Inspection on 15/12/05 for Chatham House

This inspection was carried out on 15th December 2005.

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.

Other inspections for this house

Chatham House 28/09/09

Chatham House 08/10/08

Chatham House 29/01/08

Chatham House 31/07/07

Chatham House 13/09/06

Chatham House 24/06/05

Chatham House 01/02/05

Chatham House 06/07/04

Chatham House 11/02/04

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

CARE HOMES FOR OLDER PEOPLE Chatham House Chatham House 44/46 Wembdon Rise Bridgwater Somerset TA6 7QZ Lead Inspector Barbara Ludlow Announced Inspection 09:40 15 December 2005 & January 10th 2006 th 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 Chatham House DS0000015985.V264706.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. Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chatham House Address Chatham House 44/46 Wembdon Rise Bridgwater Somerset TA6 7QZ 01278 427758 01278 427758 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) MRS JESSIE JOAN POPE MRS JESSIE JOAN POPE Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th June 2005 Brief Description of the Service: Mrs Pope is both the Registered Manager and the Proprietor of Chatham House. Chatham House is situated in the residential area of Wembdon, 2 miles from Bridgwater town centre. The home is registered to provide personal care for up to 26 elderly service users. Two large Victorian houses are linked by a modern annexe. There is car parking at the front of the house. To the rear there are extensive gardens with wheelchair access and handrails with a pleasant patio area. Accommodation is on two floors, comprising of 24 bedrooms, including 2 double rooms. There are 19 rooms with en-suite WC facilities, some have a bath (some not in use)/shower facility. TV points are available in each room. There is a passenger lift and two sets of stairs to the first floor, one with stair lifts. The communal rooms comprise of a very large lounge with three distinct seating areas, a smaller lounge and an adequately sized dining room. There are three payphones in different locations in the home, plus the use of a mobile phone for incoming calls. There is a call system fitted to all areas of the home. Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out by B Ludlow for CSCI. Mrs Pope and her daughter Ms Hall were available throughout the day to assist with the inspection process. There were nineteen service users in residence and two places were booked for admissions. The home was calm and there was a pleasant relaxed atmosphere on arrival although quite busy with sixteen service users having breakfast together in the dining room. Pre inspection information had been presented to CSCI and feedback forms had been returned to CSCI from service users, relatives/carers and visiting professionals. The analysis is included in the body of this report. A tour of the premises was made and all service users were seen and spoken with in the communal rooms and a number in private in their rooms. Staff from all departments were seen and spoken with during the day and some of the visitors to the home were seen and spoken with. The inspector was invited to join the service users and the manager for lunch in the dining room, an excellent meal was served. Records were sampled and these included care plans, financial contracts, staff recruitment, maintenance and servicing records. Feedback was given to Mrs Pope and Ms Hall at the end of the inspection. This was a very positive inspection, the home was well presented, service users feedback was very positive and all looked well cared for. Visitors spoke positively about the care at the home and said they felt welcome when visiting. Staff interactions with service users were observed to be kindly and appropriate. Lunch was a very social occasion and it was unhurried and was nicely presented, assistance with dining was observed to be given with care and sensitivity. An Immediate Requirements was made for recruitment practice, which was not up to standard, and for all future recruitment practice to meet the National Minimum Standard and Care Home Regulation 19. This was followed up by a second visit to the home, which was made on January 10th 2006, and this visit concluded the inspection process. At this visit the outstanding references had been obtained and one full CRB had been returned. All were found to be satisfactory, a new form has been introduced to aid record checking and to readily highlight the stages of the recruitment process and the information received. Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 7 An immediate requirement was made for staff recruitment, CRB/POVA First checks and references had not been made before employment commenced and references were outstanding. Anomalies were required to be rectified by 24.12.05 and all future practice was required to be in line with the Care Home Regulation 19. A satisfactory follow up visit was made on 10th January 2006 to confirm that out standing references had been obtained and that all CRB checks were in place. Medication administration charts were seen, some hand transcribed entries did not have signatures by the writer or a countersignature to demonstrate checking, nor were the amounts received on these entries recorded. Variable doses were not clearly defined to indicate what has been administered. The medicine trolley was not secured to the wall when not in use. These anomalies require attention. One bedroom was seen that required to be deep cleaned, this was reported at the second inspection day to have been undertaken, this will be monitored at the next inspection. It was noted that the bath hoist was due to be serviced, Mrs Pope agreed to follow this up with the engineer. It was reported on the 10th January visit that this bath hoist is now ‘out of use’ awaiting parts for repair by the engineer, confirmation of this repair will be required with the inspection response. Care plans were sampled one had not been reviewed on a monthly basis, this is required. 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. Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 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 Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 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): 1,3,4, NMS 6 does not apply. The home has literature for prospective service users and their families/carers to make an informed decision about moving into this care home. Visits to the home are welcomed; it is the manager’s usual practice to make her assessment of the service user care needs at this time. The home has been sufficiently adapted to meet the needs of elderly people requiring personal care. EVIDENCE: The home has a Statement of Purpose and a Service User Guide, copies are held by CSCI. 13 relatives commented positively that they had access to the homes inspection report. The current fee rates stated in the pre inspection questionnaire, range from £328.00 to £370.00 per week. One relative commented that this was very reasonable. Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 10 Care plans were sampled including one for a recent admission to the home, these were found to contain comprehensive information. There was the social services single assessment process (SAP) form seen on file and necessary information obtained from the G.P and the home managers assessment. Adaptations are made within the home to assist those with mobility problems, e.g. passenger lift, stair-lift, and walk-in shower facility. Two newly refurbished bedrooms have walk-in shower facilities. The assisted bath was due to be serviced on the first day of the inspection and was awaiting spare parts on the second day and so was currently ‘out of order’. The garden has ramps and handrails for access. Twelve service users answered positively to the question ‘Do you like living here?’ Ten said yes and 2 said sometimes. Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 11 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 Care plans are used to record all relevant information and contacts. Daily entries are made of service users health and condition, these records were adequate, and one monthly review was not up to date. Community professionals are involved where care needs required input by the District Nurse/GP/Specialist Social Worker. Medications management requires attention to signing and checking of hand transcribed entries. Service users were observed to be treated well and in an appropriate manner. EVIDENCE: Care plans were seen, the recordings reflected the needs of the service user and their personal history. Assessment of needs was documented and in one case the deterioration of a condition was reported and the action taken was recorded. Daily entries were recorded to monitor progress at the home and log Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 12 daily care. One person had a fluid intake monitored by a balance chart; the entries when checked were up to date. The home had copies on file of the single assessment process (SAP) undertaken by the social workers. There was evidence of input by the G.P and of specialist social worker input into the care planning. Contact made with relatives was also recorded. The MAR charts were examined, hand transcribed entries were seen that require signing. Countersigning is recommended to indicate the cross checking of the entry and is good practice. The number of tablets etc. should be noted at this time. Where medication is by a variable dose, the amount given should be indicated at each administration. The medications trolley was seen unsecured to the wall when stored and not in use. The home has purchased a medication fridge; this was not in current use and had been switched off until required for storage. Comment cards indicated that all 10 respondents felt well cared for. One said that care varied from day to day controlled by time and they were sometimes rushed. 14 of the 15 relatives commenting felt that there was sufficient staff on duty at all times; 1, said No. All 15 relatives commented that they were satisfied with the overall care provided. One person felt their relative was safe and well cared for. Another commented that they were not informed of lost and broken aids. One person felt the care was reasonable another was thrilled their relative was at such a wonderful home. Feedback from a GP and visiting health care professionals indicated that they are satisfied with the care given at the home. One respondent commented that staff training in pressure area care and continence may be helpful to junior care staff and earlier referral to the District Nurses when care needs change by the manager may also be helpful. All could see the service users in private and all were satisfied with medications management. Chatham House DS0000015985.V264706.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): 12,13,14,15 Service users and visitors reflected that staff are kindly. Service users said they are well cared for and can spend their time as they choose. The lunch was well served, hot, sufficient in quantity and quality, lunchtime was very much a social occasion. The catering was of a very good standard. EVIDENCE: The home encourages visitors at all reasonable times. Two visitors were spoken during the inspection, positive feedback on the care and visiting experience at the home. The afternoon activity was a relative playing for the service users to sing along. Staff helped out to include all service users wishing to participate to join in. This was a well managed event. Lunch was served in the main dining room to 18 service users, The Manager and the inspector joined the service users for lunch. The meal was a very social occasion. The dining room was nicely presented and the food well served and was served hot. The meal itself was nicely presented and delicious. Cold Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 14 drinks were served with the meal, and hot tea/coffee was served after the meal. Service users commented that they enjoyed their lunch. Kitchen records were not up to date, freezer and hot food probing temperatures had not been recorded, this was brought to the attention of the cook at the time of the first inspection day, a recommendation is made to follow the Environmental Health Office guidance for food handling and storage. Comment cards: All 13 responses to the question of consultation about a relatives care where they could not make decisions were positive however out of the 15 relatives responding to whether or not they were informed about important matters affecting their relative 2 said they were not. Six service users felt the home offered suitable activities, 6 said sometimes. Nine service users said they liked the food 3 said sometimes. All 15 visitors/relatives felt welcomed by staff and confirmed that they could visit their relative/friend in private. Chatham House DS0000015985.V264706.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 There are policies and procedures in place to protect service users from harm. The management acts openly and cooperatively with CSCI. One outstanding complaint re-investigation has not yet been finalised. EVIDENCE: There is a complaints policy available in the home with clear guidance of how and who to complain to. One of two complaints made to CSCI is currently subject to being re-investigated at the request of a family who were not satisfied with the CSCI first response when the complaints made were not upheld/not substantiated. Staff files were sampled and an immediate requirement was made for references to be taken up and an outstanding CRB to be sent for. Follow up within 4 weeks was made to check the outcome of the immediate requirement, which was found to be in place. A whistle blowing policy was seen to be in place in the home. It is highly recommended that POVA training be held at the home to ensure that all staff are aware of the signs and symptoms of abuse and know how to act should they be alerted to poor care practices. Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 16 One relative said a complaint raised was addressed immediately. Eleven relatives said they knew about the complaints procedure, 4 said No. Asked if any complaints had been made 11 said No, 3 said yes. Twelve service users said they felt safe at the home 1, said sometimes. All 13 respondents said they would know who to talk to if unhappy with their care. Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 17 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 Chatham House encourages service users to retain a level of independence in their daily living. The range of activities available each day is limited. Visitors are welcome and family support is encouraged. The meals offer a choice and are nicely served in the communal dining room. EVIDENCE: The home offers a limited range of activities, trips out in the minibus are offered. A music activity took place on the day of the inspection, this was run by a service user relative and staff assisted, the majority of service users present enjoyed this. Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 18 Service users can access large print and other books. More able service users have unrestricted access around the home and garden. Service users’ visitors seen confirmed that they are welcomed and contact with families is supported. Lunch was taken with service users and the manager on the first day of inspection. Service users were seen seated at tables in small groups of four or less. Those requiring assistance were observed being given one to one attention in a discrete attentive manner. An appetising menu was offered which was nicely served and the meal was observed as an unhurried social occasion. Feedback from service users confirmed their satisfaction with the food and catering service offered at Chatham House. Comment cards indicated that: 6 said they liked the food and 6 said sometimes. Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 19 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 There was sufficient staff on duty at this inspection. There are policies and procedures in place to protect service users from harm. Recruitment practice was unsafe, an immediate requirement was made on day one and the required action had been taken, this was confirmed when the second days visit was made. Training is encouraged. EVIDENCE: The duty rotas demonstrated sufficient staff on duty. Mrs Pope and Ms Hall spend time at the home and live locally, being available to staff at all times. The home has RCPA policies and procedures in place to promote good practice. These are held in the staff room. Four recruitment records were seen, there were some significant deficits in the recruitment practice since the last inspection. Three POVA First/CRB checks had not been taken up prior to employment and references had not been received for two staff. An immediate requirement was made, a second visit was made to the home and all the outstanding information had been obtained and was confirmed on file. Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 20 The homes Manager encourages staff training in NVQ after demonstrating 6 months commitment to the home. Currently there are 20 care staff employed at the home, 17 care staff have worked at the home for over six months. 8 care staff have NVQ 2 in care and 2 staff are studying to NVQ Level 3 and 2 staff are waiting to join the NVQ 3 programme. Two staff that do not have formal qualifications have extensive experience in caring. Other training identified in the pre inspection questionnaire includes, fire training/lectures and fire extinguisher training, first aid training, manual handling training, safe handling medicines course, food hygiene and safety. Training planned includes dementia care, diabetes course, bereavement and a medicines course. Progress with these will be followed up at the next inspection. POVA training is recommended for all staff at this inspection. Comment cards indicated that: 11 service users said that staff treat them well, one, said No and added that ‘some do, some don’t’. All 12 respondents said they were well cared for and 11 said their privacy was respected, one said sometimes. Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 21 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): 31,32,33,34,35,37,38 Mrs Pope is an experienced home Manager and provides clear leadership to staff employed at the home. The home should continue to work towards developing more effective quality assurance systems. All records were available, financial accounts and service users finances are clearly and well managed. Health and safety, maintenance of the home are generally well managed. Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 22 EVIDENCE: Mrs Pope has successfully managed Chatham House since 1983 and has considerable experience in caring for the elderly. Mrs Pope and her daughter Ms P Hall manage the home on a day-to-day basis. Mrs Pope provides leadership to her staff team, training is encouraged and staff are valued. The home is currently applying for Quality Rating with Somerset Social Services. The home should continue to develop its Quality Assurance monitoring and development of the home. There has been some upgrading of en suite facilities in two bedrooms to meet the modern demand of walk in shower facilities. The home has current Employers Liability Insurance and displays the CSCI certificates. Accounts and finances are well managed. Service users accounts are clear and the Manager holds no personal savings accounts, small purchases can be made by prior arrangement, for three persons on behalf of their families. Records were seen to be safely and appropriately stored. Maintenance records were seen, these included: Kitchen records: the temperature records for the freezer and for hot food checks had not been regularly recorded, this was brought to the attention of the cook. These records should be maintained in line with practice required by the Environmental Health Department for good practice. The most recent EHO visit had been recorded as 24.10.05. Fire Records: The home has completed a fire risk assessment, correspondence from the fire safety officer dated 15.4.05 confirmed this risk Assessment as suitable and made a recommendation only, this was for a policy for contractors working on site. This has been completed. Fire extinguishers had been serviced on 23.9.05. Fire Alarm testing was carried out weekly and records were seen dated to 2.12.05. Monthly Emergency Lighting checks had been made to 15.11.05. Hoist servicing: portable hoists had been service on 3/8/05. The bath hoist was reported to be due, on the second day visit the inspector was informed that a part had been ordered and the hoist was now ‘out of order’. This hoist must be repaired; confirmation of this repair or progress must be notified to CSCI in line with the requirement made date or before. Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 23 Electrical safety: Portable Appliance Testing was completed on 9.06.05. Records showed installation checks on 6.10.03 and 14.4.05. Accident records were seen held in care plans for the individual concerned. Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 24 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 X 3 3 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 2 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 X 3 3 2 Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 19 Requirement CRB /POVA First checks must be carried out and two references taken up before an employee commences working at the home. Immediate Requirement: Anomalies by 23/12/05 and all future recruitment practice in line with CHR19. This requirement was confirmed as having been met at a follow up visit on 10/01/06 Hand-written entries made on the Medication Administration Record charts must be signed by the person making the entry and the amount of medications received must be recorded to create an audit trail. It is recommended also that a competent second person checks and signs the entry. Variable dose prescriptions must be more clearly recorded when administered to clearly indicate the amount given. Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 26 Timescale for action 23/12/05 2 OP9 13(2) 20/02/06 3 4 5 OP19 OP7 OP22 23(2)(d) 15(2)(b) 23(2)(c) One room as identified, for deep cleaning. Care plans should be reviewed on a monthly basis or when needs change. The bath hoist identified as awaiting parts and ‘out of order’ must be repaired. CSCI to be notified of the progress made with this repair by Regulation 37. 20/02/06 20/02/06 28/02/06 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 Refer to Standard OP38 Good Practice Recommendations Temperature records for freezers and hot foods should be checked daily and recorded in line with the EHO recommendations. Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Chatham House DS0000015985.V264706.R01.S.doc Version 5.0 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. 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. 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