Inspection on 10/09/07 for Colne Place

This inspection was carried out on 10th September 2007.

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

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

Other inspections for this house

Colne Place 10/07/08

Colne Place 12/10/05

Colne Place 12/04/05

Colne Place 11/11/04

Colne Place 06/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Colne Place 97 High Street Earls Colne Colchester Essex CO6 2RB Lead Inspector Diana Green Key Unannounced Inspection 10th September 2007 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 Colne Place DS0000017797.V350583.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. Colne Place DS0000017797.V350583.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Colne Place Address 97 High Street Earls Colne Colchester Essex CO6 2RB 01787 222314 01787 223984 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) Handsale Limited Mrs Maria Connolly Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Colne Place DS0000017797.V350583.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th September 2006 Brief Description of the Service: Colne Place is a residential care home for the elderly set in a period residence with large well-maintained grounds in a village location. Registered for 33 residents, accommodation is mainly in single rooms many of which have en suite facilities. The home provided 24-hour care for service users with varying levels of dependency and was fully equipped to provide a safe environment for those with restricted mobility. The fees range from: £426.00 -£439.00 per week Additional costs apply for chiropody, toiletries, hairdressing and newspapers. This information was provided to the CSCI on 15/10/07. Colne Place DS0000017797.V350583.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 that took place on the 10/09/07, lasting 7 hours. The inspection process included: discussions with the registered manager, head of care, three staff, the cook, laundry assistant, six residents and one relative, a district nurse/continence nurse, Macmillan nurse and a general practitioner; a partial tour of the premises including a number of residents’ rooms, bathrooms, communal areas, the kitchen and the laundry; and inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Surveys were distributed to residents, relatives, care managers and health care professionals and the views from those completed and returned to CSCI have been included in the report. Information from the home’s Annual Quality Assurance Assessment has also been included in this report. Twenty-four standards were inspected and five requirements and one recommendation made. The manager and staff were welcoming and helpful throughout the inspection. What the service does well: Colne House provides a homely environment. The premises are clean and well maintained. The gardens are attractive and fully accessible to wheelchair users. Residents are regularly taken out around the gardens and to the local shops. Care staff are friendly and work well as a team. Senior staff provide good support to the manager and are well informed of residents’ needs. The standard of care is good and there is good access to health care services. There is good liaison with district nurses and local general practitioners. The standard of food is good with homely type meals and snacks are provided at times suitable to residents. The chef consults with residents on an individual and daily basis to determine their preferences. Colne Place DS0000017797.V350583.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. Colne Place DS0000017797.V350583.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 Colne Place DS0000017797.V350583.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 good based upon sampled inspected standards 1 & 3. Residents were well informed and had their needs assessed prior to moving in to the home. The service does not offer intermediate care. 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. The service user guide required updating to detail the CSCI rather than the NCSC as the regulatory body. A relative spoken with confirmed this had been made available prior to admission. Copies were displayed in the entrance of the home for visitors’ information. Feedback from relatives indicated they were able to view the home without an appointment and found the manager and staff very helpful. Colne Place DS0000017797.V350583.R01.S.doc Version 5.2 Page 9 Pre-admission assessments were carried out by the manager or head of care and information used to complete a full assessment following admission. A sample pre-admission assessment form was seen. The home does not provide intermediate care. Colne Place DS0000017797.V350583.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 good based upon sampled standards 7, 8, 9, 10 & 11. The health and personal care needs of residents are well met through care planning that is closely monitored and regularly reviewed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A sample of four residents’ files were viewed. All files contained an assessment form completed on admission and used to inform care plans. The assessments detailed the residents’ wishes for funeral arrangements and additional individual assessments had been completed in regard to specific needs (e.g. risk of falls, moving and handling, dependency, continence, nutrition, pressure sore risk, dementia etc.) that had been regularly reviewed. However one resident’s file had no care plan for a specific need that required hospital admission, although it was evident that staff were closely monitoring the condition. The manager stated that care plans were drawn up within 48 hours of admission and agreed with the relative and/or their representative. This was also confirmed from the care plans sampled. Care plans included Colne Place DS0000017797.V350583.R01.S.doc Version 5.2 Page 11 nutritional assessments with regular weight monitoring and most confirmed appropriate action had been taken, i.e. referral to dietician, specialist diets, supplements provided. The records confirmed that residents received had good access to health care through visits by district nurses, continence nurses, Macmillan nurses, community psychiatric nurses, GPs, dentists, chiropody and opticians, and that some attended outpatient clinic appointments as needed. This was also confirmed from completed surveys received from residents and their relatives. Feedback from some health professionals indicated that referrals were not always made promptly but that advice was always followed. Positive comments were received from residents and relatives: “We are happy that out mother is safe and well cared for”; “this is a good caring home”; “they care for their clients as individuals and the family is always involved with any decisions that are made and asked before anything is done”. The home had medication policy and procedures that were available. However the procedures were not sufficiently detailed to provide clear guidance to staff. Medication was provided by the local pharmacy in pre-dispensed packs and individual containers and appropriate ordering and disposal procedures were followed. Medication was stored in a cupboard in the office and a drug trolley that was secured to the wall as required. There was no monitoring of room temperatures to show that temperatures were within recommended levels (25°Centigrade) and advice was given with regard to this. A drug fridge was available and monitoring of temperatures were checked but not recorded to demonstrate that appropriate action would be taken as necessary. Medication was administered by designated staff who had received relevant training. A list of authorised staff names with signatures and initials was available but needed review to include currently employed staff only. Five residents records were inspected. All residents supplies were checked and confirmed that the prescribed medication was available. Some prescribed medication with a limited shelf life had no date of opening. Medication administration records (MAR) were generally well recorded, although several ommissions were evident that had not been followed up and the reason recorded. The home had a Controlled Drug (CD) Register as required. This did not detail the name and address on receipt and disposal and one CD drug had been entered on the MAR sheet and not in the register; one member of staff had confirmed it had been administered rather than two staff as required. New MAR sheets had been provided which had no codes recorded on them but the Head of Care confimed this had been raised with the local pharmacy who had agreed to provide them in future. A PCT pharmacist had undertaken an audit since the previous inspection and the head of care said the outcome was positive. Care files contained clear information and indicated each person’s preferred name. Staff were observed to be friendly toward residents but to also treat them with respect and to uphold their privacy and dignity when providing Colne Place DS0000017797.V350583.R01.S.doc Version 5.2 Page 12 personal care. Residents were not routinely provided with keys to their room but the manager confirmed this could be arranged if they wish. This standard was not fully assessed. However from the care files viewed, discussion with the manager and feedback from health and social care professionals, it was evident that at the end of life, residents and their relatives would receive care and comfort. The assessment process took into account the wishes of residents in the event of their death. A GP spoken with said the home provided good end of life care. Colne Place DS0000017797.V350583.R01.S.doc Version 5.2 Page 13 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 The social and therapeutic activities provided enhanced residents’ daily lives and met their cultural expectations. 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 employs a part-time activities coordinator (29.5hours per week), who also worked as a carer assistant and who arranged a variety of activities during the week. These comprised individual and group activities (e.g. bingo, games, quizzes, art & craft, reading & writing letters etc.). An activities plan for the week was observed displayed for residents’ information. Residents care files seen included evidence that their interests had been discussed with them and a life history recorded. Individual records were also maintained of residents’ involvement in the activities. Outings had also been provided i.e. for pub lunches, trips to the zoo etc. and entertainment provided monthly. The home held an annual fete and during the festive season, carol singers were invited from the local school. Residents were also taken for walks around the Colne Place DS0000017797.V350583.R01.S.doc Version 5.2 Page 14 grounds and a dog was brought into the home at times. Relatives spoken with and who completed surveys were positive about the activities at the home. Comments made were: “Staff are learning sign language and take my mother to the local luncheon club for the deaf and hard of hearing”; “Usually good activities attended by most of the patients”. Residents said that their friends and relatives could visit at any time, and they could meet with them in private in their rooms. The home arranged a monthly communion service and representatives of other faiths attended the home as relevant. Information received from the manager stated that some local community groups had visited the home at Christmas (local school children carol singing etc). An annual fete was arranged to which relatives and friends were invited. 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.) The home provides a varied and nutritional menu with fresh fruit and vegetables provided each day. The main meal served on the day of the inspection looked appetising and comprised a choice of pork chop or smoked haddock served with mashed potatoes, broad beans and cabbage followed by fruit crumble and custard or yoghurt /ice cream. Residents spoken with said they enjoyed the meal. Liquidised food was provided for residents who had difficulty swallowing/chewing. Hot and cold drinks were seen being served during the day. The menu of the day was observed displayed on the notice board in a dining room. The chef said that he meets with residents to determine their choices and obtains feedback on how they have enjoyed the meals. Relatives and residents who completed surveys stated the home “we have good food”; “I like the food”; “they will accommodate snacks at time suitable to residents”. The kitchen was clean and well organised with appropriate cleaning schedules in place that were adhered to. Colne Place DS0000017797.V350583.R01.S.doc Version 5.2 Page 15 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 good 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 included in the statement of purpose/service user guide and 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. One said they had no issues of concern and another “the senior staff deal with any issues quickly”. No complaints had been received since the previous key inspection. From discussion with the manager it was evident that any issues would be appropriately investigated and appropriate action would be taken as relevant. The home had a policy and procedures for safeguarding vulnerable adults and a whistle blowing procedure. The records confirmed that all care staff with exception of two had received training in protection of vulnerable adults as required from previous inspections. From discussion with the manager it was evident that any allegations of abuse made would be appropriately referred and relevant procedures followed. There had been no allegations of abuse made since the previous inspection. Colne Place DS0000017797.V350583.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 good based upon standards 19, 22 & 26. Colne Place was well maintained and had a homely environment; residents’ rooms were individually furnished and equipped for their safety, comfort and privacy. The home was clean and hygienic throughout. 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, several bathrooms, a number of residents’ rooms, the kitchen and the laundry. The home provided a secure, friendly and homely environment, was furnished in accordance with the client group and was well maintained. Records provided evidence that the building complied with the requirements of the local fire and environmental health department. The home had stairs and two passenger lifts to enable access to the first and second floors of the premises. There were grab rails, and aids in bathrooms, Colne Place DS0000017797.V350583.R01.S.doc Version 5.2 Page 17 toilets and communal rooms to meet the needs of residents. Assisted baths and toilets were provided. Some refurbishment of the home had taken place including decoration of a bathroom with installation of a new bath. Call systems were provided throughout all individual and some communal rooms, but none were available in the dining room. Call bell leads were not sufficiently long to enable all residents to call for assistance. One relative stated “being unable to walk makes it impossible to reach a bell. I feel that something could be arranged to make it easier to call for help”. Pressure relief equipment was assessed and provided by the district nursing service to meet the needs of residents. Specialist moving and handling equipment was also available that included a turntable. All equipment was serviced as per manufacturers recommendations and confirmed from the records inspected. Ramps were provided to enable access throughout the premises and to the gardens. The home was clean throughout with no malodorous smells. The home had policies and procedures for infection control available for staff guidance and advice was also given to obtain a copy of the Essex Health Protection Unit’s guidance as there was no access to the internet from where this could have been downloaded. The majority of care staff had received updated infection control training, although this had been arranged in-house. The laundry room was situated in an outside building and was found unlocked and unsupervised. There were two washing machines and one drier that were in working order. Washing machines had the capacity to carry out sluice wash cycles but there were no water soluble or soluble stitched bags available for any laundry soiled by body fluids, to be placed directly in the washing machines. Liquid soap was provided for staff hand washing but paper towels were not provided in all areas where staff provided personal care, for example residents’ rooms and some en-suites. Also the laundry room had no sink for staff hand washing. Colne Place DS0000017797.V350583.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 good based upon 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: There were 29 residents in the home. Staffing levels were seen to be appropriate to meet the needs of residents and comprised the Head of Care and 5 care staff. The manager was also in attendance. Ancillary staff on duty comprised 1 chef, 1 kitchen assistant, 1 laundry assistant and 3 domestic staff. The home also employed a maintenance person and gardener. Staff were observed to spend time with residents in the communal areas and with individual residents during the day. However some comments inferred there were not always enough staff on duty: “they look after my mother to the best of their abilities and the number of staff on duty”; “Staff are friendly and sympathetic but are very busy at times”. The home had four staff with NVQ level 3 and 10 care staff with NVQ level 2. A further five care staff were working towards NVQ level 2 qualifications. The percentage of staff with NVQ level 2 training was therefore more than the recommended 50 . Colne Place DS0000017797.V350583.R01.S.doc Version 5.2 Page 19 The recruitment process was robust. The personal files of two recently employed staff were inspected. Both 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 employment at the home. All had received a statement of terms and conditions of employment. The manager reported that all staff recently employed had completed the Skills for Care Common Induction 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. Training provided since the last key inspection comprised infection control, medication, moving and handling, first aid, fire safety and food hygiene. Colne Place DS0000017797.V350583.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 standards 31, 33, 35, 36, 37 & 38 The manager is supported well by senior staff in providing good leadership. Good health and safety standards are maintained with appropriate action taken where risks to service users and staff are identified. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager had substantial experience in care and has been employed at Colne Place since 1988. She is supported by a Head of Care. The manager had an NVQ level 4 qualification and had undertaken some updated training. Colne Place DS0000017797.V350583.R01.S.doc Version 5.2 Page 21 The home had recently implemented a quality assurance system. This had commenced with an audit undertaken corporately and service user satisfaction questionnaires being sent out to relatives. The report from this had not yet been produced. The manager said that there were plans to also distribute residents’ questionnaires annually in the future. There had been no residents’ or relatives meetings held this year. All residents had an advocate/representative to manage their finances on their behalf and some managed their finances with assistance of a relative. The home had secure facilities for the storage of any money looked after on their behalf. The personal monies of four residents were inspected and found to be correct with records and receipts held. Handover sessions were also held between each shift to discuss residents’ needs. There had been three staff meetings held this year. There was a formal system of documented supervision that included a staff contract. However this had not been undertaken recently with staff receiving informal supervision only. 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. 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 fire alarms and emergency lighting, hot tap water temperatures, etc.). A number of risks were identified at inspection including a cleaner’s trolley with hazardous items left unsupervised and the laundry room, also with hazardous substances left unlocked and unsupervised and water temperatures in bathrooms in excess of 43° Centigrade. Colne Place DS0000017797.V350583.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 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 2 X X x 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 3 2 Colne Place DS0000017797.V350583.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 To ensure the safe receipt, storage, administration, recording and disposal of medication: 1. Medication policies and procedures must be reviewed to provide more detail for staff guidance. 2. Monitoring of medication’ Room temperatures must be undertaken daily and action taken when this is exceeded. 3. Individual containers of medicines with a maximum life must have the date of opening recorded. 4.Controlled drugs must have the name and address recorded on receipt and disposal. 5.Administration of CD drugs must be witnessed and signed in the registered by two staff members. 6.Ommissions must be monitored and the reason for non-administration recorded on the MAR sheet. Timescale for action 31/10/07 Colne Place DS0000017797.V350583.R01.S.doc Version 5.2 Page 24 2. OP22 23(2)(n) 3. OP26 13(3) 4. OP36 18(2) 5. OP38 13(4) & 18(1)(c) To ensure residents are able to call for assistance, call bells with longer leads must be made available. To ensure risks of infection are minimised 1.Liquid soap and paper towels must be provided for staff hand washing in the laundry and where personal care is provided. 2.Water soluble or soluble stitched bags must be provided to enable contaminated laundry to be placed directly in the washing machine. The registered person shall ensure that persons working at the care home are appropriately supervised. This specifically refers to resuming documented supervision sessions. To ensure the safety of residents and staff: 1.Water temperatures must be kept near to 43° Centigrade. 2. COSHH items must not be left unsupervised. This refers to the cleaners’ trolley. 3.The laundry room with COSHH items stored must be kept locked when not in use. 4.Kitchen and domestic staff must receive load management training. 30/11/07 30/11/07 30/11/07 31/12/07 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 OP33 Good Practice Recommendations A copy of the quality audit report should be forwarded to the CSCI. DS0000017797.V350583.R01.S.doc Version 5.2 Page 25 Colne Place 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 Colne Place DS0000017797.V350583.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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