Inspection on 15/01/07 for Coombe Dingle

This inspection was carried out on 15th January 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.

Other inspections for this house

Coombe Dingle 17/12/07

Coombe Dingle 30/08/05

Coombe Dingle 28/04/05

Coombe Dingle 28/07/04

Coombe Dingle 06/04/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOMES FOR OLDER PEOPLE Coombe Dingle 14 Queens Park Road Caterham Surrey CR3 5RB Lead Inspector Denise Debieux Unannounced Inspection 15th January 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 Coombe Dingle DS0000013311.V325415.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. Coombe Dingle DS0000013311.V325415.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Coombe Dingle Address 14 Queens Park Road Caterham Surrey CR3 5RB 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) 01883 345993 01883 341869 alphacarecaterham@yahoo.co.uk Alpha Care (Caterham) Ltd Nirmala Anandi Devi Read Care Home 42 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (42), Learning disability (1), Learning disability of places over 65 years of age (1) Coombe Dingle DS0000013311.V325415.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Up to 1 bed may be used for people with a Learning Disability (LD(E)) 65 years old and over. Up to 5 beds may be used for respite care. Up to 1 resident may be cared for on Day Care basis between the hours of 0800 - 2000 hrs. One place for (DE) Dementia under 65 years of age may be for the named service user only. One place for (DE) Dementia under 65 yrs of age and (LD) Learning disability under 65yrs of age, may be for the named service user only. 30th August 2005 Date of last inspection Brief Description of the Service: Coombe Dingle is a registered care home providing nursing care for up to 42 people with dementia. The home is situated in a quiet residential road in Caterham facing a large park. The property is detached and has a large garden to the rear and also offers car parking for several vehicles. Additional parking is on the road. Accommodation is provided over three floors. There are a few (9) en suite single bedrooms and 2 double bedrooms with ensuite facilities. The home is owned by Alpha Care (Caterham) who are the registered providers. Fees range from £475 - £1200 per week (with an average figure of £600). This fee does not include toiletries and hairdressing. This information was provided on 17/01/07. Coombe Dingle DS0000013311.V325415.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place over 8 hours and was carried out by Denise Débieux, Regulation Inspector. Mrs Meera Read (Registered Manager) and Mr Bhagirath Patel (Responsible Individual) were present as the representatives for the establishment. A tour of the premises took place. The lunchtime meal and medication round was observed during this visit. Five of the forty-two service users and five onduty staff were spoken with during the visit. Ten relatives’ survey forms were received prior to the visit. In addition, four service user survey forms and fourteen staff survey forms were completed and handed in to the inspector on the day of this visit. Some of the comments made to the inspector and made on the survey forms are quoted in this report. The home had completed a pre-inspection questionnaire and service user care plans, staff recruitment and training records, health and safety check lists, menus, policies, procedures, medication records and storage were all sampled. The inspector would like to thank the service users and staff for their time, assistance and hospitality during this visit and the service users, staff and relatives who participated in the surveys. What the service does well: The staff work hard to ensure that service users’ needs are met, whilst encouraging and enabling service users to maintain their independence where possible. Meals are varied, well balanced and nicely presented offering choice and variety. All interactions observed between the management, staff and service users evidenced that the home has a close and caring staff team. When asked what was the best thing about working at Coombe Dingle, one member of staff answered ‘Residents, staff, visitors, manager, directors and environment’ another answered ‘That I am helping people who need support’ and another answered ‘Team work and communication’. Many positive comments were also received from relatives that were surveyed. Comments included: • The staff always make us so welcome,. We have come to know them well. All the staff work very well and are always happy. Coombe Dingle DS0000013311.V325415.R01.S.doc Version 5.2 Page 6 • • • The overall care of my relative has been first class and the staff are all very considerate and kind. The staff and owners at Coombe Dingle are always friendly and I am confident that my relative is happy and well cared for. The whole team at Coombe Dingle are excellent in every way. 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. Coombe Dingle DS0000013311.V325415.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 Coombe Dingle DS0000013311.V325415.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user is only admitted to the home following a comprehensive needs assessment to ensure that the home can meet the service user’s identified needs. The home does not offer intermediate care. EVIDENCE: The inspector was advised that the manager or one of the trained nurses would visit a prospective service user and carry out a pre-admission assessment. Three care plans were sampled during this visit. In each case comprehensive pre-admission assessments had been carried out, prior to admission, to ensure that the home could meet the service users’ identified needs. Information from other health care professionals and relatives is also obtained, if available. Coombe Dingle DS0000013311.V325415.R01.S.doc Version 5.2 Page 9 New regulations came into force earlier last year that require additional information to be included in the service users’ guide and that all service users be given a full breakdown of their fees. These regulations were discussed with the management during this visit and the inspector was advised that the manager will be reviewing their documentation against the new regulations. Coombe Dingle DS0000013311.V325415.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): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home needs to ensure that all service users have an up to date, individual care plan that includes risk assessments and details the care required to fully meet all aspects of their health, personal and social care needs. Policies, procedures and practices are in place to ensure the safe administration of medication. However, the home needs to ensure that staff follow the policies and procedures and any professional guidelines for the handling of medications and record keeping. The arrangements for health and personal care ensure that service users’ privacy and dignity are respected. EVIDENCE: The care plans sampled during this visit were all based on pre-admission assessments and had been drawn up shortly after the service users’ admission to the home. The care planning system at the home includes care plans for each identified need and requires that goals or objectives are established, together with staff actions to be taken to meet these goals. The home is in the process of Coombe Dingle DS0000013311.V325415.R01.S.doc Version 5.2 Page 11 transferring from one care planning system to another and there were a number of inconsistencies identified: • Not all needs identified in the pre-admission assessments had been included in the care plans; • Not all care plans included actions to be taken to meet identified needs; • Not all risk assessments had been completed; • Some care plans had actions that were not applicable or were not being carried out (e.g. supervising at all times, weighing service users twice weekly); • Pre-printed actions to be taken on risk assessments did not reflect the procedures at the home; • Monthly reviews of care plans had been carried out, but the care plans had not been updated to reflect the current status; • Daily notes did not always relate to the care plans and did not provide evidence that service users’ needs were being met; • The majority of entries in the care plans had not been dated or signed by the staff members making the entries. Care plans were discussed and sample care plans shared with the home for ideas. A requirement has been made and it is recommended that the home review professional guidelines of record keeping with the trained nurses. All staff surveyed stated that they would refer to the care plans for information on what care a service user needed. From observations made at this visit it was clear that the staff have a good knowledge of the needs and preferences of the service users and all relatives surveyed said that they were satisfied with the overall care provided at the home. One relative added: ‘I have nothing but praise for the staff at Coombe Dingle and feel that they give my relative the best care possible’. The medication administration records were sampled and found to be in order for all oral medications. However, topical medications (i.e. creams, shampoos) were not being signed for and there was no indication as to whether or not these medications had been given. Some of the topical medications needed to be reviewed by the GP and there needs to be clear instructions on where creams are to be applied. (i.e. one prescription stated ‘apply to rash’ with no details of the position of the rash). Medication storage, policies and procedures were all sampled and found to be in order and the controlled drugs register was well maintained and tallied with the controlled drug count. The lunchtime medication round was observed and seen to be in line with the home’s policies and procedures. During the tour of the home staff were observed to always knock before entering the service users’ bedrooms and all personal care was provided behind closed doors. All interactions observed between staff and service users Coombe Dingle DS0000013311.V325415.R01.S.doc Version 5.2 Page 12 were seen to be caring and respectful and the service users were obviously at ease and comfortable with the staff on duty. Of the four service users who returned comment cards, three answered that their privacy is always respected and one answered ‘usually’. Coombe Dingle DS0000013311.V325415.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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The ongoing development of the home’s activity provision is leading to a more varied and individualised activity programme. Contacts with family and friends are encouraged. Meals are well-balanced and varied with individual choices and preferences catered for. EVIDENCE: At present the home’s activity coordinator works three days a week, for two hours on each day. The home have also established an ongoing link with the National Association for Providers of Activities for older people (NAPA) and the majority of care staff were able to attend two training days which were provided by NAPA in October 06. This is leading to an increased provision of meaningful activity for the service users in all areas of their daily life. All staff are involved and are enthusiastic about this new way of working. The home are in the process of developing individual activity plans for the service users. Of the service users surveyed, one answered that there were always activities they could participate in and three answered ‘usually’. Coombe Dingle DS0000013311.V325415.R01.S.doc Version 5.2 Page 14 There are no restrictions to visiting times and staff support and encourage service users to maintain family links and friendships both inside and outside the home. Relatives surveyed said that the staff welcome them in the home at any time. Menus were sampled and seen to be varied and well-balanced. The lunchtime meal was taking place during the visit and the food was presented in an appetising manner. Of the four service users who returned comment cards, two said that they always liked the meals at the home and two answered ‘usually’. A recommendation has been made that the home consult an appropriately qualified professional and review the variety, method of use and suitability of the eating and drinking aids currently available at the home, to ensure that the service users are able to maintain their independence in this area for as long as possible. Coombe Dingle DS0000013311.V325415.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): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a simple, clear and accessible complaints procedure which includes timescales for the process. The policies and procedures in place to protect service users from harm or abuse need to be reviewed in line with the Surrey Multi-agency Procedure and the Department of Health ‘No Secrets’ guidelines. Current recruitment practices must be revised as they are placing service users at risk of potential harm or abuse. EVIDENCE: The home has a complaint’s procedure in place that is available to all service users and their relatives and is also included in the service users’ guide. All relatives surveyed stated that they were aware of the home’s complaint’s procedure. There have been no complaints made to CSCI or the home in the past 12 months. The home also has a ‘Whistle Blowing’ policy in place and basic awareness of the protection of vulnerable adults is included in the home’s induction training. A copy of the latest ‘Surrey Multi-agency Procedure for the Protection of Vulnerable Adults’ is available in the office. Of the fourteen staff members surveyed, twelve stated that they would immediately report any suspicion or report of abuse to the person in charge. However, two members of staff indicated that they would investigate further, prior to reporting the incident. This is contrary to the Surrey local procedure Coombe Dingle DS0000013311.V325415.R01.S.doc Version 5.2 Page 16 but is in line with the home’s own policy. A recommendation has been made that the home revise their written procedure on the protection of vulnerable adults to reflect the local Surrey multi-agency procedure and ensure that all staff are aware of the correct course of action to take. All service users spoken with and surveyed told the inspector that they felt safe at the home. Staff recruitment is covered in more detail in the ‘Staffing’ section of this report. Coombe Dingle DS0000013311.V325415.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): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the home and gardens are suitable for their stated purpose. An ongoing redecoration programme provides the service users with clean, pleasant and homely surroundings in which to live. EVIDENCE: During the tour of the home the premises were seen to be well maintained with service users able to freely access all areas. All personal rooms seen were individualised to the service users’ wishes and were seen to contain many personal items and mementos. The gardens were well kept, with separate seating areas provided for the use of service users and their visitors in warmer weather. On the day of inspection the home was found to be warm and bright with a homely atmosphere and a good standard of housekeeping apparent. Coombe Dingle DS0000013311.V325415.R01.S.doc Version 5.2 Page 18 Three of the four service users surveyed stated that the home was always fresh and clean and one answered ‘usually’. Coombe Dingle DS0000013311.V325415.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The skill mix of the staff meets service users needs but the home needs to review staffing arrangements at mealtimes. Staff recruitment procedures must be improved to ensure that the service users are not placed at unnecessary risk of harm or abuse. The home has a staff training programme which is designed to ensure, as far as reasonably possible, that service users are in safe hands at all times. EVIDENCE: The staff rota evidenced that staff are mostly provided in sufficient numbers to meet the needs of the service users at the home. Of the four service users surveyed, two stated that staff are always available when needed and two answered ‘usually’. Nine of the ten relatives surveyed felt that there were always sufficient numbers of staff on duty. However, there are a high number of service users at the home that require full assistance at mealtimes. During the lunchtime meal the inspector observed that, on each dining table, one member of staff was feeding two service users. This meant that the service users being assisted were having to wait between each mouthful and were faced with the staff member’s back when it was not their turn. It could also mean that their meals could be cold before they had finished, which in turn could lead to a reduced food intake. Mealtimes are an important activity for all service users and the current mealtime staffing levels and/or mealtime arrangements must be reviewed to Coombe Dingle DS0000013311.V325415.R01.S.doc Version 5.2 Page 20 ensure that all service users requiring one to one assistance receive this. This was discussed during the visit with the possibility of introducing ‘staggered’ sittings explored. A requirement has been made. During this visit the recruitment files of two care staff were sampled. The files were seen to contain proof of identity and enhanced Criminal Record Bureau (CRB) and Protection of Vulnerable Adult (POVA) list checks. However, at present the home has not been verifying applicants’ reasons for leaving previous employment with vulnerable adults; are not obtaining full employment histories and some gaps in employment had not been explained or explored and one person did not have a reference from their last employment working with vulnerable adults. The home were not aware of amendments to The Care Homes Regulations 2001, which came into force in July 2004 and relate to staff recruitment and supervision. These amendments were discussed with the management during this visit and immediate requirements were made. The manager expressed a firm commitment to staff training and the home has a comprehensive induction and ongoing training programme that meets the specifications set out by the Skills for Care organisation. Over 50 of the care workers are qualified to National Vocational Qualification (NVQ) level 2 in care, with a number having achieved level 3. The training records evidenced that all mandatory training and updates are provided promptly. Additional training is provided that is relevant to the needs of the individual service users at the home. No new staff have been employed after the 1st October 2006 but the home are now aware of the new Skills for Care induction standards and procedures that became mandatory from that date. Staff were happy with the training provided by the home with one commenting ‘Training is updated regularly, it is informative and helpful’ and another that ‘Training is essential because things are changing every day. It keeps me up to date.’ Service users spoken with were complimentary about the staff at the home. Of the four service users surveyed, all stated that staff always listen and act on what they say. One relative commented ‘I am satisfied with my relative’s care. All carers are very attentive and respond to any requests made. They are all doing a great job.’ All interactions observed between the staff and service users were caring and respectful. Coombe Dingle DS0000013311.V325415.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, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from the clear management approach at the home which provides an open, positive and inclusive atmosphere. The home has a quality assurance and monitoring system in place that is based on seeking the views of the service users and their relatives. Policies and procedures are in place to protect service users’ financial interests. All policies, procedures and practices are in place to ensure, so far as is reasonably practicable, the health safety and welfare of service users and staff. EVIDENCE: Mrs Read has been the manager of Coombe Dingle since 2005. She is a registered nurse; holds a Registered Manager’s Award and is an A1 NVQ assessor. Her management style is inclusive and the service users benefit from the ethos, leadership and clear management approach of the home. Coombe Dingle DS0000013311.V325415.R01.S.doc Version 5.2 Page 22 A total of fourteen care staff questionnaires were returned to the inspector on the day of this visit. From observations made on the day and from comments made on the staff questionnaire it is clear that the home have a close and happy staff team. When asked what was the best thing about working at the home, staff comments received included: ‘Good relations with management and owners’ and ‘Working in a friendly, happy environment. Manager and owners that are approachable.’ The home has a quality assurance and monitoring system in place that is based on seeking the views of the service users, as far as is possible. There are relatives’ meetings held every three months and monthly quality assurance reviews (Regulation 26 visits) take place. A recommendation has been made that the home expand their quality assurance system to include stakeholders in the community (e.g. GPs, chiropodists, care managers and other health and social care professionals). During the tour of the home the kitchen fire door was seen to be wedged open during the serving of lunch. This was to assist the staff when taking food trays out. The wedge was removed immediately and the inspector was advised that the home will arrange for an approved magnetic catch to be fitted. All required safety monitoring checks, fire drills and safe working practice training and updates have been carried out. Staff were observed to be following appropriate health and safety practices as they went about their work. All interactions observed between the staff and service users were inclusive, caring and respectful. Coombe Dingle DS0000013311.V325415.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 2 10 3 11 X 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Coombe Dingle DS0000013311.V325415.R01.S.doc Version 5.2 Page 24 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 OP7 OP8 Regulation 14(2)(a) (b) 15(1) 15(2) (a-d) 16(2)(m) (n) Requirement The registered person must ensure that each service user has an individual plan of care that includes the following: • A comprehensive assessment of needs covering all areas of health, personal and social care (activity) needs; • Risk assessments, to include: prevention of falls, use of bed rails, nutrition, risk of pressure sore development, moving and handling; • Details of all individual needs identified, including social care needs; • Individual preferences for how service users would like their care carried out; • Goal/objective for each need; • Actions to be taken to ensure the goals are met and to include the service users’ preferences; • Daily report writing to evidence that identified needs and goals are being met; • Newly identified needs or problems must be promptly added to the care plan; DS0000013311.V325415.R01.S.doc Timescale for action 29/03/07 Coombe Dingle Version 5.2 Page 25 2 OP9 3 OP27 4 OP29 5 OP29 • Signature of service user/representative to signify their involvement and agreement with the plan; • All entries to be dated and signed by the staff member(s) making the entry; • A review of care plans and risk assessments must take place at least once a month. 13(2) The registered person must ensure that complete and accurate records of all medication administered to service users is kept, including topical medications. 18(1)(a) The registered person must review the current mealtime staffing levels and/or mealtime arrangements to ensure that all service users requiring one to one assistance receive this. 19(1)(b) The registered person must not Schedule2 employ a person to work at the care home unless he/she is fit to work at the care home and the registered person has obtained the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). 19(1)(b) The registered person must Schedule2 check all staff files and make arrangements to obtain the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004) retrospectively for all staff employed since 26th July 2004. DS0000013311.V325415.R01.S.doc 15/01/07 15/02/07 15/01/07 22/01/07 Coombe Dingle Version 5.2 Page 26 6 OP29 18(3) (a-b) 7 OP29 The registered person must 15/01/07 ensure that any staff that do not have all the required checks and 19(1)(b) documentation in place, are Schedule2 closely supervised until all requirements of Regulation 19 and the amended Schedule 2 of the Care Homes Regulations 2001 are fully met. 18(1) The registered person must 15/01/07 (c)(i) ensure that all staff responsible for staff recruitment are aware 19(1)(a-c) of, and understand, the Schedule2 requirements of The Care Homes Regulations 2001 and Schedule 2 (as amended by The Care Standards Act 2000 (Establishments and Agencies) (Miscellaneous Amendments) Regulations 2004). This must take place before any further recruitment of staff. 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 OP7 OP8 OP9 OP9 OP9 OP15 Good Practice Recommendations It is recommended that the registered person carries out a review with all trained nurses of the Nursing and Midwifery Council’s professional guidelines on records and record keeping and the administration of medications. It is recommended that the exact site for the application of prescribed, topical medications is documented on the MAR sheets. It is recommended that the registered person ask the GP to review repeat prescription topical medications. It is recommended that the registered person consult an appropriately qualified professional and review the variety, method of use and suitability of the eating and drinking aids currently available at the home, to ensure that the service users are able to maintain their independence in DS0000013311.V325415.R01.S.doc Version 5.2 Page 27 2 3 4 Coombe Dingle 5 OP18 6 OP33 this area for as long as it is possible. It is recommended that the registered person revise the home’s procedure on the protection of vulnerable adults to reflect the local Surrey multi-agency procedure and ensure that all staff are aware of the correct course of action to take. It is recommended that the home expand their quality assurance system to include stakeholders in the community (e.g. GPs, chiropodists, care managers and other health and social care professionals). Coombe Dingle DS0000013311.V325415.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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