Inspection on 22/11/06 for Derwent Residential Care Home

This inspection was carried out on 22nd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Derwent Residential Care Home 17/10/08

Derwent Residential Care Home 06/11/07

Derwent Residential Care Home 09/12/05

Derwent Residential Care Home 01/04/05

Derwent Residential Care Home 31/01/05

Derwent Residential Care Home 17/06/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

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 Derwent Residential Care Home 38 Sedlescombe Road South St Leonards-on-sea East Sussex TN38 0TB Lead Inspector Caroline Johnson Key Unannounced Inspection 10:30 22 November 2006 nd 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 Derwent Residential Care Home DS0000041049.V295743.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. Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Derwent Residential Care Home Address 38 Sedlescombe Road South St Leonards-on-sea East Sussex TN38 0TB 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) 01424 436044 derwent.admintconnect.com The Derwent Residential Care Ltd Denise King Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty-five (25) Service users must be aged sixty-five (65) years or over on admission Date of last inspection 9th December 2005 Brief Description of the Service: The Derwent Residential Care Home is a large detached house situated on the outskirts of St Leonards On Sea. It is registered for twenty-five older people. There is good access to St Leonards where there are a range of shops and services. There are fifteen single and five sharing bedrooms, all with en-suite facilities. In the main, the service caters for residents who are very able and fairly independent. Communal space includes a dining room, lounge and conservatory. There are very pleasant grounds to the rear of the house. The range of fees is £322-£382 per week as of 22/11/06. Additional charges are made for chiropody, hairdressing and other individual requirements. Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this inspection process a site visit was carried out on 22 November 2006. The visit lasted from 10.30am until 5.45pm. During the visit time was spent with the manager and deputy manager and two staff were interviewed. A full tour of the building was not undertaken on this occasion but a number of areas were seen including the dining room, the laundry area and four bedrooms. There was an opportunity to meet with four residents in private and with one relative. Time was also spent observing a bingo session that was being run in the afternoon. A range of records were examined including pre admission documentation held in respect of a newly admitted resident, care plans, records held in relation to complaints, medication, staff recruitment and training and health and safety. Another part of the inspection process involved contacting another two relatives of residents and a district nurse to seek their views of the care provided in the home. Comments received included ‘staff are very kind and pleasant’, ‘it is homely’, and the residents are ‘well looked after’. One relative commented on the staff turnover and also stated that mealtimes can be a bit quiet. She suggested that either staff should try to encourage more conversation or that the home should play some music softly in the background. Prior to the site visit comment cards were sent to the home for distribution to the residents so that they could share their views about the home. Eight responses were received. Overall feedback received was very positive. Comments included the food is ‘exceptionally high standard, well cooked and well served’. Another commented that the deputy manager is always ‘helpful and caring’. One person stated that they have difficulty getting to their bell as it is the opposite side of their room and another stated that one toilet downstairs is not enough and there is always a queue. These matters were raised with the manager. It should be noted that an extension is currently being built to the rear of the property. This will provide additional ensuite bedrooms, an assisted bathroom, a large lounge area, a new laundry area and a staff room. At the time of inspection the foundations were being laid. What the service does well: There are good training opportunities available to staff and staff spoken with valued this. Staff described the manager as ‘supportive’. Residents spoken with praised the staff team for their care and support. They also stated that the food was very good. There is a varied programme of activities in place to suit the different needs and wishes of the residents. Residents advised that Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 6 they choose to attend the activities that appeal to them. Staff encourage residents to maintain their independence for as long as possible. One resident stated that she likes to be able to make drinks in her room and she has a fridge and kettle to enable her to continue with this task. Overall care planning is good and record keeping is kept up to date ensuring that staff have clear information about the needs of the residents. 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. Derwent Residential Care Home DS0000041049.V295743.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 Derwent Residential Care Home DS0000041049.V295743.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): 1,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre admission documentation should be kept separate to the care plan. The assessment should inform the initial care plan but will not suffice as part of the care plan as each individual’s needs would vary in different settings. EVIDENCE: The statement of purpose was seen and was up to adequate. Pre admission documentation was seen in relation to one resident recently admitted to the home. Generally the home completes the pre admission assessment and then sections of the assessment are then separated and used within the actual care plan. Unfortunately this means that it is not always easy to see which sections were completed prior to admission. Within the assessment seen there were sections not completed but by the care plan stage most but not all areas had been completed. Sections completed were clear and detailed information was provided. There is space for each section to be dated and signed. This is not always achieved. The home does not cater for intermediate care. Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has made some very good changes to the management of residents’ medications and the changes should ensure that safe practices are followed at all times. A local policy on the home’s actual procedure for the administration of medication at the Derwent would enhance the revised systems. EVIDENCE: Three care plans were examined in detail. As with the previous standard the integration of the pre admission documents in with the care plan can cause confusion, as old and new information is then stored together. One care plan seen where this had not been done was much easier to follow. Information is reviewed and updated at regular intervals. In each file there were up to date risk assessments, nutritional assessments had been carried out and weights were monitored on a regular basis. Where it was necessary for a district nurse to visit then arrangements had been made for this to happen. Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 10 Since the last inspection there have been some changes in the arrangements for managing medications in the home. Medication is stored in a cupboard in the dining room but the home ensures that medication is dispensed at a time when it is easy for staff to concentrate on the task. Medication is stored in a monitored dosage system and any extra medication is stored in individual baskets for residents. The home has ceased their practice of pre-dispensing medication at some meal times. All staff have received training on medications in use in the home. There is a detailed policy in place on the safe administration of medication. The policy is a general policy and does not reflect the home’s actual procedure. All changes to the MAR charts are signed, dated and cross-referenced. Controlled drugs are stored securely but the storage cupboard is not bolted to the wall. New arrangements will be made for this to happen in the coming months. A newly adopted practice is to keep a controlled drug register. All controlled drugs need to be signed and witnessed and this is recorded in the register. A record is kept of all medication returned to the home’s pharmacy and the pharmacy signs receipt. A record is kept of all staff authorised to administer medication and their usual signatures. When a resident chooses to self-administer their own medication the home carries out a risk assessment, which is then signed by the resident, their gp and the home manager. As part of the inspection process contact was made with one of the district nurses who visits the home on a regular basis. The nurse advised that the home is a good home and that staff discuss any worries that they might have about residents’ care needs and follow any instructions given in relation to dressings or care. Residents are supported to attend healthcare appointments as necessary. Chiropodists visit the home as required. Staff observed during the course of their duties were courteous and treated residents with respect. Residents spoken with stated that staff are very caring in their approach. Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good range of activities on offer in the home to suit the varying needs and wishes of the residents. Residents appreciate the individual arrangements made for them. EVIDENCE: A motivation class is held in the home every other Tuesday. The manager reported that this is a very popular class. Two manicurists also visit the home every fourth Friday to provide a manicure service to those residents that choose to attend. They have also recently started to provide a tuck shop selling fruit, biscuits, drinks and sweets. A Vicar visits to provide a Communion service every fourth Wednesday. One of the residents spoken with stated that a Nun visits her regularly. There are also visiting chiropody and hairdressing services. There is a book club and a mobile library visits for those who like large print books. The manager advised that they are hoping to start a craft club. They are also looking at clubs in the local area to see if any of the residents would be interested in joining. One of the residents spoken Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 12 with stated that she regularly attends a club. Three residents recently attended a sausage and mash evening held in another care home. The manager reported that they are currently arranging Christmas activities. They have already arranged for a choir to visit the home and are hoping to arrange for a children’s choir to visit also. They are consulting with the residents about whether they would like to go out for a Christmas meal or if they would prefer to have a party in the home. The manager advised that there is one resident whose first language is not English. However, they are fluent in English. The ex cook was able to converse with her in her first language but once she left the home there were no other staff able to speak the language. The manager advised that she would carry out an assessment to see if the resident would benefit from having someone to communicate with occasionally in her first language or if she would like to have books or films. Visitors are welcomed to the home at any reasonable time. Residents stated that their relatives are always made welcome and that refreshments are always offered to them. One of the residents spoken with has facilities in her room to make drinks and she advised that she enjoys and values being able to maintain her independence in this way. There was a bingo session in the home on the day of inspection. Staff were available to support residents that required assistance. When residents won a prize they were given a choice of biscuits, drinks or toiletries. Menus seen were varied and well balanced. The manager advised that they cater for special diets and at the time of inspection there were two residents who had diabetic diets. There is a set main meal but there is always an alternative option available and the cook can be very flexible with individual requirements. The manager advised that the majority of the food served is homemade. Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is good at ensuring that any complaints made are investigated but record keeping of the actual investigation carried out is not always evident so its not easy to see how conclusions are reached. EVIDENCE: Records showed that three complaints had been recorded since the home was last inspected. On discussion with the manager it was clear that the matters raised had been resolved satisfactorily. However details of the actual investigation are not clearly documented. In relation to one of the complaints made there were some issues raised that could have been raised with Social Services for possible investigation under adult protection. Since the last inspection there have been no formal complaints made to the Commission about the home. No adult protection alerts have been made. The manager and deputy manager have completed the first part of the adult protection and prevention of abuse course. They are due to complete the training in February and will then cascade this training to the staff team. Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 14 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): 19,20,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All areas of the home seen were well decorated and many of the rooms are homely. The plans to change the laundry area and to create additional lounge space will improve the quality of the environment for the residents. EVIDENCE: Work has recently begun to create an extension to the property. The extension will provide additional ensuite bedrooms, a new laundry area, a staff room and a large lounge area. The conservatory has been demolished as part of this process. At the time of inspection foundations for the new extension were being put in. The manager advised that a new call system would be installed throughout the home in the coming months. There are also plans to have new tables and chairs in the dining room and carpet will be replaced in Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 15 communal areas and corridors. It was reported that a new hoist has been purchased for the home. A full tour of the home was not carried out on this occasion. All areas seen were well decorated. Bedrooms had been personalised. Some of the residents spoken with had brought items of personal possessions with them, such as furniture, photos and ornaments and they stated that this made them feel more at home. At the time of the last inspection the washing machine was broken and the tumble drier was in the conservatory. Both machines are in working order. The location of the laundry is not ideal in that it is close to a bedroom and is also a fire exit route. However, the laundry will be moved when the extension is completed. All areas seen during the inspection were clean and there were no unpleasant odours. Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are minimal and need to be kept under review particularly in the evenings and at weekends to ensure the continued safety of the residents. Whilst the home’s induction is good, reference to the newly introduced Common Induction Standards would further enhance the induction process for new staff. EVIDENCE: The manager confirmed that her management hours have increased and she now generally only works on shift when there is a staff shortage through sickness or annual leave. In addition there is an administrator employed to work eighteen hours a week. On a morning shift there are three care staff plus a manager on duty. Alongside care staff there is a cook, kitchen assistant, laundry assistant and a domestic. The cook works 8am to 5pm Monday to Friday and 8am to 3pm at the weekends. In the afternoon after 4pm there are two care staff. A kitchen assistant is employed to work from 5pm until 7pm seven days a week. Two waking night carers work through the night. At weekends there are three care staff on duty in the mornings and two care staff in the afternoon with a manager on call. Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 17 Four staff have completed NVQ at level two or above. Another two staff are currently studying for NVQ and two carers have enrolled to commence training in January 2007. Staff have received recent training on moving and handling, medication, and fire safety. The manager confirmed that a couple of the staff team are due to attend training on infection control and this will then be cascaded to the staff team. All staff are up to date with first aid. Training in health and safety and COSHH is to be arranged. Minutes of the most recent staff meeting were seen and they were detailed ensuring that staff were kept advised of all proposed changes. Staff meetings are held quarterly. In relation to staff recruitment POVA first checks had been carried out on all new staff and applications had been made for full CRB (Criminal records Bureau) checks. When there is no CRB in place staff work under supervision. Two staff files were examined and all required checks had been carried out. One of the staff had advised that they had attended a number of courses in their previous employment. The home had written to them to ask that a copy of the certificates be brought to the home. The home’s induction is detailed but is not currently linked to the newly revised Common Induction Standards. Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 18 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): 31,32,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed. The introduction of the self-analysis form for staff supervision is considered good practice. Some of the health and safety issues raised are linked in with work carried out on the extension to the home. The owner needs to ensure that he is meeting with staff and residents on a regular and that issues raised are recorded. This will enhance the home’s quality assurance system. EVIDENCE: The manager has completed NVQ level four in management and care. Staff spoken with described the manager as ‘supportive’. One member of staff said that she was a ‘brilliant boss’. Prior to every staff supervision staff are Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 19 required to complete a self-analysis form. Any issues raised in this way are then discussed in supervision. As part of the home’s quality assurance system the manager had distributed satisfaction questionnaires to residents, their relatives and visiting professionals. A number of responses had been received and the manager advised that when all the responses had been returned she would collate the information and respond to all concerned with any action taken as a result. During the site visit there was an opportunity to speak with the relative of one resident and following the site visit contact was made with another two relatives of residents. Feedback received was very positive including comments such as ‘staff are very kind and pleasant’, ‘it is homely’, and the residents are ‘well looked after’. One relative commented on the staff turnover and also stated that mealtimes can be a bit quiet. She suggested that either staff should try to encourage more conversation or play some music softly in the background. Prior to the site visit the Commission sent comment cards to the home for distribution to the residents. Eight responses were received. Overall comments were very positive with one resident stating that the food is ‘exceptionally high standard, well cooked and well served’. Another commented that the deputy manager is always ‘helpful and caring’. One person stated that they have difficulty getting to their bell as it is the opposite side of their room and another stated that one toilet downstairs is not enough and there is always a queue. These matters were raised with the manager. The home manages money on behalf of some of the residents. Records were seen in relation to the management of two of the residents’ finances and they were in order. Whilst records are currently kept together the manager advised that in the new financial year records would be individualised. The manager advised that a new call system would be installed throughout the home in the coming months. At the present time call points are not serviced. If it is noted that a call point is not working then arrangements are made for it to be repaired but there are no arrangements in place to routinely check that all call points are working properly. Portable appliances have yet to be tested. The manager reported that arrangements have been made to have an inspection report carried out in relation to the electrical wiring. The report will identify what work needs to be carried out to obtain an electrical wiring certificate. The gas is serviced annually and the boiler, two of the fires and the cooker are also serviced. It was reported that an assessment was carried out in relation to the need for door guards and as a result it was decided that all the main doors should be kept closed at all times. Two guards were fitted in key areas. It was noted that both dining room doors were wedged open. The manager confirmed that Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 20 they had sought advice about having door guards fitted to these doors but they were advised that both doors were too heavy to have guards fitted. This needs to be considered carefully as part of the home’s fire risk assessment and if it is considered necessary to have the doors open then the doors may need to be replaced. Records of fire drills were not in the home at the time of inspection and will be seen at the next inspection. The last monthly report carried out by the provider was seen. There was evidence that the provider looked at a range of documentation but no record that time was spent speaking with staff and residents. Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 21 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 3 X 2 X X 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 2 17 X 18 3 2 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 3 3 X 3 3 X 2 Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 22 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(2) Requirement To have detailed policies on all aspects of medicines management which reflect actual practice. [This was a requirement of the previous inspection, timescale given 15/04/06] Records held in relation to complaints must include details of the actual investigation of the complaints. Staffing levels must be kept under continual review particularly in the evenings and at weekends. In relation to health and safety the owner must ensure that there is an electrical certificate in place and that all call points are checked on a regular basis to ensure that they are working appropriately. Records of fire drills must show that each drill has been evaluated. The length of each drill must be recorded. Fire doors must not be propped open. [This was a DS0000041049.V295743.R01.S.doc Timescale for action 28/02/07 2. OP16 17(2) Sch 4 para 11 18(1a) 31/01/07 3. OP27 15/01/07 4. OP38 13(4a,c) 28/02/07 5. OP38 23(4a,e) 15/02/07 Derwent Residential Care Home Version 5.2 Page 23 requirement of the previous inspection. Records were not seen at this inspection so this will be followed up at the next inspection]. 6. OP38 23[4a,c(i) ] 13(4a,c) The home’s fire risk assessment must consider the need to have door guards fitted to the dining room doors. The testing of portable appliances must be carried out annually by someone qualified to do so. [This was a requirement of the previous inspection timescale given 31/03/06] 31/01/07 7. OP38 31/01/07 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 OP3 OP12 OP30 OP31 Good Practice Recommendations Pre admission documentation should be kept separate from the care plan and all documentation should be signed and dated. The home should carry out an assessment to see if one of the residents would benefit from having someone to communicate with in their first language occasionally. The home should ensure that their staff induction programme is in line with Skills for Care’s Common Induction Standards. The provider’s monthly report should include reference to conversations with staff and residents. Derwent Residential Care Home DS0000041049.V295743.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. 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