Inspection on 23/11/05 for Cheverels Care Home

This inspection was carried out on 23rd November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cheverels Care Home 15/09/06

Cheverels Care Home 29/07/05

Cheverels Care Home 20/12/04

Cheverels Care Home 13/04/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

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

CARE HOMES FOR OLDER PEOPLE Cheverels Care Home 52 Dorchester Road Maiden Newton Dorchester Dorset DT2 0BE Lead Inspector Rosie Brown Unannounced Inspection 10:00 23 November 2005 rd 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 Cheverels Care Home DS0000043799.V252007.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. Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cheverels Care Home Address 52 Dorchester Road Maiden Newton Dorchester Dorset DT2 0BE 01300 320348 01300 321682 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) Altogether Care LLP Mrs Martina Goble Care Home 19 Category(ies) of Dementia - over 65 years of age (19), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (19), Physical disability over 65 years of age (19) Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Manager will attend training (as identified to the Commission for Social Care Inspection) in the protection of vulnerable adults by the 1st June 2005. The Registered Manager will attend training (as identified to the Commission for Social Care Inspection) in holistic dementia care by the 1st June 2005. 29th July 2005 2. Date of last inspection Brief Description of the Service: Cheverels Care Home is registered to provide nursing care to a maximimum of 19 elderly people with mental confusion and physical disability. On the day of the inspection there were 18 service users accommodated in the home. The home is established in a converted 16th century coaching house which is situated in the middle of Maiden Newton. It is close to all local amenities, post office, public house, church and petrol station. The accommodation is available over two floors with the first floor access by passenger lift. The second floor provides two staff offices and a WC and accommodation for two members of staff. There is a small private garden with raised borders at the back of the home and a parking area for visitors use is available at the side of the house. The Registered Individual (RI) is Mr Peter Cotterill on behalf of Altogether Care LLP, the Registered Manager is Mrs Martina Goble. Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 24th November 2005 between the hours of 10.00am and 2.30pm. The purpose of the visit was to review the progress with requirements and recommendations set out in the previous inspection report. Information was gathered through discussion with the manager, Mrs Martina Goble, three service users and four staff on duty at the time. The inspector used observation skills to access some of the findings. The communal areas and a selection of residents’ rooms were seen during the visit, certain records were examined and the home’s policies gave further information. The inspector, Rosie Brown, was also accompanied by Pharmacy inspector Christine Main who assessed Standard 9 which relates to the medications arrangements and practice in the home. The previous report acknowledges that the manager has undertaken the necessary training to meet the conditions of her the registration and a new certificate is in the process of being issued by the Commission. Prior to this inspection, comment cards supplied by the Commission were returned. These included 5 cards from residents 11 from relatives/visitors and 5 from care professionals and one from a GP. The views expressed were mainly positive and are referred to within this report. It is recommended that the previous inspection report be read in conjunction with this report to achieve a clear ‘picture’ of the home. What the service does well: What has improved since the last inspection? Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 Page 6 The statement of purpose has been amended so that the information no longer refers to the previous owners of the home. Care plans now include information concerning each resident’s wishes and care needs when dying and following their death. Social Care provision is being actively developed to include individual resident’s preferences and needs. The RI has provided the Commission with a copy of the plans for the home to be developed and extended in 2006. The intension being to addressed the requirements noted in this and the previous inspection report. The RI visits the home each month and writes a report concerning the visit: copies of these reports are supplied to the manager and the Commission. What they could do better: The home should follow guidance from the Pharmaceutical Society as recommended during the inspection to improve the home’s medication recording systems. The following issues regarding the environment remain unchanged since the previous inspection of August 2005. The central heating radiators are not covered or protected and individual riskassessments concerning each person’s vulnerability to hot surface temperatures have been drawn up by the manager. A programme of covering and protecting the radiators must be planned to ensure that service users are safe from accidental harm; commencing with those rooms where remedial action has been identified. The registered persons should consider how to provide a comfortable place where visitors can meet with service users in private particularly because there several shared bedrooms in the home. The home’s call system is old and needs to be replaced with a system that is easy to use. Service users must be able to call for assistance from their bed or armchair when in their room and when in the communal areas of the home, eg lounge and dining room. A proper area for the storage of incontinence products and items of equipment that are not in continual use: on the day of the inspection such items were inappropriately stored. The previous inspection report also identified the need for the registered persons to consult with the Fire Safety Officer to establish the most suitable door closure to be fitted onto the staff rooms/office doors; when fire doors are Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 Page 7 propped or wedged open they compromise the fire safety precautions in the home (as was the case on the morning of this and the previous unannounced inspection). Also the need for an extractor fan and/or air conditioning must also be discussed/considered to ensure these rooms are comfortable for the manager and staff to work in. The extractor fan in one en-suite was out of order and must be repaired and the home’s fire risk assessment should be updated to include details of where extractor fans are situated throughout the home, their cleaning and servicing schedule. The home’s staff team has diminished since the previous inspection: two qualified nurses have left, so the home is currently depending on agency staff for some shifts. The registered manager is also working as part of the care team to cover shortfalls. It is understood that the home is in a rural village but a concerted effort must be made to ensure there are sufficient permanent staff employed. 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. Cheverels Care Home DS0000043799.V252007.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 Cheverels Care Home DS0000043799.V252007.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 The home has a statement of purpose and guide compiled in a colourful wallet and this is supplied to prospective service users and their representative on request. This information enables the reader to make an informed choice about the facilities and care supplied by the home. Standard 3 was met at the previous inspection and Standard 6 does not apply to this home. EVIDENCE: Since the previous inspection the manager has amended the coloured photograph and location map include in the information wallet so that the information supplied is up to date. Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 A plan is in place for each resident so that staff are provide with guidance to ensure assessed care needs are met. Residents’ health needs are monitored and responded to appropriately with support from community services. The home has systems in place for managing residents’ medicines and the records seen indicated that they are given as prescribed. The policy and some records and monitoring of storage and recording need improving to protect service users. It was evident from observation and records kept by the home that residents are treated with respect and that their privacy is protected. EVIDENCE: The care plans and associated records for two residents were examined. Care plans provided clear guidance for staff to determine how each identified need should be met. The majority of care plans now include information about residents’ care needs when dying and upon death. Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 Page 11 The care plan for one resident must include the agreed arrangements for visitors other than family members. Daily care notes and records demonstrated that other care professionals are contacted for guidance and assistance when necessary, eg contact with the GP or District Nurse and (Community Psychiatric Nurse) CPN. The pharmacy inspector checked the medication policy and the storage arrangements and spoke with the manager. In addition, five residents’ medicines were checked along with their Medication Administration Record (MAR) charts to see if they were given as prescribed. The medication policy needs revising to reflect that nurses give medication, not care staff and some other additions were recommended. Nurses usually sign the Medicine Administration Record (MAR) chart to record when medicines are given but 2 gaps were seen for one medicine and when a choice of dose was prescribed the actual dose given was not recorded. The records and audit of medicines checked indicated that they were given as prescribed but the audit trail for medicines not in the MDS was not easy to follow, as there was no recent reference point. Medicines added to the MAR chart were not countersigned and there were no directions for a cream that had been added to one chart. Medicines were stored securely and new arrangements for disposal of medicines have been introduced to comply with legislation. The actual rather than the maximum and minimum temperatures of the medicines fridge were monitored. The date of opening some creams and liquids with an “in use” shelf life was not recorded and it should be so that they are not used beyond the expiry date. Prior to this inspection a number of cards were received from residents, their relatives and representatives and all commented positively about the care provide by the home. They also noted that resident’s privacy is always respected. During the inspection staff were observed treating residents in a sensitive and respectful way. Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 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 and 14 The home provides regular and varied activities for residents in order to meet expectations and personal daily choice. Standards 13 and 15 were met at the previous inspection. EVIDENCE: Due to high degrees of confusion amongst service users, it was difficult to engage meaningfully with them about their views of the life in the home although the inspector received five comment cards from residents that confirmed they like living in the home and are well cared for. The home is gradually developing an activities programme, which is integrated into each residents care plan. Records evidenced that a variety of calming activities take place, these include, reflexology, gentle exercise, craftwork and trips out to the seaside. On the morning of the inspection one resident was enjoying a relaxing aromatherapy massage. One resident’s records clearly indicated that the person plays chess and reads the paper each day. The inspector spoke with five residents during the visit: one was able to confirm he sometimes chooses to go to the ‘pub’ for lunch with his wife when she visits. Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 Page 13 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): 18 Standard 16 was assessed as met at the previous inspection. The home has guidance available on the proper response that should be made to any suspicion or allegation of abuse but staff have yet to be trained in the local guidance to properly ensure that service users are routinely protected. EVIDENCE: The home keeps a copy of the local ‘No Secrets’ and a procedure to following regarding the identification of abuse and the appropriate response to allegations of abuse. There is also a copy of the POVA guidance kept in the staff room. Staff have signed to acknowledge they have read and understand both sets of guidance and associated policies. Staff are untrained in the local ‘No Secrets’ procedures and the manager has yet to attend a two-day awareness course provided by the local Social Care & Health training department. Notifications of untoward events are forwarded to the Commission as required and indicate that action ids taken to prevent recurrence. Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 Page 14 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): The shortfalls identified during the previous inspection remain unchanged therefore, the call facility, which is old and difficult to use and central heating radiators that are not guarded place vulnerable residents at risk of injury. Standard 26 was assessed at met at the previous inspection. EVIDENCE: On the day of the inspection the home was clean throughout, it is pleasantly decorated and comfortably furnished creating a homely environment. The shortfalls in the environment remain unchanged from the previous inspection report and the 5 requirements and one recommendation from the previous report are not met. However, prior to this inspection the Commission received a copy of plans to extend and improve the facilities in the home and these have been submitted to the local Planning office and Building Control department for approval. Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 Page 15 Bedrooms are available on the ground and first floor and selection of these were viewed. It was noted that a number of bedrooms felt ‘chilly’ and the manager explained that there was a problem with the central heating system and the plumber had be called in to resolve the situation. The door to staff room was propped open with a chair and the door to the manager’s office was wedged open when the inspector arrived at the home. The practice of propping open fire doors must cease as it compromises the fire safety precautions in the home. The manager assured the inspector that this matter would be resolved by fitting a suitable door closure that allows both doors to be left safely in the open position. Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 Page 16 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 The staff rota confirmed that a registered nurse is on duty 24hrs each day supported by health care assistants and domestic staff to ensure that the needs of mentally frail residents are met. The manager follows a standard company staff recruitment and employment procedure to protect residents from harm: Induction and NVQ training is provided in line with NTO specification. A staff training and supervision programme is in place and is currently being developed to provide training directly related to the diagnosed conditions of residents. EVIDENCE: The staff team comprises of 4 registered nurses and 7 health care assistants (HCA), three HCA’s have NVQ 3 qualifications while a further three are undertaking NVQ level 3 training in care. Normally the manager works each weekday and her hours total approximately 42hrs and in an additional capacity to the staff team. On the day of the inspection the manager was working as part of the care team on a 12-hour shift. She was on duty with one other registered nurse and two care assistants: other staff on duty included a domestic and a cook. Additional staff employed, include: an activities co-ordinator, a kitchen assistant, and a maintenance worker and agency staff. Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 Page 17 The manager said that two permanently employed nurses had recently left and that agency staff were being used to cover the shortfalls until new staff were successfully recruited: as the home is situated in a quite rural village it is difficult to recruit. A discussion took place concerning the need for the manager to be additional to the staff team and the possibility of employing a deputy manager to providing management cover when the manager is off duty also working as part of the staff care team. Whilst it is acknowledged that it may be necessary for the manager to cover unexpected shortfalls in a nursing capacity, the situation must not continue long-term. The home was able to evidence that the staff-training programme includes a supervised induction process that meets National Training Organisation (NTO) specifications. Additionally, two individual staff training files indicated that all statutory training was up date. The manager said she is continuing to develop other aspects training directly relevant to resident’s individual needs. The recruitment record for the most recently recruited member of care staff (maintenance worker) was examined. This demonstrated that all relevant references and checks were undertaken and on file: employment commences January 2006. There was written evidence that regular supervision of all staff is taking place and this includes nurses clinical supervision. Comment cards received prior to the inspection were complimentary about the staff that work in the home. One Care Manager stated ‘ the staff at Cheverels are very proactive and caring about their residents. I am impressed with the standard of care they provide’. One relative commented ‘ Overall what matters is the standard of nursing and this is good’. Staff on the day were observed to patient and helpful with residents. Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 Page 18 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): 33, 35 and 38 Standard 31 was assessed as met at the previous inspection. EVIDENCE: The manager showed the inspector the report from a recent external quality assurance survey: the recommendations have yet to be implemented by Altogether Care but the main issue raised was about the levels of privacy, e.g. highlighting shared rooms and no separate room for visitors to be received. The manager keeps personal allowance for approximately half of the resident group. Each person’s money is kept separately in a locked drawer and a record of all expenses with receipts is kept and signed: one resident’s money was sampled and this tallied with the record held. Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 Page 19 Records demonstrated that care staff and nurses are supplied with training in manual handling, food hygiene, and first aid, control of infection and fire safety. The home has a comprehensive policies and procedures manual for staff reference and practice guidance. It is recommended that all staff are asked to sign a record to evidence that they have read and understand the home’s policies and procedures including when they are updated, changed or new one’s implemented. The home’s fire records demonstrated that the regular in house tests and routine servicing of the fire safety system and equipment are up to date. The fire risk-assessment should make reference to all cupboards and en-suites where extractor fans are situated and their cleaning/maintenance. It was noted that the extractor fan to the en-suite in room 6 was out of order. Other maintenance records evidence that routine checks of the central heating system, hot water supply, sluice facility, moving and handling equipment and certificated documentation is in place. Until improvements are made to the environment, eg the call bell system, this standard remains unmet: see requirements and recommendations in this report. Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 Page 20 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X X X X X X X 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 X X 2 X 3 X X 2 Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 Page 21 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. Standard Regulation Requirement The care plan for one resident must include the specific arrangements for visitors other than family members. (The manager contacted the Commission on 29.12.05 to say that this matter is being addressed). All staff must be supplied with training in the local No Secrets guidance: the manager and senior staff must undertake the advanced training available regrading the protection of vulnerable adults, as planned. All radiators must be guarded or have guaranteed low temperature surfaces. A action plan detailing how this situation will be resolved must be supplied to the Commission. (previous timescales of 1.2.05. and 31. 10.05 not met although riskassessments have been drawn up). The Commission has received plans to extend and refurbish the home during 2006. The registered persons must DS0000043799.V252007.R01.S.doc Timescale for action 1. OP7 14 & 15 31/12/05 2. OP18 18 31/01/06 3. OP19 13(4)(c) 31/03/06 4. OP19 23(2)(1) 31/03/06 Page 22 Cheverels Care Home Version 5.0 5. OP19 23(2)(j) 6. OP19 23(2)(m) ensure that there are adequate storage areas for incontinence supplies and other items of equipment.(previous timescale of 31.10.05 not met). The Commission has received plans to extend and refurbish the home during 2006. The second bathroom must be cleared and kept free of all items inappropriately stored in the room and action taken to identify and supply a more suitable bathing aid. Measures must be taken to ensure that the damage to the bath enamel in the assisted bathroom does not promote cross infection. (previous timescale of 31.10.05 not met). The Commission has received plans to extend and refurbish the home during 2006. The old call system must be replaced with a more suitable system that suits the needs of service users and be available for use in all communal rooms. (previous timescale of 31.10.05 not met). The Commission has received plans to extend and refurbish the home during 2006. Fire doors must not be propped open. The registered persons must consult with the Fire Safety Officer to ensure this situation does not continue: see details in this report.(previous timescale of 31.10.05 not met). (The manager contacted the Commission on 29.12.05 to say that this matter is being addressed). The extractor fan in the en-suite to room 6 must be repaired. (The manager contacted the Commission on 29.12.05 to say that this matter is being DS0000043799.V252007.R01.S.doc 31/03/06 31/03/06 7. OP19 13(4)& 23(5) 16/12/05 8. OP19 13(4)(c) 31/12/05 Cheverels Care Home Version 5.0 Page 23 9. OP19 23(2) 10. OP27 18 addressed). The central heating system must be repaired so that it functioning properly. (The manager contacted the Commission on 29.12.05 to say that this matter is being addressed). The manager must work in an additional capacity to the staff team. Consideration must be given to the employment of a deputy manager to provide management cover when the manager is off duty, this person could also work as part of the staff care team. The home must employ permanent staff in sufficient numbers. (It is acknowledged that the home is recruiting for new staff). 16/12/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The home should follow guidance from the Pharmaceutical Society: The medicines policy should be reviewed and updated with the recommended additions. The maximum and minimum temperatures of the medicines refrigerator should be monitored daily (see guidance provided). When a choice of dose is prescribed the actual dose given is recorded. When medicines are handwritten on the MAR chart a second nurse should check the details are accurate and countersign. There should be a clear audit trail for medicines e.g. by recording the date when a new pack is started or entering a carry forward balance on the MAR chart when new DS0000043799.V252007.R01.S.doc Version 5.0 Page 24 1. OP9 Cheverels Care Home 2. OP13 3. OP38 supplies are received and medication records and audit trails should be regularly monitored. The registered persons should consider how to provide a comfortable place where visitors can meet with service users in private particularly because there a several shared bedrooms in the home. (The Commission has received plans to extend and refurbish the home during 2006). The home’s fire risk assessment should be up dated to make reference to each room/en-suite and cupboard where extractor fans are fitted. Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Cheverels Care Home DS0000043799.V252007.R01.S.doc Version 5.0 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. 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