Inspection on 16/05/05 for Eastbrook House

This inspection was carried out on 16th May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eastbrook House 17/11/09

Eastbrook House 08/12/08

Eastbrook House 02/08/06

Eastbrook House 18/10/05

Eastbrook House 15/02/05

Eastbrook House 04/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE EASTBROOK HOUSE 16 Eastbrook Avenue London N9 8DA Lead Inspector Peter Illes Announced 16th May 2005 @ 09:30 am 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 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. EASTBROOK HOUSE Version 1.10 Page 3 SERVICE INFORMATION Name of service Eastbrook House Address 16 Eastbrook Avenue, London, N9 8DA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8805 6632 020 8805 6637 Roland and Janet Beacham Mr Jonathan Beacham PC Care Home 43 Category(ies) of OP registration, with number of places EASTBROOK HOUSE Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 15/2/05 Brief Description of the Service: The home is owned by Mr & Mrs Beacham and managed by their sons Jonathan and Richard, the former being the registered manager. Eastbrook House has been run by the Beacham family for the past twenty years. The home provides care for older people. The number of double rooms had been decreased so that there is now only one double room. At the time of the inspection there were thirty seven service users living in the home. The communal space includes three lounges and a dining room. There is a passenger lift and the garden is to the rear of the property. Eastbrook House is situated in a quiet part of Edmonton at the end of a short residential road. The home is accessible by public transport and within ten minutes walking distance of the local amenities. The home aims to provide a safe and caring environment for service users. EASTBROOK HOUSE Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took approximately one and a half days with one of the registered providers present throughout and the registered manager and other senior staff being present for the majority of the time. The home had made a decision to limit the maximum number of service users to forty while it further reviewed the use of its double rooms. There were thirty seven service users accommodated at the time of the inspection and three vacancies. The inspection included: discussion with ten service users and independent discussion with eight care staff; five relatives and a GP and District Nurse who visited the home during the inspection. Further information was obtained from a tour of the premises, the pre-inspection questionnaire and a range of documentation kept at the home. A CSCI pharmacy inspector separately inspected the home’s medication and administration of medication policies and procedures as part of the overall inspection process. What the service does well: The home is well managed and the care staff provide sensitive and personalised care to the service users that both they and their relatives greatly appreciate. There is a range of relevant information displayed in the home for the benefit of both service users and relatives. Overall record keeping is good with particular attention shown to service users financial allowances. The home has developed effective ways of communicating with service users and relatives to obtain their views on the running of the home. Both service users and relatives appreciate this. The home has a strong commitment to health and safety procedures and practices. EASTBROOK HOUSE Version 1.10 Page 6 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. EASTBROOK HOUSE Version 1.10 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 Standards Statutory Requirements Identified During the Inspection EASTBROOK HOUSE Version 1.10 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 standard(s) 3 Prospective service users can be confident that their needs will be assessed at the point of admission to the home to ensure they can be effectively met. Their needs continue to be reviewed if they are admitted to ensure that their changing needs will also be able to be met. EVIDENCE: Four service user’s files were inspected, three of these service users having been admitted to the home since the last inspection. All contained a range of clear assessment information relating to the time of their admission. These assessments had been undertaken by the referring authority and in three cases also by a multidisciplinary team including health professionals. There was also evidence that the home carried out its own assessment at the point of admission with service users needs then being reviewed on a regular basis to ensure that their changing needs can also continue to be met. Service users and relatives spoken to indicated that they were confident that service users needs were being appropriately addressed by the home. The home does not provide intermediate care. EASTBROOK HOUSE Version 1.10 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 standard(s) 7, 8, 9 & 10 Service users needs are well set out in their care plans but some further attention to assessment of risk is needed in identified areas. Their health needs are well met although the CSCI is not always informed of serious occurrences related to their health. The policies and procedures for the safe and secure handling of service users medication are, with a few minor exceptions, in place to ensure service users medication needs are met. The recording of the receipt and administration of service users medication has improved but still requires some further attention to properly protect them. Service users receive sensitive care and are treated with respect and dignity. EVIDENCE: The home had invested in a modular care plan format, a copy of which was seen as part of the four service user files inspected and staff reported that these worked well. The plans were generally detailed, up to date and were reviewed regularly by the key worker with one of the home’s two heads of care. The plans were drawn up with the involvement of the individual service user and where appropriate involvement from their relatives. A range of relevant risk assessments informed the plans including assessments on nutrition, lifting and handling and body mass index. There was an identified EASTBROOK HOUSE Version 1.10 Page 10 risk regarding smoking for one service user and an assessment of this risk was seen. Staff stated that as part of dealing with this risk it had been agreed that the service user should only smoke in the designated smoking area of the home. Staff would then retain his smoking material at other times including when he was in his bedroom. Neither this guidance for staff, nor where it had been agreed, was recorded on the risk assessment or on his care plan. A requirement is made that this is done. The home reported that there were no service users suffering from pressure ulcers at the time of the inspection. The inspector noted however that a number of service users had fragile skin but that there was no assessment recorded on any of the files seen regarding this potential risk. A requirement is made that a regular assessment of skin vulnerability is undertaken for all service users. All service users are registered with a GP, the majority with one practice. The inspector met the GP from this practice during the inspection and the GP stated that in his opinion the service users were well supported with their health needs by the home. A community nurse attached to the GP surgery also gave some helpful feedback regarding the care in the home. There was evidence of other health professionals visiting the home on a regular basis including a dental hygienist, chiropodist and an optician. Information about these services was prominently displayed on the home’s notice board for service users and relative’s attention. It was noted that service users have been occasionally sent to hospital by ambulance if they have suffered a significant accident and that the CSCI are not always notified of such serious occurrences as is required by regulation. A requirement is made regarding this. The medicines policy is now complete but would benefit from a summary that is totally specific to the home with cross referencing to the main policy for details. A recommendation is made regarding this. The receipt of medication has improved but medication that is not contained in the Nomad boxes has not been recorded and signed for. A requirement is made regarding this. The administration charts are generally satisfactory except for a few gaps where the administration has not been signed for or non-administration coded as to the reason why it was not administered. A requirement is restated regarding this. Medication profiles (histories) for each service user are not available and a recommendation is made regarding this. The disposal of medication records was found to be satisfactory. When a service user goes on social leave for a short period their medication is decanted by staff into a compliance aid. The compliance aid is not fully labelled and there is no record of the decanting process; a requirement is restated regarding this. The storage of medication was satisfactory and the medication room was tidy. Temazepam is the only Controlled Drug being used. The administration is recorded in a Controlled Drug Register and a recommendation is made that this is stored in a metal cupboard. No homely remedies are being used at present and a recommendation regarding how to record administration of this, if needed in future, is made. The rest of this standard was found to be met. EASTBROOK HOUSE Version 1.10 Page 11 Service users were observed being assisted by staff, where appropriate, with a variety of tasks including going to the toilet and with eating their lunch. This was done in a friendly and respectful manner and at a pace that suited the service user. Service users and relatives stated that the support at the home was very good. Key worker notes on some care plans seen had specific reference to individuals likes and dislikes with regard to assistance needed with personal care. The GP spoken to stated that service users “were treated with dignity at the home”. EASTBROOK HOUSE Version 1.10 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 standard(s) 12, 13 14 & 15 The home provides a range of appropriate activities to meet service users needs and wishes that enrich service users social opportunities. Service users are also supported to maintain and develop relationships with relatives and others to the extent that they wish. The home assists service users to retain as much control as possible over their daily lives. The home serves varied and healthy meals that service users enjoy although further improvements are needed regarding the storage of food and overall responsibility for the kitchen. EVIDENCE: The home offers a range of activities both inside and outside the home and the inspector was pleased that the home had reviewed its activity programme as required at the last inspection. The home has a part time activities coordinator who was very enthusiastic about her job and who informed the inspector that she had attended a two day course run by Age Concern for activity coordinators since the last inspection. She also confirmed that she had reviewed the activity programme offered to service users. Service users and relatives spoken to confirmed that the home provided music and movement, art and craft, bingo and regular outings by minibus to various places of interest. The home also has a programme of entertainers who visit the home throughout the year. During this inspection a singer visited the home to entertain the service users, those spoken to indicated that they enjoyed this. During the inspection a lay person from a nearby church visited to give EASTBROOK HOUSE Version 1.10 Page 13 communion to a service user. The registered provider stated that the home endeavoured to assist meet the varying spiritual needs of service users at their request. Relatives spoke warmly about their reception at the home by staff when they visited and that they were always made welcome. One relative spoken to stated that their was always a senior member of staff to speak to if he had any issues when he visited the home. He continued by saying that senior staff always made time for him if he needed it. A significant number of relatives and other visitors attended the home during the inspection and a number of relatives stated that they visited the home on a regular basis including some daily and others weekly. Service users or their relatives manage the service users finances directly with one of the registered persons being appointee for one identified service user for whom there is no other option. The home does hold the personal allowances for some service users. The records of personal allowances sampled showed clear audit trails and were accurate with money physically held in the home being kept in individual service user wallets. Evidence was seen of information regarding relevant external agencies, including the last CSCI inspection report, displayed on the home’s notice board for service users and relatives. Service users, relatives and staff confirmed that service users could bring agreed personal possessions to the home with them if they so wished. Service users and relatives spoken to were enthusiastic about the quality and variety of the meals served at the home. Lunches during the inspection were seen to be nutritious and attractively presented. Special diets including low fat and gluten free meals are catered for. The home has a rolling four week menu with evidence seen of alternatives being served as requested. The kitchen was clean and tidy with up to date records seen including of fridge and freezer temperatures. There is a knowledgeable full time cook employed who is responsible for the main meals with care staff preparing breakfast and tea. It was noted that there was a bowl of tuna in the kitchen fridge that had been removed from its original packaging and covered in cling film. There was no label or date stating when it had been placed there or recording its use by date. The cook stated that this was not her responsibility as care staff that were responsible for preparing other meals had placed it there. A requirement is made that the home must designate a member of staff to have overall responsibility for the food stored in the kitchen and that all food that is stored is labelled appropriately including a specified use by date. EASTBROOK HOUSE Version 1.10 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Service users and their relatives can be confident that concerns raised will be effectively dealt with by the home. The homes adult protection procedure and practical guidance to staff need to be further improved to ensure that service users are properly protected. EVIDENCE: The home has a clear and satisfactory complaints procedure, a copy of which was seen displayed on the home’s notice board for the attention of service users, relatives and other visitors. The inspector was pleased to see that an improvement to the layout of the complaints recording book had been made as required at the last inspection. One complaint had been received by the home since the previous inspection and this was seen to have been dealt with satisfactorily. Relatives stated that they were confident that any issues raised by them with the home would be appropriately dealt with and one gave a recent example of this. The home had an overall but generalised adult protection policy that did not give sufficient practical guidance to staff on what action to take in the event of an allegation or disclosure of adult abuse being made to them. The home did have a copy of the local authority adult protection procedure although it also had a copy of a neighbouring local authority’s procedure as well. The inspector was not confident that relevant staff were aware enough of which procedure to follow, and why, except that all care staff spoken to stated that they would report any concerns to the registered persons. A requirement is made that the home reviews its own guidance to staff and ensures that it is consistent with the local authority procedure the home is located in. The home must then EASTBROOK HOUSE Version 1.10 Page 15 ensure staff are familiar with the practical steps that need to be taken, and why, should a disclosure or allegation of abuse be made to them. EASTBROOK HOUSE Version 1.10 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21, 24 & 26 Service users live in a home that overall is safe and well maintained. They benefit from sufficient numbers of toilets and bathrooms although some identified maintenance is needed regarding these. Service users bedrooms generally suit their needs although replacement of equipment is needed in some of these. The home was clean and tidy throughout creating a pleasant environment for those living there and visiting. EVIDENCE: Service users live in a safe and comfortable building that meets their needs despite some design limitations relating to the home being originally built in the early 1970’s as a local authority children’s home. There is clear evidence however that the registered persons have extended and adapted the premises to best meet the needs of older people. They also stated that they were considering further adaptations to the communal areas to continue to improve the environment. They stated they are considering converting a lounge on the second floor into two en-suite bedrooms and extending the ground floor to provide an additional lounge there. The inspector was pleased to see that some EASTBROOK HOUSE Version 1.10 Page 17 new chairs had been provided in one of the existing lounges as required at the last inspection. There are sufficient bathing and toilet facilities in the home that were clean and tidy although all are internal and have no windows. Staff spoken to stated that these could became very hot when in use and on occasion they did not smell particularly pleasant as there was no direct ventilation. On inspection all these facilities were seen to have ventilation grills that linked to a central internal duct in the home that in turn led to the roof. The registered provider stated that there was an extractor fan in the roof that allowed the bathrooms and toilets to be ventilated via their individual ventilation grills to the central duct. This fan was not working at the time of the inspection and a requirement is made to ensure effective ventilation in the bathrooms and toilets is provided at all times. The metal covering on an identified shower hose in a first floor shower room had started to unravel and was a potential health and safety risk. A requirement is made that this is replaced. Over half the bedrooms in the home were inspected and were generally pleasantly decorated and personalised in accordance with service users wishes. Each room had a sink fitted into a vanity unit and some of these had started to wear and needed replacing. A requirement is made for these worn units to be replaced on a planned basis within a six month timescale. The home was clean throughout during the inspection and despite the difficulty identified with the ventilation in the toilets was free from offensive odours. The home has satisfactory laundry facilities and the inspector was pleased that the floor in the laundry had been cleaned as required at the last inspection. The home had a satisfactory system for dealing with soiled waste and staff spoken to were aware of the home’s procedures regarding infection control. EASTBROOK HOUSE Version 1.10 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 An effective staff team with sufficient numbers address service users needs. The home needs to make some further improvements to its recruitment procedure and the method of delivering training to staff to ensure that service users are fully protected and staff are fully competent to meet service users needs. EVIDENCE: The home satisfactorily deploys sufficient numbers of staff to meet service users needs. The staff rota was seen and showed a minimum of seven care staff working on the early shift, six on the late shift and two waking night staff. There are sufficient overlaps of staff in place to deal with busy times of the day such as during late evening when medication is being administered and early morning when service users are getting up. Domestic staff and a cook are employed in addition to the above. Staff on duty during the inspection matched those recorded on the rota. The inspector checked enhanced criminal records bureau (CRB) clearances for all staff and found that four were not satisfactory. The home was waiting for two to be returned although the staff in question were working under supervision and two needed an additional protection of vulnerable adults (POVA) checks having clearances from another employer. A requirement is made regarding this. Four staff files were inspected at random and contained a range of other documentation to evidence a clear recruitment procedure. EASTBROOK HOUSE Version 1.10 Page 19 The home is committed to staff skills development and offers a range of training to staff. The registered persons stated at the time of this inspection fourteen of the twenty-eight care staff employed had attained the required NVQ level 2 in care. A number of staff spoken to confirmed that they had completed this qualification. The home has invested heavily in a range of distance learning for induction, foundation and other required training for care staff. Examples of the material used for this were seen to be detailed and thorough and included an external verifier checking written material that has to be submitted at the end of each element of training. However, following discussion with various stakeholders during the inspection the inspector was concerned that there was no direct trainer input to supplement the distance learning. While in some areas this was judged to be acceptable it is not so for moving and handling training or first aid training, both of which require some direct input from a trainer i.e. in practical training with using lifting aids and to ensure that resuscitation training is being implemented correctly. The registered persons stated that they had identified this as an issue when monitoring the effectiveness of the distance learning and were planning to remedy the situation. A requirement is made regarding this. EASTBROOK HOUSE Version 1.10 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 36 & 38 Effective systems for regularly consulting with service users and others, and systems for ensuring service users money is carefully monitored, contribute to the home being run in the best of service users and for their financial interests to be safeguarded. Further improvements need to be made regarding staff supervision to ensure that staff remain supported to meet service users needs. The home has robust health and safety systems to protect service users and others in the home. EVIDENCE: The home has an annual questionnaire for service users and relatives that was seen to be clear and provide a range of useful information for the home to continue to improve its services. Several relatives stated that the home was responsive to suggestions made. The inspector was informed that the name badges that staff were seen to be wearing had recently been introduced following feedback from stakeholders as a way of improving communication. The home has a clear development plan that was seen within its overall EASTBROOK HOUSE Version 1.10 Page 21 business plan for 2005. The business plan had been informed by a range of consultation with stakeholders and included targets for overall improvements in meeting the national minimum standards, a building improvement plan and in staff development. A registered person is the appointee for one service user’s finances as there is no other practical option for that person. The inspector was informed that relatives managed the majority of the other service user’s finances. The home does look after personal allowances for a number of service users. The records of this for two service users were inspected and found to be accurate with the money physically held by the home matching the individual records for the service user that showed a clear audit trail regarding the movement of the money. The inspector was pleased to see that some progress had been made with a requirement made at the previous inspection regarding formal staff supervision. Records were seen that all care staff were now being given twomonthly supervision by the two heads of care employed in the home. It was confirmed by the heads of care and the care staff spoken to that this was given on a one to one basis and was recorded with notes of the session being given to the supervisee. This formal supervision had not yet been implemented for the two heads of care or for the home’s cook. This requirement is therefore restated. A full range of health and safety documentation was inspected including those relating to fire precautions as well as the required gas, electricity and water documentation. This was seen to be satisfactory and provided evidence that the health and safety of service users, staff and visitors remained a priority for the home. EASTBROOK HOUSE Version 1.10 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 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 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 x 2 x x 2 x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 3 x 3 2 x 3 EASTBROOK HOUSE Version 1.10 Page 23 Yes 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 7 Regulation 13(4)(b) Requirement The registered persons must ensure that guidance for staff in minimising the identified risk regarding one identified service user who smokes must be clearly agreed and recorded on his care plan. The registered persons must ensure that regular assessments of skin vunerability are undertaken on all service users and that any risks identified are addressed appropriately. The registered persons must ensure that the CSCI is notified of any significant accident to service users that result in an emergency attendance at a hospital. The registered persons must ensure that all food stored in the home is appropriately labelled and stored and must designate a member of staff to have overall responsibility for the kitchen and food stored there. The responsible persons must review the homes adult protection procedures and devise practical guidance for staff relating to this. Version 1.10 Timescale for action 30/6/05 2. 7 13(4)(c) 30/6/05 3. 8 37(1)(c) 30/6/05 4. 15 16(2)(i) 30/6/05 5. 18 13(6) 30/6/05 EASTBROOK HOUSE Page 24 6. 21 23(2)(p) 7. 21 13(4)(a) 8. 24 23(2)(c) 9. 29 19(5)(d), Sch.2(7) 10. 30 18(1)(c) 11. 36 18(2) 12. 9 13(2) 13. 9 13(2) 14. 9 13(2) The registered persons must ensure that the central ventilation system to the homes bathrooms and toilets is working effectively. The registered persons must ensure that the identified shower hose in the first floor shower room is replaced. The damaged vanity units in identified service user bedrooms must be replaced on a planned basis. The registered persons must ensure that all staff employed have satisfactroy enhanced CRB/ POVA checks and that the four staff identified without these are closely supervised at all times by staff in the interim. The registered persons must ensure that the distance learning staff training provided in lifting and handling and in first aid is supplemented with direct physical input from a trainer. The registered persons must ensure that all staff have one to one supervision at least every two months.(Previous timescale of 30/4/05 not met). The registered manager must ensure that medicines supplied to the home in bottles and containers are checked and signed for on the administration charts. The registered manager must ensure that all medication that is administered is signed for on the MAR sheet or non administration coded as to the reason why. (timescale of 30/4/05 not met). The registered manager must ensure that, if medication is decanted into a compliance aid for service users to go on leave, the process is recorded, signed Version 1.10 30/6/05 30/6/05 30/11/05 30/6/05 30/6/05 30/6/05 30/6/05 30/6/05 30/6/05 EASTBROOK HOUSE Page 25 for and checked by another senior member of staff. (timescale of 30/4/05 not met). 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 9 9 9 9 Good Practice Recommendations The registered manager should ensure that a short medication policy specific to the home is available for use. The registered manager should ensure that medication profiles are introduced for each service user so as to provide a medication history. The registered manager should ensure that Controlled Drugs are stored in a metal cupboard, which complies with the Misuse of Drugs [safe custody] regulations. The registered manager should ensure that the administration of any homely remedies to service users is recorded either on the service user’s MAR chart or in a book kept specifically for the purpose. EASTBROOK HOUSE Version 1.10 Page 26 Commission for Social Care Inspection North London Area Office Solar House, 1st Floor 282 Chase Road London N14 6HA 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 EASTBROOK HOUSE Version 1.10 Page 27 - 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!