Inspection on 27/03/07 for Elms, The

This inspection was carried out on 27th March 2007.

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

The inspector 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

Elms, The 12/01/09

Elms, The 15/01/08

Elms, The 28/02/06

Elms, The 15/09/05

Elms, The 15/03/05

Elms, The 17/11/04

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 Elms, The 147, Barry Road London SE22 0JR Lead Inspector Ms Alison Pritchard Unannounced Inspection 2.30pm 27 March 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000007086.V326187.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. DS0000007086.V326187.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elms, The Address 147, Barry Road London SE22 0JR 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) 0208 693 4622 0208 693 9403 susan@theelms.co.uk None South East London Baptist Homes Susan Baterip Care Home 25 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places DS0000007086.V326187.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 28th February 2006 Brief Description of the Service: The Elms is located in a residential road in East Dulwich close to local amenities such as a library, shops and several bus routes. The home is registered to provide care for up to 25 older people. At the time of the inspection there were 23 residents who all have single bedrooms. The home has a large, well maintained garden to the rear and off street parking is available. The home has been managed by South East London Baptist Homes since the home opened in 1953. The work of the home is based on Christian principles and it is stated in the home’s Statement of Purpose that Christians from any denomination may apply. The aim of the home is stated as: ‘to provide a secure, comfortable and caring home for residents, so they can spend the rest of their days in peace and security. We provide comfort and support in a Christian atmosphere where mutual help and friendship are encouraged.’ Potential residents are given information about the home and the services available through providing an application pack. The pack includes a range of documents including the residents’ guide and letter of contract. Potential service users are visited by senior staff and invited to spend a day at the home. Copies of the most recent CSCI reports are available on request from the home’s secretary or the Registered Manager. This information is included in the residents’ guide to the home. During the inspection visit the Registered Manager agreed to place copies of the CSCI report in the hallway of the home. The current fees for the home are between £500 and £550 a week. These charges do not include the costs of hairdressing, newspapers or toiletries. DS0000007086.V326187.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over two days, in late March and early April 2007. The inspection methods included observation of care practice, discussion with residents, relatives and staff, inspection of service user files, as well as a range of other records. Involved professionals and relatives were sent survey forms so that they could contribute to the inspection process. Written feedback was received from thirteen residents, two relatives and one professional. The Inspector is grateful for their contributions. The CSCI also has access to information gathered through notifications from the home. A pre-inspection questionnaire was sent to the home prior to the visit asking for information. This questionnaire was returned to the CSCI. All of this information has been taken into account in compiling this report. All of this information has been taken into account in compiling this report. The inspection visits were facilitated by the Registered Manager and support staff who were helpful and courteous throughout the process. What the service does well: What has improved since the last inspection? DS0000007086.V326187.R01.S.doc Version 5.2 Page 6 All of the requirements of the last inspection report were met. The action taken includes the following improvements: • A new care planning system has been introduced and is in the process of being developed. • Medication administration records include details of allergies that some residents have. • Staff are now more careful to ensure that they use wheel-chair footplates when assisting residents to move around the building. 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. The summary of this inspection report can be made available in other formats on request. DS0000007086.V326187.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000007086.V326187.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The admission procedures ensure that potential residents and the home have enough information to decide whether the placement is suitable. EVIDENCE: Potential residents are given information about the home and the services available through providing an application pack. The pack includes a range of documents including the residents’ guide and letter of contract. The service user guide includes information about how to obtain a copy of the most recent CSCI inspection report. The guide includes views of some residents about the home. These views were gathered some years ago. It is recommended that the guide is amended to include more recent feedback about the home so that potential residents can be sure that they are basing their decision on current information. DS0000007086.V326187.R01.S.doc Version 5.2 Page 9 Potential service users are invited to spend a day at the home. Potential residents are visited by senior staff who carry out an assessment of their needs. The file of a person who recently went to live at The Elms was examined. It was found that these procedures had been followed and that the full range of needs had been assessed. Also on the file was a copy of the letter to confirm that the home could meet the person’s needs and giving details of the fees and the range of services covered by the sum. Several other residents who completed questionnaires confirmed that they had been given a contract about the home. The staff have showed particular sensitivity in helping residents to deal with the loss that may be involved with moving to The Elms. Staff from The Elms accompanied a resident to her previous home and took photographs so that she could be assisted to keep and share her memories. Another resident said that her experience of moving to The Elms was positive because ‘they took notice of me’ and assisted her to settle in. The home does not provide intermediate care. DS0000007086.V326187.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A introduction of a new care planning system has improved the recording or residents’ needs and how they will be met, but needs further development to ensure that cultural and spiritual needs are fully recorded. Residents’ medical needs, although well met in practice, were not fully recorded. Medication is well managed. A particular strength of the home is the attention paid to residents’ right to privacy and the respect afforded to them. EVIDENCE: The home has introduced a new care planning system. Three care plans were examined during the inspection visit. It was found that there is good attention paid to a range of residents’ needs including physical and social needs. However the plans need further development in relation to residents’ spiritual and cultural needs. Although these had been assessed as part of the initial assessment and there were a range of ways in which spiritual needs were addressed in practice this was not reflected in the documented care plans. On the form used to record care planning goals there is no specific section for spiritual or cultural issues. The Care Manager should consider adding this the form. DS0000007086.V326187.R01.S.doc Version 5.2 Page 11 Although the assessment for one person referred to needs arising from dietcontrolled diabetes this was not detailed on the care plan. There was information to confirm that the person’s needs are being met and that the diet was appropriate. However the documentation did not adequately reflect this. Other care needs arising from the medical condition were detailed on the care plan. Care plans had been signed by residents and reviewed each month. The GP, with whom all of the residents are registered, visits the home each fortnight and is available as necessary for advice and visits in between these times. The District Nurse also visits every fortnight and more frequently if required. A range of other health care professionals including the optical, dental and podiatry services also make visits to the home. Arrangements are made as part of the admission process for new residents to be registered with the GP, if they do not wish to maintain their previous one, and in accordance with their particular needs to see other health professionals. Medication is safely stored and well managed. A member of the senior care staff team was observed administering medication, she carefully checked to person’s identity to ensure that it was given to the right person. The medication administration records (MAR sheets) had no unexplained gaps. The known allergies of residents were recorded on the records. It would be best practice, if a resident has no known allergies, for this to be recorded on the record sheet. Some of the sheets had holes punched in them so they could be inserted in a file. However this had resulted in some of the names of medications being illegible. This prevents safe administration as it would not be possible for staff to check the entry on the MAR sheet against the name of the medication they were giving to a resident. This was pointed out to the Registered Manager who agreed to ensure that this practice was not continued. Residents confirmed that they are able to spend time alone when they choose and that their privacy is respected. The observation during the inspection was that staff treat residents with warmth and respect. DS0000007086.V326187.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There is good attention to residents’ social and spiritual needs. Residents are supported to maintain important relationships with family and friends. Residents’ views are sought and listened to. Residents needs are met by the meals provided. EVIDENCE: The residents are given the opportunity to tell staff the kind of activities they like to follow and this information was noted in the care plans. The home has visits from a mobile library which makes available large print and audio books to meet the needs of residents with a visual impairment who like to read. Newspapers and magazines of residents’ choice are ordered. A resident told the inspector that she enjoys completing a crossword each day. Other activities in the home include exercise, artwork, games such as skittles and darts and music. Two comments made on surveys returned to the inspector that residents would like more opportunities to take part in exercise at the home. The other eleven people who completed surveys did not express this view. A volunteer comes to the home to play the piano and occasional visits from local schools are arranged. A hairdresser visits the home regularly. DS0000007086.V326187.R01.S.doc Version 5.2 Page 13 The home pays particular attention to meeting the spiritual needs of residents and the information supplied to potential residents makes it clear that an aim of The Elms is to provide a Christian homely atmosphere. Daily prayers and weekly services are an important part of the communal life of the home. Local clergy visit the home and residents are assisted to make visits to churches in the area whenever this is possible and in keeping with residents’ needs and wishes. Activities away from the home include, in the warmer weather, walks in the park and trips to the coast, attending coffee mornings and prayer meetings, visits to a local art gallery and attending meetings of the Parkinsons’ Society. Residents’ relatives and friends are able to visit at all reasonable times. The inspector had the chance to talk to two residents’ relatives who all said they are welcomed on their visits. One couple said that whenever they visit they are offered a cup of tea and given information on how their relative has been that day. A pay telephone is available for residents to use and several have chosen to have their own telephone line fitted in their bedrooms. There is a suggestion box in the hallway where residents, relatives or visitors may make comments about any issues they wish. In addition the home holds regular meetings for residents who are encouraged to give their views on the way that the home runs and to put forward any suggestions they may have. A resident talked to the inspector about these meetings and said that the residents were asked how they could make the home better – she said that the response of all of the residents was ‘you couldn’t better it’. The menu provided for the inspector showed that a range of food is available in accordance with the residents’ cultures. The main meal is served at lunch time and includes dishes such as lamb stew and dumplings, steak pie, and fish in parsley sauce, with a range of vegetables. A lighter evening meal is served and consists of, for example, soup and sandwiches, poached egg on toast or Welsh rarebit. Alternative meals are provided on request and residents’ preferences and dietary needs are known to care and catering staff so that they can take these into account. Special meals are prepared for significant occasions, for example, there were plans to provide a special meal for St George’s Day. There is careful observance of religious needs in relation to food, for example fish is always served on a Friday and a special fish meal was planned for Good Friday. When the inspector visited the dining room was decorated to mark the forthcoming Easter celebrations. Residents told the inspector that birthdays are always marked with a home-made cake. Feedback about the meals was very positive and included the comments – ‘the food’s beautiful, it’s just like home-cooked’ and another person said ‘I do appreciate the fresh fruit which is offered as an alternative to cake, ice cream etc at main meals. The menus are varied and very well planned.’ DS0000007086.V326187.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s procedures contribute to the protection of residents and the promotion of their rights. EVIDENCE: The complaints procedure is included in the information given to residents at the time of admission and is displayed in the hallway of the home. It includes appropriate timescales for the investigation of complaints. One complaint is currently under investigation, there have been no other complaints made to the home or to CSCI over the last year. Postal voting for residents has been arranged so that those people who wish to do so can take part in elections. Staff have received training in adult protection issues during the last year and further training is planned. Residents expressed confidence in the ability of the home’s staff to address any concerns they might have. The staff handbook is clear that employees must not be involved in or benefit from gifts or bequests from residents and gives instructions on the action to take if residents make such an offer. DS0000007086.V326187.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from a building which is homely and clean. Care must be taken to ensure that repairs are carried out promptly so that residents’ safety is not compromised. EVIDENCE: The building is homely and comfortable. All of the residents have single bedrooms which they are assisted to personalise with items of furniture, ornaments and photographs. The majority of bedrooms are on the ground floor, those bedrooms on the first floor are accessible by a passenger lift if people are unable to use the stairs easily. There are four lounges available for residents, one large main lounge and three smaller rooms, one of which has doors to the large well kept garden to the rear of the home. In addition there is a dining room at the front of the building. The home was very clean and tidy at the time of the inspection. One area needing attention was at a rear fire door where the flooring was damaged and could have been a trip hazard. This was pointed out to the Registered Manager who DS0000007086.V326187.R01.S.doc Version 5.2 Page 16 agreed to ensure that the area was made safe. There were no unpleasant odours during the inspector’s visits to the home. The home has plans to make substantial improvements to the facilities available at the home. This will include increasing some room sizes and modernising some areas of the building. DS0000007086.V326187.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are well trained and supported and available in sufficient numbers to meet residents’ needs. The recruitment procedures do not adequately ensure the safety of residents. EVIDENCE: In addition to the Registered Manager the care staff team consists of a Deputy Manager, five senior care staff and fifteen care staff. A secretary undertakes administrative and financial duties. The catering staff team is made up of a Head Cook, a Deputy Cook, a Tea Cook and a two Kitchen Assistants. There are four domestic staff, including one person who works in the laundry and there is a handyman. There are two ‘casual’ staff who cover gaps in the rota caused by vacancies, sickness and annual leave. There are five care staff on duty in the mornings and four on duty in the afternoon. On each shift there is a senior member of staff with additional management support from the Registered Manager and Deputy Manager on weekdays. At night time there are two care staff awake and one member of the management team on call in the in the building. These staffing levels are judged to be appropriate for the needs of the residents. The shifts are arranged to ensure that there is adequate time to allow information to be passed between staff at a ‘handover meeting’. Of the twenty care staff twelve have achieved qualifications to NVQ level 2 and three have achieved NVQ level 3. This is 75 of the team and this exceeds the DS0000007086.V326187.R01.S.doc Version 5.2 Page 18 standard required. The team have undertaken a range of training in the last year, including moving and handling, adult abuse issues, dementia care, death and dying and medication issues. Further training is planned in nutrition and health, anatomy and physiology and palliative care. Four care staff have left their work at the home over the last year and five new care staff have begun employment at The Elms, two of whom are senior care staff. Several members of the team have worked at the home for a number of years. This contributes to consistency of care. A sample of four recruitment records was checked. A number of problems were found, only one file had two references. Some references had been taken up after the person had been employed and begun work at the home. Although all files had Enhanced Criminal Records Bureau checks, some had been transferred from previous employers which is no longer allowed, and not all employment histories were detailed and complete. An immediate requirement was left at the home at the end of the first visit to ensure that these issues were highlighted as needing urgent attention. Since then the Registered Manager has confirmed that the system for ensuring that staff have the required checks and references has been made more robust. It is anticipated that the recruitment and employment procedures will be strengthened as a consultant has been employed by the home to review these issues and the produce a recruitment policy. A requirement is made to ensure that a the policy is produced within an acceptable timescale DS0000007086.V326187.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management of the home is generally good with account taken of residents’ and relatives views to inform how the home is run. Improvement to the management of health and safety matters will ensure that residents are not at risk. EVIDENCE: The Registered Manager has worked at the home since 1983, immediately before taking on the post of Manager she was the Deputy Manager. She is appropriately qualified and experienced for the role, she holds the Registered Managers Award and NVQ level 4. She is supported in her role by the Deputy Care Manager who holds NVQ level 3. The Registered Manager continues to undertake training to ensure that her knowledge is kept up to date and relevant to her role. DS0000007086.V326187.R01.S.doc Version 5.2 Page 20 The manager is knowledgeable about the needs of the residents and they expressed confidence in her abilities. Warm relationships were observed between the senior staff, the residents and the relatives. There are a number of quality assurance systems used to ensure to monitor the quality of the service. Trustees from the management committee visit the home each month and complete a report of their findings. The visits include discussion with residents, staffing issues as well as an assessment of the premises, examination of records and health and safety matters. An survey of residents was completed in 2006, fourteen questionnaires were completed and the feedback seen was positive. One of the questionnaires referred to the ‘patience and understanding’ of staff and another mentioned their satisfaction with the meals and that their dietary needs were catered for. It is required that the results of the surveys are collated to form a report which can be shared with the CSCI, residents, relatives and other people who may be interested such as people who make referrals to the home. The residents’ meetings are another important aspect of ensuring that the home meets their needs and preferences. A draft annual development plan for the home is under consideration by the Trustees. The home does not manage the financial resources of any of the residents who are encouraged, whenever possible, to maintain this responsibility for themselves, or for relatives to take over the role. The staff receive supervision from an external consultant who visits the home every six weeks. The Registered Manager, her Deputy and the Secretary also meet with the consultant for regular supervision. Issues requiring management input are addressed by the Registered Manager or, if necessary, the Trustees. Staff meetings are also held and a copy of the agenda for the March meeting showed that there is appropriate time spent on staff and residents’ issues. Weekly tests of the fire alarm are made but the drills have not been conducted with sufficient frequency. The Registered Manager ensured that a drill was carried out soon after the inspector’s visit and confirmed that staff will be involved in drills at no less than quarterly intervals. Other health and safety checks had taken place. However as noted above the rear fire exit from the home had damage on the floor. This should have been noted as part of the home’s regular health and safety checks and addressed without delay. DS0000007086.V326187.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 4 X X X 3 X 4 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X 2 DS0000007086.V326187.R01.S.doc Version 5.2 Page 22 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. Standard OP7 Regulation 15(1) Timescale for action The Registered Person must 01/07/07 ensure that the care plans reflect the way that the home intends to meet residents’ needs which arise from their religion and health. The Registered Person must 01/05/07 ensure that there are safe arrangements for the administration of medication by ensuring that the names of medications on the medication administration record are clear and legible. The Registered Person must 01/05/07 ensure that residents’ safety is ensured by attending to required repairs promptly. The Registered Person must 29/03/07 ensure that recruitment procedures reflect the requirements of NMS 29 and Regulation 19 of the Care Homes Regulations 2001. The Registered Person must 01/07/07 Version 5.2 Page 23 Requirement 2. OP9 13 3. OP19 OP38 13(4)(a) 23(2)(b) 4. OP29 19 5. OP29 19 DS0000007086.V326187.R01.S.doc ensure that residents’ safety is protected through the production of a recruitment procedure which takes account of regulatory requirements. 6. OP33 24(2) The Registered Person 01/07/07 must ensure that the results of the residents’ survey are collated to form a report to be distributed as required by regulation. The Registered Person must 01/05/07 ensure that residents’ safety is maintained by ensuring that staff are involved in fire drills at no less than quarterly intervals. 7. OP38 23(4)(e) 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 OP1 Good Practice Recommendations It is recommended that the residents’ guide is amended to include recent feedback about the home so that potential residents can be sure that they are basing their decision on current information. DS0000007086.V326187.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000007086.V326187.R01.S.doc Version 5.2 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. 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