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Inspection on 30/05/07 for Cooksditch House Nursing and Residential Home

Also see our care home review for Cooksditch House Nursing and Residential Home for more information

This inspection was carried out on 30th May 2007.

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

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

What has improved since the last inspection?

The cook has attended training courses since the last inspection and is awaiting results, having just completed a Health and Nutrition course. The service users spoken to who had been here for some time said they felt the menus and meals served had improved.

What the care home could do better:

The following issues were raised with the registered manager during the inspection process. It is not comprehensive but highlights the areas of highest priority. The registered manager needs to ensure that all staff employed have a satisfactory Criminal Records Bureau check before they start. Staff currently working with service users who have not received their check must be supervised at all times. The findings from the inspection of the medication ordering, storage administration and recording showed that service users are not always being given the medication which is prescribed for them. Medication is not always being recorded when it comes into the home. In some cases there was too much stock being held. Staff should undertake the required training to make sure they can meet the service users` needs safely. There is an expectation that care staff will achieve an NVQ Level 2 in Care as a minimum, currently just 9 out of 31 staff have gained this award. When it is necessary to record such things as a service users` fluid intake and output then these charts should be fully completed every day and stored correctly.

CARE HOMES FOR OLDER PEOPLE Cooksditch House Nursing and Residential Home East Street Faversham Kent ME13 8AN Lead Inspector Sally Hall Key Unannounced Inspection 9:30 30th May 2007 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 Cooksditch House Nursing and Residential Home DS0000023399.V337887.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. Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cooksditch House Nursing and Residential Home Address East Street Faversham Kent ME13 8AN 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) 01795 530156 Mrs Gillian Ilsley Tina Anne Cloke Care Home 55 Category(ies) of Old age, not falling within any other category registration, with number (55) of places Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2006 Brief Description of the Service: Cooksditch House is a large detached property situated in the centre of Faversham. The original house is a Grade 2 listed building. It offers care to up to 55 people. This includes up to 35 Older people with nursing needs, 19 Older people and One Service User with a learning difficulty. The home has a variation of registration to care for 6 of the older people that now come within the Dementia category. Buses stop outside the Home. There is a local park and church within a few minutes walk of the Home. The Home has two lifts to enable access to all the areas. Accommodation is provided in both single and double rooms many of which offer en-suite facilities. All bedrooms have a call bell system and television point in situ. The fee range £326.33 to £488.00 and is dependent on the individual needs of the service user and whether nursing care is required. Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key Inspection at Cooksditch Residential and Nursing Home took place on Wednesday 30th May 2007 between 9.15 and 16.30. The link inspector was Sally Hall On the day of the inspection the Inspector agreed and explained the inspection process with the Registered Manager. Time was spent reading a sample of care plans, written policies and procedures and records kept within the home. Staff were spoken with and a tour of the premises was undertaken. The focus of the inspection was to assess Cooksditch Residential and Nursing Home in accordance with the National Minimum Standards for Older People. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. The home was asked to complete an AQAA but this was not returned prior to the inspection due to an agreed extension to the time to complete the form being granted by CSCI. Consequently surveys had not been sent out prior to the inspection. These still will be sent out to families, health professionals etc. and the information received will be feedback to the home and be included in the planning of the next inspection. Fortunately the inspector did have the opportunity to spend time with service users and a number of families during the inspection process and their comments have been included in this report. What the service does well: The home has a weekly programme of activities both inside and outside the home. Many of the service users spoken to said they are offered a choice of things to do and that they get the opportunity to go out if they wish. Some talked about the entertainers that come in to the home from time to time. The activities include events that are happening in the local community and a favourite with some service user was a trip to the local café for breakfast. The activity co-ordinator arranges group activities and one to one sessions to sit withindividual service users. The service users praised the meals and were of the view that the food presented to them is always nicely cooked. The cook confirmed that mainly fresh ingredients are used. Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 6 The home, although large, has a homely fee. There are several lounges, a conservatory and other places in which residents may sit. The home also has a separate room in which activities such as arts and crafts are offered. What has improved since the last inspection? What they could do better: The following issues were raised with the registered manager during the inspection process. It is not comprehensive but highlights the areas of highest priority. The registered manager needs to ensure that all staff employed have a satisfactory Criminal Records Bureau check before they start. Staff currently working with service users who have not received their check must be supervised at all times. The findings from the inspection of the medication ordering, storage administration and recording showed that service users are not always being given the medication which is prescribed for them. Medication is not always being recorded when it comes into the home. In some cases there was too much stock being held. Staff should undertake the required training to make sure they can meet the service users’ needs safely. There is an expectation that care staff will achieve an NVQ Level 2 in Care as a minimum, currently just 9 out of 31 staff have gained this award. When it is necessary to record such things as a service users’ fluid intake and output then these charts should be fully completed every day and stored correctly. Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 7 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. Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users can be confident that if they are offered a permanent placement at the home the staff will be able to meet their individual needs. EVIDENCE: Several examples of pre-inspection assessments were seen in the files of service users newly admitted to the home. The assessments seen had been completed fully and covered a wide range of information as required in Standard 3. The home also receives an assessment from care managers when social services are supporting admissions to the home. Examples of these were seen in the files sampled. The assessments are used to determine if the home can meet service users’ needs prior to offering them a trial stay at the home. Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 10 To make sure that the identified needs of service users can be met, the staff at the home receive appropriate training but it was noted that not all training for some staff was up to date. The home does not offer intermediate care. Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 11 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 poor. This judgement has been made using available evidence including a visit to this service. Although the care plans and the outcomes are well written service users cannot feel confident that they will be involved in the formation of their care plans. Service users cannot be confident that they will receive the medication prescribed for them. EVIDENCE: The care plans seen were generally well written and indicate to staff the actions they need to follow to meet the needs of service users. However, there was no indication that service users had been involved in the formation of their own plans. Discussion with service users indicated that they had not been included in the care-planning process. The care plans have been written from the in-depth assessments undertaken by the home. These assessments also identified the level of risk for various needs, i.e. nutrition, pressure sores, mobility. However, not all these areas were covered by the care plan and there was no evidence in many cases of the risk management strategy. The outcomes recorded each month for individual items on the plan of care was Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 12 extremely good and gave a good indication as to whether the actions of the staff were meeting the service users’ needs or whether changes were needed. The daily record system used by the home recorded the provision of care by staff and other events which were recoded at the time that staff entered the information onto the record rather than when things actually took place. The records themselves lacked detail and for many service users, who actually required high staff input, little was recorded. The assessments seen were well documented. In many cases they were reviewed monthly and they identified the level of perceived risk to service users. However, it was not always possible to see the risk management strategy to minimise those risks either through the care planning process or separately. One example seen in more than one file sampled was where a high risk of pressure sores was identified but no guidance was documented to assist staff in offering appropriate care. A large number of service users’ charts - fluids, nutrition etc. were stored in a wall mounted box in the corridor. Whilst some sections of the charts had been other parts had not. Some charts appeared not to have been completed for several days. The observation that many had not been completed fully by staff was something that the registered manager had already evidenced when monitoring. The registered manager had had a meeting with most the trained nurses, the record of which was seen, reminding them of their responsibilities. However it would seem that at the time of the inspection the request to complete records fully had still not been fully implemented by nurses and staff. The inspector inspected the medication storage arrangements and some records, including Medication Administration Record (MAR) sheets, and the protocols for the administration of PRN/As Required Medication. Most MAR sheets were completed correctly but not all of those examined by the inspectorwere fully completed. In both sites medication was stored appropriately; the ground floor room contained an air conditioning unit to ensure it did not get too hot. The registered manager confirmed that all staff who dispense medication have received appropriate training. There was a clear list of who is authorised to give out medication on which was written their usual signatures for identification purposes. Several areas of concern were seen and brought to the attention of the registered manager and head of care. It was evidenced that doses of medication were not given to some service users as a partial audit of medication both in the nursing and the residential areas showed tablets had been signed for but not given. The gaps on MAR sheets evidenced that medication had not been signed for as given, or recorded as omitted or refused as appropriate in some cases. Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 13 Medication that had been prescribed as two every morning for one service user had been clearly given out as just one every morning by staff. Medication coming into home on a monthly basis is signed in on the MAR sheets. However, medication that had come into the home during the month had not. New entries on the MAR sheet had not been dated and signed. The MAR sheets seen did not indicate the amount of medication already in stock at the start of the month. The amount of stock being kept for some service users was excessive. The registered manager agreed to make suitable arrangments to deal with this matter. The registered manager was aware of the need to monitor the administration and recording of medication and identify staff and nurses who are not following the policies and procedures and take appropriate action given the seriousness of this situation. This was identified and documented in the last inspection report and the information has been passed on to the CSCI pharmacy inspector for her consideration. The home has been requested to confirm in writing that medication is administered, stored and recorded as required under the regulations and detail the action taken with staff that are not following policy. The home needs to ensure that the recording and administration of medication follows The Royal Pharmaceutical Society guidelines (amended June 2003). Service users spoken to said that they felt staff treated them with respect and their dignity and privacy was protected. Staff were seen talking to service users in an appropriate and sensitive way. Staff were seen to knock on service users’ doors before entering. Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 14 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): 12,13,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that there are activities and outings arranged at the home in which they can join if they wish. Service users can also feel confident that the meals offered by the home will be nutritious and varied. EVIDENCE: The activities co-ordinator explained the various activities that she undertakes with service users in the home. Her commitment to her role was evident both from the way she spoke and from the comments received from the service users spoken to by the inspector. She showed a good understanding of the range of differing needs of the service users cared for at the home. A programme of organised activities was displayed in the corridor, and time is set aside for one to one sessions with those less able or who do not like doing things in groups. Outings are also arranged, mainly locally, and every effort is Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 15 made to ensure service users are kept in touch with the events happening locally. A favourite with some service users is the outing to the local café for a full English breakfast. Although this is available in the home the registered manager confirmed service users liked to go to the café for a change. The activities are recorded in the daily record and a diary sheet is used for easy reference. The activity co-ordinator was advised that it important to record when people are offered activity but refuse since it might appear that there are service users who have little input compared with others when this might clearly not be the case. It was also noted that this home has over fifty service users but the activity co-ordinator works just 25 hours. The activity coordinator expressed the view that she did find it difficult to give as much input to service users as she would like. The service users spoken to about the meals at the home confirmed that they do get a choice and that the meals are well cooked and enjoyable. The menus were not seen on this occasion. Since the last inspection the cook has been on various training courses and her commitment to providing a varied and nutritious menu was evident. The cook had just completed aHhealth and Nutrition course and, at the time of the inspection, was awaiting the outcome. The dining areas are light and airy and are set out in a pleasing way. Drinks are available throughout the day and some meals are serve in service users’ rooms. Care does need to be taken to make sure that food and drinks are not left to go cold when a service users needs help to eat or drink. Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 16 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): 16,18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can feel confident that the management of the home will take concerns and complaints seriously. Service users cannot be confident that they will be protected by the home’s Adult Protection policies and procedures since it does not have copies of relevant Adult Protection documentation and staff have not received appropriate training. EVIDENCE: An inspection of the home’s complaints file confirmed that there had not been any formal complaints and that any problems/concerns raised have been dealt with by the home straight away. The home does have a complaints procedure. Service users spoken confirmed that if they were not happy about things happening in the home they would talk to the manager. The registered manager confirmed that the home still does not have a copy of the local authority’s Adult Protection protocols. The registered manager stated that she had recently raised an Adult Protection issue herself, which was being investigated. This indicated that the manager was able to make sound judgements when dealing with Adult Protection matters. It was noted that not all staff at the home have received recent Adult Protection training. Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 17 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, This judgement has been made using available evidence including a visit to this service. Service users live in a safe, well-maintained and clean environment. The standard of décor generally, furnishing and fittings are high, providing a homely and pleasant living environment for the service users who live there. EVIDENCE: A tour of the building was undertaken with the registered manager. On the first floor a number of the service users’ rooms were inspected. The rooms seen were furnished to a high standard, and been personalised by service users. Some bedrooms seen were in need of some redecoration where over time the walls had become marked or stained. The same problems were noticed in parts of the corridors. The home has mainly single rooms with just five shared rooms. Many of the rooms also offer an en-suite facility. In the shared rooms, to give privacy, there are dividing curtains. Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 18 In was noted that some of the nursing beds have bed sides with bumpers to protect the service users. Some of these were not clean and this could become an infection control issue. The laundry is on the first floor it is small and compact. There is no sluicing facility on the washing machine. Evidence of PPE, personal protective clothing was seen around the building for staff to use. There was a smell of stale urine around the building even though the home has a good air freshener system. Two of the families and a two of the service users spoken had noticed this. One family and service users said that they had noticed the home was not as clean as usual since two members of staff had left. The registered manager confirmed that she was aware of the problem and they were trying to recruit new staff. Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30. Quality in this outcome area is poor, This judgement has been made using available evidence including a visit to this service. Whilst the home is adequately staffed, the safety of service users may be compromised because of shortfalls in the home’s recruitment procedures and the lack of training of some staff. EVIDENCE: In the files of recently recruited staff randomly sampled there were application forms, proof of identity documentation, and references. However, no CRB checks were evident other than in the files of the staff who had been at the home for some time. The registered manager was reminded that staff should not be employed and working in the home unless it can be guaranteed that they can be supervised at all times. The manager agreed that this was not happening and that one of these members of staff is a nurse who would normally be in charge in the manager’s absence. Evidence was seen of the home’s induction programme plus one member of staff who had been on external course that meet the work force training targets. The rotas indicated that there is sufficient staff to meet the needs of the service users. However, this needs to be monitored by the registered manager Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 20 to ensure the staffing levels correspond with the dependency levels of the current service users. The registered manager confirmed that when staff are absent for any reason they are covered and that they do use agency staff. The registered manager was unable to show the current level of staff training fully because the training matrix was not up to date. However, she was aware that staff training was not up to date and that h a large number of staff did not have up to date certificates for all of the required courses. The registered manager explained that not having a training budget had made it difficult to confirm sourced training, which meant training places had been lost. The registered manager confirmed that just nine care staff have achieved the NVQLlevel 2 in Care or above. The home currently employs 31 care staff and therefore this is well down on the numbers of staff who should hold this qualification. Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 21 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): 31,33,36, 37, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the manager of the home is qualified and brings a breadth of experience to management of the home, the care of service users is compromised because staff are not receiving reglar supervision and the health and safety of service users is compromised by staff not having all the required training. EVIDENCE: The Manager has now been registered, she is well qualified for her position and has a number of years experience in residential nursing care both here and at a previous establishment. Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 22 Evidence was seen that service users are consulted about things that happen in the home. Residents’ meetings are held periodically when sufficient service users are able to attend. When this is not the case then service users’ views are sought by staff on an individual basis. The home has policies and procedures in place. However, a number of these had not been reviewed within the yearly time frame. The home’s policies and procedures are accessible to all staff. The home has secure storage for all confidential information. However, it was a concern that service users’ charts were left in a corridor and that many of these had not been fully completed. The registered manager had devised a spreadsheet showing when staff supervision takes place. Although staff are still not receiving regular supervision at the level of the Standard, this has improved. It was apparent that the registered manager is working towards it. It was recommended that other staff could be trained to assist her as the number of staff who require supervision is high for one person. Staff training needs to be kept current since not all the statutory training for staff is up to date. The minimum training expected for all staff is health and safety, infection control, moving and handling, first aid, adult protection, and fire training. The registered manager confirmed that the maintenance certificates were in date. The registered manager confirmed that regular tests are undertaken on the fire alarm systems and that the log is up to date. These were not seen during the visit. Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 23 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 2 2 Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? 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 Requirement Timescale for action 30/07/07 12, 18, 23 A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. With regular monthly reviews by staff and new assessments and care plan six monthly, more often if change in condition. 2. OP8 13, 14, 16 The registered person promotes 30/07/07 and maintains service users’ health and wellbeing, by not only identifying the level of risk but by developing a strategy to minimise perceived risks. 13,17, The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling, administration and disposal of medicines. With monitoring systems being put in place to identify staff who are not doing this correctly. With the outcome of this investigation and the action taken by the DS0000023399.V337887.R01.S.doc 3. OP9 30/06/07 Cooksditch House Nursing and Residential Home Version 5.2 Page 25 home to be documented and sent to the CSCI. 4. OP18 12, 13 The registered person ensures that service users are safeguarded from any type of abuse, in accordance with up dated written policies as supplied by the local authority and by ensuring staff receive adequate training. Plus refreshers every three years The premises are kept clean, hygienic and free from offensive odours throughout A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) was required by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. Now the home should be working towards 100 , please confirm that more staff have been enrolled on the relevant courses. 30/08/07 7. 8. OP26 OP28 26 18 30/07/07 15/07/07 9. OP29 19 The registered person operates a 01/06/07 thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. All staff must have a satisfactory CRB check before they can work in the home not chaperoned at all times this includes nursing staff. As there are a number of staff who this currently affects please ensure that there is no more than one such person on each shift. It would be totally inappropriate on night duty. DS0000023399.V337887.R01.S.doc Version 5.2 Page 26 Cooksditch House Nursing and Residential Home 10. OP30 18 11. OP36 18,19 The registered person ensures 01/12/07 that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. By ensuring all staff have undertaken the required training and any special training to meet specific needs of service users cared for at the home. The registered person ensures 30/07/07 that the employment policies and procedures adopted by the home training and supervision arrangements are put into practice and are ongoing to the required level. The registered manager ensures 30/08/07 so far as is reasonably practicable the health, safety and welfare of service users and staff by making sure that staff undertake the relevant health and safety training, which includes moving and handling training yearly for example. 12. OP38 12, 13, 23, 37 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 OP37 Good Practice Recommendations Records such as charts with information that should be recorded daily for individual service users are up to date DS0000023399.V337887.R01.S.doc Version 5.2 Page 27 Cooksditch House Nursing and Residential Home and accurate. Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Cooksditch House Nursing and Residential Home DS0000023399.V337887.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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