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Inspection on 14/12/05 for Chichester Court Nursing Home

Also see our care home review for Chichester Court Nursing Home for more information

This inspection was carried out on 14th December 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.

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

Despite the size and layout of the building, which is long and extensive, the atmosphere and environment is welcoming, bright and homely. The Home provides a pleasant and comfortable place for people to live. Staff are friendly and courteous and treat residents with respect and sensitivity. They also make visitors welcome to the Home at any time.

What has improved since the last inspection?

Since the new manager has started work at the Home staff have worked hard to keep the care and atmosphere in the Home stable and this has helped to make the change of management easier and less unsettling for residents and staff. The facilities, decoration and furniture have been looked at and plans are underway to change and improve them throughout the Home, in the near future. When this is completed it will improve the appearance and comforts in the Home for residents.

What the care home could do better:

Residents` care plan records must improve so that they fully document residents` needs and guide staff as to how those needs are to be met. The reviews of care given must show whether the plan of care is working, and be changed if not. Some areas of medicines storage, administration and recording were not satisfactory and the Manager needs to make sure that correct procedures are followed by staff who deal with medicines. The Manager must make sure that all the necessary security clearance checks and appropriate references for new staff are obtained before they start working in the Home. Examination of the files of four recently appointed staff showed that they started work there before all checks were returned to the Home. These checks are necessary in order to protect the vulnerable people living in the Home. The new manager must send in an application to become the Registered Manager, to the Commission and continue the Registered Managers Award training in order to become appropriately qualified as a manager. When the planned study of the staffing takes place it must make sure that all residents` needs can be catered for, particularly their nutritional and medication needs. The Staff at the Home must not allow fire doors to be `chocked` open as this increases fire safety risks. All areas where hazardous items are stored must be kept locked to prevent the risk of accidents.

CARE HOMES FOR OLDER PEOPLE Chichester Court Nursing Home Chichester Road South Shields Tyne And Wear NE33 4HE Lead Inspector Mrs P A Worley Unannounced Inspection 14th December 2005 10:00 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 Chichester Court Nursing Home DS0000000272.V256351.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. Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chichester Court Nursing Home Address Chichester Road South Shields Tyne And Wear NE33 4HE 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) 0191 454 5882 0191 454 6455 chichester.court@fspc.co.uk Grandcross Limited(wholly owned subsidiary of Four Seasons Health Care Ltd) Valerie Ann Ralph Care Home 52 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (52), of places Physical disability (15) Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 2005 Brief Description of the Service: Chichester Court Nursing Home was purpose designed and built in 1997. It is registered to accommodate up to 52 older people with personal care and nursing needs. The building is single storey with wide corridors and doors providing good access for people with mobility difficulties, or wheelchair users. All bedrooms have en-suite toilet facilities. A variety of lounges and sitting areas are available, also two dining rooms, and two internal courtyards that provide outdoor seating areas. An additional, paved outdoor seating area is provided at the top end of the home. The home is located close to public transport facilities including the Metro railway system, and buses, and is within easy reach of local shops and amenities, and the town centre. Local parks and the seacoast are approximately two miles away. Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day by two inspectors with a second visit made at a later date by one Inspector, to complete the inspection. Time was spent talking with service users, staff and people who visited on the day. Inspection of a sample of records was undertaken including assessments, care plans, medication records and staff files. Time was also spent looking around the building to check the facilities and equipment available for service users and the general maintenance of the property. A meal was shared with service users by one Inspector on the first floor to sample the food and get a feeling of what the mealtime experience is like for people living at the home. A new manager has taken up post since the last inspection and as she was the deputy manager at the Home this time last year, is known to many residents and relatives. A number of residents and relatives said they welcomed her back in her new role. She is still in the process of making assessments about the care and service provided in order to identify any areas that are in need of improvement or further development. What the service does well: What has improved since the last inspection? Since the new manager has started work at the Home staff have worked hard to keep the care and atmosphere in the Home stable and this has helped to make the change of management easier and less unsettling for residents and staff. The facilities, decoration and furniture have been looked at and plans are underway to change and improve them throughout the Home, in the near future. When this is completed it will improve the appearance and comforts in the Home for residents. Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 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 Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 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. Service users have their needs assessed and identified by appropriate persons prior to and on admission, to ensure that their needs are identified and can be met by the Home. EVIDENCE: Inspection of a sample of residents’ files and discussion with the Manager indicated that assessments are carried by Care Managers and/or Nurse Assessors prior to residents’ being admitted to the Home. The Home carries out a pre-admission assessment and further assessments following admission. Conversations with some residents and relatives indicated that residents’ needs were generally met but some commented that they felt that there were insufficient staff at times to spend much time with them. They were agreed that staff worked hard and were helpful but felt that they often had to wait a long time before staff could attend to them if they called for assistance. Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 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, 9 & 10. Service users appeared well and spoke of staff meeting their health and personal needs. However, residents’ care plans do not fully reflect their observed or changing needs and the care necessary to meet those needs. This can limit the guidance available to staff regarding care practice, and reliability of the documentation. Medication procedures do not all ensure that the service users health care needs are fully addressed. The medicines’ storage, administration and recording procedures are not all carried out safely and consistently. Personal care and support by staff is offered to residents in a way that respects, promotes and protects their privacy and dignity. EVIDENCE: A sample of residents’ care plans was examined. The quality and level of information of those seen was not adequate. Initial assessments were informative but were not all dated or had been reviewed, one care plan regarding pressure area care to cover two different parts of the body would have been better as separate plans, as they were confusing to read with too Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 Page 10 much detail for the different elements of intervention required. Some statements were made to indicate residents’ condition, level of mobility or dexterity but insufficient information as to how to deal with it. For example, ‘arthritis in hand’ but no mention of how to assist the person with holding a knife, fork, spoon or cup, ‘doubly incontinent’ but no mention of skin care, and ‘safety to be maintained at all times’ but no information as to how, when or where this should be done. Risk assessments were in place in most cases and were up to date, although one resident clearly had difficulties with nutrition but no risk assessment had been completed. Evaluations were not up to date in all cases and many tended to contain information that only demonstrated the plans are monitored. Evaluations did not review how effective the care plan was for that particular area of need and did not show where this evaluation had highlighted the need for a change in how care is planned. Entries were often uninformative and lacked detail for example ‘no change’, ‘care plan appropriate’, ‘skin remains in tact’ or ‘no change to care’. From concerns that had been raised about a residents care recently, some interventions and changed needs had been identified but were not reflected in the care plan records. Care plans generally did not reflect increased, changed or all observed needs. The Regional Manager indicated that care plan documentation was to be provided in the New Year that would adopt a more person centred approach, which should assist staff to complete more quality records. Although procedures and systems for the ordering, receipt, administration and disposal of medicines are in place, inspection of the arrangements and practices were not satisfactory on this occasion. Actions had been taken regarding the requirements made at the last inspection but deterioration of some of the procedures for the safe receipt, storage, administration, recording and disposal of medicines was evident. Examples of unsatisfactory practices include: audits of some records against stocks of medicines did not equate, containers of eye ointments and drops did not show the date of opening and they should, as they must not be used after 28 days of opening, and a cream prescribed three times a day is only administered twice daily with no reason why. Not all records were completed to show the quantity and date of receipt of medicines, or stocks brought forward to produce a new balance of stock. There were some gaps where signatures should be to confirm the administration of medicines. Excessive stocks of medicines for disposal were stored in boxes and on a shelf in the medicine room and were mixed with current stocks, as the cupboards were full. A contract is in place for the appropriate disposal of medicines but Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 Page 11 the timing of collections should be reviewed in order to reduce the amount of stocks of medicines for disposal at any one time. An audit of Controlled Drugs was carried out and was correct. However, some inappropriate items were stored in the Controlled Drug cupboard. The administration of the breakfast time medicines to those residents who receive personal care only did not commence until 10:30 with the effect that subsequent medicine administrations were also late. The Senior Carer is the only carer responsible for those residents and also administers the medicines to those residents, and does not commence the ‘medicine round’ until breakfasts and other care duties are completed in the early morning This arrangement must be reviewed in order that all residents receive their medications in a timely way, as prescribed, to ensure their health care needs are met. Residents described how staff maintained their privacy and dignity and also confirmed that they were treated respectfully and in a kind manner by all members of staff, especially when personal care was being carried out, such as bathing. Staff treated residents throughout the day in a friendly, sensitive and respectful manner, although in one dining room more time and attention to allow residents who need assistance to complete their meal would demonstrate more respect of their limited abilities. (See standard 15). Chichester Court Nursing Home DS0000000272.V256351.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): 13, 14 & 15. Residents are encouraged and supported to lead lifestyles based on their preferences and choices and abilities. Links with families, friends and the community are maintained and residents are supported by staff in doing this. The meals are satisfactory and offer choices and variety and catering for special dietary needs. However, the staffing arrangements in one dining room did not provide sufficient support for residents, particularly those who needed assistance, and ensure that residents’ dietary needs are fully met. EVIDENCE: Two choices of meal are available on the menu and residents are asked for their choice the evening before. Evidence was seen that alternatives are provided if requested. One inspector joined residents in one of the two dining rooms for the lunchtime meal. The experienced felt rushed as only one care staff was supervising the mealtime and the chef, kitchen assistant and activities co-ordinator gave some assistance though not throughout the whole period. The meals were served on cold plates and yoghurt was served for sweet in its carton, which some residents found difficult to balance and deal with, and would have been more appropriately served in a desert bowl. Some meal plates were removed from residents without regard to whether they had Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 Page 13 managed sufficiently or had finished, if they were slow to respond when asked if they were finished. Only tea was served at the mealtime. Two family visitors said they came daily to the Home to help with their relatives’ meals as they felt that staff were too rushed and not always around to ensure adequate nutritional care was provided. Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 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. There is a satisfactory complaints system in place with evidence that service users and relatives views are listened to and acted upon. EVIDENCE: A policy/procedure is available for staff and a copy of the homes’ complaints procedure is in the Service Users Guide and in each residents’ bedroom. Inspection of the complaints records was made and was satisfactory, although only one complaint was recorded since the last inspection. Two complaints have been made about the Home to CSCI and Social Services, which were known to the Home and the Manager was advised that these should also be recorded in order to assist with reference and the monitoring of complaints about the service. A recommendation was also made as to a more coordinated way of keeping complaints records and of using an index for easy reference. A relative who had previously made a complaint through the Commission was spoken with. That complaint had been dealt with and a satisfactory outcome had been achieved at the time, and she indicated that she felt her mother was happy with the staff and the people she knew. She said that the care was generally good and her mother was looked after, and any concerns she had were dealt with appropriately and satisfactorily. Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 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. The standard of the environment within the Home is satisfactory and provides a comfortable and homely place to live, and plans are in place for major refurbishments throughout the communal areas to update and further improve this. EVIDENCE: A tour of the premises showed that the Home is clean and generally well maintained. Although some areas have been decorated and re-carpeted within the past year, other areas, showed that the décor, carpets and furniture were ‘shabby’ and in need of refurbishment. The Manager and Regional Manager said that a major refurbishment of a number of areas is planned and will begin early in the new year, to include new flooring, curtains and accessories in the communal rooms. Following the completion of this work internally, refurbishment of the garden areas is scheduled with the provision of such additions as sensory and water features. Service areas such as the laundry room, which is in need of decorating maintenance, is also to be included in the Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 Page 16 programme. A programme of the planned decoration and maintenance of the Home was requested and is to be forwarded to the Commission. The Manager also spoke of the review of the call system to improve the facility and to isolate the front door ‘buzzer’ from the resident call system. This will enable staff to identify a resident call separately from the front door call. Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 & 29. Staffing levels are sufficient to meet the majority of needs of the current service users, but will benefit from the planned review and increase, to ensure all service users needs are met. Recruitment procedures are in place to support and safeguard service users. However, practices carried out for the employment of the most recent staff did not ensure the protection of service users. EVIDENCE: Staffing is maintained at minimum acceptable levels to meet the needs of the residents. However, comments received from residents and relatives were consistent and included: “the staff are friendly and very caring and kind, but they are too busy”, “rushed off their feet”, “take so long to come and give assistance”. The issuers of staffing numbers and skill mix were discussed with the Regional Manager and the Home Manager and the affects mentioned in previous sections of the report concerning mealtime and medicines administration, and the Regional Manager indicated that staffing levels were currently being looked at with a view to increasing them to meet the increased dependency needs of residents. Examination of the files of four of the most recently appointed staff was carried out. Application forms were available; also interview records and induction Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 Page 18 training records. In only one case the Protection of Vulnerable Adults (POVA) register check was returned before the person came into post, all others were returned after the staff started working at the Home. Two staff had commenced in post prior to the return of Criminal Records Bureau (CRB) clearance, and no CRB checks were available for the other two members of staff. No references were available for one person, only one was available for another and the references for the two other staff were inappropriate with no references from their last employers. The findings and failure to follow the correct procedure for staff recruitment was discussed with the Manager, and the Regional Manager who was present and who indicated that he would investigate and take appropriate action. Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. The Manager has an appropriate qualification and the experience to manage the Home, but needs to gain a further qualification in management, and apply to the Commission for registration as manager. Systems to are in place to determine the quality of the service provided by the Home, and ensure that it is run in the best interests of the residents. Appropriate systems are in place and function well, to safeguard service user’s personal allowances. Records are clear and well documented. Staff follow safe working procedures in most cases but some fire safety and accident prevention practices were not followed therefore did not fully promote and protect service users’ health, welfare and safety. EVIDENCE: Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 Page 20 The new manager is a Registered General Nurse (RGN) and has worked as a deputy manager at this Home, and more recently and briefly, worked as the manager of another Care Home. She had commenced the Registered Managers Award qualification training and will continue that training through the Company channels. She indicated that her application for Registered Manager would be forwarded to the Commission in the near future. Since commencement in post, the Manager has been making assessments of the care and service provided to residents, and other issues such as the environment of the Home. She has identified some areas that she feels would benefit from improvement for residents such as review of the dining areas, the call system and the garden and external areas of the Home. However, issues such as staffing allocation, medications arrangements and the quality of the care plans would benefit from priority attention, which she agreed and was supported in by the Regional Manager. Some Company quality assurance systems are in place and include anonymous service user questionnaires and random questionnaires issued by the Company to service user’s relatives. An annual audit of the Home takes place and inhouse audits are usually carried out in areas such as care plans and falls and accident reports and complaints. However these have not occurred recently as the manager has been making other appraisals within the Home since appointment. The Regional Operations Manager submits monthly reports to the Commission as required by Regulation 26. Residents are encouraged to maintain control of their own financial affairs where they are able to do so but currently only four residents deal with their own personal allowances. The security arrangements and records of service users’, whose monies are held in the home, are well organised and well maintained. The Home’s petty cash and personal allowance monies of service users, and the Residents’ ‘float’ are the only accounts that are dealt with at the home, by the administrator. Individual records are kept on computer and are available for residents or their representatives to see if requested. Numbered receipts, with copies and two signatures for entries, back up the well-maintained records. The hairdresser and the chiropodist, provide numbered and signed receipts, which aids reference and audits. Receipts are given to anyone handing in monies for safekeeping for residents. The Home’s administrator keeps photocopies of all cheques given or received on behalf of residents and personal allowances given from the float to residents are recorded on a hard copy record. Weekly checks are carried out and the administrator submits monthly financial reports to head office. The Regional Support Administrator has recently carried out a full financial audit. Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 Page 21 Although the Company has a training programme for staff to cover all areas of health and safety, discussions with a number of staff revealed that some aspects of this training was not up to date or had not yet been provided for some of the more recently appointed staff. One member of staff has not had training in fire safety or moving and handling since 2003 and has not had any food safety training. Another staff member who has worked at the Home since September has not had fire safety, moving and handing or protection of vulnerable adults (POVA) training. Health and safety practices and procedures were generally satisfactory however, some fire doors were wedged/chocked open and some doors where potentially hazardous items were held were not locked. Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 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 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 2 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement The Home must ensure that all information provided in the care plans identifies all service users’ needs, including changed needs and how they are met. The Home must ensure the safe handling, storage, administration and recording of medicines at all times. The staffing arrangements in the Home must ensure that all service users needs are be met. Recruitment procedures regarding security clearances for all new staff must be carried out prior to staff taking up post to protect the vulnerable people living in the home. Staff training in health and safety must be up to date and practices and procedures must ensure that all matters of health and safety are upheld. Timescale for action 28/02/06 2. OP9 13(2) 14/12/05 3. 4. OP27 OP29 18(1)(a) 19(1) Schedule 2 01/02/06 14/12/05 5. OP38 18(1) 13(40) 23(4) 14/12/05 Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 Page 24 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 OP31 Good Practice Recommendations The Manager should submit an application to become Registered Manager, to the Commission. Chichester Court Nursing Home DS0000000272.V256351.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Chichester Court Nursing Home DS0000000272.V256351.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. 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!