Inspection on 21/12/05 for Downs Cottage

This inspection was carried out on 21st December 2005.

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

The inspector 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

Downs Cottage 28/08/08

Downs Cottage 22/08/07

Downs Cottage 06/06/06

Downs Cottage 06/10/05

Downs Cottage 20/05/04

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

CARE HOMES FOR OLDER PEOPLE Downs Cottage 183 Great Tattenhams Epsom Downs Epsom Surrey KT18 5RA Lead Inspector Pat Collins Unannounced Inspection 21st December 2005 15.50h 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 Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 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. Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Downs Cottage Address 183 Great Tattenhams Epsom Downs Epsom Surrey KT18 5RA 01737 352632 01737 371068 care@downscottage.co.uk 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) Mr D Thomas Mrs N Thomas Mrs Norma Thomas Care Home 23 Category(ies) of Dementia (23), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (23), Old age, not falling within any other category (23) Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Out of the 23 (twenty three) registered numbers, service users may be either within the categories mental disorder/older persons MD (E) or dementia / older persons DE (E). Of the 23 registered numbers one service user may be between 60 and 65 years of age, within the categories MD (mental disorder) or DE (dementia). 6th October 2005 Date of last inspection Brief Description of the Service: Downs Cottage is a care home with nursing for older people. Service provision includes care of older people with dementia and mental disorders. The registered providers are both qualified nurses and have relevant management qualifications. They are directly involved in the day – to – day management and administration of the home and its operation. This two-storey property has been converted and extended over the years, retaining the domestic style and character of the building. The home has carparking facilities to the front of the premises. A spacious, secluded, enclosed garden is provided to the rear. This has suitable ramped access and a furnished patio and affords an interesting outlook from lounge and some bedroom windows. The garden has mature shrubs and trees and is set mainly to lawn. Bedroom accommodation is arranged on the ground and first floor and is part accessible by chair lift. Whilst the bedroom accommodation is mostly for single occupancy there are some twin rooms available, if preferred. Most bedrooms have en suite facilities and all have wash hand basins and emergency call bells. Communal areas are situated on the ground floor, comprising of a combined lounge / dining room and a separate, small lounge. Assisted bathing facilities and hoisting equipment is available. The home is within walking distance of local shops in Tattenham Corner village and is served by public transport. The home’s location, near to the open countryside of Epsom Downs, affords a peaceful, semi-rural environment. It is however within a short distance of a number of towns and all community amenities. The home’s website address is www.downscottage.co.uk Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second for the year 2005/2006. It was unannounced which means staff and service users were unaware it was to take place. The duration of the inspection was over a period of four hours and thirty minutes. The inspection process involved review of progress made for compliance with requirements made at the time of the last inspection. A partial tour of the premises was undertaken. The inspector engaged in discussions with both providers who were in attendance for part of the inspection. Observations included some care practices, sampling records and consultation with five staff and six service users. The inspector would like to extend thanks and appreciation to the providers, service users and staff for their assistance and hospitality throughout the inspection. What the service does well: What has improved since the last inspection? Action had been taken for compliance with immediate and other statutory requirements made at the time of the last inspection. Remedial action had been taken to reduce environmental hazards. The home’s statement of purpose, service users’ guide and latest inspection report were now Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 Page 6 prominently displayed in the hallway and accessible to the public. Staffing levels had been increased on the late shift. A new development was the proposed implementation of a recognised risk assessment tool for the prevention of falls as standard practice. At the time of the inspection this had been implemented for one service user following a complaint from a relative. The requirement for staff to use footplates when transporting service users in wheelchairs had been reinforced to the team by management unless risk assessments and care plans dictated otherwise. Referral had been made for an occupational therapy assessment of the seating needs of a named service user to ensure this individual’s comfort and safety. 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. Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 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 Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 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, 4. Prospective service users and/or their representatives had access to information necessary to enable an informed choice about admission. Preadmission procedures could be further enhanced by implementation of a formal assessment tool. This should be used to develop preliminary care plans addressing known needs, risks and behaviours. EVIDENCE: The home’s statement of purpose had been recently updated and accurately depicted service provision. The statement of purpose and service users guide was prominently displayed beside the visitor’s book in the hall, accessible to the public. This was considered to be a positive new development. A copy of the inspection report carried out by the Commission in 2004 was on display and replaced with the latest inspection report at the time of the inspection. This latest report had been only recently finalised. Admission - assessment procedures were again discussed in the context of preparation being made for the admission of a service user anticipated to take place the following day. The nurse preparing the admission documentation was did not have access to up to date assessment information. The Health and Social Services assessments at her disposal were both dated 2004. It was Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 Page 9 confirmed that the providers had jointly undertaken a pre-admission assessment for this individual to be satisfied that the home could meet this individuals’ needs. Use of an assessment tool was not the practice. Discussed with the providers was the benefit of implementing a more formal approach to pre-admission assessment practices. A preliminary care plan can be then easily generated from this assessment and built on after admission. In her contact with the provider the nurse established that the admission had been cancelled/deferred. In sampling care plans the home’s capacity to meet assessed needs was overall demonstrated. A new development was a risk assessment tool for prevention of falls, which it intended to implement as standard practice. The same had been implemented for one service user in October 2005 following a second fall since the time of admission in which injuries had been sustained. Areas of discussion included the need to ideally implement use of this tool as soon as practicable for all service users. It was noted that six staff had signed that they had read clinical guidance produced by the National Institute of Clinical Excellence specific to prevention of falls. It was positive to note that since the last inspection referral had been via the general practitioner for an assessment of seating by an occupational therapist for a named service user. This is necessary to ensure the comfort, suitable positioning and suitability of current practices for maintaining the safety of this individual. A nurse stated this was the second referral for this individual and that the occupational therapy department had not responded to the first referral. The providers were urged to ensure this was followed up with the relevant professionals to ensure the needs of this individual were fully met. The inspector was informed that the multi-disciplinary team, in consultation with relatives of this individual, had agreed the current restraint method used. Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8,9, 10. An individualised approach to care was evident. It was intended to offer service users representatives/relatives opportunity for involvement in care planning. Though arrangements for health care and management of medication were overall satisfactory, improvement was necessary to infection control practices. A positive new development was the proposed implementation of a falls risk assessment as standard practice. Pending full implementation the providers should ensure a targeted approach to implementation and review to enhance current arrangements for prevention of falls. The care practices observed respected the privacy and dignity of service users. EVIDENCE: The inspector observed staff to be polite and professional in their approach towards service users. Attention had been given to service users personal appearance and delivery of personal care gave due regard to privacy and dignity. Observation made of care practice of a nurse and two care assistants identified the need for improvement and education in infection control procedures. All three were observed wearing aprons and gloves in public areas having just delivered personal care in bedrooms. It was noted that staff were using the same gloves and aprons for carrying out personal care for multiple service users heightening the risk of cross – infection. Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 Page 11 Service users each had an individual care plan. Due to levels of incapacity the service users who contributed to the inspection process were unaware that care plans were in place. A system was in place for monthly review of care plans by named nurses with support from a nurse with time designated one shift a week for following up reviews to ensuring care plans and risk assessments were up to date. Of the random sample of care plans and risk assessments inspected some required review. It was stated that this nurse had just returned from leave. Discussed was the importance of named nurses maintaining overview of the care plans for which they were responsible to ensure these were updated as required. A nurse stated that significant changes to care plans were communicated to service users representatives in person or by telephone. It was stated that where practicable and appropriate nurses will in future ask service users’ representatives to sign care plans. This was a recent development. At the time of the inspection only one of the care plans sampled had been signed by that individuals’ representative/relative. Equipment necessary for the prevention and treatment of pressure sores was available in the home. At the time of the inspection the nurse in charge stated that none of the service users had a pressure sore. Observations identified the need to increase the frequency of reviewing pressure sore risk assessments for individual service users. The nurses on duty confirmed that since the last inspection wound care refresher training for nurses had taken place at the home. The home’s medication policy was stated by the nurse in charge to have been updated since the last inspection. Discussed with the providers was a legislative requirement governing the disposal of medication in care homes providing nursing care. The pharmacy supplying medication to the home was stated to be in the process of applying for a waste disposal license and it was planed that this pharmacy will continue to dispose of the home’s medication. Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13. Based on observations the home meets these assessed standards, promoting opportunities for social stimulation. Visitors may visit service users at any reasonable time. EVIDENCE: The records sampled demonstrated effort was made to establish service users former interests and to life history information. A basic programme of social activities was displayed in the home. Owing to the limited time available provision for social stimulation was only partly inspected. Service users had recently enjoyed a Christmas party attended by relatives and friends. The home was festively decorated for Christmas. Particular consideration was given to the needs of people with dementia and other conditions causing short - term memory loss by provision of suitable orientating information in the home. Family and friends of service users were encouraged to visit and visiting times were unrestricted. Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 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. The home’s complaint procedure was clear and a copy had been issued to service users’ representatives and was displayed in the home. The complaint record required updating. Service users were protected by the home’s training policies for adult protection. A review of recruitment procedures was necessary to ensure POVA/First checks request were in place before new staff take up post. Until receipt of full CRB Enhanced Disclosures for new staff a system must be in place for new staff to be directly supervised when carrying out personal/nursing care interventions. EVIDENCE: The home’s complaint procedure was included in the Service Users Guide, which had been posted to named representatives of service users since the last inspection. A copy was also prominently displayed in the home in the entrance hall. In discussion with the providers it was understood that formal complaints were rare and outweighed by complimentary letters received from relatives/friends of service users, which were sampled. On examination of the complaint record this was found to require updating to include a recent, formal complaint initially made to the Commission. This had been passed to the providers for investigation under the home’s complaint procedure. Areas of discussion with the providers included the importance of being satisfied that the complaint procedure was sufficiently accessible. It is acknowledged that in February 2005 at the time of carrying out a quality assurance survey that 6 respondents rated management’s response to Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 Page 14 complaints as excellent and 7 stated it was good. There were no adverse comments at that time regarding the home’s complaint procedure. The home was stated to have an adult protection policy though this was not examined on this occasion. A copy of the latest multi-agency adult protection procedures was now available in the home. A rolling programme of staff training in adult protection was verified at the time of the last inspection. An adult protection issue indirectly affecting the home, involving an employee, was discussed at the time of this inspection in the context of management of risk. Staff recruitment procedures included applications for CRB Disclosures for all new employees through an ‘Umbrella Body’. The providers were aware that CRB Disclosures were no longer portable and sought POVA/First clearance if staff vacancies needed to be urgently filled. This enabled staff to take up post prior to the CRB Disclosure being issued. Observations identified the need to review the home’s recruitment procedures to ensure the providers were satisfied that POVA/First checks on new staff had been carried out before new staff took up post. This was on the basis of being unable to evidence that a POVA/First check had been carried out for a care assistant on duty. The day after the inspection the providers confirmed that they had since received email confirmation of a POVA/First check carried out on this employee. The original email confirmation could not be traced as received. Observations on the evening of this inspection confirmed that the same care assistant was not working at all times under direct supervision in the delivery of personal care. It had been earlier emphasised to the providers that such arrangements must be implemented for all new employees. Other discussions with the providers included proposals for a young person to come into the home for a few hours to talk with service users. The providers confirmed proposals for this person to be directly supervised at all times and that she would not engage in any personal care tasks. Advice given was for a thorough risk assessment to be carried out relating to this person’s role. They were also referred to the CRB disclosure newsletter (issue 29) to assist them in determining whether a CRB Disclosure was necessary for this individual. Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 Page 15 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, 22, 25, 26. A reasonable level of accommodation was provided appropriate to the needs of current service users. EVIDENCE: On the day of the inspection the premises were clean and tidy and odour control was well managed. Appropriate action had been taken to address and minimise hazards in the environment identified at the time of the last inspection. Furnishings in communal areas were domestic in character and generally comfortable and adequate. The home was tastefully decorated with Christmas decorations. There was stated to be a rolling programme of redecoration. Lighting was domestic in nature and sufficiently bright to enable service users to read. The home was adequately heated and ventilated. The environment was secure to ensure service users’ safety. The home was fitted throughout with appropriate aids and adaptations, including assisted baths. A nurse stated the home had three airflow mattresses Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 Page 16 and other pressure relieving mattress overlays and pressure relieving air cushions. Grab rails were fitted in hallways, and seen to be available in bathrooms and WCs at the time of the last inspection. A chair lift was available for service users accommodated in most first floor bedrooms. There were two bedrooms on the first floor not served by the lift and service users occupying these bedrooms were required to be fully ambulant. Discussions with the providers included suggestion for consideration to be given to storing yellow bags containing used incontinence pads in sealed bins in the yard. Observations relating to improvement necessary to infection control practices are recorded in the health care section of this report. Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 Page 17 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. Staffing levels appeared adequate and staff were attentive to service users needs. Areas for improvement were identified in relation to the home’s recruitment procedures, personnel record keeping and monitoring staff’s infection control practices. The staff-training programme included NVQ training. EVIDENCE: Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 Page 18 Staffing levels had been increased since the last inspection in consultation with staff. Comments from individual staff at the time of the inspection indicated that staffing levels were adequate. Staff were observed to be attentive to service users needs at the time of observing direct care practice. Comments regarding improvement necessary to staff recruitment/vetting procedures specific to CRB Disclosures are detailed under standard 18. Additionally it is required to ensure record keeping, storage and disposal of CRB Disclosures is in accordance with CRB Policy. The personnel records examined confirmed these were organised and mostly contained relevant information/documentation. Discussed was the requirement to ensure that a full employment history for new staff is obtained together with satisfactory written explanations of any gaps in employment. Also for all staff files to include a recent photograph. Observations identified that a new employee had undertaken a relevant induction and foundation training certificated college course in compliance with the National Training Organisation workforce specification, prior to taking up post. A local induction record must also be available for inspection. A rolling programme of statutory staff training was evidenced. Since the last inspection moving and handling refresher training had been provided for the team. The provider/manager and a nurse were both accredited NVQ Assessors. Out of a total of 15 care staff, to date only 2 existing staff had attained NVQ Level 2 certificates, one of which was on leave. The providers reported that other staff had attained this qualification and had since resigned. One care assistant was reported to be currently undertaking this training. Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 Page 19 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, 38 The home is managed and administered by the providers who are suitably qualified and experienced. Quality assurance systems were in place however these should be further developed. EVIDENCE: The providers had defined areas of responsibility for the home’s management and administration. They confirmed that records of management hours were now accurately maintained. Both providers are qualified nurses. The provider responsible for the day-to-day management of the home had additionally attained the Registered Manager in Care Award qualification. Discussions with the providers identified areas for development in relation to the home’s quality assurance systems. Records of regular audits should be instituted. It was suggested that these include fire, health and safety, infection control, pressure sore prevention and treatment, dementia care and activities for social stimulation. It was positive to observe a system for canvassing the Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 Page 20 views of service users’ representatives. It would be useful if the analysis of questionnaire responses was visibly linked to a development/action plan to evidence the continuous self-monitoring and improvement described. This should ideally be published in the service users guide displayed in the home. Since the last inspection action had been taken to reduce environmental risks. Additionally a falls risk assessment had been instituted for a named service user. This was intended to be implemented in due course as standard practice. The inspection outcomes highlighted the need for a more pro-active approach to accident prevention through risk assessments, care planning and auditing systems. Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 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 3 3 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 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 3 x 3 x x x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x x x 2 2 Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? 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 OP3 Regulation 14(1)17 (1)(a) Sch1(a) Requirement Timescale for action 21/01/06 2. 3. OP4 OP7 13(4) 14(1)(2) 15(1,2) 15(2) For records of pre-admission assessments carried out by staff to be accessible to staff at the time of admission and maintained on service users files. Requirement brought forward from the last inspection report and timescale for compliance exceeded. To ensure effective assessments 28/12/05 and care planning for prevention of falls and regular review. To ensure care plans and 28/12/05 relevant health / risk assessments are reviewed at least monthly. For review and improvement in infection control practices specific to use of protective aprons and gloves. For appropriate arrangements to be made for disposal of medication in care homes with nursing. For records of complaints to be maintained up to date. For systems to be improved to DS0000013315.V275185.R01.S.doc 4. 6OP 8, 26, 30, 38. OP9 13(3) 18(1)(a) 24(1) 13(2) 04/01/06 5. 21/03/06 6. 7. OP37OP16 OP 16, 37 OP 18, 29 17(2) Sch 4.11 19 28/12/05 28/12/05 Page 23 Downs Cottage Version 5.1 Sch 2.2 ensure new staff for which POVA/First checks are carried out do not take up post prior to checks being verified. Staff employed on this basis must be directly supervised in the delivery of nursing/personal care until a full CRB Disclosure is obtained. For the staff recruitment 21/01/06 procedures for verifying proof of identity to include a recent photograph which must be held on personnel files. Documentary evidence of a full employment history for prospective staff must be held. There must be adherence to CRB policy on the recording, storage and disposal of CRB Disclosures for staff. For the home’s quality control 21/03/06 and quality assurance systems to be further developed. 8. OP 29, 37. 19 Sch 2.1, 2.2, 2.6 9. OP 33 24(1)(a) (b) 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 OP 38 Good Practice Recommendations Fr consultation with the Environmental Health Department on best practice for storage of yellow bags outside. Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Downs Cottage DS0000013315.V275185.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!