Inspection on 16/01/07 for Egerton House Residential Home

This inspection was carried out on 16th January 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Egerton House Residential Home 28/01/09

Egerton House Residential Home 18/12/07

Egerton House Residential Home 20/01/06

Egerton House Residential Home 28/06/05

Egerton House Residential Home 02/03/05

Egerton House Residential Home 13/10/04

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Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Egerton House Residential Home 113 Hill Top Lane Kimberworth Rotherham South Yorkshire S61 2ER Lead Inspector Jayne Barnett-Middleton Key Unannounced Inspection 10:20 16th January 2007 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 Egerton House Residential Home DS0000056460.V311161.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. Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Egerton House Residential Home Address 113 Hill Top Lane Kimberworth Rotherham South Yorkshire S61 2ER 01709 559643 01709 559643 egertonhouse@aol.com 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) Mrs Parneet Virk Mr Sarbjit Singh Virk Post Vacant Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. An action plan with timescales for the renewal of furniture and soft furnishings to be developed, agreed and provided to the NCSC within 3 months of this registration date. 20th January 2006 Date of last inspection Brief Description of the Service: Egerton House is a Care Home providing care and accommodation for up to 21 service users in the category of older people. The home provides both long and short-term care for its client group. Mr and Mrs Virk own the home. The home is situated in the Kimberworth area of Rotherham and is within easy reach of the town centre and other local amenities. Egerton House is a two-storey building, which has been extended to provide its current accommodation. There are 17 single and 2 double bedrooms. The communal areas consists of a dining room and two lounges. There is a small quiet room on the first floor for use by residents and their relatives. Bathrooms and toilets are available on both floors. The kitchen and laundry are located on the ground floor. There is a call system in all rooms used by residents. There is a passenger lift to facilitate access between the two floors. The Home has a garden and patio area and there is car parking facility at the front of the building. The fees for care at the home at 13th October 2006 are £329 per week. Items not covered by the fee include hairdressing and personal toiletries. The homes statement of purpose and service user guide is available. Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection conducted by Jayne Barnett-Middleton. Prior to the visit contacts made to The Commission For Social Care Inspection, the homes service history and a pre-inspection questionnaire were examined. A fieldwork visit took place from 10.20am until 17.00pm. Opportunity was taken to make a tour of the premises, inspect a sample of records including care plans, training records and staff recruitment files. The inspector spoke to most staff and in detail to the three of the staff on duty about their knowledge, skills and experiences of working at the home and to six of the residents about their views on aspects of living at the home. The inspector wishes to thank the manager, staff and residents for their assistance and time throughout the inspection process. What the service does well: There is a friendly and welcoming atmosphere within the home. During the visit residents appeared comfortable and were observed to be following their preferred routine. The manager and staff were welcoming and relaxed to talk to the inspector about the service that they provided. Residents spoken to were happy at the home commenting, “ I love it” and “ the food, cleanliness and the staff are 100 ”. One visitor described the service as “ marvellous”. The owner has continued to improve the environment. Since the last visit the dining and lounge area have been redecorated and new furniture provided to a good standard. Residents felt that they were treated with respect and that their dignity was maintained. Residents were observed to be cared for in a manner that respected their privacy and dignity. Residents seen were clean, appropriately dressed and it was evident that residents who required help to wash and dress had been assisted with this in a manner that respected their dignity. The inspector was invited to join the residents during their lunchtime meal. The atmosphere within the dining room was relaxed and unhurried. Staff assisted residents who needed assistance to eat in a sensitive manner. The meal served was hot, well presented and very tasty. Residents said that they were satisfied with the quality of food provided commenting, “it’s good”, “nice” and “ I can’t fault it”. Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 6 Over 50 of the staff hold a National Vocational Qualification level 2 or 3 in care, enabling them to develop their knowledge and promote good care practices. There is good staff team in place whom the manager appropriately supports. Relatives, via a recent survey, had made positive comments about the care that their relatives received. Comments included “ I am happy about the home I know that the residents are well cared for” and “ my relative looks well and has come on in leaps and bounds ”. What has improved since the last inspection? What they could do better: Resident care plans need to be reviewed more frequently to reflect the changing needs of the individual. Daily records require some improvement, to ensure that the health and wellbeing of the resident can be fully monitored. The staff are not always following the homes policy for the safe storage and administration of medication, therefore the safety and welfare of residents may be placed at risk. The homes recruitment procedures require some improvement to fully promote the protection of the residents. Some staff are in need of moving and handling, fire and adult protection training to promote the residents safety. The manager did inform the inspector that the training is scheduled to soon take place at the home. Records of the visits carried out by the provider, to check the standard of care provided, need to be completed monthly as required by the regulations. Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 7 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. Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 8 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 Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 9 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 from evidence gathered both during and before the visit to the service. Resident’s needs were assessed prior to their admission, confirming that the service was appropriate to meet the residents individual needs. EVIDENCE: Three care plans were checked all of which contained a full needs assessment, which had been carried out by an appropriate professional, prior to a placement being offered. The staff from the home also visited prospective residents to carry out an assessment, enabling staff to formulate a plan of care and to confirm that the service was appropriate to meet the residents’ individual needs. Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected 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 from evidence gathered both during and before the visit to the service. Residents’ assessed needs were reflected in their plan of care. However, the care plans seen needed to be reviewed more frequently to reflect the changing needs of the individual. Daily records did require some improvement, to ensure that the health and wellbeing of the resident could be fully monitored. Residents felt that they were treated with respect and that their dignity was maintained. The staff were not always following the homes policy for the safe storage and administration of medication and therefore the safety and welfare of residents may be placed at risk. Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three care plans were checked which detailed the residents individual physical, social and emotional needs. Two of the three care plans seen had not been reviewed monthly. Where reviews had taken place there was good information to support that residents and their relatives had been invited to discuss their care and to confirm that the staff were meeting their care needs. The staff maintained daily records of the care that they had provided to the resident. However, these needed to provide more detail in relation to the residents’ wellbeing. For example accident records seen for one resident recorded that they had suffered a fall. There was however no record of this in the daily care records. The manager was in the process of implementing a new care plan format. The care plan seen, using the new format, was detailed and the information provided easy to access. Nutritional screening was undertaken for residents on their admission, which identified any dietary requirements and any eating difficulties. A format was in place to monitor the residents’ weight. One record seen identified that the resident had not been weighed since February 06. The care plans need to include information as to how often the resident should be weighed, to enable staff to identify any potential healthcare problems. Healthcare records were in place, which demonstrated that residents were receiving regular visit from their general practitioner, optician and chiropodist. Residents spoken to during the visit said that their healthcare needs were met. One resident spoke in detail of the care that they needed and how the staff helped them to shower and dress commenting, “ They look after me”. Relatives, via a recent survey, had made positive comments about the care that their relatives received. Comments included “ the residents are well cared for” and “ everyone is well looked after”. Medication was checked on a sample basis. There were some gaps on medication administration records where medication had been administered and not signed for. In some instances the amount of medication received into the home had not been recorded on the medication record. The medication record for one resident did not correspond with the medication that was still in stock. On two occasions there was a signature to confirm that the medication had been administered. However, the medication was still in the ‘blister pack’ provided. During the visit keys were left in the drug trolley unattended. The manager said that she did intend to commence regular checks of the medication system to ensure that it was appropriately administered. Residents were observed to be cared for in a manner that respected their privacy and dignity. Residents seen were clean, appropriately dressed and it was evident that residents who required help to wash and dress had been Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 12 assisted with this in a manner that respected their dignity. The staff described how they promoted the residents dignity for example knocking on residents bedroom doors prior to entering, and detailing the practices that they carried out when assisting residents with their personal care. Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 13 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 good. This judgement has been made from evidence gathered both during and before the visit to the service. The routines within the home were varied and flexible which met the residents’ individual needs, promoting their choice and independence. Social activities were planned for residents who wished to participate. Residents were encouraged to maintain contact with their family, friends and the local community as they wished, enabling them to continue to be included in community and family life. The mealtime observed were relaxed and unhurried. A choice of menu was offered and special dietary needs were catered for, promoting the resident’s health and wellbeing. EVIDENCE: During the visit residents were observed to be following their preferred routines. The residents said that the routines within the home were flexible. One confirmed, “ there are no hard and fast rules, I can do what I want”. One Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 14 resident spoke in detail of their preferred daily routine and said that the staff always supported them to spend their day as they wished. The staff were responsible for providing activities for the residents on a daily basis. The manager said that the residents were encouraged to choose what they liked to do. Residents spoken to were happy with the level of activities provided. One resident commented that they had really enjoyed a quiz that had taken place the previous day. Professional entertainers visited the home on a monthly basis. Residents have access to a pleasant and private garden area. The manager said that this was well used during the summer months and described how the residents always enjoyed ‘ fish and chip suppers’ that the staff organised. Residents confirmed that they were able to see their visitors in private. Those spoken to said their visitors could come at any time, and that the home helped them maintain contact. The menu was varied and a balanced diet was provided to maintain residents health. A choice of a hot meal, salad or sandwiches was offered for the lunchtime meal. One resident said that irrelevant of the time that they got up they could still have a cooked breakfast if they wanted one. During the visit one resident, with communication difficulties, was keen to express to the inspector their satisfaction with the food provided. The inspector was invited to join the residents during their lunchtime meal. The atmosphere within the dining room was relaxed and unhurried. Staff assisted residents who needed assistance to eat in a sensitive manner. The meal served was hot, well presented and very tasty. Residents said that they were satisfied with the quality of food provided commenting, “it’s good”, “nice” and “ I can’t fault it”. Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 15 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 from evidence gathered both during and before the visit to the service. The residents were confident that any concerns or complaints would be listened to and dealt with appropriately. The homes adult protection policy and procedure promoted the protection of residents from harm or abuse. EVIDENCE: The homes complaints procedure was incorporated in the homes service users guide. Copies of this were available in all of the residents’ bedrooms. Since the last inspection one complaint made to the Commission For Social Care Inspection has been investigated appropriately by the registered provider. Residents spoken to during the visit said that they had no complaints, yet felt that the staff were approachable, should they have any concerns in relation to their care. The home had an adult protection policy and procedure. All staff spoken to had a good knowledge of the types of abuse that may occur and the action that they would take to protect the residents. Training records demonstrated that most, but not all staff, had received adult protection training. The manager said that this was scheduled to take place in the near future. The home had made no referrals to the protection of vulnerable adults register since the last inspection. Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is Good. This judgement has been made from evidence gathered both during and before the visit to the service. The environment within the home was well maintained and clean, providing a comfortable environment for residents to live. All areas of the home were accessible. Homely touches had been provided to create a comfortable environment. Communal areas were well maintained, and residents’ bedrooms were well decorated and personalised. EVIDENCE: The building was clean and free from offensive odours. The lounge and dining areas were well decorated providing sufficient sitting and dining space. There was a pleasant garden, and garden seating was provided for residents’ enjoyment. The current owner has continued to refurbish the home. Since the last visit the dining and lounge area had been redecorated and new furniture provided to a Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 17 good standard. A programme for redecorating and renewal of equipment was in place. The programme seen identified the areas that there were plans to continue to redecorate several residents’ bedrooms, communal areas and to replace some furniture and linen. Several bedrooms were seen, all of which were clean, tidy and had been personalised by the residents. Residents said that on their admission they had been able to bring small items of furniture with them enabling them to create a homely environment. Areas seen during the visit were clean, tidy and odour free. Some staff had attended infection control training, ensuring that they had a good knowledge of hygiene practices and managing the control of infection. Laundry facilities were sited away from all food preparation and storage areas. Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected 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 adequate. This judgement has been made from evidence gathered both during and before the visit to the service. The ratio of staff provided was sufficient to meet the needs of the residents. A training and development programme was in place. Regular training opportunities were available enabling staff to keep up to date with practice and changing legislation. Some staff are in need of moving and handling training to promote the residents safety. Over 50 of the staff hold a National Vocational Qualification level 2 or 3 in care, enabling them to develop their knowledge and promote good care practices. The homes recruitment procedures require some improvement to fully promote the protection of the residents. EVIDENCE: Residents and one visitor spoke highly of the staff team and the care that they provided. Comments included “ they are marvellous”, “ The staff are very helpful” and “ they look after me very well”. Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 19 The number of care hours provided at the home had been calculated based on the dependency needs of the residents. Staff rotas checked, prior to the visit, demonstrated that the number of staff provided was sufficient to meet the needs of the residents. The manager said that in general the home exceeded the number of hours that were required. All staff said that the number of staff provided enabled them to offer the residents the care that they needed; in particular the residents with high dependency care needs. Residents spoken to said that, in their opinion, there were always enough staff on duty. One commented, “ we only have to ask and they help us”. The staff confirmed and training records demonstrated that regular training was offered to meet the general and specific needs of the residents. The manager, via the pre inspection questionnaire, said that a range of training had taken place since the last visit. This included health and safety and adult protection. Over 50 of the staff team hold a NVQ level 2 or 3 in care. A training matrix was in place to evidence the training that the staff had received. The record seen did indicate that some staff was in need of Moving and Handling and Fire training. The manager said that this was scheduled to take place in the near future. Two staff files were checked for staff who had recently commenced employment at the home. The files seen contained two forms of identification, an application form and two references. Both files seen identified that they had commenced employment at the home prior to a satisfactory Criminal Records Bureau check being received. The manager said that the staff were given one to one supervision at all times until a satisfactory check had been received. However, one file seen did evidence that the staff member had worked from December 2005 to March 2006 until receipt of a satisfactory check. Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The residents and staff were benefiting from the organisation and leadership of the manager. Forums were in place for the staff, residents and their relatives to contribute to the development of the service. Systems were in place to safeguard residents’ financial interests. In general the homes policies and procedures promoted the health, safety and welfare of residents and staff. Staff are in need of refresher fire training to fully promote the health, safety and welfare of the residents and their colleagues. Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager had been recently been promoted having previously worked as assistant manager at the home. She has recently applied to the Commission For Social Care Inspection to register as manager. She has relevant experience of working in a caring environment and is currently working towards a Registered Managers qualification. The manager conducts regular resident and relative surveys, to enable them to comment on the service that is provided and to suggest areas of improvement. Relatives had given positive feedback from a recent survey conducted in December 2006. Comments included “ the standard of care is very good” and “ the staff are very caring and helpful”. Staff meetings were held frequently and the staff said that the management team supported them. The manager said that she did receive good support from the owner and that they regularly visited the home. However, records of these visits, to check the standard of care provided, need to be completed monthly as required by the Regulations. Residents’ were able to maintain control of their finances if they wished and had the capacity to do so. The financial records of two residents’ were inspected. Written records of all transactions were maintained with a receipting mechanism and signatures of two persons. There was a secure facility for the safekeeping of monies and valuables on behalf of the resident. Areas throughout the home were well maintained and a programme of renewal and redecoration is in place. Information provided prior to the visit demonstrated that all major systems and equipment had been routinely serviced to promote a safe environment. A training programme is in place. However, staff are in need of fire refresher training to fully promote the health, safety and welfare of the residents and their colleagues. Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 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 3 X 3 X X 2 Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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. 2 Standard OP7 OP7 Regulation 15 15 Requirement Resident care plans must be reviewed monthly. Daily records must be more detailed to ensure that the health and wellbeing of the resident can be fully monitored. Where there is an identified need, the weight of the resident must be monitored and the frequency recorded in their plan of care. Medication must be safely and securely stored at all times. Records of medication received into the home must be maintained. Accurate records of medication administered must be maintained. Staff must not commence employment at the home until a satisfactory Enhanced CRB disclosure and POVA 1st check has been carried out. All staff must receive adult protection training. A written report of the providers’ monthly visits must be completed and retained on site DS0000056460.V311161.R01.S.doc Timescale for action 01/04/07 01/04/07 3 OP8 13,15 01/04/07 4 5 6 7 OP9 OP9 OP9 OP29 13 13 13 19 16/01/07 01/04/07 01/04/07 01/02/07 8 9 OP18 OP33 13 26 01/05/07 01/04/07 Egerton House Residential Home Version 5.2 Page 24 10 OP38 13 for inspection. All staff must receive fire training 01/05/07 at the required frequency. 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 manager should commence medication audits to ensure that medication is appropriately administered. Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Egerton House Residential Home DS0000056460.V311161.R01.S.doc Version 5.2 Page 26 - 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. 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