Inspection on 21/08/07 for Cornerways Rest Home

This inspection was carried out on 21st August 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 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 11/08/06

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 21st August 2007 09:45 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.V345825.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.V345825.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 Joyce Lilian Nay Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Cornerways Rest Home DS0000023633.V345825.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 17. Date of last inspection 11th August 2006 Brief Description of the Service: Cornerways is registered to provide accommodation and personal care for seventeen Older People. The Home’s owner is Mr. A Khanna. The registered Manager is Miss. Joyce Nay. Cornerways occupies detached premises with 15 single bedrooms and one shared bedroom. Some of these have en-suite 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 to the front and side of the home. 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; this is currently used for residents who smoke. 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 £340-£430 per week. Cornerways Rest Home DS0000023633.V345825.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspection of this service has been undertaken. The inspection has involved analysis of information received about the home and from the home since the last inspection, in addition to an unannounced site visit undertaken on 21/08/07 between 9:45 am – 3:45 pm. The site visit comprised the assessment of all key inspection standards for older persons in addition to those standards where shortfalls have been identified previously, or where outcomes became evident during the visit. A review of some key documentation and a tour of the premises were included, in addition to interviews with the manager, staff and discussions with individuals living in the home. These contributions have been helpful in compiling this report. Surveys of people living in the home, relatives and health and social care professionals have been distributed but responses have not been received in time to be included, as a consequence of this feedback has been sought from health and social care professionals obtained through telephone interviews following the site visit, and their contributions have been incorporated. Whilst the home may not have achieved all outstanding requirements and recommendations issued previously, progress has been good, with sustained evidence of planning and review and this is reflected in the ratings awarded at this inspection. What the service does well: The home provides a comfortable, safe and homely environment. People living there can be confidant that their needs have been assessed and that the home can support them appropriately. People living there feel well supported and able to express their views. The manager demonstrates an understanding of and willingness to address diversity issues. People generally enjoy the quality and variety of food offered. The home has an active training programme and is supportive and encouraging of staff training. Cornerways Rest Home DS0000023633.V345825.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: That staff are clearly accountable for handwritten entries on Medication administration sheets and that these are signed and dated by staff. A new requirement has been issued to ensure that two written references are obtained for new staff prior to commencement of employment in the home, the manager has also been asked to more clearly evidence interview and appointment processes and review the quality of references accepted. A review of newly revised support plans highlighted an omission of important health care information for one person, and concerns have been expressed by health and social care professionals regarding similar issues. As a consequence the home are asked to review all care support plans to ensure that information concerning health needs has been fully transferred between the old and new support plan formats. The manager needs to ensure that policy and procedure are robustly adhered to and that the care and health needs of individuals are clearly understood, Cornerways Rest Home DS0000023633.V345825.R01.S.doc Version 5.2 Page 7 recorded within support plans, and that all staff are familiar with them. Communication between staff generally and at handover needs improving. A recommendation is repeated for the development and implementation of Medication profiles and PRN guidelines for individual residents. The home is still to fully implement and record behaviour management strategies. In view of comments received from people living in the home during the site visit a further review of staffing levels is recommended with particular emphasis paid to peak care activity times of the day 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. Cornerways Rest Home DS0000023633.V345825.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 Cornerways Rest Home DS0000023633.V345825.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, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that their personal and health care needs will be assessed, to ensure these can be appropriately supported by the home. The home is not resourced to provide an intermediate care service but can offer occasional respite and short stays; some of these may be people transferring from hospital to home. EVIDENCE: A review of files belonging to those people admitted since the last inspection confirmed that the home manager undertakes an assessment of needs, in addition to any professional assessment information provided. In most cases this occurs prior to admission to ensure needs can be met by the home. In the case of emergency admissions the manager seeks assessment information from referring professionals in the first instance in order to inform decision- Cornerways Rest Home DS0000023633.V345825.R01.S.doc Version 5.2 Page 10 making; with a fuller assessment of need undertaken by the home upon the new resident’s arrival. The home does not have the specialist facilities or staffing to offer an intermediate care service. However, from time to time if a vacancy occurs, the home can offer periods of respite or a short stay whilst awaiting a permanent resident; the manager has indicated that increasingly the take up of these breaks can be for those people seeking interim transition between hospital and home, and that they receive input from a range of health and social professionals to aid this process. The manager has indicated that the home may wish to develop a limited day care service to people in the community; considerations will need to take account of the dependencies of the resident group, and the capacity of present staffing levels to provide support additional to this. Any new service should not impact negatively on the welfare or quality of life of existing residents. The Statement of Purpose and User guides will need to be updated to reflect any further changes to the service. Cornerways Rest Home DS0000023633.V345825.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): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home have a plan of care that is mostly reflective of the needs and support they require around their personal care, improvements are needed in the recording of health care support. They are protected by improved practice in the management of medication. People feel staff understand their needs and support them sensitively. EVIDENCE: The manager has implemented new care plans that are more person centred and contain a life history element. A sample of files viewed indicated that the majority of people sign their plans if they have the capacity to do so. Most people spoken with during the site visit indicated that they felt staff understood their specific care and support needs and gave them as much help as they needed, although quality of delivery they felt was often dependent on individual staff members. One person who spends a lot of their time in their room confirmed frequent visits by staff to check on their welfare, but Cornerways Rest Home DS0000023633.V345825.R01.S.doc Version 5.2 Page 12 conflictingly reported that they found this to be at times, welcome support but also intrusive dependent on their mood. A key worker system is being implemented. Support plans provided evidence of health care interventions from District Nurses and GP’s, and some people spoken with confirmed access to routine Health checks. The home must ensure that health care support needs are cross referenced with support plans to ensure these are not overlooked. Social and health care professionals commented that better communication between staff is essential in providing appropriate and improved levels of healthcare support and expressed some concerns that in three examples recently the home manager had not clearly understood health care issues and this was reflected in the support they received from the home. Recent transfers of support plan information to new formats highlighted an important omission on one file viewed and it is recommended that support plans are reviewed to ensure all important health information has been incorporated. Improvements have been made to the management of medication within the home, with the introduction of monthly medication audits and 3 monthly staff competency assessments planned. A previous requirement and some recommendations have been implemented. The home has purchased a new medication trolley and controlled drugs cabinet. The medication procedure has been revised and a system for recording and monitoring drug errors implemented. A review of medication administration sheets highlighted that these are being completed satisfactorily with evidence of medication received recorded, however handwritten entries on these records are unsigned and undated , in view of the risk posed by wrong entries this remains and outstanding requirement. Whilst the home is maintaining separate records of medications on individual care files, the development of medication profiles and PRN guidelines would be of benefit to staff and remains an outstanding recommendation. People living in the home indicated satisfaction and approval with the manner in which their personal care needs are supported. The make up of the staff team is reflective of the resident group. The home has a cross gender care policy and a male carer indicated that they felt comfortable in providing personal care support to female residents but respected their right to request a same gender carer and if this occurred they would be provided with one. Cornerways Rest Home DS0000023633.V345825.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An activities programme that meets the individual and group expectations and preferences of those living in the home is under development. People living in the home are supported and encouraged to maintain links with their families and exercise control of their daily lives. They enjoy a varied and wholesome diet. EVIDENCE: Discussion with the manager and staff indicated that there had been a review of activities and staff no longer had a dual role or expectation placed upon them that they would provide activities for residents. Bingo and cards and an exercise session are now available, although with the introduction of key workers there are plans to encourage key workers to take some residents out. One staff member indicated that she felt this would be a good thing as some people often comment to her that they would like to go out to the seafront. Some people spoken with said that they already go out with their relatives and are quite content with their personal level of activity, and in one case would not choose to mix with other residents. Cornerways Rest Home DS0000023633.V345825.R01.S.doc Version 5.2 Page 14 Generally people were relaxed and happy and did not express boredom or a need for additional activities. The manager is aware of the need to develop this area and plans are underway to offer a more stimulating range of activities and outings to people in the home. The manager is hopeful that planned weekly meetings between people living in the home and staff will enable residents to engage more fully in discussions about activities and to express their views. People spoken with commented on visits from family and friends and indicated that there are no restrictions on the frequency or timings of these. People are encouraged to bring possessions and have access to personal monies the manager was reminded of the need to ensure that financial arrangements and who has legal authority to oversee peoples finances should be clearly recorded on file. People are offered keys to their rooms and have the facility to lock them when out. The home has a varied and wholesome menu, two choices are provided at the main lunchtime meal, and this was noted in menu records and the menu board for the day, which was seen to be accurate and confirmed by residents spoken with. Observations of lunch indicated that people enjoyed their meals and ate a good portion; discussion with one of the cooks indicated an awareness of special dietary requirements for individual people in the home. Both cooks have attended training and have current food safety in catering certificates. The manager has now implemented a supper session in addition to breakfast lunch and tea. Cornerways Rest Home DS0000023633.V345825.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People feel listened to and that concerns will be acted upon. Systems in place to safeguard the safety and welfare of people in the home are improving. EVIDENCE: The complaints procedure has been reviewed and is displayed in the home. The manager has also ensured that every person in the home has a complaints form in their file available for use if they raise issues with their key worker or another worker. The manager has implemented a complaints index. One new complaint has been received by the home since the last inspection, a review of this indicated that the provider and manager had been proactive in tackling an issue of diversity and had resolved the matter sensitively and to the satisfaction of the parties concerned. People spoken with found the manager supportive and felt confident about raising issues with her or other staff. A training matrix indicates that adult protection training is being provided and staff spoken with have an awareness of protection issues. The manager has made a start on implementing a strategy for managing behaviour including the use of interventions and the need for this to be Cornerways Rest Home DS0000023633.V345825.R01.S.doc Version 5.2 Page 16 discussed with a wide range of professionals. Documentation to support behaviour management would benefit from improved detail and this was discussed with the manager and remains an outstanding recommendation. Some improvements in the recruitment vetting of staff has helped to promote the safety of people in the home although further improvements are needed. Cornerways Rest Home DS0000023633.V345825.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): 19,20,21,22,24,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a comfortable, safe clean and homely environment that will benefit from the planned improvements and promote better safety. EVIDENCE: The home provides a comfortable and homely environment to the people living there. The manager has indicated within annual quality assurance information that a programme of upgrading is now in place, and this was evident from the recent repainting of the quiet lounge. Proposals for upgrading bathrooms and some building works to improve the environment are under consideration. The manager was reminded that any change in the present accommodation Cornerways Rest Home DS0000023633.V345825.R01.S.doc Version 5.2 Page 18 Schedule must ensure no loss of individual, or communal facilities or space for people living in the home. Carpeting on some staircases is badly worn and the manager was asked to make this safe at the site visit. In response to a previous recommendation a maintenance book has been implemented; a review of this indicated that minor repairs are being carried out in a timely manner. The home has serviced and reviewed equipment for the use and support of people in the home; a new mobile hoist has been purchased. A small stair lift has also been ordered that will allow people living on the 1st floor mezzanine level with mobility problems, easier access to this landing and the lift. Bedrooms visited with resident’s permission are personalised with possessions and small items of furniture etc. The majority of people in the home have now been given keys to their rooms, where they are deemed to lack capacity to do so this must be clearly evidenced and recorded in their files. The manager has made progress in reviewing the fire risk assessment for the home and a copy of this has now been forwarded to the fire officer. A number of staff are still to undertake infection control training, however, the manager and staff demonstrated a good understanding of infection control procedures and were observed to use protective clothing appropriately. The home was clean and free of unpleasant odours. One staff member commented that they felt the home was cleaner since the new manager came. People living in the home expressed satisfaction with the laundering of their clothes, and some improvements have been made to the laundry area, although this will benefit from planned upgrading of the washing machine and further thought as to relocation of the laundry. Cornerways Rest Home DS0000023633.V345825.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 adequate. This judgement has been made using available evidence including a visit to this service. Staffing arrangements are generally satisfactory but need further review at peak times. The home is encouraging of staff development with an active programme of professional and routine training provided. The recruitment procedure needs further strengthening. EVIDENCE: In response to previous comments the new manager has implemented a clear staff structure, introducing both a senior carer and team leader role. Staffing levels have been reviewed but remain at two care staff per shift in addition to the manager when she is present. Whilst discussions with staff on duty and people living in the home indicate no overall concerns about staffing levels, staff recognised that at peak times of the day they do feel particularly pressured; some residents commented that if they could improve the service they would wish call bells to be answered more quickly, as delays cause them anxiety and fear that their dignity may be compromised if they are not supported quickly enough. In the light of these comments it remains an outstanding recommendation that staffing levels are reviewed to take account not only of individual resident dependency levels but peaks and troughs of care activity throughout the day. Cornerways Rest Home DS0000023633.V345825.R01.S.doc Version 5.2 Page 20 Staff have commented that communication is not always good at handover and this can mean that important information is not passed over and could impact on the welfare of individual residents; similar concerns have been expressed subsequent to the site visit by health and social care professionals. The manager has been asked to look at how current handover and general communication arrangements can be improved upon. The home have indicated in pre-inspection information received that all but two staff have now attained an NVQ level 2 or higher; those staff as yet unqualified have been enrolled to commence NVQ 2 training. This Home should be commended for the excellent progress they have made in this area. A sample of staff files viewed at the site visit, highlighted that whilst the home has addressed a previous requirement to ensure POVA 1st and CRB checks are in place, and made improvements to the order and content of staff files. Two out of three new staff files viewed lacked two written references, or evidence that these are being pursued; telephone references are not routinely recorded. The quality of some references prompted further discussion with the manager. A requirement has been issued that two written references in addition to relevant police checks are in place prior to commencement of employment. It was also recommended that the manager more clearly evidence the interview process and ensure offer letters etc are in place, the manager was also advised to evidence the monitoring of staff on probation to support judgements about their capacity or not to be offered a long-term post. Discussion with staff indicated that those more newly appointed are undertaking induction training using skills for care workbooks. In response to a previous recommendation, a staff-training matrix is in place and the manager has identified skills gaps within the team and is seeking training to address these. Catering and cleaning staff are also encouraged and supported to attend relevant training. Individual staff training profiles have been developed. Cornerways Rest Home DS0000023633.V345825.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): 31,33,35,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager demonstrates a commitment to developing the service and addressing identified shortfalls but must ensure these are carried out robustly, Residents and staff feel listened to and supported by the manager and systems are in place for them to express their views. The health safety and welfare of residents and staff is generally protected and promoted although minor shortfalls should be addressed to ensure this is not compromised. EVIDENCE: The new manager has NVQ4 and RMA; this is her first management post although she has successfully acted in deputy position for some years. She has shown commitment and enthusiasm to addressing the previously identified shortfalls within the home and has worked very hard over the past 6 months to achieve this. Cornerways Rest Home DS0000023633.V345825.R01.S.doc Version 5.2 Page 22 Feedback from health and social care professionals although limited, indicated that generally the management of the home is satisfactory; some reservations were expressed that in the recent past the managers inexperience, and some over confidence in addition to breakdowns in communication has meant a failure to fully grasp important changes to the health and social care needs of some residents in particular, and how this impacts on the support they receive. Staff spoke positively about the manager, who they considered provided them with good support, one staff member felt that the manager had appropriately and sensibly addressed a complex diversity complaint, and had felt supported through this process. The manager has reviewed and updated all policies and procedures, made progress in addressing identified shortfalls and implementing systems to promote and protect the health, safety and welfare of staff and people living in the home. Unfortunately shortfalls identified within staff recruitment indicate a less than robust adherence to procedure by the manager, and a requirement has been issued; it is an expectation that the manager will at all times se t an example to staff in day to day practice and adherence to policy and procedure. An up to date certificate of insurance is in place. The manager has made a good start on the development of a quality assurance programme, and this would benefit from improved detail and clarity and was discussed during the site visit. The views of people living in the home have been analysed and incorporated into the annual development plan, further regular consultation opportunities for people living in the home, their relatives, and staff are to be introduced. . A review of financial arrangements for people living in the home, and records of cash balances etc was found to be satisfactory at the time of the visit. The manager is reminded of the need to record clearly the legal basis on which relatives or representatives undertake the management of individual resident’s finances. Servicing of equipment and fire safety systems is being maintained, although the manager was advised to ensure that routine monthly visual and tests of emergency lighting and extinguishers currently carried out are clearly recorded. Some shortfalls within the recruitment of staff could impact on the health and safety of people living in the home if not addressed and a requirement for improvement has been issued (See standard 29) Cornerways Rest Home DS0000023633.V345825.R01.S.doc Version 5.2 Page 23 Accidents records are appropriately maintained and indicate an overall low level of accidents. Cornerways Rest Home DS0000023633.V345825.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 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 X 3 X 3 STAFFING Standard No Score 27 2 28 4 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X 3 3 Cornerways Rest Home DS0000023633.V345825.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 Handwritten entries on MAR charts must be checked and signed by two carers (not met within previous timescale of 2/11/05, 15/9/06) new timescale Timescale for action 15/09/07 2. OP29 19(1) Two satisfactory written references in addition to appropriate CRB/POVA checks must be in place before commencement of employment 15/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2. Refer to Standard OP7 OP9 Good Practice Recommendations Home to review all care plans to ensure that important health care information has not been overlooked in the transition to new care plan formats. Medication profiles would benefit from the incorporation of homely remedies and the development of PRN guidelines DS0000023633.V345825.R01.S.doc Version 5.2 Page 26 Cornerways Rest Home for those individuals in receipt of this. 3. OP18 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. Manager to review care staffing levels with reference to individual resident dependencies and peaks and troughs within care activity in the home. Home to evidence more clearly interview and appointment process including interview notes, offer letters etc Home to evidence clearly assessment of new staff during probationary period 4. OP27 5. OP29 Cornerways Rest Home DS0000023633.V345825.R01.S.doc Version 5.2 Page 27 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 Cornerways Rest Home DS0000023633.V345825.R01.S.doc Version 5.2 Page 28 - 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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