Inspector examined four staff recruitment files. These indicated that appropriate pre employment checks had been made on some of the staff, including criminal record checks and two written references. Two staff files were incomplete and did not evidence references. In one case there was no record of a criminal record check. The Acting Manager said that she felt this information could be at the organisation’s head office. Appropriate checks must be made on all staff and completed staff files must be held at the home. The home employs volunteers from abroad to offer additional support. At the time of the inspection there was one volunteer at the home and one was due to start shortly afterwards. Appropriate checks are made on volunteers. Staff on duty reported that they attended a range of training. There is a thorough induction package of training and support and staff who have completed this then apply to take NVQ qualifications. All Care Manager (senior staff) working at the home are qualified to at least NVQ Level 2. Four individual staff training records were seen. These staff had undertaken induction training and a range of other training relevant to their roles. There was a record of regular individual supervision meetings for all staff. The Inspector saw records of regular staff meetings. These indicated that staff were able to contribute their ideas and were well informed about procedures, practices and the Commission for Social Care Inspection. Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 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, 37, 38 The home was being appropriately managed by the Deputy Manager at the time of the inspection. There is an appropriate quality monitoring system. Procedures to check health and safety and equipment are in place. EVIDENCE: The Registered Manager left her post earlier in 2005. The Deputy Manager has been acting as the Manager on a temporary basis. The Deputy Manager reported that a permanent Manager had been recruited and was due to start work in January 2006. The organisation must notify the Commission for Social Care Inspection (CSCI) in writing of this appointment and the new Manager must make an application to be registered with the CSCI as soon as practical. Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 21 The Deputy Manager completed her Registered Managers Award shortly before the inspection. The Deputy Manager is experienced and very knowledgeable about the home. She told the Inspector that she did not want the Manager’s role on a permanent basis and will be pleased to return to some of her former work, in particular direct support of service users. She demonstrated a very good knowledge of individual service user needs and staff issues. Her skills, knowledge and experience will be an invaluable support to the new Manager. Since the last inspection there have been a number of falls, accidents, hospital admissions, incidents and deaths at the home. The Commission for Social Care Inspection (CSCI) has not been notified of all of these. The Registered Person must make sure that the CSCI is notified of these events. The requirement made at the last inspection is restated. Central and Cecil Housing Trust organise for a representative to visit the home on a regular basis and make an assessment and audit of a specific area. Reports from these visits are sent to the CSCI. Recent visits looked at food, fire safety, activities and the environment. Regular meetings with service users at=re held on individual units facilitated by senior staff. The chef meets with service users on a regular basis to discuss the quality of food. There is evidence of regular checks on fire safety, water temperatures, food storage temperatures and other areas of health and safety. Large containers of washing detergent are stored within laundry rooms. These rooms are not locked. The Registered Person must make sure that this storage arrangement is risk assessed and that appropriate action is taken to make sure service users are safe. The Fire Officer visited in June 2005. the Acting Manager reported that requirements made by the Fire Officer had been met. There was a record of regular fire drill tests. There is a record of electrical and gas safety checks. Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X X 3 3 2 Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 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 OP7 Regulation 15 17 Requirement Timescale for action The Registered Person must 31/01/05 make sure that mistakes in service user plans do not change the meaning of plans and that all information is clear and easy to understand. The Registered make sure: Person must 01/01/06 2. OP9 13(2) 1. Arrangements are in place for the safe storage and administration of all external preparations. 1st December 2005 2. The administration/nonadministration of all medication is recorded accurately. 30th November 2005. 3. Arrangements are made to maintain sufficient supplies of medication at all times. 30th November 2005. 4. All medication is given as Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 24 directed unless other wise recorded and arrangements are in place to audit medication to supplied in the monitored dosage system. 5. The receipt medication is accurately. 1st 2006. 3. OP19 23(2)(e) & (g) of all recorded January The Registered Person must 31/03/06 make sure there is sufficient and suitable seating for all service users of the ground floor unit to eat in the dining room if they wish to. Previous requirement timescale 31/12/05. 4. OP29 13(4) (6) 18 19 S.2 The Registered Person must 31/01/06 make sure thorough pre employment checks are made on all staff. Records of these checks must be held at the home. The Registered Person must 31/12/05 notify the CSCI of any significant event in accordance with this Regulation. Previous timescale 31/07/05 5. OP31 37 6. OP31 8 9 The Registered Person must 31/01/06 notify the CSCI in writing regarding the appointment of a new Manager for the home. This person must make an application to be registered with the CSCI as soon as practical. Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 25 7. OP38 13(4) (6) The Registered Person must 31/12/05 make and record an assessment of risk on the storage of washing detergents in unlocked rooms and must take appropriate action to minimise any risks. 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 OP7 Good Practice Recommendations Further work should take place to expand information on social wishes and needs for each service user. The Registered Person should make sure that baths are appropriately recorded. 1. It is recommended that the quantity of medication carried over from one month to the next be recorded on the administration record. 2. It is recommended that Temazepam be stored in the controlled drug cupboard. 4. OP15 The Registered Person should make sure the menu is clearly displayed in all units so that service users can refer to this before meals. The Registered Person should consider the replacement of stained carpets and worn flooring. 2. OP10 3. OP9 5. OP19 Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Cecil Court DS0000017354.V260140.R01.S.doc Version 5.0 Page 27 - 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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