CARE HOMES FOR OLDER PEOPLE
Cheviot Nursing Home 11 Park Road Colchester Essex CO3 3UL Lead Inspector
Diana Green Key Unannounced Inspection 11th April 2007 09:30 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 Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Cheviot Nursing Home Address 11 Park Road Colchester Essex CO3 3UL 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) 01206 763648 01206 763987 cheviot@balkernegardens.fednet.org.uk Balkerne Gardens Trust Limited Vacant Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (3), Physical disability over 65 years of age of places (33), Terminally ill over 65 years of age (2) Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 33 persons) Persons of either sex, aged 65 years and over, who require general palliative care (not to exceed 2 persons) Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 3 persons) Persons of either sex, aged 65 years and over, who require intermediate care. Care to be provided in the new wing of main building; bedroom numbers 2, 3, 6, 8, 9, 10 and 11. Dedicated lounge/dining facilities to be provided and designated sessions for rehabilitation (not to exceed 7 persons) The total number of service users accommodated must not exceed 33 persons 20th December 2005 5. Date of last inspection Brief Description of the Service: Cheviot Care Home provides nursing and personal care with accommodation for up to 33 older people. The home provides intermediate care, a short term rehabilitative service and is also registered to care for service users with a terminal illness. As there is no longer a registration category for TI (terminal illness), a revised certificate will be issued. Cheviot is owned by a charitable organisation, named Balkerne Gardens Trust Limited. The home is located in a quiet cul-de-sac within walking distance from Colchester town centre. The home was opened in 1989 and consists of a two-storey building with a newer purpose built wing also two-storey. There are 29 single en-suite bedrooms and 2 double en-suite bedrooms. There is a passenger lift. The home has enclosed gardens to the rear of the property that are attractive and accessible to wheelchair users. Cheviot is accessible by road and rail and the nearest station is in Colchester. Parking is available in the small car park and adjacent road. The fees range from: £749.00 -£770.00 per week Additional costs apply for chiropody, alternative therapies, toiletries, hairdressing, taxis and newspapers. This information was provided to the CSCI on 5/03/07. Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced key inspection on the 11/04/07 and lasted 7 hours. The inspection process included: discussions with the administrator, deputy manager, senior nurse, the cook, the laundry assistant, two activities coordinators, four residents, eight staff, four visitors, a Macmillan Nurse and Community Matron; a tour of the premises including a sample of residents’ rooms, bathrooms, communal areas, the kitchen, the laundry and the sluicerooms; an inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Twenty-nine standards were inspected of which seven were exceeded and two requirements and one recommendations were made. The deputy manager and staff were welcoming and helpful throughout the inspection. The home has been going through a transition since the former manager left to manage another home within the trust. A new manager has been appointed and a deputy manager has very recently come into post. Residents and their representatives were unanimous in their praise of Cheviot. Typical comments made were “they’re marvellous”; “they’re all wonderful”; “the staff are very attentive”; “staff are welcoming”; “I’m very, very happy here”. What the service does well:
Cheviot provides excellent standards of personal and nursing care that are person centred. Residents and their representatives were very satisfied with the individual attention paid by staff and management. The home provides end of life/palliative care and staff are skilled and well trained in this area of care. The home has been flexible in the provision of intermediate care, developing the service to meet the changing needs of the community. Staff support is excellent. There is a regular training programme in place. Staff are well supervised and actively encouraged and supported to undertake additional training courses. All senior staff are supported by the Trust to develop management and leadership skills. Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent based upon sampled inspected standards 1, 3, 4, 5 & 6. Residents were very well informed and had their needs fully assessed prior to moving in to the home. Good multi-disciplinary teamwork ensured all residents, including those receiving intermediate care, were assessed to ensure their changing/developing needs were appropriately met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a statement of purpose and service user guide that met regulatory requirements. Prospective residents and or their representatives were provided with copies prior to admission. Some were observed in residents’ rooms and copies were displayed in the entrance of the home for visitors’ information. Both documents were under review to reflect the developing intermediate care and palliative/end of life care services provided. Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 9 Pre-admission assessments were carried out by the manager or deputy manager either in hospital or home. One relative confirmed that the manager had visited their loved one prior to admission and discussed their needs fully with them. Assessments were completed in full following admission and detailed in the care files inspected. Regular weekly review meetings were held with the community matron, social worker and occupational therapist to ensure the needs of residents receiving intermediate care were appropriately met. The relatives of one resident spoken with said they were very pleased with the care provided at Cheviot and that the care promised had been fulfilled. The statement of purpose and residents’ contract detailed the home’s policy on a period of trial stays. The home provided an intermediate care service. Residents were cared for in a separate wing of the home with access to rehabilitation facilities. The service included support by occupational therapists and physiotherapists, in addition to the personal and nursing care provided at the home. Recently the service had developed to admit more residents from the community as part of admission avoidance rather than post-operative rehabilitation. Positive feedback was received from health and social care professionals about the standard of the service provided. Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent based upon sampled standards 7, 8, 9, 10 & 11. The health and personal care needs of residents are consistently well met through care planning that is closely monitored and regularly reviewed. Residents’ privacy and dignity is a key principle of care and upheld by close monitoring of individual residents. Residents receiving palliative/end of life care are assured they will receive care and comfort from well-trained and skilled staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of five files were viewed. All files contained a pre-admission assessment form detailing their care needs. Following admission additional individual assessments had been completed in regard to specific needs (e.g. safe environment, risk of falls, moving and handling, dependency, continence, nutrition, pressure areas, etc.). These contained a good level of detail of the action required by staff to help the person meet their needs and was regularly reviewed. Feedback from relatives indicated that staff spent time with
Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 11 residents, listening to them and supporting them emotionally as well as physically. The home was supported by a GP practice that visited regularly to review residents including those admitted through the intermediate care service. Visits were also undertaken by residents’ individual GPs where these were from other practices. There were strong links with the primary care team that included regular meetings with the community matron. The records confirmed that residents received regular chiropody treatment, had visits from occupational therapists, physiotherapists, dentists, clinical nurse specialists and attended outpatients as relevant. Nutritional needs were assessed, weights monitored and supplements/specialist diets given as needed. One resident spoken with said that they found the manager and staff lovely”; I’m very, very happy here”; “ I’m pain free for the first time in years”. The home had a medication/clinical room for medication storage with storage cupboards and a drug fridge. A trolley was used for storage and dispensing and was secured to the wall as required. Room temperature checks were undertaken and recorded and advice was given to ensure checks were made at times during the day and night. Temperature monitoring of the drug fridge was also undertaken and recorded and showed that levels were within safe limits. The home had medication policy and procedures that were available for staff guidance. The procedures provided clear guidance to staff with exception that they did not clearly indicate the need to record the name and address on receipt and disposal for controlled drugs. Registered nurses administered all medication at the home. Medication was supplied through a local pharmacy and appropriate ordering and disposal procedures were followed. The home had a contract for disposal of drugs. Medication administration records (MAR) were well recorded. Advice was given to ensure that for prescribed creams, only the person administering the cream must confirm by signature. Care files contained clear information and indicated each person’s preferred name. Staff were noted to treat residents with courtesy and dignity; A resident spoken to was seen to have a key to their room with them, and others confirmed they could have a key to their door. Residents and their representatives said that care staff were caring and respectful staff at all times, had empathy with residents and always supported them with sensitivity. The home provided care for people at the end of their life and those needing palliative care. All care staff had received additional training on palliative care including the manager who had a B SC Hons degree in Palliative Care. There were good links with the hospice and specialist nurses. A Macmillan Nurse had provided training for the home to introduce end of life care tools as part of the care planning process. In partnership with the Primary Care Trust, the home had introduced documentation to discuss with residents their preferences (preferred place of care) for end of life care. One resident confirmed that the manager had sensitively discussed this with them. Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled standards 12, 13, 14 & 15. Cheviot provides social activities that meet residents cultural expectations and enhance their lives. Visitors were warmly welcomed into the home. The home provided residents with a well-balanced and nutritious diet with choices acommodated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has six staff who have received training in social activities. A range of activities were coordinated during the week (e.g. art therapy, story telling, discussion/videos, seated exercise, musical entertainment, outings, coffee mornings, etc.). Two staff were spoken with and showed interest and motivation in their work and confirmed that all care staff supported them. A gardener also worked with residents who had an interest in gardening. Evidence of an activities programme was seen displayed in the home. Records of activities were maintained of service user involvement in the activities and advice was given to also include the outcome for residents. Feedback received from residents and relatives indicated that, although they were encouraged to
Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 13 take part, they were enabled a choice. One resident said they had recently been on trips to Clacton, for a pub lunch and enjoyed the fish and chip supper. Residents said that their friends and relatives could visit at any time, and they could meet with them in private in their rooms. A visitors/relatives room was also available. Representatives of various faiths attended the home as needed. Staff reported that some residents accessed local community groups (e.g. the Women’s Institute) and through coffee mornings and parties that were arranged at Christmas and Easter. Relatives spoken with said that said that they were welcomed into the home at any time and found the staff very friendly yet professional. Residents’ rooms seen were well personalised, showing that people could bring their own possessions into the home with them. All rooms had locks and residents were able to have keys to their room should they wish. Residents spoken with said they were enabled choices in their daily lives (e.g. time in getting up, going to bed, where and what they ate etc.) Information on advocacy services was included in the statement of purpose and available in the home. Residents spoken with were generally positive about the meals served at Cheviot. The main meal served on the day of the inspection looked and smelt appetising, and residents observed were enjoying this. Hot drinks were seen being served during the day, and water jugs were seen in residents’ rooms and in lounges. A menu was displayed near to the dining room. The home’s menus are regularly changed in consultation with residents and efforts are made to accommodate individual choices where possible. Menus viewed showed an appropriate range of meals, with choices available at all meals. Themed days were arranged with meals to reflect the occasion (e.g. Spanish day). Specialist diets were provided where indicated and soft diets and nutritional supplements as needed. Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent based upon sampled standards 16 & 18. Appropriate policies, procedures and practices were in place to promote the protection of residents from abuse. The manager actively promoted awareness of protection issues through staff training, recruitment practices and respecting individual rights. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure that was displayed in the reception area of the home. Feedback received from relatives indicated they knew there was a complaints procedure and who to refer to if they had a complaint. Residents spoken to were clear that they felt able to tell someone if they had any concerns. The home’s record of complaints detailed all concerns no matter how minor and the investigation and action taken as a result. Twenty-two complaints had been received since the previous inspection. These were with regard to staff attitude, beverages being served too hot, medication left out and delays in responding to a call bell. All had been investigated and appropriate action taken where relevant. The home had a protection of vulnerable adults policy and procedures and a whistle blowing policy. A regular training programme included sessions for protection of vulnerable adults and the records confirmed that staff had
Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 15 received training in this area. There had been no incidents/allegations since the last inspection. Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent based upon sampled standards 19, 22, 24 & 26. Cheviot is clean and hygienic and provides a safe, well-maintained homely environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial inspection of the premises was made that included communal areas, bathrooms, a number of residents’ rooms, the sluices, clinical room and the laundry. The home was appropriately furnished for the client group and in a good state of décor and repair. The entrance hall and several rooms had been redecorated since the previous inspection. The home has a full time maintenance person. Feedback received from residents indicated they felt safe and secure. Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 17 The home had stairs and a passenger lift to enable access to the first floor. There were grab rails, and aids in bathrooms, toilets and communal rooms to meet the needs of residents. Assisted baths and toilets were provided and the home and garden were fully accessible to wheelchairs. Designated storage areas for equipment were provided. Call systems were provided throughout all individual and communal rooms. Pressure relieving equipment was available including specialist pressure relieving mattresses. The standard of cleaning at Cheviot was observed to be very good. Residents spoken with said they were very satisfied with the standard of laundry and cleaning of their rooms. The home had health and safety policies and procedures in place for staff guidance that had been reviewed in 2006. Advice was given to also obtain a copy of the Guidance on Infection Control for Care homes published by the Department of Health and review these in accordance with the document. The laundry area was clean and well organised, with separate areas for clean and dirty laundry. Sluice facilities were located on each floor of the home. Systems were in place to minimise risk of infection via the use of red bags for any laundry soiled by body fluids, placed directly in the washing machines; washing machines had the capacity to carry out sluice wash cycles. The records confirmed that laundry staff had received training on health and safety and were observed to follow safe practice. Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent based upon sampled standards 27, 28, 29 & 30. The staffing levels (skill mix, number and competence) were appropriate to the needs of residents. Recruitment practices were thorough and promoted the protection of service users. Staff are supported to develop skills and qualifications through an established training programme. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels were seen to be appropriate to meet the needs of residents. Staff were observed to closely monitor residents in the communal areas and to spend time with individual residents during the day. Feedback was received from relatives that there were always enough staff on duty. Most residents spoken with said that staff responded quickly when they used the call bell. The home had twelve care staff with NVQ level 2 and five care staff who were undertaking training. The percentage of staff with NVQ level 2 training was therefore 38 but on completion of training would be 47 . The recruitment files of seven staff including four recently employed staff were inspected. All had evidence that the required checks had been obtained (two satisfactory references, CRB/POVA checks) and copies of birth certificates, passports, and photographs obtained before the individuals commenced
Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 19 employment at the home. All had received a statement of terms and conditions of employment. The deputy manager reported that all staff received induction to Skills for Care Standards (records were not inspected). The home had an established training programme. Records viewed confirmed that all had completed training on Protection of Vulnerable Adults, fire safety, and moving and handling. Training had also been provided on first aid, health and safety and food hygiene. Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon sampled standards 31, 33, 35, 36, 37 & 38. The manager is supported well by senior staff in providing clear leadership throughout the home with all staff demonstrating a good understanding of their roles and responsibilities. Good health and safety standards with wellmonitored practices were evident that ensured the safety of service users and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is a registered nurse level 1 and holds the following qualifications: BSc. Hons. Palliative Care; ENB 931 Care of the Dying; ENB 941 Care of Older People; RSA Assessors Award and has a number of years experience as a senior nurse at Cheviot. During that period she has
Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 21 undertaken regular updated training and attended a number of courses relevant to her clinical and managerial position. A deputy manager has recently been appointed. Cheviot has an annual plan. Annual audits are undertaken, the most recent being on staffing. The quality of the service is monitored through good communication with residents and their representatives. Action is taken promptly any issues identified through monitoring of complaints. Registered provider visits required under regulation 26 had been undertaken and reports sent to the CSCI. Policies and procedures were regularly reviewed. All residents had an advocate/representative to manage their finances on their behalf. Personal allowances were held for some residents and the home had secure facilities for the storage of any money looked after on behalf of residents. The personal monies of three residents were inspected and found to be correct with records and receipts held. Some valuables are kept for residents and these were seen to be recorded and safely stored. A senior nurse spoken with confirmed that they had regular peer supervision, which they found beneficial. Each registered nurse supervised a number of care assistants where they were able to discuss their care practice and these sessions were recorded. Handover sessions were held between each shift to discuss residents’ needs. Records held on behalf of residents were kept up to date and stored safely in secure facilities in a locked office in accordance with the Data Protection Act 1998. Records viewed at this inspection included: care plans, medication records, statement of purpose, service user guide, staff recruitment and training records, maintenance records, accidents/incident records and fire safety records. The home had a health and safety policy and procedures for staff guidance. A designated person employed by the Trust had responsibility for health and safety. All staff received regular training updates in health and safety. . Evidence of a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities (e.g. gas, electricity certificates, lift, hoists, annual PAT testing etc.), and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g. checks on fire equipment and door closures, fire alarms and emergency lighting, hot tap water temperatures, etc.). Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 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 4 x 4 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 4 28 2 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 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 OP9 Regulation 13(2) Requirement Omissions in recording of medicines administration must be followed up promptly and the reason recorded on the MAR sheet to ensure records are clear and medication is given as prescribed. The administration of prescribed creams must be confirmed by the signature of the person who administers it to ensure they are given as prescribed and to comply with the Medicines Act 1968 and the Misuse of Drugs Act 1971. Timescale for action 30/04/07 2. OP9 13(2) 30/04/07 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 OP26 Good Practice Recommendations A copy of the Department of Health Guidance on Infection Control for Care Homes should be obtained and policies and procedures reviewed to ensure they meet current guidance.
DS0000015332.V336058.R01.S.doc Version 5.2 Page 24 Cheviot Nursing Home Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Cheviot Nursing Home DS0000015332.V336058.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!