Inspection on 04/07/07 for Courthill

This inspection was carried out on 4th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Courthill 25/06/08

Courthill 18/01/07

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 Courthill 2 Court Road Caterham Surrey CR3 5RD Lead Inspector Joseph Croft Unannounced Inspection 4th July 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 Courthill DS0000067720.V338984.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. Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Courthill Address 2 Court Road Caterham Surrey CR3 5RD 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 341024 01883 341024 roshanwest@aol.com Ms Simlah Panchoo Mr Roshan Panchoo Ms Simlah Panchoo Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6) of places Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New Service Brief Description of the Service: Courthill is registered with the CSCI (Commission for Social Care Inspection) to provide accommodation and care home for six people with learning disabilities who are over the age of 65 years. Courthill is a large detached family styled house and is in a residential street in Caterham-on-the-Hill. The service is close to shops, public amenities and transport. In addition the service has its own transport to enable the service users to enjoy a flexible service. The accommodation is arranged over two floors of the house. On the ground floor there is one large bedroom with an en suite, a communal lounge, separate dining room, kitchen, one toilet and the office. The first floor has five bedrooms and the bathroom. There is a moderately sized garden at the rear of the property, and a limited amount of off street parking for cars at the front of the house. The service does not have a lift. The provider is owner/manager involved in the day-to-day provision of care and management of the service. The weekly fees range from £1000 to £1250. Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 4th July 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. Regulation Inspector Mr Joe Croft undertook this visit and the registered manager, who is also the joint owner of the home, assisted him throughout. This site visit took place over a period of four hours, commencing at 10:00 and concluding at 14:00. The inspection process included a tour of the premises and sampling of residents’ care plans and risk assessments. Other documents sampled included the staff duty rota, menu, policies and procedures and records of medication. The Inspector had discussions with two members of staff on duty, and two residents who were part of the case tracking process. However, due to the degree of learning disability, the discussions with the residents were limited. Residents informed the Inspector that they were very happy living at the home, that the staff look after them well, and the food is good. During observations staff and residents were interacting in an appropriate manner, and residents were being addressed by their preferred names. The Annual Quality Assurance Assessment (AQAA) completed by the home has been used as a source of evidence in this report, however, only a limited amount of information was provided in this document. At the time of writing this report the Commission For Social Care Inspection had not received completed survey cards from residents, their relatives or other associated professionals. The inspector would like to thank the manager, members of staff and residents for their cooperation during this visit. Feedback was provided to the manager at the end of this site visit. What the service does well: People who use the service are protected by the home’s medication procedures. Physical and health care is offered in such a way as to promote service users’ privacy and dignity. Residents’ lifestyles match their needs and preferences, and where possible they are able to maintain contact with family, friends and the local community. People who use the service are offered a balanced diet. People who use the service have access to a satisfactory complaints system that enables residents and their families to raise concerns. Staff having knowledge, training and an understanding of adult protection Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 6 issues protect residents. The home provides very good communal and individual living space making it a safe and comfortable place to live. 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. Courthill DS0000067720.V338984.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 Courthill DS0000067720.V338984.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): Standards 1, 3 and 6 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the services are provided with information about the home. Assessments would be undertaken to ensure the individual needs of residents can be met. EVIDENCE: The home has a Statement of Purpose, however, the manager informed the inspector that this is currently being reviewed. A copy of this document will be forwarded to the Commission For Social Care Inspection upon completion. The owners acquired the home in August 2006, and inherited the three current residents who have been living at the home for many years. The home has not admitted any new residents. The home has an Admission and Referral policy dated August 2006. This document describes the procedures to be followed when enquiries are made to the home by prospective resident and/or their representatives. The manager informed the Inspector that she would undertake an assessment of needs at Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 9 the prospective residents home or current placement, and would request an assessment from the resident’s care manager. Prospective residents would be encouraged to visit the home for tea, then for an evening meal and an overnight stay. The manager stated that admissions would also depend on the compatibility of the current residents living at the home, and their opinions would be sought in regard to new admissions. The manager stated that the home would not admit any person whose assessed needs cannot be met. The Annual Quality Assurance Assessment (AQAA) completed by the manager contained no specific information in regard to these standards. The home does not offer intermediate care. Courthill DS0000067720.V338984.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): Standards 7, 8, 9 and 10 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are protected by the home’s medication procedures. Physical and health care is offered in such a way as to promote service users’ privacy and dignity. Care planning requires further attention to ensure the changing needs of residents are being met. EVIDENCE: On the day of this site visit there were three residents living at the home. The home uses the Person Centred Care plans, two of which were sampled as part of the case tracking process. Care plans included information in regard to religion, ethnicity, mobility, personal care and likes and dislikes. Care plans detailed how residents preferred to be supported or prompted with their personal care. During discussions residents could not remember if they had a care plan. Staff informed the Inspector that they key work with residents, and were able to give an account of the care plans. Care plans had recently had the statutory annual reviews, however, they had not been reviewed on a monthly basis by the home, or signed by residents or their representatives. A requirement in regard to this has been made. Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 11 Health care plans evidenced that residents are registered with the local GP and have access to the Dentist, Optician, Chiropody and all NHS services. Information in regard to oral and foot care was also recorded. Risk assessments were in place and included risks in regard to eating, falls, accessing the community and using the kitchen. However, there were no nutritional risk assessments on residents’ files, and monthly weights are not being monitored. The manager must seek advice from the community nurse or the dietician in regard to meeting the nutritional needs of residents living at the care home. A requirement in regard to this has been made. The manager informed the Inspector that no current resident suffers with pressure sores. Residents spoken to informed the Inspector that they see the GP when they need to, and attend dental and optical appointments. One resident was able to convey to the Inspector that he receives his medication on time. The home uses the blister packs that are provided by the local pharmacy, and Medical Administration Record sheets (MARs) for the recording of medicines. The home maintains records of medicines received and returned to the Pharmacist. Medicines are appropriately stored in a locked metal medicine cabinet. The MAR records for residents who were part of the case tracking process were accurately maintained. Evidence was viewed that staff who administer medication had received the appropriate training for this on the 21st June 2007. The manager informed the Inspector that no resident is currently prescribed a Controlled Drug or is self-medicating. The home has a Medical Policy that was produced in August 2006. During discussions staff informed the Inspector that they respect residents’ privacy and dignity at all times through knocking on bedroom doors, calling residents by their preferred names and attending to personal care needs in the privacy of their bedrooms. Residents have access to a cordless telephone in the home. Staff stated that residents receive their own mail, and wear their own choice of clothing. Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 12 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): Standards 12, 13, 14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyles match their needs and preferences, and where possible they are able to maintain contact with family, friends and the local community. People who use the service are offered a balanced diet. EVIDENCE: During discussions, staff informed the Inspector that activities are provided for residents to take part in if they wish to. Activities offered to residents include visits to parks, seaside trips, shopping, going to pubs and visits to the cinema. Residents’ interests and hobbies are recorded in their care files; activities are recorded in the daily notes maintained at the home. The three residents living at the home are of White British origin, and their religion is Church of England. Only one resident practices his religion, and informed the Inspector that he goes to church once a month. The home has a diverse staff team. During discussions, staff stated that racial, religious and cultural needs of any resident living at the home would be respected and promoted. The manager informed the Inspector that there are no restrictions on visitors to the home. One resident has relatives who keep in contact with him. The other two residents have no family contact. The manager informed the Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 13 Inspector that a contact has been made with a local advocacy group, and they are waiting for advocates to be allocated. Staff informed the Inspector that they encourage residents to make decisions for themselves in regard to how they would like to spend their day and the food they like to eat. They support residents in decision making as and when necessary. The home uses a four-week rolling menu. Residents are provided with four meals each day. The menus include fresh meat, fish, pasta, salads, fresh vegetable and fruit. The manager informed the Inspector that menus are discussed with residents. The home does not employ a cook or domestic staff; therefore care staff attend to these duties. Evidence that all staff had received training in regard to Food Handling and Hygiene were observed in staff training files. Residents spoken to state the food at the home is good. One resident informed the Inspector that you get different meals if you do not like a particular meal. This was confirmed during discussions with staff, who also stated that any alternative meals provided to residents are recorded in the food book that is maintained in the home. Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 14 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): Standards 16 and 18 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a satisfactory complaints system that enables residents and their families to raise concerns. Staff having knowledge, training and an understanding of adult protection issues protects residents, however, the policy and procedure requires reviewing. EVIDENCE: The Commission For Social Care Inspection has not received any concerns, complaints or allegations in regard to the care home. The home has a Complaints Procedure that includes the timescales for responding to complainants, and the Commission For Social Care Inspection contact details. It was noted that the complaints procedure is not displayed in the home. A good practice recommendation has been made in regard to this. Residents spoken to state they would talk to the home’s manager if they needed to make a complaint. The home has an up to date copy of the Surrey Multi-Agency Protection of Vulnerable Adults Procedures. Discussions took place with the manager in regard to the content of the home’s Protection of Vulnerable Adults Policy, as the procedures are not in line with the Surrey Multi – Agency procedures. A requirement has been made that the Protection of Vulnerable Adults Policy and Procedure must be reviewed to ensure it is written in line with the Surrey Multi-Agency guidelines on the Protection of Vulnerable Adults of February 2005. A recommendation has been made that the manager should attend the Surrey Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 15 Multi – Agency training in regard to Protection of Vulnerable Adults. Evidence was viewed that all staff have attended training in regard to the Protection of Vulnerable Adults on the 1st January 2007. During discussions, staff were able to give an accurate account of who they would report suspicions of, or actual abuse to, and were aware that the manager must follow the Surrey Multi – Agency procedures. Staff stated they would not hesitate to report bad practice, and they had read the home’s Whistle Blowing Policy. Evidence found during the site visit supported the information provided in the AQAA in regard to all staff having received training in the Protection of Vulnerable Adults. Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides very good communal and individual living space making it a safe and comfortable place to live. EVIDENCE: A tour of the premises was undertaken. The accommodation is arranged over two floors of the house. On the ground floor there is one large bedroom with an en suite, a communal lounge, separate dining room, kitchen, one toilet and the office. The first floor has five bedrooms and a bathroom. Three bedrooms have en-suite facilities. The home has recently been refurbished throughout, including new furniture for all bedrooms, fitted kitchen and new carpets. There is a garden to the rear of the property with a large building that is being converted to accommodate new laundry facilities and a sensory room for the residents to enjoy. The standard of the environment is excellent, and residents have unrestricted access to all communal parts of the home. Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 17 On the day of the site visit the home was very clean, tidy and free from offensive odours. There were papers towels and liquid soap dispensers in the bathroom and toilet. It was noted that the frosted window in the bathroom did not have a blind/curtain to ensure the privacy of residents when using this facility. The manager informed the Inspector this would be attended to immediately. During discussions, residents stated they liked their bedrooms and having their own things around them. The home has an Infection Control Policy, however, staff have not received the appropriate training. Requirements in regard to this have been made under the Staffing part of this report. The manager informed the Inspector that the Environmental Health Office is conducting an inspection in the home the day after this site visit. Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service are protected by the organisation’s recruitment policy and procedures. Issues in regard to training and staff numbers working at the home must be addressed. EVIDENCE: The manager informed the Inspector that there are five staff employed to work at the home. Staff are used from a sister home as and when needed. The duty rota was viewed, and this evidenced that there is one member of staff on duty each shift during the week, with the manager as supernumerary. However, the hours the manager works were not specified on the duty rota. A requirement has been made in regard to this. The weekends are covered by one person on duty each shift. The home does not employ a cook or domestic staff. Discussions took place with the manager in regard to the supervision of residents when staff are attending to the cooking duties, and what cover is in place should an emergency arise and the lone member of staff has to attend to this. The manager informed the Inspector that she and the other registered provider cover the on call duties and could be at the home within five minutes should the need arise. A requirement has been made that a review of the staffing arrangements must be undertaken to ensure there are sufficient numbers of staff on duty as appropriate for the health and welfare needs of residents. Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 19 The deputy manager has the NVQ level 4, and one other member of staff holds the NVQ level 2. The manager informed the Inspector that a third member of staff would commence NVQ level 2 training in the week beginning 16th July 2007; therefore the home is on course to meet the National Minimum Standards in regard to a minimum of 50 of the current staff to hold the relevant NVQ qualifications. The home has a Recruitment Policy that was viewed during the site visit. However, a recommendation has been made that this document should be reviewed to ensure it includes all information and documents that will be required in respect of new staff. During discussions, residents informed the Inspector that the staffs are very nice and always here to help you. They also stated they like the new manager of the home. The manager informed the Inspector that the staffs employed by the previous registered provider have been kept in employment at the home. Two staff recruitment files were sampled and found to contain all the necessary information and documents as required under Schedule 2 of The Care Home Regulations 2001, as amended. A good practice recommendation has been made that Criminal Record Bureau clearances should be undertaken every three years. Evidence was seen that existing staff had received induction training when they first commenced working at the home. Discussions took place with the manager in regard to the Skills For Care Council. The manager informed the Inspector that she would find out more information in regard to registering staff with the Skills For Care. Staff training files provided evidence of training undertaken, however, it was noted that training in regard to the aging needs of residents, Learning Disabilities or Dementia had not been provided for staff. A requirement has been made that staff must receive training appropriate to the work they are to perform to ensure the changing needs of older people can be met. Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, and 38 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was evidence of areas of good management and practice within the home; however, issues in regard to care plans, risk assessments, staffing, staff training and health and safety must be addressed to ensure the safety and welfare of the residents is maintained. EVIDENCE: The manager, who is also the joint owner, informed the Inspector that she holds a Registered Learning Disabilities Nursing qualification, NVQ level 4 and the Registered Managers Award (RMA). The manager has thirteen years experience working in care homes for residents with Learning Disabilities, with six years experience in the role of manager. The manager has undertaken training in regard to staff supervision, recruitment and the mandatory training as required. Further training is being sought to ensure the manager maintains up to date knowledge on legislation and other matters in regard to managing a care home. Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 21 Discussions took place with the manager in regard to the completing of the AQAA form. The manager was advised that responses must be made to all the standards and the standards highlighted in bold are the key standards that care homes are inspected against. Quality assurance surveys had been sent residents, their relatives and other associated professionals in March 2007. However, the manager stated not all surveys have been returned, and that she will follow this up. Evidence was seen that some completed surveys had been returned. Residents attend the staff meetings undertaken at the home, however, their names had not been included in the minutes of these meetings as attendees. Each resident has an individual bank account, and the home holds small amounts of money. Records sampled as part of the case tracking process were accurately maintained and matched with balance of monies in the individual’s monies held at the home. The home has a Policy and Procure in regard to the management of residents’ money. Staff training files provided evidence that staff had attended all but one of the mandatory training required. Training in regard to Infection Control has not been provided to staff. A requirement in regard to this has been included under the Staffing part of this report. Information provided in the AQAA informs that annual Health and Safety checks are undertaken. The home had a policy regarding Health and Safety. During the site visit a sample of Health and Safety checks undertaken were viewed. These included the gas certificate, 29/11/06, electrical installation, 10/10/06, fire detection and fighting equipment, 25/04/07, and the Employers Liability Insurance that expires on the 01/08/07. It was noted that the home has not had Portable Appliance Testing (PAT) undertaken. A requirement in regard to this has been made. Staff spoken to were complimentary about the manager, and the changes that have taken place since August 2006. Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 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 4 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (2) Requirement Timescale for action 04/08/07 2. OP8 12(1) (a)(b) 13(1)(b) 3. OP18 13 (6) Care plans must be reviewed on a monthly basis to ensure the changing needs are being met. Residents or their representatives must sign care plans to evidence their involvement. Advice must be sought on the 04/08/07 introduction of suitable nutritional risk assessments for residents, and arrangements must be made to weigh all residents. The Protection of Vulnerable 04/08/07 Adults policy and procedure must be reviewed to ensure it is written in line with the Surrey Multi-Agency guidelines on the Protection of Vulnerable Adults of February 2005. A review of the staffing arrangements must be undertaken to ensure there are sufficient numbers of staff on duty as appropriate for the health and welfare needs of residents, and a copy of the duty rota detailing the hours of all DS0000067720.V338984.R01.S.doc 4. OP27 18 (1) (a) 11/07/07 Courthill Version 5.2 Page 24 5. OP30 OP38 12 (1) 18 (1) (c) 6. OP38 13 (4) persons actually working at the care home must be maintained. Staff must receive training appropriate to the work they are to perform to ensure the changing needs of older people can be met, and must include Infection Control. Annual testing of Portable Appliance Testing (PAT) must be undertaken to ensure unnecessary risk to the health and safety of residents are identified and as far as possible eliminated. 11/09/07 04/08/07 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. 3. 4. Refer to Standard OP16 OP18 OP29 OP29 Good Practice Recommendations A copy of the Complaints Procedure should be displayed in the home. The manager should attend the Surrey Multi – Agency training in regard to the Protection of Vulnerable. The Recruitment Policy should be reviewed to ensure it includes all information and documents that will be required in respect of new staff. Criminal Record Bureau clearances should be undertaken every three years. Courthill DS0000067720.V338984.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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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