CARE HOMES FOR OLDER PEOPLE
Dove Court Nursing Home Shuttleworth Street Burnley Lancashire BB10 1EN Lead Inspector
Mrs Marie Matthews Unannounced Inspection 09:30 15 & 16th August 2006
th 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 Dove Court Nursing Home DS0000022501.V297648.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. Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Dove Court Nursing Home Address Shuttleworth Street Burnley Lancashire BB10 1EN 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) 01282 830088 01282 839898 www.bupa.com BUPA Care Homes (CFHCare) Limited Mr Alasdair Swan Care Home 120 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (60), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (20), Old age, not falling within any other category (90), Physical disability (15) Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Staffing for service users requiring nursing care will be accordance with Notice issued 25 May 1999 The home is registered for a maximum of 120 service users to include:A maximum of 90 service users who require nursing care. A maximum of 90 service users who fall into the category of OP. A maximum of 15 service users who fall into the category of PD. A maximum of 20 service users who fall into the category of MD(E) A maximum of 60 service users who fall into the category of DE(E). A maximum of 10 service users who fall into the category of DE. 14th February 2006 Date of last inspection Brief Description of the Service: Dove Court Nursing and Residential Home is a 120 bedded home situated on the outskirts of Burnley. The home comprises of four units. Robin is an elderly frail nursing unit; Kingfisher and Swallow are dementia units and Nightingale a residential unit. Each unit has 30 beds, all are single rooms and on the ground floor. The communal areas on each unit comprise a lounge, dining area, conservatory and smoke room. Swallow also has a snoozalum therapy room. There is a central administrative block that contains the main office, kitchen and laundry areas and a hairdressing salon. Ample parking areas are provided for visitors and staff. Garden and patio areas surround each unit. There is also a sensory garden and a secure themed garden that provide pleasant, stimulating areas for residents and their visitors. The home is located on a main bus route and is close to local amenities, including a Post Office, a Church, Public House, bowling green and local shops. A health centre and public library are also within the locality. Dove Court provides care for 120 people, male or female, generally over the age of 65 years. Care can be provided for young adults, who are under pensionable age, who have physical disabilities. The registered provider is Care First Health Care Ltd. A company owned by BUPA. Information about the services that the home offers is provided in the form of a service user guide and brochure and is available to existing and prospective residents and their relatives. A summary of the most recent inspection report is also available. The fees from April 2006 range from £315.00 to £550.00. Additional charges are made for hairdressing, chiropody and personal toiletries.
Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 5 Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. The key unannounced inspection was conducted at Dove Court on 15th and 16th August 2006. The inspection involved looking at records, talking to the registered manager, thirteen staff, two visitors and nine residents, a tour of the premises and generally looking at what was happening in the home. Survey forms were sent out to the home for residents and relatives and to local GP’s and district nurses to fill in; none of the forms were returned. This inspection looked at things that should have been done since the last visit and a number of areas that affect resident’s lives. There were one hundred and twelve people living in the home on the day of the inspection. What the service does well:
Residents were admitted to the home only when it was clear their needs could be met and they were certain the staff had the skills to be able to look after them properly. Staff spoken to had a good awareness of what care each resident needed and residents and relatives were happy with the care and attention they received. The home was well equipped with specialised healthcare equipment. Residents and relatives were happy with the care they were given. One resident said staff are kind they know what I need, they look after me. A relative said mum is really well looked after, she looks peaceful and comfortable. Other comments from residents included I have nothing to complain about as staff are very kind and helpful and staff are very nice and I am well looked after. A relative said everyone is very pleasant. The home was very good at providing activities to suit each resident based on detailed information, provided by residents or their relatives, about hobbies, interests, previous occupations and likes and dislikes. Records showed that a range of activities, entertainments and one to one sessions were provided. The records and discussions with staff and residents showed that staff tried hard to meet people’s diverse needs.
Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 7 Residents said they were given choices in many aspects of their daily life. One resident said ‘there is always a choice and I can stay in bed if I liked’. Another said I have been told I can do what I like as this is my home. Residents said they were offered a wholesome, varied and appealing diet. A choice of meal was always available from either the ‘choice’ menu, the ‘alternative’ menu or from whatever was available in the kitchen. Residents said I would defy anyone to complain about the food as it is plentiful and tasty, ‘the food is good and there is always a choice’ and the food is good. All units had a small kitchen where relatives and residents could make snacks and drinks. Kitchen staff visited the units to make sure they were providing meals that people enjoyed. Residents were protected from abuse by the homes policies, procedures and staff awareness. The home had a good complaints system and people were happy that their concerns would be listened to and responded to. One relative said if she was unhappy with any aspect of care she would speak to staff who had always been helpful. The standard of the environment both inside and outside provided residents with a well maintained, accessible, safe, clean and comfortable place to live. Redecoration and refurbishment was an ongoing process to ensure that the home was safe, comfortable and clean. All areas were bright and comfortable. Some of the units had themed areas and one had a therapy room providing a quiet place for residents to relax in. Bedrooms were not en-suite but were spacious, bright and clean; aids and specialised equipment was provided to ensure comfort and safety. One resident said I enjoy being in my room, I have everything I need and I can look outside and enjoy the lovely gardens. Secure gardens were provided for residents on the dementia units to ensure they were safe and protected. Garden furniture was provided and bird tables and bird feeders were placed where residents could watch the birds from their rooms. All units had sufficient staff who had different skills and experience to ensure they were able to meet the diverse needs of the many individuals living in the home. Staff said we have a good team and we get extra staff when needed, ‘staffing is enough, the team gets on well’ and ‘Im happy to come to work. Records and discussion with staff showed that all staff were given relevant training and updates to help them to meet the needs of the residents in their care. Staff employment files were looked at and the records showed that a safe recruitment procedure had been followed and all checks were in place prior to new staff starting work. This made sure residents were protected from unsuitable people. The home regularly consulted others to determine whether they were meeting people’s needs. A recent survey had been done and staff confirmed these were discussed at meetings to help them to continually improve the service. Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 8 Clear accounting and financial records were maintained; the company regularly monitored these records to ensure residents best interests were protected. Records showed that the home was a safe place for the people who lived, worked and visited the home. What has improved since the last inspection? What they could do better:
Whilst it was noted that the standard of care planning had improved, some of the care plans still did not contain enough detail about resident’s needs or what action staff would need to take to ensure their needs were met. Some of the units needed to improve the way they involved residents and relatives in decisions about their care and to make sure the care plans were reviewed regularly. The home had taken action to ensure these aspects of care planning were improved. The medication system was not consistently well managed on all units and potentially placed residents at risk. There were still some areas of concern particularly around maintaining clear and accurate records and the registered manager and clinical services manager were made aware of the areas of risk to residents.
Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 9 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. Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 10 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 Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 11 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): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were admitted only when the home was clear their needs could be met. EVIDENCE: Five care plans of recently admitted residents were looked at. All five contained in depth assessments that had been done by a senior member of staff before residents were admitted to the home to ensure the home could meet their needs. Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 12 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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The standard of care planning had improved however the care plans did not consistently detail resident’s needs or what action staff would need to take to ensure their needs were met. The home had taken action to ensure that residents or their representative could be involved in the development or review of care plans. The medication system was not consistently well managed and potentially placed residents at risk. EVIDENCE: Five care plans were looked at. The standard of care planning had improved on most units and the care plans were organised and detailed. Areas for concern relating to individual units were discussed with the senior staff on the unit, the registered manager and the newly appointed clinical service manager. Some care plans did not clearly detail the action to be taken by staff to ensure resident’s needs were met. The majority of care plans had been reviewed regularly but there was little evidence to support involvement of relatives or
Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 13 residents in discussions about care. However the home was addressing this problem and had recently sent out letters to all relatives explaining the care planning process and inviting them to come and take part. A new communication form had been included in the care plans. Staff confirmed that all the care plans were being reviewed and that regular audits had commenced. Staff were supported in this process by the clinical service manager; there was evidence of her input to ensure all care plans detailed residents needs and that needs were met. There was evidence that residents had access to healthcare and specialist services and specialised equipment had been provided to meet their needs. Staff spoken to had a good awareness of the needs of the residents in their care and residents and relatives were happy with the care they received. One resident said staff are kind they know what I need, they look after me. A relative said mum is really well looked after, she looks peaceful and comfortable. The way that each unit managed medication was looked at. The system had been changed recently to ensure medication was managed safely. However there were still some areas of concern particularly around maintaining clear and accurate records. The concerns were discussed with the registered manager. Residents said staff treated them well and were seen to knock on doors and talk to residents in a friendly but respectful manner. Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 14 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 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The home met residents individual and diverse needs, expectations and preferences and helped them to maintain contact with friends and family. Residents were offered a wholesome, varied and appealing diet. EVIDENCE: Care plans included detailed information, provided by residents or their relatives, about hobbies, interests, previous occupations and likes and dislikes. Records showed what activities or one to one sessions each resident had been involved in. Residents on two of the units had been provided with personalised boxes containing familiar items and photographs of their family, friends and pets to help them to recognise their room; families had been involved in this. Photo boards on each unit showed various activities had taken place. Activity staff were employed to provide a range of suitable activities and entertainments, both inside and outside the home. The records and discussions with staff and residents showed that staff tried hard to meet people’s diverse needs. Residents were given a choice in many aspects of their daily life. One resident said ‘there is always a choice and I can stay in bed if I liked’. Another said I
Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 15 have been told I can do what I like as this is my home. Another said there are things going on but I like to keep myself to myself. Two relatives spoken to said they were happy with the care and were made to feel welcome. They said staff keep coming to see if we are ok and ‘mum is really well looked after and looks peaceful and comfortable. Residents were always offered a choice of meal. Meals were ordered the day before and delivered to each unit in hot trolleys. From discussion with the chef and some residents it was clear that meal times were flexible and a choice of meal was provided from either the choice menu, the alternative menu or from whatever was available in the kitchen. Residents said I would defy anyone to complain about the food as it is plentiful and tasty, ‘the food is good and there is always a choice’ and the food is good. The chef said that some residents visited the kitchen to discuss alternatives or special requests and this was welcomed. Staff were seen giving dicreet assistance to those residents who needed help with their food. All units had a small kitchen where relatives and residents could make snacks and drinks. The chef had recently completed a survey to ask what meals residents liked in preparation for the ‘winter’ menu and to obtain opinions about the service given by the kitchen; there had been no issues raised. The chef and her staff visited each unit and attended unit meetings to meet with residents and a comments book was provided for each unit. All kitchen staff were appropriately qualified and clear records were maintained. Staff confirmed that relatives or friends could stay for meals. Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were protected from abuse by the homes policies, procedures and staff awareness. The home had a good complaints system and people were happy that their concerns would be listened to and responded to. EVIDENCE: The record of complaints was up to date and showed that generally concerns had been responded to appropriately. One complainant had been unhappy with the response and this was being resolved. Residents spoken to knew who to complain to, were happy to voice any complaints and were happy their concerns would be dealt with. All staff attended customer care training to help them to respond to people appropriately. One relative said if she was unhappy with any aspect of care she would speak to staff who had always been helpful. All staff had been given training about the protection of vulnerable people as part of their induction and further training was planned. Policies and procedures were clear and detailed and provided staff with appropriate guidance to ensure residents were protected. Staff spoken to showed an awareness of what abuse is and what action they needed to take to protect residents in their care. Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 17 Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24, 25 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The standard of the environment both inside and outside provided residents with a well maintained, accessible, safe, clean and comfortable place to live. EVIDENCE: A tour of units showed they were clean, odour free and tidy. A range of equipment was available and this was clean and in a good state of repair although the hoist on one of the units was in need of attention. Staff confirmed they were given training in the use of equipment to ensure they used them safely. The maintenance records showed that repairs were done promptly and the home was well maintained. Redecoration and refurbishment was an ongoing process to ensure that the home was safe, comfortable and clean. One of the units was undergoing refurbishment and the residents needs had been taken into consideration prior to this. the home meets the
Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 19 requirements of the Disability Discrimination Act and the layout and design was suitable for the people who live in the home. All areas were bright and comfortable. Some of the units had themed areas and one had a therapy room providing a quiet place for residents to relax in. Bedrooms were personalised, spacious, bright and clean; aids and specialised equipment was provided to ensure comfort and safety. One resident said I enjoy being in my room, I have everything I need and I can look outside and enjoy the lovely gardens. As noted earlier boxes were provided outside residents rooms on the dementia units which contained personal items and photographs of the resident, family, friends and pets to help them to recognise their room. All bedrooms were provided with lockable storage and locks to doors although risk assessments in respect of non provision of keys were not seen. Not all rooms were carpeted but this was discussed with relatives and residents prior to admission to ascertain their wishes. Call bells were supplied in all areas or risk assessments were seen to support non-provision. The outside of the home was well maintained and residents said they enjoyed the gardens. Secure gardens were provided for residents on the dementia units to ensure they were safe and protected. Garden furniture was provided and also bird tables and bird feeders were placed in the gardens for residents to enjoy watching . One resident said she enjoyed watching the seasons change from her bedroom window as she was not able to go out. The laundry was efficient and organised. Laundry staff explained how they dealt with laundry from each unit, missing and unamed clothing and any specialist treatment required for ‘infected’ linen. Residents were well dressed in clean and matching clothes and one resident said staff helped her to choose clothes. Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home was well staffed with a competent team of staff to meet the needs of the residents. The home followed safe recruitment procedures to make sure residents were safe from unsuitable people. EVIDENCE: The staff rotas showed that the home provided staff in sufficient numbers and that any gaps, due to sickness or holidays, had been covered by staff from other units to provide continuity of care for the residents. All units had staff with different skills and experience to ensure they were able to meet the diverse needs of the individuals living in the home. Staff said we have a good team and we get extra staff when needed, ‘ staffing is enough, the team gets on well’ and ‘Im happy to come to work. There were a number of staff that had an appropriate qualification in care and others were working towards one. Records and discussion with staff showed that all staff were given relevant training and updates to help them to meet the needs of the residents in their care. Staff employment files were looked at and the records showed that a safe procedure had been followed and all checks were in place prior to new staff starting work. This made sure residents were protected from unsuitable people.
Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 21 Comments from residents included I have nothing to complain about as staff are very kind and helpful and staff are very nice and I am well looked after. A relative said everyone is very pleasant. Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home was well managed and was a safe place to live and work in. Staff were supervised to ensure they had the skills to meet the needs of the residents. EVIDENCE: Mr Alasdair Swan is the registered manager for the home. He is supported by a clinical services manager and senior staff on each unit. Staff commented that they received support from management, were happy to raise areas of concern and said they would be listened to. Staff meeting were organised regularly for staff to voice their opinions. Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 23 The home regularly consulted others to determine whether they were meeting people’s needs. A recent survey had been done and staff confirmed these were discussed at meetings to help them to continually improve the service. Clear accounting and financial records were maintained; the company audited these records to ensure residents best interests were protected. Records showed that staff had received one to one supervision to update their skills and knowledge to help them to look after the residents. Health and safety records had been properly maintained and systems protected residents, staff and visitors to the home. Dove Court Nursing Home DS0000022501.V297648.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 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X 3 X 2 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 3 Dove Court Nursing Home DS0000022501.V297648.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 OP7 Regulation 15 Requirement The registered person must ensure that the residents plan sets out in detail the action needed to be taken to ensure that all aspects of health, personal and social needs are met. Timescale 30/07/04 not met. The registered person must ensure residents or their representatives are involved in the development of the care plan and must be reviewed by care staff at least monthly. The registered person must ensure that risks to residents are fully assessed and interventions documented in the care plan and kept under review. Timescale 03/04/06 not met. The registered person must ensure that staff maintain accurate records of receipt and disposal of medicines. The registered person must ensure prescriptions are seen by the home prior to dispensing. Timescale for action 01/10/06 2. OP7 15 01/10/06 3. OP8 13 01/10/06 3. OP9 13 01/10/06 4. OP9 13 01/10/06 Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The registered person should ensure criteria for the administration of when required and variable dose medication is clearly defined and recorded on all units. The registered person should ensure that transcribing is witnessed. The registered person should ensure residents are provided with keys to bedrooms and secure storage unless a risk assessment suggests otherwise. The registered person should ensure that 50 of care staff are qualified to NVQ level 2 or equivalent. 2. 3. 4. OP9 OP24 OP28 Dove Court Nursing Home DS0000022501.V297648.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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