Inspection on 07/09/06 for Cedar House

This inspection was carried out on 7th September 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cedar House 27/04/09

Cedar House 27/10/08

Cedar House 01/10/07

Cedar House 26/02/07

Cedar House 19/04/06

Cedar House 04/01/06

Cedar House 02/08/05

Cedar House 09/09/04

Cedar House 26/04/04

Cedar House 17/03/04

Cedar House 19/01/04

Cedar House 18/09/03

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

CARE HOMES FOR OLDER PEOPLE Cedar House 39 High Street Harefield Middlesex UB9 6EB Lead Inspector Mrs Clare Henderson Roe Key Unannounced Inspection 7th September 2006 10:25 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 Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cedar House Address 39 High Street Harefield Middlesex UB9 6EB 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) 01895 820 700 01895 820 600 www.schealthcare.co.uk Southern Cross Healthcare Services Limited Care Home 42 Category(ies) of Dementia - over 65 years of age (0), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (0) Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To comply with the Minimum Staffing Notice required by the previous regulator as at 31st March 2002. Five of the beds currently registered can be used for service users of 55 years of age and over, as agreed by the Commission for Social Care Inspection, on 1st February 2005. 19th April 2006 Date of last inspection Brief Description of the Service: The home is situated in Harefield village. The village centre is within walking distance of the home and public transport, that being bus services, are available. Cedar House offers care to service users who are over 65 and suffer from Dementia. It is a purpose built care home with service user areas on two floors and services and staff areas on the third floor. The floors are interconnected by a lift, which also accesses the third floor. There is parking to the front and an enclosed garden to the rear. The home is entered and exited by a keypad system. The administrators office is sited in the foyer. There is a designated person who oversees leisure activities. There are two General Practitioners providing input for the home, both of whom visit weekly. Monthly visits from a psychiatrist take place to review the service users mental health needs. Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out as part of the regulatory process. A total of 10 hours was spent on the inspection process. The Inspector carried out a tour of the home, and a selection of service user plans, staff records, administration records and servicing & maintenance records were viewed. 6 service users, 9 staff and 4 visitors were spoken with as part of the inspection process. Additional information received following the inspection has also been used to inform this report. It must be noted that it is sometimes difficult to ascertain the views of service users with dementia care needs. This is the second key inspection carried out in this inspection year, and where key standards were met at the last inspection, they have not all been revisited at this inspection. What the service does well: What has improved since the last inspection? The home has worked hard to address the requirements from the last inspection. Some staff have received training in dementia care and further training is planned. An experienced activities co-ordinator has been employed and is putting programmes in place for activities and outings to meet the service users interests. A record of service users meal choices is now being kept at each meal. Bathing and shower facilities are being maintained in working order, and sluice rooms are no longer being used as storage facilities. More domestic staff have been recruited and the home was clean and smelled fresh. Training to include NVQ in care training is being progressed, with several staff having attained NVQ level 2 in care or an equivalent qualification. Health & Safety training for staff has been implemented at frequent intervals to bring all staff up to date. Fire drills are being carried out at required intervals, and the fire risk assessment had been updated. Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 4. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are assessed prior to admission to ensure that the home are able to meet their needs. Staff have undertaken training in dementia care in order to provide them with the knowledge to care for service users’ specialist needs. EVIDENCE: The home has a comprehensive pre-admission assessment document, and assessments are carried out by the Manager Designate for all prospective service users, to ascertain if the home is able to fully meet the service users needs. The home also obtains a copy of the Social Services or Primary Care Trust service user assessment. The Manager Designate has developed a training matrix. Several staff have undertaken dementia care training, and the Manager Designate has recently completed the Trainers course for the Alzheimers Society ‘Yesterday, Today & Tomorrow’ dementia care training course. In addition the Manager Designate is accessing other training available in this specialist area. Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user plans are up to date, thus providing staff with a clear picture of the service users needs. Shortfalls should be easily addressed. Generally medications are being well managed, but the shortfall identified could potentially place service users at risk. Staff care for the service users in a gentle and courteous manner, thus respecting their privacy and dignity. EVIDENCE: A sample of service user plans were viewed on each floor. Overall these were comprehensive and gave a clear picture of the service users needs and how these are to be met. The service user plans had been updated monthly and there was evidence of input and review from service users representatives. Risk assessments for falls and for any other identified risks were in place. Wound care documentation was viewed. The Manager Designate has introduced a skin integrity chart that is completed by the registered nurse on duty on each shift. There is also a weekly dependency and pressure area audit document that is completed. In one instance the information did not tally between the two documents, and this was clarified and addressed at the time Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 10 of inspection. Otherwise the documentation for wound care was clear and complete, with evidence of wounds healing and of input from the tissue viability nurse specialist. The need to archive some old documentation was discussed with the registered nurse on the first floor. Pressure relieving equipment was seen in use in the home, and is identified on the weekly audit document. Assessments for moving & handling, dependency, continence and nutrition were in place, and care plans had been formulated to address needs identified. Where bedrails were in use, bedrail assessments had been carried out and written consent for their use obtained. It was noted in 2 service user plans that care plans for the use of bedrails had been formulated, however no risk assessment or consent was in place. On investigation it was found that bedrails were not in use for these 2 service users, and the registered nurse had completed the care plan in case they should be needed in the future. The need to ensure that such documentation reflects the actual situation regarding the use of equipment was discussed. There is evidence of input from the GP and from other healthcare professionals, and these visits are recorded in the service user plan. The medication records were sampled for each floor. Since the last inspection an air conditioning unit has been installed in the clinic room to maintain the room temperature below 25˚ centigrade. A list of signatures and initials for all registered nurses administering medications was available. The 28 day medication cycle had commenced on the day of inspection. All receipts and administration of medications had been recorded. Medications are disposed of in accordance with current legislation. Liquid medications had been dated on the day of opening. Some of the eye drops stored in the fridge did not require to be, and were removed at the time of inspection. The start date for the insulin pen in use for a service user was clearly recorded. The home has individual blood sugar monitoring devices in use, that are labelled for the two service user concerned. The importance of ensuring that each device is only ever used for the individual for whom it is labelled to minimise cross-infection risks was emphasised to the registered nurse and the Manager Designate. Copies of the prescriptions for the medications currently in use were available. A front sheet with service users details to include their name, a photograph, known allergies plus any information such as non-compliance with medication was in place for each service user. Where a service user is non-compliant, clear risk assessments are carried out and this is discussed and agreed in writing with the GP and/or Consultant and the service users representative. For one service user two medication administration record (MAR) charts were in use, with 3 of the same medications recorded. It was noted that for some days administration signature entries had been made on both sets of charts. There was also some confusion over the administration of a forth medication. Following discussion with the registered nurses it was ascertained that the medications had been administered in accordance with the doctors instructions. The importance of ensuring all entries are correct and of using one set of MAR charts per service user was discussed. Controlled drugs are correctly stored and recorded in the home. Overall medications are being well Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 11 managed, but the shortfall identified could potentially place service users at risk. Staff were seen caring and conversing with service users in a courteous and gentle manner. Staff were heard chatting with service users about various topics and there was some good interaction noted. Service users are supervised in the lounge areas to minimise the risk of accident. Service users were dressed appropriately for the weather, and looked well groomed. There was a peaceful atmosphere on both the floors. Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & aspects of 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity input for the home is good and geared to meet the specialist needs of the service users, thus providing for their interests and needs. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. The food provision in the home is good, offering variety and choice, to meet the service users needs. EVIDENCE: Since the last inspection a new activities co-ordinator has been recruited. It was clear from speaking with her that she has a good knowledge of providing activity programmes to meet the specialist needs of service users with dementia. A weekly activities programme was on display, along with the programme of events for the year. In addition to in house activities, outings are arranged using specialist transport to enable service users with varying physical needs to go out. A garden party had recently been arranged, and the Manager Designate reported very good attendance from service users, staff and visitors. An individual ‘Map of Life’ is being formulated for each service user, to provide information about their life history. Staff were heard chatting with service users about their past and service users were participating interestedly in the conversation. Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 13 The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made very welcome at the home. Representatives said that they are kept informed of any concerns about their loved ones. The recording of service users meal choices at mealtimes has been reintroduced. On the day of inspection staff were seen assisting service users as necessary with the lunchtime meal. On one floor it was noted that for service users who require feeding, all of the meals had been plated up. Some had been left uncovered on the bottom of a trolley, with no action taken to prevent them from becoming cold. The cook explained that there is a system for staff to return the meals to the heated trolley in order to keep them hot, for delivery from the kitchen when the staff are ready to assist the service users. The Manager Designate said that he would ensure this system was being followed in future. The kitchen and food provision was viewed in depth at the last inspection. Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by service users and their visitors. The system in place for protection of vulnerable adults is robust, thus safeguarding service users. EVIDENCE: The home has a clear complaints procedure in place. There had been 5 complaints recorded since the last inspection. The Manager Designate records all concerns raised and takes prompt action to address them. It was clear that the Manager Designate realises the importance of being approachable, listening to concerns, and of taking action to address them. The home has had one POVA allegation since the last inspection and this was reported and addressed appropriately. Staff spoken with said that they would report any concerns, but some were not clear about Whistle Blowing procedures. The Manager Designate said that he had met with the Safeguarding Adults Manager from London Borough of Hillingdon and is arranging for POVA training for staff in September 2006. Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Aspects of 19, 21 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is evidence of ongoing redecoration and refurbishment work, to provide the service users with an attractive and homely environment to live in. Infection control procedures are in place and adhered to, thus safeguarding service users. EVIDENCE: The Inspector carried out a tour of the home. Bedroom doors had been redecorated in line with dementia research information. The activities coordinator was arranging for door furniture to be offered to service users, to individualise their doors. Overall the home was in a good state of décor, and the Responsible Individual has advised CSCI that arrangements are in place for areas in need, such as some corridor areas to be redecorated in the near future. New armchairs were being delivered on the day of inspection. Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 16 At the last inspection it was identified that areas to include sluice rooms were being used as storage. The Manager Designate has addressed this and sluice rooms were uncluttered and clean. The liquid dosing system in the laundry had been repaired. The laundry room was clean and tidy and clothing neatly stored in the service users individual baskets or hung on rails available. Protective clothing to include gloves and aprons was available in the home. The home has infection control policies and procedures in place, and there were no infection control issues identified during the inspection. Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was no evidence of staffing review in line with service user dependencies, thus the home may not always be staffed to meet service users needs at all times. Recognised training programmes to provide staff with the skills and knowledge to care for service users needs have been commenced, with induction programmes to be progressed to provide a knowledge base for all new staff. Robust recruitment and vetting procedures are in place, thus safeguarding service users. EVIDENCE: The Manager Designate has worked hard to recruit more staff since the last inspection. The home is staffed to meet the minimum staffing notice issued by a previous Registration Authority. This notice was issued some years ago and the staffing needs to be reviewed in conjunction with the current dependency levels of the service users. Staff who were asked did comment that they are very busy and do not always have time to provide care to the level they would like. The lunchtime meal was an example where there were not enough staff on one floor to feed the service users, and the system in use to address this was not working satisfactorily, to ensure all service users received their meal hot. Since the last inspection action had been taken to recruit more cleaning staff, although there was not any cover for sickness on the day of inspection. The home was clean and it was clear that the domestic supervisor works extremely hard to maintain the home in a clean condition. There must be Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 18 ongoing review of staffing levels in accordance with service user need, and not just an expectation to provide minimum staffing levels. The Manager Designate provided the following information. Since the last inspection 4 care staff have completed the NVQ in care level 2 training, with 4 more in progress. In addition, there are 8 other care staff with NVQ level 2 or an equivalent qualification. The Regional Manager explained that Southern Cross Healthcare is aware of the need to ensure that a minimum of 50 of care staff are qualified to NVQ level 2 in care or the equivalent and are taking steps to address this corporately. At the last inspection repeated shortfalls in staff employment records were identified. Correspondence has taken place with the Responsible Individual in respect of these findings. At this inspection three sets of staff employment records were viewed. These contained the information required under the Care Homes Regulations 2001. In light of the previous shortfalls, the home must continue to ensure that robust procedures are followed for all recruitment in the future. Southern Cross Healthcare have an induction and foundation programme that meets the Skills for Care core standards. New care staff spoken with said that they had received an initial 2 or 3 day induction, but had not undertaken the full induction programme. The need to ensure new staff undertake this programme was discussed with the Manager Designate. Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 19 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, 33, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager Designate has the nursing qualifications and experience to manage the home, and does so effectively. He is aware of the need to complete an appropriate management qualification and to apply for registration with CSCI. Systems for quality assurance are in place, thus providing an ongoing process of system and practice review. Staff supervision sessions need to be formally commenced, to provide a forum for individual discussion and reflection on practice. Systems for the management of health and safety are good, thus safeguarding service users, staff and visitors. EVIDENCE: The Manager Designate is a first level registered nurse with a mental handicap qualification. He has been in post for 6 months, and previously worked for several years as a unit manager in a care home environment. The need to undertake an NVQ level 4 in management qualification or the equivalent was Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 20 discussed. The Manager Designate is aware of the need to submit an application for registration as the Registered Manager to CSCI, and said he would address this. Staff spoken with said that the Manager Designate is approachable and deals with issues raised. The Manager Designate showed the Inspector the auditing system in place for quality assurance. The auditing system is comprehensive and includes monthly audits of all aspects of the home. The Manager Designate holds a monthly relatives meeting on the first Thursday of each month, and is also happy to attend the home outside his normal working hours in order to meet with relatives. There are separate weekly staff meetings for ancillary staff and for nursing & care staff on each floor. Health & safety meetings take place regularly for Heads of Department. Regulation 26 unannounced monthly visits to the home take place on behalf of the Responsible Individual and a copy of the report is forwarded to CSCI. The Manager Designate has carried out individual meetings with staff to discuss their roles and future training and development needs. He is aware of the need to introduce formal supervision, and the training of heads of department and the registered nurses as supervisors to enable supervision to be cascaded down from the Manager Designate was discussed. The Inspector sampled servicing and maintenance records. It was clear that work had been done since the last inspection to get these up to date, with the exception of the portable appliances testing, last carried out in April 2006. The Manager Designate has since confirmed that this will be completed by 22/09/06. Southern Cross Healthcare has issued a new health & safety policy along with updated risk assessments for all equipment and safe working practices, and these were available in the home. It is recommended that those for the kitchen and laundry be copied so that they can be at hand in those departments. There was evidence of monthly fire drills taking place, to include day and night staff. The fire risk assessment had been updated in April 2006 and weekly checks of the fire alarm system and equipment are carried out. The Manager Designate has introduced weekly moving & handling training for staff. Fire safety training has also taken place, and the Manager Designate is accessing food safety and 1st aid training and updates for staff. Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 21 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 2 Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 22 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 OP8 Regulation 17 Requirement Where service user information is recorded on more than one document, all entries must tally and accurately reflect the service users condition. Following the assessment of a service user, care plans must be formulated to accurately reflect the actual needs of the service user and how these are to be met. The MAR charts must be accurate and clearly reflect the medications administered to each service user, in conjunction with the medications prescribed. One set of MAR charts only must be in use at any one time to avoid and duplication of information. There must be robust systems in place to ensure that service users receive their meals hot. Where there is any delay in providing a service users meal, appropriate procedures to maintain the food in a good condition must be in place. Staff must have a clear DS0000010927.V311330.R01.S.doc Timescale for action 22/09/06 2. OP8 17 22/09/06 3. OP9 13(2) 07/09/06 4. OP15 16(2)(i) 22/09/06 5. OP18 13(6) 22/09/06 Page 23 Cedar House Version 5.2 6. OP27 18(1)(a) 7. OP30 18(1) 8. OP36 18(2) 9. OP38 23(2)(b) (d) understanding of Whistle Blowing procedures. There must be evidence that the staffing levels are kept under review on an ongoing basis in order to ensure the needs of service users are being met at all times. There must be evidence that all new staff complete recognised induction and foundation training. (previous timescales 01/06/06 & 01/11/06 not met) A system of formal supervision for all staff providing care must be introduced. This must take place a minimum of 6 times per year for each member of staff. The Portable Appliances Testing must be carried out and thereafter carried out annually. Any electrical appliances brought into the home must be tested before use. 01/10/06 01/11/06 01/11/06 22/09/06 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 OP8 OP38 Good Practice Recommendations It is strongly recommended that old service user plan documentation no longer in use be archived. It is strongly recommended that copies of the risk assessments for kitchen and laundry equipment and safe working practices be made available in these departments. Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Cedar House DS0000010927.V311330.R01.S.doc Version 5.2 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!