CARE HOMES FOR OLDER PEOPLE
Claremont Parkway Nursing & Residential Home Holdenby Kettering Northants NN15 6XE Lead Inspector
Stephanie Vaughan Unannounced Inspection 29th November 2005 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 Claremont Parkway Nursing & Residential Home DS0000066165.V268667.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. Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Claremont Parkway Nursing & Residential Home Address Holdenby Kettering Northants NN15 6XE 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) 01536 484494 01536 524262 Avery Healthcare Limited Vacant Care Home 57 Category(ies) of Old age, not falling within any other category registration, with number (57), Physical disability (30), Terminally ill (30) of places Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. To include up to four (4) service users with Dementia, excluding Mental Disorder, providing personal care To provide care for Physical Disability from the age of 35 years To provide care for the Terminally Ill from the age of 35 years The maximum number registered Fifty Seven (57) Date of last inspection Brief Description of the Service: Claremont Parkway is a large purpose built facility on the outskirts of Kettering. It has been extended to provide accommodation in 57 single rooms. It is Registered to provide both Personal Care and Nursing Care. Its location in the town makes it easily accessible by private or public transport, being close to the main A14 road. Local amenities in close proximity include a cinema, supermarket, gym, pubs and restaurants.The home is spacious and well equipped. All rooms have telephone facilities, ensuite wash and toilet facilities and TV points. There are pleasant grounds, easily accessed by wheelchair users. Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection is the first inspection of the home since changes to the ownership on the 1st November 2000, previous requirements and recommendations have not therefore been carried forward. This inspection was conducted over a period of five hours during which the inspector made observations and spoke to several residents. A limited tour of the premises was conducted which involved viewing the communal areas and a selection of the private accommodation. Case tracking is the method used during inspection where a sample of three residents were selected and all aspects of their care and experiences reviewed, including individual plans of care and associated documentation. Three members of staff were spoken to and a sample of staff files were viewed. Prior to the inspection a period of 30 minutes was spent in preparation, which included a review of the service history. What the service does well:
The new management have submitted a Statement of Purpose to the Commission for Social Care Inspection in support of their application for registration and this contains the required information. Evidence provided within the individual plans of care demonstrates that prospective residents have a pre admission assessment to determine whether the home is able to meet the needs of the individual resident. This is a comprehensive assessment and forms the basis for detailed individual plans of care. The individual plans of care are generally of a high standard providing detailed instruction to staff about how care is to be provided to meet the individuals needs and expectations regarding health, personal and social care. Health care is generally managed well, with individual plans of care providing detailed and specific instruction to staff regarding the residents’ needs All residents are assessed for the risk of pressure and there was evidence that the appropriate care, equipment and specialist support is obtained. Outcomes for residents who had been admitted with pressure ulcers were seen to be good. Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 6 Residents are also assessed for nutritional risk and seen to generally have access to specialists such as the dietician and the provision of special diets. Privacy and dignity is managed well within the home, all residents spoken to confirm that the staff were nice and treated them appropriately. Individual plans of care evidenced that residents preferences in relation to their preferred form of address, food and personal routines such as times of rising retiring to bed Residents spoken to confirmed that routines within the home were flexible and that they were able to participate in a range of group and individualised activities Residents were also able to confirm that visiting was flexible and that they were able to receive their chosen visitors in either the communal area of the home or in the privacy of their own accommodation. The lunchtime service was viewed and seen to be served in small pleasant dining areas or in residents’ rooms according to their need and preference. Meals appeared well presented, of adequate proportion and to offer a balanced diet. Residents confirmed that they were able to make selections from the menu according to their choice and their satisfaction with the standard of meals available. The home was seen to be well maintained, clean and hygienic throughout. Residents confirmed satisfaction with their individual accommodation and the communal areas. Claremont Parkway Nursing Home base staffing levels on the calculated dependency levels of residents Staff spoken to confirmed that staffing levels were generally adequate and that the home is currently recruiting more nursing and domestic staff. Staff confirmed a thorough recruitment process, with appropriate references and Criminal Records Bureau Clearances having been obtained. Staff were also able to confirm access to appropriate induction and other mandatory training. What has improved since the last inspection?
The new owners have recently increased the number of hours dedicated to social activity from ten to thirty hours per week. Two activities coordinators now produce a weekly programme of activities provided by the staff and external entertainers. The programme is circulated individually to residents. Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 7 The Commission for Social Care Inspection have received no complaints about Claremont Parkway Nursing Home and the new owners have produced an appropriate complaints policy, which is included within the new Statement of Purpose Existing policies and procedures for the home are currently under review including the Protection Of Vulnerable Adults and Whistle Blowing policy Recent improvements to the home include the provision of an extra office further planned improvements for the near future include redecoration and replacement carpets. Staff confirmed that the new owners have supplied new bed linen, towels and hoist slings. Following the change in ownership the management have appointed a new manager. The manager is known to the Commission and has the necessary qualifications, skills and experience to manage the home What they could do better:
One most recently admitted resident had not had access to the Statement of Purpose or the Service Users Guide and was consequently unaware of the facilities and arrangements within the home to access services such as hairdressing and podiatry. In addition the resident was also unaware of what services were included within the terms and conditions of residency and some basic arrangements such as how to use the telephone and associated costs. The most recent admission, admitted within the last five days had not yet had a risk assessment for the prevention of falls. Individual plans of care evidenced that care plans are reviewed on a monthly basis however there was no evidence that the resident or their representative had been involved in either the development of the care plans or the review. One recently admitted resident had been admitted to the home with Percutaneous Endoscopic Gastrostomy Feeding, the records indicated that this had been commenced as a temporary measure and that a further review should be conducted and include an assessment by the speech and language therapist to as to whether this could be discontinued and this must be followed up. Some of the residents are unable to use the existing scales; currently weight loss of gain is estimated by measuring the upper arm. Whilst this does provide an indication of weight it is not particularly accurate and inadequate for
Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 8 residents with a high level of need and more accurate alternatives should be sought. One resident who had recently been admitted from hospital was noted as having shortness of breath on exertion although this had been recorded in the records the senior staff had not been informed and therefore the appropriate referral to the general practitioner had not been made. Liquid medication was seen to be appropriately stored; however there was no record made of when the bottle was opened to ensure that the liquid was used within its shelf life In addition the inspector noted that two 500mg of Paracetamol (still within the foil packaging) had not been administered and left on the residents bedside table. An immediate requirement was made regarding the safe storage and administration of medication Individual plans of care contain minimal information regarding the residents spiritual needs and wishes regarding terminal care and death Some residents were noted to have bed rails in place, there was no evidence that consent had been obtained from the resident or their representative for their use. In addition there was no evidence that risk assessments had been conducted regarding the need for these to be in use or any of the associated risks such as entrapment. An immediate requirement was made at the time of inspection for these to be conducted, in line with current guidelines. 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. Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 9 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 Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 10 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): 1,2,3 & 6 The home generally has good admission procedures however improvements must be made to ensure that residents have access to appropriate information about the services provided, to enable them to make informed choices. EVIDENCE: The new management have submitted a new Statement of Purpose to the Commission for Social Care Inspection in support of their application for registration and this contains the required information. Other documentation, including the Service Users Guide is currently under review. This information is generally made available to prospective and existing residents and is available within a file in each of the residents’ private accommodation. However, one most recently admitted resident had not had access to this documentation and was consequently unaware of the facilities and arrangements within the home to access services such as hairdressing and podiatry. In addition the resident was also unaware of what services were included within the terms and conditions of residency and some basic arrangements such as how to use the telephone and associated costs.
Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 11 Evidence provided within the individual plans of care demonstrated that prospective residents have a pre admission assessment to determine whether the home is able to meet the needs of the individual resident. This is a comprehensive assessment and forms the basis for detailed individual plans of care. The home does not provide intermediate care. Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 12 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Healthcare is generally managed well, however some improvements must be made to ensure that residents’ needs are consistently met and safety maintained. Improvements are also required in the safe storage and administration of medication and wishes regarding terminal care and death. EVIDENCE: Each of the residents selected for case tracking purposes has an individual plan of care, which had been generated following pre admission and subsequent assessments. The individual plans of care are generally of a high standard providing detailed instruction to staff about how care is to be provided to meet the individuals needs and expectations regarding health, personal and social care. However the most recent admission, admitted within the last five days had not yet had a risk assessment for the prevention of falls. Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 13 Individual plans of care evidenced that care plans are reviewed on a monthly basis however there was no evidence that the resident or their representative had been involved in either the development of the care plans or the review. Furthermore the most recent admission had not been involved in the development of these plans and was unaware of how the home intended to meet her needs. Discussion with senior staff on duty at the time of the inspection confirmed that generally residents or their representatives are involved in the reviews, however this is currently not recorded within the care plan. Health care is generally managed well, with individual plans of care providing detailed and specific instruction to staff regarding the residents’ needs. Of note was the guidance issued regarding the management of Percutaneous Endoscopic Gastrostomy Feeding and Methicillin Resistant Staphylococcus Aurous. All residents are assessed for the risk of pressure and there was evidence that the appropriate care, equipment and specialist support is obtained. Outcomes for residents who had been admitted with pressure ulcers were seen to be good with ulcers having either improved or healed. Residents are also assessed for nutritional risk and seen to generally have access to specialists such as the dietician and the provision of special diets. However one recently admitted resident had been admitted to the home with a Percutaneous Endoscopic Gastrostomy Feeding, the management of which was being supervised by the dietician, small amounts of fluid and soft food had been introduced to enhance the resident’s quality of life. However the records indicated that the Percutaneous Endoscopic Gastrostomy Feeding had been commenced as a temporary measure and that a further review should be conducted and include an assessment by the speech and language therapist to as to whether this could be discontinued. Discussion with the senior staff on duty indicated that a decision had been taken by the dietician that the Percutaneous Endoscopic Gastrostomy Feeding should continue indefinitely. However there was no record of this decision within the records and no action had been taken to obtain guidance from the Speech and Language Therapist. Residents are generally weighed on a regular basis and this is used to inform both assessments for pressure and nutrition. However some of the residents are unable to use the existing scales, currently weight loss or gain is estimated by measuring the upper arm. Whilst this does provide an indication of weight it
Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 14 is not particularly accurate and inadequate for residents with a high level of need and more accurate alternatives should be sought. Residents have access to appropriate medical and specialist services such as dentists, opticians and podiatrist in addition to hospital and other National Health Services. However one resident who had recently been admitted from hospital was noted as having shortness of breath on exertion although this had been recorded in the records the senior staff had not been informed and therefore the appropriate referral to the general practitioner had not been made. In addition the resident had also been supplied by the hospital with elastic stockings to manage swollen ankles. The resident was noted to have her legs elevated by use of a footstool, however the position was such that the legs were hyper extended, providing unnecessary pressure on the knee joints. The elastic stockings were noted to be stained and the resident confirmed that she had a spare pair but these, along with other missing items had not yet been returned from the laundry. Medication is generally managed well within the home, staff were noted to be conducting an internal audit and stock take during the inspection. Residents’ medication administration records were seen to be maintained in good order and to correspond with the monitored dose system used by the home. Liquid medication was seen to be appropriately stored; however there was no record made of when the bottle was opened to ensure that the liquid was used within its shelf life. In addition the inspector noted that two 500mg of Paracetamol (still within the foil packaging) had not been administered and left on the residents bedside table. An immediate requirement was made regarding the safe storage and administration of medication. Privacy and dignity is managed well within the home, all residents spoken to confirm that the staff were nice and treated them appropriately. Individual plans of care evidenced that residents preferences in relation to their preferred form of address, food and personal routines such as times of rising retiring to bed. Staff were observed to be respectful and to knock on residents doors prior to entry. Residents were observed to be freely moving about within the home and
Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 15 to be sitting in the areas of their choice. Residents were well presented in their individual clothing. Individual plans of care contain minimal information regarding the residents spiritual needs and wishes regarding terminal care and death Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 16 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Daily life is managed well at Claremont Parkway Nursing Home and meets the needs and expectations of individual residents. EVIDENCE: Residents spoken to confirmed that routines within the home were flexible and that they were able to participate in a range of group and individualised activities. The new owners have recently increased the number of hours dedicated to social activity for ten to thirty per week. Two activities coordinators now produce a weekly programme of activities provided by the staff and external entertainers. The programme is circulated individually to residents. Residents were also able to confirm that visiting was flexible and that they were able to receive their chosen visitors in either the communal area of the home or in the privacy of their own accommodation. The lunchtime service was viewed and seen to be served in small pleasant dining areas or in residents’ rooms according to their need and preference. Meals appeared well presented, of adequate proportion and to offer a balanced diet. Residents confirmed that they were able to make selections from the
Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 17 menu according to their choice and their satisfaction with the standard of meals available. Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 18 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Complaints and the Protection Of Vulnerable Adults are managed well at Claremont Parkway Nursing Home EVIDENCE: The Commission for Social Care Inspection have received no complaints about Claremont Parkway Nursing Home and the new owners have produced an appropriate complaints policy, which is included within the new Statement of purpose. This is generally made available to prospective and existing residents and their representatives. Existing policies and procedures for the home are currently under review including the Protection Of Vulnerable Adults and Whistle Blowing policy Staff spoken to were able to demonstrate an understanding of the action that would be required in the event of a Protection Of Vulnerable Adults incident. Staff were also able to confirm that training in the Protection Of Vulnerable Adults was scheduled for the near future. Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 19 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 & 26 The home meets the needs of residents and is well maintained, clean and hygienic throughout EVIDENCE: A limited tour of the premises was conducted and was seen to be suitable for the stated purpose. Recent improvements to the home include the provision of an extra office further planned improvements for the near future include redecoration and replacement carpets. However the home was seen to be well maintained, clean and hygienic throughout. Residents spoken to confirmed satisfaction with their individual accommodation and the communal areas. Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 20 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, 29 & 30 Staffing levels, recruitment processes and staff training ensure that residents’ safety is maintained. EVIDENCE: Claremont Parkway Nursing Home base staffing levels on the calculated dependency levels of residents. At present the home provides a total of ten staff for the morning shift, which includes three Registered Nurses; seven staff for the afternoon and evening shifts, including one Registered Nurse, and four waking staff for the night shift including one Registered Nurse. Staff spoken to confirmed that staffing levels were generally adequate. The home is currently recruiting more nursing and domestic staff. One new member of staff has been recruited since the change in ownership of the home and although the file was unavailable to the inspector in the absence of the new manager; the member of staff spoken to confirmed a thorough recruitment process, with appropriate references and Criminal Records Bureau Clearances having been obtained. Staff were also able to confirm access to appropriate induction and other mandatory training. Further training is planned for the New Year to include, Fire Safety, Health and Safety, Movement and Handling and the Protection Of Vulnerable Adults Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 21 Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 22 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 & 38 Safe working practices are generally managed well, however improvements must be made to ensure that residents who require the use of bed rails have appropriate risk assessments in place to ensure their safety EVIDENCE: Following the change in ownership the management have appointed a new manager. The manager is known to the commission and has the necessary qualifications, skills and experience to manage the home. It is recommended the new manager seek registration with the Commission for Social Care Inspection in the near future. The premises provide a safe environment for residents and safe working practices are supported by access to appropriate mandatory training.
Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 23 However, some residents were noted to have bed rails in place, there was no evidence that consent had been obtained from the resident or their representative for their use. In addition there was no evidence that risk assessments had been conducted regarding the need for these to be in use or any of the associated risks such as entrapment. An immediate requirement was made at the time of inspection for these to be conducted, in line with current guidelines. Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 2 Standard OP1 OP2 Regulation 4&5 5 Schedule 4 (8) 13 (4b&c) 15 (1) Requirement All new residents must have access to the statement of Purpose and Service Users Guide All new residents must have access to appropriate contracts, which specify the terms and conditions of residency. All residents must have appropriate risk assessments for the prevention of falls Individual plans of care must be drawn up with and evidence the residents or their representatives involvement. Individual plans of care must evidence the residents or their representatives’ involvement in the review Guidance must be sought from a Speech and Language Therapist regarding the need to continue with Percutaneous Endoscopic Gastrostomy Feeding and decisions regarding this must be recorded in the individual plan of care Residents must have appropriate referrals to the general
DS0000066165.V268667.R01.S.doc Timescale for action 06/12/05 06/12/05 3 4 OP7 OP7 06/12/05 06/12/05 5 OP7 15 (2) 31/12/05 6 OP8 12 (1) 13 (1) 31/12/05 7 OP8 13 (1) 06/12/05 Claremont Parkway Nursing & Residential Home Version 5.0 Page 26 8 9 OP8 OP9 13 (4 b) 13 (2) practitioner Residents must be supported to maintain safe and comfortable positions Medication must be safely stored and administered at all times. Immediate Requirement Information regarding the residents spiritual needs and wishes regarding terminal care and death must be obtained and recorded in the individual plan of care Residents must have comprehensive risk assessments conducted regarding the use of bed rails and associated equipment. Immediate Requirement 06/12/05 29/11/05 10 OP11 12 31/12/05 11 OP38 13 (4c) 06/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard 8 8 9 31 38 Good Practice Recommendations Alternative equipment should be obtained for residents who are unable to use the standard weighing equipment. Items necessary for the maintenance of health should be returned from the laundry within an appropriate time scale The date of opening of liquid medication should be recorded to ensure that medication is not used beyond its recommended shelf life The manager should seek registration with the Commission for Social Care Inspection Prior to the use of bedrails consent should be, sought from the resident or their representative and recorded Claremont Parkway Nursing & Residential Home DS0000066165.V268667.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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