Inspection on 11/08/06 for Cornerways Rest Home

This inspection was carried out on 11th August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Cornerways Rest Home 21/08/07

Cornerways Rest Home 01/11/05

Cornerways Rest Home 24/11/04

Cornerways Rest Home 23/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Cornerways Rest Home 1 Tanners Hill Hythe Kent CT21 5UE Lead Inspector Michele Etherton Unannounced Inspection 11th August 2006 9:40 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 Cornerways Rest Home DS0000023633.V297505.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. Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cornerways Rest Home Address 1 Tanners Hill Hythe Kent CT21 5UE 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) 01303 268737 Mr Arvind Rajendra Khanna Miss Tamara Frances Brown Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the category of DE(E) to be restricted to three (3) whose D.O.B are 16/02/1919; 02/10/1925; 16/03/1911. 1st November 2005 Date of last inspection Brief Description of the Service: Cornerways is registered to provide accommodation and personal care for seventeen Older People. The Home’ owner is Mr. A Khanna. The registered Manager is Mrs Tamara Brown. Cornerways occupies detached premises with 15 single bedrooms and one shared bedroom. Some of these have ensuite facilities. Accommodation is on the ground, first and second floors, and there is a shaft lift. There is a garden area for Service Users to use. Two assisted baths are available on the ground and first floor. The Service Users have a choice of sitting areas with a lounge, conservatory and a small quiet room for their use. The Home is located on the outskirts of a small town, with access to shops, public transport and other local facilities, some of which are within walking distance. The fee range for this service is between £350-£410 per week Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection comprised of an analysis of pre-inspection information provided by the home, survey responses from 7 service users, 8 relatives and 5 health and social care professionals, and a review of information received about the home since the last inspection, in addition site visits were made to the home on 11th and 14th August comprising a total of 7.30 hours. The site visit on 11th August comprised of interviews with service users individually and in groups, interviews with staff, a review of some records and a part tour of the premises. The 2nd site visit comprised a review of staff and service user records, and an interview with the manager. What the service does well: What has improved since the last inspection? Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 6 The manager has made some progress in addressing outstanding requirements and recommendations, and in developing and updating documentation within the home. The first floor bathroom has now been upgraded. All of the care staff are enrolled to commence NVQ2 qualification training in September 2006, training courses have been held for medication, fire, moving and handling, infection control. 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. Cornerways Rest Home DS0000023633.V297505.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 Cornerways Rest Home DS0000023633.V297505.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4,5,6 The overall quality of this outcome group is good. This judgment has been made using available evidence including a visit to the service. Service users are provided with contracts/statements of terms and conditions. All prospective service users’ benefit from receipt of an assessment of their needs prior to admission. Service users can be confident that the home can meet their needs. Opportunities for service users to undertake initial visits prior to admission are provided. The home lacks the appropriate resources to provide an intermediate care service. EVIDENCE: Five user files viewed during the site visits provided evidence of detailed assessments undertaken prior to admission, in addition, some also contained Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 9 social service needs assessments. The manager stated irrespective of whether a social service assessment has been undertaken, she will undertake her own homes assessment on every prospective service user prior to their admission, and this could be evidenced on those files of users admitted since she was appointed. Contract/terms and conditions statements are issued to all service users irrespective of their funding arrangements; these were noted on user files viewed. The manager demonstrated an awareness of the homes limitations to deal with changes in the health and mental state of some service users, and a proactive approach in seeking professional interventions and reassessment at the earliest opportunity. The home is supportive of families and service users where a need has been identified for alternative placement. Survey responses from users and their relatives and direct discussion with users during the site visit indicated opportunities for them to visit the home prior to the service users admission. The home is able to provide occasional respite if a vacancy arises in the longterm beds but has no aspiration or appropriate resources to provide an intermediate care service. Cornerways Rest Home DS0000023633.V297505.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The overall quality of this outcome group is good. This judgment has been made using available evidence including a visit to the service. Detailed and informative individual plans of care are in place for each service user and are reviewed. The routine and specialized healthcare needs of service users are promoted and supported by the home. Arrangements’ for the safe storage, administration and recording of medication’ need further strengthening. Service users feel they are treated with respect by staff and that their privacy and dignity are upheld. EVIDENCE: Five user plans were viewed at the site visit. These contained detailed information in respect of users individual care and support needs and specific preferences. All contained evidence of regular review and updating. Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 11 Discussion with service users at the site visit indicated that they have regular access to routine health care checks with some retaining their own dentists and opticians in the community, this was also evidenced in user files viewed and in the service users in/out register detailing their departures from the home for outpatient, GP and other health appointments. Service user weights are recorded regularly, staff’ indicated that appropriate action and interventions are sought where there is cause for concern in respect of unexpected or unusual weight loss. The manager needs to ensure that where users prescribed resource drinks have difficulty in taking the prescribed amounts, this is brought to the attention of and discussed with the GP, the outcomes of which are recorded in the user file. Jugs of juices were in evidence throughout the home and in close proximity for service users use. Call bells were noted in easy reach of service users in those bedrooms viewed. Medication administration sheets were viewed at inspection, handwritten entries of medication or changes in medication are still not being signed (countersigned where possible) and dated by the staff entering this information, this remains an outstanding requirement. The home retains good medication information on individual residents with medication profiles and current photographs of service users in place, consents for medication administration are in place, some service users who are not self administering their prescribed medications are enabled to administer their own homely remedies, in order to ensure that this is undertaken in a safe manner the home should support this with appropriate risk assessments for these individuals, and this is a requirement. Medication profiles would benefit from the incorporation of homely remedies and the development of PRN guidelines for those individuals in receipt of this and these are recommendations. Staff were clear as to how medication errors are recorded and the home manager may wish to consider whether these should be recorded as incidents rather than accidents and a system implemented for monitoring of frequency and patterns of error and this is a recommendation. The home has addressed a previous requirement to ensure the room where handover medication is stored is securely locked, however, the medication storage facility does not meet the specified guidelines for medication storage cabinets as prescribed within the Royal Pharmaceutical guidelines and it is recommended that this is reviewed. Responses from GP’s surveyed at local surgeries indicated a good level of satisfaction that the general health care needs of service users are supported and that medications are appropriately administered. One commented positively on the great age attained by some of the service users living at the home. Service users reported through survey information and direct interviews that they are happy with their care routines and the manner in which these are conducted by staff, they spoke positively of staff attitudes towards themselves Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 12 and felt staff upheld their privacy and always treated them with respect. Interactions observed during the course of the site visit supported the friendly but respectful attitude of staff to service users. Cornerways Rest Home DS0000023633.V297505.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The overall quality of this outcome group is good. This judgment has been made using available evidence including a visit to the service. The activities programme would benefit from some further development. Service users are supported and enabled to maintain contact with family, friends and representatives, but would benefit from more opportunities to access the community. The home encourages and enables service users where able to, to retain their independence and to continue to exercise choice and control in their daily lives. The home provides service users with a varied and appealing diet. EVIDENCE: Service user comments received through survey and direct discussion indicated overall satisfaction with the home and their individual lifestyles; they spoke positively of the home and its inclusive and friendly atmosphere. Some users indicated a desire to have more opportunities to go out into the community, and the home will need to consider how it can facilitate this on an individual basis. The users in and out register indicated that the majority of users already Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 14 access the community in the company of relatives, friends and members of staff on an occasional basis for health care appointments and outings. The current activity programme is overly dependent on staff providing time to undertake puzzles, games etc with service users and in the provision of in house activities only, discussions with service users did not provide evidence that staff are available to provide activities on a routine basis, the manager has identified this as an area needing further development. Feedback from relatives survey information and discussions with users at the site visit indicated no issues in respect of maintaining contact, users spoke of regular visits from family and friends and relatives reported being made to feel very welcome whenever they visited. Two relatives reported they would wish to be advised more frequently of the health and welfare of their respective relative, rather than just significant events; some user files viewed already contain clearly established requests from families in respect of under what circumstances they are to be contacted, clearly these arrangements need to be extended to all families in conjunction with the wishes of the service user concerned. Service users are encouraged and supported to retain control over finances, medication etc for as long as they are able, and to make choices and decisions in respect of their daily routines. Service users confirmed in discussion they are satisfied with their day-to-day routines and the level of decisions and choices they make. A member of the kitchen staff was interviewed during the course of the site visit and provided access to the four-week menu plan, they confirmed this is developed through consultation between the kitchen staff with the manager and incorporates feedback from service users. It could not be evidenced how service user involvement and quality assurance surveys undertaken by the home have been influential on the menu development (see standard 33). The majority of users spoken with and surveyed found the food to their liking, it being varied, tasty and plentiful. Service user comments ranged from: “The food is good, we’re offered a choice to main meal of a salad if you want” “Foods good, and plenty of it” “The food is good, but food cooked in bulk always tastes different” The home has surveyed service users in respect of meals and mealtimes and feedback received indicates service users are satisfied with the current mealtimes on offer, where users have indicated they would like a later meal, Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 15 this has been offered on an individual basis to those users, but not taken up to date. At present the cooks only have one specialised diet to cater for but the staff member interviewed demonstrated an awareness of good practice in respect of preparation of pureed meals and meeting the dietary needs of those service users from other ethnic backgrounds or have specific dietary needs. Cornerways Rest Home DS0000023633.V297505.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The overall quality of this outcome group is good. This judgment has been made using available evidence including a visit to the service. A satisfactory complaints procedure is in place that service users and their families are confident in using. Systems in place to protect service users from abuse need strengthening. EVIDENCE: Survey responses from some relatives indicated some lack of awareness of the complaints procedure, this is however, clearly and openly displayed in the entrance hall of the home, and some relatives have made use of it. Complaints information viewed at inspection indicated that complaints are appropriately recorded and investigated by the home manager with details of outcomes; it is recommended that an index for recording all complaints be maintained. The manager demonstrated an awareness of her responsibilities under POVA regulations and has actively referred former staff to POVA; however, shortfalls within the recruitment process in respect of required vetting of staff could place service users at risk (see standard 29). There was evidence within user files viewed that the manager and staff monitor changes in service users health and seek appropriate interventions; where behavioural issues are impacting on the home the manager has given some guidance to staff in respect of strategies for them to use in managing Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 17 behaviour, it is recommended that in all such cases behaviour management guidelines are formerly developed for the individual concerned and agreed and reviewed by all parties along with the risk assessment. The home are fortunate to have a mixed gender staff team, that can support the needs of the user group, and shifts should accurately reflect the gender mix at all times. It is recommended that the home develop clear guidance for staff and service users in respect of arrangements involving gross gender care by staff. Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24,26 The overall quality of this outcome group is adequate. This judgment has been made using available evidence including a visit to the service. A planned programme of sustained upgrading is needed to ensure the home maintains a comfortable, safe and homely environment. Service users are able to personalise and individualise their rooms and should routinely be provided with keys to protect their privacy. Service users benefit from living in a clean and hygienic environment. EVIDENCE: The home provides a warm, friendly, comfortable and homely environment, some communal areas including a downstairs Bathroom, lounge; quiet room and hallways are showing signs of wear and tear and need upgrading. The manager has stated that proposals based on priority are made to the provider and has already highlighted some areas for upgrade that will need consideration this year. There is no current development plan for the home Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 19 that incorporates a sustained programme of upgrade for the environment (see standard 33). Service users bedrooms viewed during the site visits were personalised with personal possessions to reflect the tastes and interests of the respective resident, service users are not routinely offered keys to their bedrooms, and are only provided with keys if they request one and have been risk assessed to do so. It is an expectation that all service users are able to protect their privacy by locking their rooms if they choose to do so, and this remains an outstanding recommendation. During a tour of the premises it was noted that previously identified repairs had been addressed, however, a service user highlighted a minor repair that had been reported in a daily log more than a week earlier but was still outstanding. In the absence of the usual people responsible for repairs and minor maintenance the manager must ensure that contingency plans are in place, the system of recording repairs in daily logs and communication books is prone to some issues being overlooked and as a consequence delays occurring, in order to ensure repairs and minor issues are dealt with efficiently and in a timely manner it recommended that a repairs and maintenance book is implemented that the manager is able to routinely monitor. The site visit highlighted the routine practice of bedroom doors being propped open at users request. The manager is aware of this and has raised concerns with relevant service users and these are recorded in risk assessments on file. This practice could compromise the safety of the home and its service users and the manager is required to review the current fire risk assessment with the fire officer to reflect current practices, and implement approved options to ensure user safety is maintained. Service users reported through survey responses and direct discussion that they were satisfied with the cleanliness of the home, no noticeable odours were present in the home at the time of both unannounced site visits, and staff were noted using gloves and aprons when undertaking personal care, and cleaning activities. Some staff are still to receive infection control training. Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The overall quality of this outcome group is poor. This judgment has been made using available evidence including a visit to the service. Staffing levels are adequate to meet the needs of current users but would benefit from review to accommodate other calls on staff time. Shortfalls within staff recruitment need strengthening to ensure users are not placed at risk. The home need to progress the number of qualified and trained staff to ensure they have the required competencies to safely support service users. EVIDENCE: There was no indication from survey responses received prior to inspection or from discussions with service users during the site visit, that staffing levels are a cause for concern, however, there is little flexibility within the current staffing numbers to support a more proactive activities programme or to prevent the need for the manager to undertake cover routinely on shift at times of sickness or staff shortage, this impacts on the managers ability to progress the development of the service. Using the care homes staffing tool-older people and user dependency level information provided by the home there would appear to be a significant Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 21 shortfall in staffing hours identified and it is recommended that the home review current staffing levels accordingly. The home manager has advised that currently only 1 of the staff team hold a care qualification at NVQ2 or above, the home manager recognises this significantly falls short of the national expected standard of 50 , and advised that action is being taken to address this; all of the current care staff have now been enrolled for NVQ2 qualification training and are due to commence the course from September, 2006. Staff spoken with confirmed they would be starting NVQ training this year. Three staff files viewed at the site visit indicated that two requirements issued in respect of shortfalls in recruitment practice are still to be addressed. Whilst CRB’s were noted in place on those files viewed, the home have not been undertaking POVA checks on new staff, this remains an outstanding requirement. Following changes implemented by POVA as to who can request POVA checks the home has not responded to the new arrangements and currently has no system in place to obtain POVA checks on staff. It is recommended that Application forms are reviewed to ensure there is adequate space for prospective candidates to detail employment history, the home has not yet amended them to ensure spent conviction information is also fully recorded, this remains an outstanding requirement. Of three applications viewed one had not completed the section on rehabilitation of Offenders Act and the home manager must ensure forms are completed in full. Two written references were noted on two files viewed, with only one character reference noted on another, this is an area that needs strengthening within the recruitment procedure with the home manager being more proactive in seeking outstanding references or alternative ones to support decisions to employ and this s a recommendation. A staff-training programme is in place although some staff are still to achieve all basic core skills. The manager has implemented a skills and knowledge scan of staff and has used this information to inform supervision and development sessions. It would benefit the manager to develop individual training profiles for staff incorporating skill scan information and to draw up an overall staff team training matrix, and these are recommendations. Staff induction records were noted on two files viewed, the manager must ensure that new care staff inductions are in keeping with the new skills for care amended induction standards, these are mandatory from September 2006 and it is a recommendation that the homes induction programme is reviewed against these to ensure compliance. Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The overall quality of this outcome group is adequate. This judgment has been made using available evidence including a visit to the service. Service users and staff benefit from the commitment and leadership of the manager in developing and improving the service. Quality assurance systems need strengthening. Systems are in place to safeguard service users finances. Systems are in place to ensure the Health, safety and welfare of service users is promoted but these could be compromised by shortfalls in the recruitment and training of care staff, and practices that undermine the current fire risk assessment. EVIDENCE: The manager is qualified to NVQ4 and is seeking to undertake the RMA to support her learning and management. The home is generally well run with the Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 23 manager adopting a hands on approach, she has the respect of staff and service users who are supportive of her approachable manner, kindness and understanding, and the ethos of the home that has developed from her leadership. It is important that appropriate investment is made to ensure staffing levels are maintained without an over reliance or expectation that the manager will fill shortfalls in staffing, as this will seriously impact on her ability to continue to develop the service, attend to areas where shortfalls have been identified and address requirements and recommendations in a timely manner, some of which stem from the managers lack of time to update knowledge in respect of current practice and legislation. The home undertakes some quality assurance measures although these are not formalised through a quality assurance policy or procedure, annual service user surveys are also undertaken, the home is unable to evidence how any of these measures influence service development. Quality assurance systems within the home need strengthening and development including the establishment of an annual service development plan and this is a recommendation. The home has indicated through pre-inspection information provided that they are only responsible for service users personal allowance monies and systems are in place to ensure these are securely stored and appropriate records are maintained. Discussions with staff during the site visit and a review of documentation confirmed that they benefit from regular formal supervision with the manager and records of this are maintained. Current arrangements for the storage and security of staff supervision records are inadequate and it is recommended that these be reviewed. Information provided by the home prior to inspection indicates that all environmental health and safety checks and servicing have been undertaken to protect the safety of service users, however, a requirement has been issued in respect of practices that may compromise the fire risk assessment for the home See standard 19), and shortfalls have been identified within the recruitment (standard 29) and training of staff (standard 30) that may place users at risk. Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement Risk assessments to be developed for those service users who are not selfadministering of prescribed medications but are enabled to administer their own homely remedies. Administration of prescribed creams must be recorded on the MAR sheet 2. OP9 13 Handwritten entries on MAR charts must be checked and signed by two carers (not met within previous timescale of 2/11/05) Manager is required to review the current fire risk assessment with the fire officer to reflect current practices and implement options to ensure user safety is maintained. Staff application form to require prospective applicants to detail DS0000023633.V297505.R01.S.doc Timescale for action 15/09/06 15/09/06 3. OP19 23(4) 15/09/06 4. OP29 19 15/09/06 Cornerways Rest Home Version 5.2 Page 26 all convictions, including those which are spent(not met within previous timescale of 14/11/05) 5. OP29 19 CRB/POVA checks must be sought for all new staff. (Only partially addressed within previous timescale of 1/11/05 15/09/06 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 OP9 Good Practice Recommendations Medication profiles would benefit from the incorporation of homely remedies and the development of PRN guidelines for those individuals in receipt of this. Manager to review current arrangements for recording medication errors as accidents and implement a system for monitoring frequency and patterns of error. Home to purchase a medication storage cabinet in keeping with specifications prescribed within Royal Pharmaceutical guidelines 2. 3 4. OP12 OP16 OP18 Activities programme to be reviewed and developed as planned. An index of complaints to be developed and maintained. Behaviour management guidelines to be formerly developed for individuals experiencing behaviour management issues, these to be agreed and reviewed by all parties along with appropriate risk assessments. Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 27 Home to develop a clear cross gender care policy for the protection of service users and staff 5 6 7 8 OP19 OP24 OP27 OP29 Minor repairs and maintenance to be recorded in a repairs and maintenance book, that the manager is able to routinely monitor Subject to risk assessment all residents to be provided with keys to their rooms if they want one Manager to review care staffing levels using current user dependencies against care staffing tool –older people, and to make known how shortfalls are to be addressed Manager to ensure written references are pursued and two are in place for all staff. Application forms to be reviewed to enable full employment history to be recorded. Manager to develop individual training profiles for staff incorporating skill scan information and to draw together existing training information into an overall staff team training matrix. The manager to review the homes induction programme against the new amended skills for Care Induction standards for care staff to ensure compliance. Quality assurance systems within the home need strengthening and development including the establishment of an annual service development plan. Manager to review safe storage of supervision records 8 OP30 9 OP33 10 OP36 Cornerways Rest Home DS0000023633.V297505.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cornerways Rest Home DS0000023633.V297505.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!