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Inspection on 21/06/06 for Chelwood Corner Nursing Home

Also see our care home review for Chelwood Corner Nursing Home for more information

This inspection was carried out on 21st June 2006.

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

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

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

What the care home does well

Care staff were observed providing good care to residents. A relative and some residents spoken with also commented favourably on the care staff and the home. An extensive programme of activities is provided with good use of an Activities Coordinator. Staff training continues to be a strength of the home.

What has improved since the last inspection?

Major concerns, particularly about the fabric of the building, were identified at the last inspection and a range of requirements made as a result. Also, as many of these had been raised at previous inspections, enforcement action was taken to stress the importance of getting these matters sorted out. It is good that these issues have been resolved. There is no need or any further action at this time to be taken against the owners and the home.

What the care home could do better:

Although there have been good improvements to the assessments of individuals prior to them coming to the home and improvements to the care planning, there is still some further work to be done in these areas. This is to make sure all care needs are identified and acted upon. There are also improvements needed to the medication system, to ensure it is safe. There have been improvements in the way the home recruits new staff. However, some gaps were identified and so improvements need to be made. Finally, the building is in need of updating and modernising.

CARE HOMES FOR OLDER PEOPLE Chelwood Corner Beaconsfield Road Nutley East Sussex TN22 3HJ Lead Inspector Niki Palmer Unannounced Inspection 21st June 2006 11:30 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 Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Chelwood Corner Address Beaconsfield Road Nutley East Sussex TN22 3HJ 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) 01825-740282 01825-740282 Mr Mehrad Foroudy Mrs Jennifer Ann Foroudy Mrs Jennifer Ann Foroudy Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27), Physical disability (27), Terminally ill (2) of places Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated at any one time is twenty seven (27) That the care home provides general nursing care to older people aged sixty five (65) or over on admission and can provide care to people with a physical disability That a maximum of two (2) service users can be accommodated with a terminal illness at any one time 20 February 2006 3. Date of last inspection Brief Description of the Service: Chelwood Corner is a privately owned large converted manor house, which offers nursing care to residents who are over 65 years of age and who may have a physical disability. The home can also provide care for up to two residents who are terminally ill. The home is located on the outskirts of the village of Nutley, East Sussex. There are no local amenities within easy access for residents, or access to public transport except taxis, although car parking is available at the home. Chelwood Corner is set within its own grounds and is spread out over two floors, which are accessible by a passenger shaft lift. The home comprises of 22 single and two double bedrooms. Nine single bedrooms have en-suite facilities, which were approved previously under old regulations, however these facilities would not be approved with today’s standards. The home provides nursing care and support to residents who are both privately funded and those who are funded by Social Services. The home’s fees as of 09 May 2006 range between £450 - £650 per person per week. Additional costs are charged for hairdressing (£5- £20), chiropody (£10 - £12) personal toiletries and newspapers. Prospective residents and their relatives are provided with written information regarding the services and facilities provided at the home prior to admission. A copy of the home’s most recent inspection report is available on request. Prospective residents know about the home through Social Services referrals, word of mouth and from living in the nearby area. Information about the home can also be obtained from the CSCI website. Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Chelwood Corner Nursing Home will be referred to as ‘residents’. Following the serious concerns that were raised at the home’s last inspection in relation to health and safety matters throughout the home, a Management Review Meeting was held at the CSCI’s East Sussex Area Office. The Fire Safety Officer and Health and Safety Executive also attended. Due to the ongoing concerns in which the Providers were in breach of the Regulations, Statutory Enforcement Notices were issued to the home on 16 May 2006. The home was required to comply with these by no later than 15 June 2006. This unannounced inspection took place on Wednesday 21 June 2006 between 11:30 and 6pm and was carried out by two Inspectors. The purpose of this inspection was to inspect all of the key standards and monitor the home’s compliance with the Statutory Enforcement Notices. 24 residents were accommodated at the time of the inspection. The inspection began with in-depth discussions with the Registered Providers of the home in respect of progress made since the last report and their compliance with the Statutory Enforcement Notices, followed by an inspection of all areas of the building. To help gather evidence on how the home is performing the Inspectors talked with a number of residents and their relatives and held detailed discussions with four members of staff in addition to the Deputy Manager and newly appointed maintenance person. Six care records were examined in some detail for the purpose of monitoring care. Other records and documentation inspected included: the home’s medication practices and procedures, the provision of activities and food, quality assurance systems, complaints procedure and the systems in place to safeguard residents from harm, the recruitment of staff and the provision of relevant training. A detailed pre-inspection questionnaire was received prior to the visit to the home. This provided the Inspectors with information relating to the home’s fees, premises and maintenance, details of the homes policies and procedures, staffing details and relevant training. 10 residents’ survey questionnaires were sent to the home prior to the inspection, only two of which have been returned. No contact was made with visiting specialists. Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 6 In order that a balanced and thorough view of the home is obtained, this inspection report should to be read in conjunction with the previous inspection report carried out on 20 February 2006. What the service does well: What has improved since the last inspection? 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. Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 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 Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 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 and 6. Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Albeit that residents are assessed prior to admission in order to ensure that no person is admitted whose needs cannot be met, further improvements are needed. EVIDENCE: There have been four new admissions to the home since the last inspection. All four pre-admission assessment records were inspected in order to ascertain whether the home’s procedures have improved since the last inspection. Whilst it was pleasing to note that all residents had been assessed prior to admission by either the Registered Manager or Deputy at their previous place of residence and that no person outside of the home’s conditions of registration had been admitted, further work is required particularly in identifying individuals’ primary nursing needs and managing the prevention of falls. Intermediate care is not provided. Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 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 and 10. Quality of this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The healthcare needs of residents are mostly well met, however care planning procedures need to be improved and all documents signed and dated. Minor shortfalls need to be addressed in relation to the management of medicines. Residents are treated well by care staff. EVIDENCE: As per the last inspection report, the Deputy Manager confirmed that she has spent much time with Registered Nurses in supporting them and helping them to devise, implement and review care plans. From those seen it was clear that they had been based on the individual’s assessment, which had been completed prior to admission, however there were still some areas particularly in relation to eating and drinking and how residents mobilise e.g. with support, where further work is needed. This will be followed up at subsequent inspections. There was evidence to show that all care plans are regularly reviewed and updated as necessary. Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 10 Some care plans were not clear in identifying residents’ needs. For example, one stated that the resident needed “assistance re standing and transferring to bed” but no details of how this should be achieved. There are also issues regarding some residents and whether they are appropriately placed at Chelwood Corner. For example, one resident spoken with during the inspection was very confused. A care plan for another resident stated “is confused walks around the nursing home trying to open the laundry door, agitated at times, argumentative”. Some documents were not dated. One visitor commented that he was very happy with the home and the care his relative receives. He said he found the staff very caring, although his relative can find changes in staffing difficult to cope with. Specialist equipment for the promotion of tissue viability is in place for those who have been assessed as requiring it. Turning charts and records for maintaining fluid balance were also seen in some individual bedrooms. Risk assessments for the use of bedrails are completed and kept within individual care plans, however some of these were noted to be unclear. These were addressed on the day of inspection and therefore no requirement made. The home’s medication systems and records were viewed. All medicines are delivered to the home on a weekly basis from the GP surgery in pre-packed boxes, which are individually labelled. Registered Nurses only administer all medicines. A sample of records and medicines were spot-checked. It was noted that one person is prescribed medicine, which is not to be given if their pulse rate falls below a certain level. Albeit that nursing staff monitor this on a daily basis and clearly record when it has been given or the reasons as to why it has been omitted, as a matter of good practice it is recommended that clear instructions for its use are recorded on the home’s medication administration record. Many residents are prescribed medicines, which are for use on an as and when required basis (PRN). These include pain relief and topical creams. The home is required to ensure that clear guidance is in place for all such medicines and that the actual dose administered is clearly recorded. Some controlled drugs are kept on the premises as prescribed for individuals. The home is required to ensure that the total balance remaining for all medicines including those in liquid form is checked and recorded. All unused and discarded/omitted medicines are put in to an empty container and returned to the pharmacy. New guidance regarding the safe disposal of waste medicines from nursing homes was given to the home on the day of inspection, which the Deputy Manager assured will be looked into and the appropriate action taken. Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 11 Staff spoken with told the Inspectors that anonymous questionnaires were recently given to residents and their relatives in the attempt to ascertain what expectations they had of the home in maintaining residents’ privacy and dignity. As a follow up to this, a teaching session was initiated, which was based on the outcome of the returned questionnaires and explored staff’s own beliefs and values. Consequently, all ideas were written up and a copy of what was agreed was placed in all individual plans of care. These were seen on the inspection. Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. An extensive range of activities are provided by the Activities Coordinator. EVIDENCE: One Inspector met with the Activities Coordinator. She provides a very good range of activities including external entertainers. On the day of the inspection she was holding a quiz in the lounge with approximately ten residents. She also hires a minibus about four times each year to take small group out for the day. She is aware of giving special one-to-one attention to those residents who have few visitors. Unfortunately the Activities Coordinator does not keep a record of what activities she organises each day and it is suggested she does so. The home employs a full-time chef, who is responsible for the devising of menus, which are changed regularly in consultation with residents based on seasonal fruit and vegetables available. All weekly provisions are currently purchased by the Providers from a nearby supermarket, however in the near future the chef hopes to be able to source more produce locally, particularly meat and vegetables. It was confirmed that specialist diets e.g. vegetarian and low sugar alternatives are available. The chef was spoken with in some detail who appeared keen and enthusiastic in her role. She has recently Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 13 attended a seminar in the local area, which was based on ‘Better Food, Better Business’ and is enrolled to undertake a short one-day course titled ‘Nutrition in Care Homes’ facilitated by an older person’s nutritionist. Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality of this outcome area is good. This judgement has been made using available evidence including a visit to this service. It is good that training has been provided to care staff on adult protection and that the one complaint has been investigated and resolved. EVIDENCE: One complaint, since the last inspection, had been made to the home from a relative regarding a resident having a fall and being admitted to hospital. This was fully recorded and dealt with by the home. Some staff confirmed that they have recently attended in-house Adult Protection training, whilst a further three sessions are booked for the end of June 2006 for remaining staff. No adult protection alerts have been raised since the last inspection. Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 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): 19, 20, 21, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst great improvements have been made to rectify the many requirements made at the last inspection about the environment, there is a need for a refurbishment programme to be established. EVIDENCE: Following the serious health and safety concerns identified during the last inspection and subsequent visits made to the home by a Fire Safety Officer, Statutory Enforcement Notices were issued to the home by the CSCI on 16 May 2006. The home was required to comply with these by no later than 15 June 2006. Since this time a new maintenance person has been employed to address some of the shortfalls, including carrying out regular general health and safety and maintenance checks. Records of these were seen on the day of inspection. Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 16 All hot water outlets have been fitted with thermostatic valves to ensure that hot water is only delivered to a maximum of 43°C. A number of taps in both individual bedrooms and communal areas were randomly checked which confirmed this. Although the shower on the ground floor was not working when Inspectors arrived, this was repaired during the day of the inspection. All corridors, which were previously fitted with thin metal guards, in order to save the walls from damage caused by wheelchair use etc. have now been replaced with smooth edged plastic strips. These no longer pose unnecessary risks to residents, staff and others. Although a number of extension leads are still in use throughout the home, it was pleasing to note that they were neat and tidy and no longer posed as a trip hazard on the day of inspection. All electrical equipment that was seen had a label in place to confirm that it had been tested and was safe for use. A Portable Electrical Appliances Test (PAT) certificate was forwarded to the CSCI on 15 June 2006 to confirm that this work had been carried out. All electrical plug sockets have been refitted and are now safe for use. Following three home visits carried out by the Fire Safety Officer between February and June 2006, resulting in a number of requirements being made, the home is considered to have taken appropriate action. Fire risk assessments of the building have been completed and appropriate action taken, including the removal of a desk and excessive paperwork from the entrance area and an application has been submitted to apply for a building application for rooms 9 and 10, to make windows into doors (fire exits). All Dorguards are now in working order and fire doors have been repaired to ensure their effectiveness. A number of files required for health and safety recording were viewed and were being maintained appropriately. These documents included evidence that fire procedures and systems are checked regularly, fire drills take place, with the last one being on 23 April 2006 and water temperatures checked weekly. The home provides one bathroom, one shower room and six toilets in the home, however it must be noted that none of these facilities are accessible on the first floor. Albeit that nine single bedrooms have en-suite facilities, which were approved previously under old regulations, these would not be approved under the National Minimum Standards today. They are cubicles separated by a curtain, which do not promote individuals’ privacy and dignity. Those seen were found to be of satisfactory cleanliness. One resident’s bedroom was noted to be particularly odorous. The Registered Manager explained that this was due to their particular personal care needs. This was discussed in length and agreed that the person would be offered another bedroom with easy access to a bathroom. Most other areas of the Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 17 home were found to be clean, tidy and reasonably well-maintained. However the general fabric of the building needs some investment to improve the facilities and a full refurbishment programme is required. Although the home is considered to have complied with the health and safety requirements of the Statutory Enforcement Notices, it must be noted that Chelwood Corner remains to be in need of general modernisation and upgrading, with the overall appearance of the building, including many resident’s bedrooms, being one of tired and worn décor, furnishings and fittings. Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by a relatively consistent, well-trained and supervised staff team, however recruitment procedures need to be improved. EVIDENCE: The employs a total of nine First Level Registered General Nurses, 15 care staff 14 of whom have achieved at least NVQ Level 2 in care and seven ancillary staff. On the day of inspection staffing rotas and residents and their relatives confirmed that the home is usually suitably staffed to meet the assessed needs of residents. The home is approved by a University to employ four adaptation nurses from overseas. Four staff are currently undertaking this course. Although there is a relatively long-standing core staff team, adaptation nurses tend to move on following the completion of their course. All staff spoken with confirmed that a good level of staff training is provided by the home both internally and externally. Examples of recent training include: multiple sclerosis, stress awareness and management, supervisory management, skin care, catheter care, privacy and dignity, Food Hygiene and manual handling. Two staff supervision records were seen. This confirmed that regular supervisory sessions take place on a one to one basis, which are facilitated by Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 19 the Deputy Manager of the home. Areas discussed include care planning, the identification of training needs and working hours. Following supervision, records are typed up and signed by both parties. Staff spoken said that they found this to be useful and helpful, particularly in helping them to identify any training needs. Two newly appointed staff recruitment files were seen on the day of inspection, both of which had been appointed via an overseas recruitment agency. Albeit that thorough application forms had been completed, two written references had been obtained and there was evidence of a PoVA First and Criminal Record Bureau police check (CRB) being applied for, both members of staff were working unsupervised without a satisfactory police check being obtained. An immediate requirement was issued on the day of inspection for supervisory arrangements to be put in place until the necessary checks have been confirmed. Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems have been put in place to improve the management of the home. EVIDENCE: The Deputy Manager has been working at the home for approximately 18 months and has submitted an application to the CSCI to become the Registered Manager of the home. She is a First Level Registered General Nurse, who has over 20 years experience working within community and residential settings. She completed her Registered Manager’s Award in February 2006 and has recently completed a Managing Learning Through Mentorship Module at University. All of the staff spoken with spoke highly of her leadership and management skills. Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 21 Some quality assurance systems have been put in place in order that the owners can monitor what is taking place in the home and ensure any problems and issues are identified and rectified. The health, safety and welfare of residents, staff and visitors to the home is greatly improved following the home’s compliance with the Statutory Enforcement Notices. Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 X X 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 3 X 3 X 3 X X 3 Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 23 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 OP3 Regulation 14(1)(a) Requirement That residents’ primary nursing needs are clearly recorded within the home’s pre-admission assessment record. This must include the action that is to be taken in order to prevent the risk of falls. That all care plans provide clear and specific guidance for staff to follow in relation to meeting individuals’ assessed needs. This must include eating and drinking and mobility. That clear guidance is in place for all medicines that are prescribed on a PRN basis. That the actual dose of medicines administered is clearly recorded. That the total balance remaining of all controlled drugs including those in liquid form are checked and recorded. That a full refurbishment programme be establishment and forwarded to the Commission That no member of staff works unsupervised prior to a DS0000013973.V291353.R01.S.doc Timescale for action 30/09/06 2. OP7OP8 15(1) 30/09/06 3. 4. 5. OP9 OP9 OP9 13(2) & Sch 2 13(2) & Sch 2 13(2) & Sch 2 23(2)(b) 31/08/06 21/06/06 21/06/06 6. OP19 31/08/06 6. OP29 19 & Sch 2 21/06/06 Chelwood Corner Version 5.1 Page 24 satisfactory CRB check being obtained [IMMEDIATE REQUIREMENT]. 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 OP9 Good Practice Recommendations That clear instructions for the use of Digoxin are recorded on the home’s medication administration records. Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Chelwood Corner DS0000013973.V291353.R01.S.doc Version 5.1 Page 26 - 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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