Inspection on 19/09/05 for Ersham House Nursing Home

This inspection was carried out on 19th September 2005.

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

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

Other inspections for this house

Ersham House Nursing Home 23/10/08

Ersham House Nursing Home 26/10/07

Ersham House Nursing Home 03/11/06

Ersham House Nursing Home 13/01/06

Ersham House Nursing Home 06/02/05

Ersham House Nursing Home 09/07/04

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

CARE HOMES FOR OLDER PEOPLE Ersham House Ersham Road Hailsham East Sussex BN27 3PN Lead Inspector Debbie Calveley Unannounced Inspection 19th September 2005 08:00 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 Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 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. Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ersham House Address Ersham Road Hailsham East Sussex BN27 3PN 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) 01323-442727 01323-849900 ershamnh@btconnect.com Lakeglide Limited Mrs Sharon Sugars Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41), Physical disability (41), Terminally ill (4) of places Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is fortyone (41). Service users must be aged sixty-five (65) years and over on admission. Service users may have a physical disability and be aged forty-five (45) and over on admission. The maximum number of service users to be accommodated with a terminal illness is four (4). 7 February 2005 Date of last inspection Brief Description of the Service: Ersham House is registered to provide nursing and supporting care for fortyone service users who meet the registration category of elderly, terminally ill and physically disabled. It was opened fifteen years ago and is set in gardens of approximately one acre, on the rural outskirts of Hailsham, with extensive views to the South Downs. The accommodation offered is thirty-nine single rooms, twenty with ensuite facilities and one double room with an ensuite bathroom. The home have a contract with social services for ten booked beds. The home offers communal areas, which are light, homely and tastefully furnished throughout the home, there is the main lounge/dining area which is central in the home, two further small lounge areas on each floor and an activities room. The bedrooms have been designed and decorated to a high standard. Residents are encouraged to personalise their rooms with small pieces of furniture and pictures. There are ample bathing facilities available which have the necessary equipment to meet the needs of the residents accomodated in the home. The lift ensures that there is level access to all parts of the home. There is a reception desk and office and receptionist that works full time Monday to Friday, thus releasing staff from answering phones and enabling them to concentrate on the needs of the service users. The gardens are rustic and well tended and easily accessed by the service users. Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 19 September 2005. It commenced at 07.30 am, and took place over seven hours. There were fortyone residents in the home at this time. The methodology of the inspection included a tour of the building, inspection of documentation and records, the delivery of care for twelve residents and informal interviews with fourteen residents, three relatives and eleven members of staff. The overall quality of care provided at Ersham House was observed to be of a good standard and the outcome for service users living in the home is one of warmth and comfort. There were some standards not met during the inspection and these were in connection with documentation and recording and do not detract from the care given. The home are aware of these shortfalls and are working towards meeting the standard required. What the service does well: The comprehensive Statement of Purpose and Service Users Guide give prospective residents the information required enabling them to make an informed choice about where they live. The health needs of the residents were seen to be met and the standard of care is maintained to a high standard. The atmosphere of the home is pleasant with good interaction seen between residents and staff. The residents are enabled to exercise the choice and control of their every day life. The relatives and representatives are welcomed to the home and are kept informed of any changes and are complimentary about the service provided at Ersham House. There is a variety of good nutritious food offered and fresh fruit is readily available. Meals are taken in comfortable and homely surroundings. The home is clean, safe and well maintained, which is appreciated by the residents and their relatives. There is a stable work force of reliable and caring staff, which work well together as a team. Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 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 Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 The comprehensive Statement of Purpose and Service Users Guide give prospective residents the information required enabling them to make an informed choice about where they live. A contract/statement of terms and conditions is given to all residents on admission, which confirms the facilities offered and care agreed. The home welcome and encourage prospective residents and their representatives to visit the home prior to admission to enable them to assess the suitability of the home and meet the staff and fellow residents. EVIDENCE: A Statement of Purpose and Service Users guide, which conforms to the Care Homes Regulations and National Minimum standards, is in place. It is available to all residents and their relatives and is written in a clear and user-friendly format. There is a comprehensive statement of terms and conditions, which includes the services covered by the fees and the room to be occupied. Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 Page 9 It was confirmed from viewing the residents’ files that a pre-admission assessment using the homes own assessment tool is completed on prospective service users, however not all were completed in full and signed and dated. One resident did not have a pre-admission assessment in place or a transfer letter from her previous home. The assessment takes place at the residents’ place of residence, and input from other relevant professionals is sought when required. It is said that the residents’ representatives are involved if possible. Eight pre-admission assessments were viewed. Four of the residents spoken with were able to confirm that they were visited before admission whilst one could not remember being involved. The pre-admission assessment identifies any specific needs of the prospective resident and this informs the admission process. The home provides nursing care for elderly people and those suffering from a terminal illness, and the documentation available demonstrates that a full assessment of the resident’s specific needs is completed following admission to the home, and then reviewed. Trial visits can be arranged and residents and their representative can spend a day in the home prior to admission. This enables them to meet the staff and other residents, and sample the food and activities. There is a month’s trial either way to ensure that the home is suitable and the home can meet the needs of the resident. Unplanned/ emergency admissions are rare, but if they do occur, assessment and care planning takes place within twenty-four hours. Two residents confirmed that they had visited the home prior to their admission; one resident said her daughter had visited and chosen the home. Another said that she had come for a short stay and then decided to move in permanently. One resident said that she had visited many homes before finally making her choice and that she had liked the atmosphere and the staff of Ersham House best. Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 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 Residents would benefit for a more comprehensive care planning system that guides staff in all aspects of personal and health care and that all risks are identified and planned for. The residents are treated with respect and dignity at all times. EVIDENCE: Twelve care plans were viewed and whilst the format of the care plan system is good, it was noted that the positive outcomes observed at this time are still dependent upon staff knowledge and memories rather than full and detailed recording. It was found that the standard of the care plans were not consistent, and that some care plans were poorly completed and not signed and dated, this included two respite residents. There was no evidence of service user involvement in some of the care plans viewed. These shortfalls were identified at the time and discussed with the manager. The risk assessments for pressure damage and nutrition and were found to be in place and regularly reviewed, however some documents e.g. bowel records are not kept up to date and so do not accurately reflect the residents health. Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 Page 11 The clinical room on the lower floor is being enlarged at the present time and so inspection of this area was not possible. The medication charts were seen and some irregularities were found, regarding entries, dates and signatures. Residents receiving respite care are enabled to administer their medication within a risk assessment framework, which will encourage and maintain their confidence and independence before discharge home. Oxygen cylinders need to be stored appropriately with the necessary “danger” sign attached. Throughout the inspection the staff were seen to be interacting positively with the residents. They were seen to treat the residents with dignity and respect whilst attending to their needs. Residents spoken with said, “Can’t find any fault with the home, they make sure I am safe, it’s sociable and I’m very happy”. Another said the “staff are very nice, I’m not lonely anymore”. One resident remarked “ they are all marvellous” and the care was “very good indeed”. The staff informally interviewed said that that the induction programme made them aware of the need to be polite and courteous as well as teaching them how to approach elderly people as individuals. Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Residents would benefit from a daily programme of activities based on their individual preferences. The homes encourages and enables residents to maintain contact with their families and friends, by having an open door policy and a welcoming reception. The dietary needs of residents are well catered for and offer a balanced and varied selection of food that has been updated in line with the personal likes and choices of residents. EVIDENCE: There is a programme of activities that are held on a daily basis. There are five co-ordinators that work on different days to provide the sessions. The residents that attended the activities were seen to enjoy them, on the day of the inspection five residents were painting, however not all residents felt that the activities were for them. Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 Page 13 Three gentlemen, all said that the activities didn’t appeal to them, that they would prefer something a little more stimulating. One resident said that she “attends the sessions everyday and enjoys the odd trip out, doesn’t say no to much”. Another resident said that she was “still fairly new and hadn’t attended the activities as yet”. Two other residents said that they did go to some events but not on a regular basis, as some activities were “too childish”. An individual social assessment for each service user is complied and each individual service user is given individual time whenever possible. The activity co-ordinators also visit individual service users on a one to one basis, and this enables the more isolated service users a chance to chat and share their news. A planned programme of activities based on residents’ preferences needs to be created and implemented. This would ensure residents are given the opportunity to continue with past hobbies and pastimes. There is an open visiting policy and relatives and friends are made aware of this in the service users guide. Visitors can be received in private and service users may choose whom they wish or do not wish to see. There are various local community groups that visit the home, and ministers of different denominations also visit the home on a regular basis. The residents spoken with were able to confirm that they were allowed to choose their daily routine, and were asked their preferred times of getting up, where they eat, what they eat and when they go to bed. It was confirmed that the routines of daily living experienced by the service users have a degree of flexibility; individual service users can request meals at a different time if they are going out and in their preference for getting up and for going to bed. The feedback regarding the food at Ersham House is complimentary, residents spoken with all said how good the food is, that there is always a choice and plenty of fresh vegetables and that it is always tasty. There is a varied and nutritious menu, which is rotated on a four weekly basis and changed according to the seasons, and there are extra choices available. Any special diets for cultural and medical reasons can be catered for and snacks are available at any time. The meal observed was of good quality and attractively presented. The dining area is attractive and congenial. The food is served from a hot trolley in the dining area, which ensures it is kept hot and all residents can also change their order if the want to. Advice is sought from the dietician and G.P when necessary. Staff are experienced in administering PEG feeds. Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18. The complaint procedure is clearly detailed in the Statement of Purpose and Services Users guide and is available to residents and their families enabling them to share their concerns formally and confidentially. Staff interviewed had a good understanding and knowledge of Adult Protection policies and procedures, which protect the residents from harm and abuse. EVIDENCE: There are appropriate policies and procedures in place and it was confirmed that these are followed when investigating any concerns raised at the home. The staff interviewed, were knowledgeable of the complaint procedure and of how to start the process if the manager is not available. The complaint book was viewed during the inspection. Three of the residents referred to the leaflet (service users guide) when asked if they knew how to make a complaint, whilst one resident said she didn’t know of a proper procedure, but would go the senior nurse and that “it would be dealt with”. There have been no complaints received by the CSCI since the last inspection. The Adult Protection policy in the home was found to be up to date and staff interviewed, were knowledgeable about the systems in place to protect vulnerable service users. There is on-going training for all staff in Adult Protection. Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 Page 15 Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 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, 20, 21, 22, 23, 24, 25 and 26. The home provides a comfortable, clean and safe environment for those living there and for those visiting. Residents are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s personalities and interests. There is specialist equipment in the home for residents’ use to maximise their independence. EVIDENCE: The home is well furnished with good quality co-ordinated furniture. The residents are encouraged and enabled to personalise their rooms with furniture and pictures, and this was evident during the visit. All personal items are listed in the individual care plans. Residents are offered the choice of having a lock and key for their bedroom, risk assessments are in place for this. Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 Page 17 All rooms have a lockable facility for the storage of personal items and valuables. Two residents said they felt this increased their independence by keeping personal papers themselves rather than handing everything over to the home. There is an on-going maintenance programme and the home was found well decorated and maintained at this time. The home provides adequate attractive communal space. The communal rooms are well used and provide adequate communal space. There is a dining area/ lounge central in the home, which has become a focal area in the home. Two smaller lounge areas also can be used as quiet areas, one on each floor, one, which leads in to the garden. There is also an activity room for the residents use. The lounge/dining area was both clean and well decorated, as were the two smaller lounges. The garden areas are well kept and a source of delight to the residents. Three residents were enjoying the garden during the visit. There are toilet, washing and bathing facilities to meet the needs of the service users, including showers and assisted baths. Specialised equipment to encourage independence is provided e.g. handrails in bathrooms, hoists, wheelchairs and lifts to all areas of the home. A call bell facility is in place and during the inspection the call bells were found in reach of the residents. Though those residents that can’t physically ring for help, need to have an appropriate risk assessment in place. The lighting in the home is of domestic quality and there are above bed lights as well as the main ceiling lights. Beds and chairs were seen to be placed appropriately for maximum benefit of those wishing to read. Water temperatures are controlled and monitored regularly and a record kept. Random temperatures were taken and were of the recommended level. Polices and procedures for infection control are in place and are updated regularly. The home was clean and free from offensive odours on the day of the inspection. Good practice by staff was observed during the day and there were gloves and aprons freely available in the home. Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 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. The staffing levels are sufficient to meet the assessed needs of the residents. There is a robust recruitment process in place, which protect and supports residents. The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their designated roles. Staff are provided with training pertinent to meeting the needs of the residents and to do their jobs competently. EVIDENCE: A staffing rota was viewed. The rota showed that the morning shift comprises of two trained nurses and eight carers, which the staff say is sufficient to meet the needs of the residents. The afternoon shift comprises of two trained nurses and five carers, which was seen to be adequate at this time to meet the needs of the residents. The night shift was staffed by three carers and one trained nurse, this needs to be regularly reviewed and assessed as the needs of the residents are increasing and becoming more complex. The feedback from the night staff was that when it was busy, they found it difficult at times to give the care, but they also said that it depended on the residents needs. Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 Page 19 Staff informally interviewed were able to discuss the training they had received whilst working in the home. Five carers said they had had training in moving & handling, infection control, fire safety, and also study sessions on different illnesses that they care for in the home. One member of staff said she had had her induction training and she felt “well supported by the senior staff and that the training and supervision she had received had enabled her to give a good standard of care”. A sample of induction folders were viewed and the induction programme is of a high standard and all staff receive a certificate when completed. A recent visit by a training body have encouraged the home to seek accreditation status for their induction programme so it can lead into the National Vocational Qualification level 2. Another carer said she felt that the standard of care in the home is high and that the senior nurses were pro-active in providing relevant training. Another carer said that the induction training she received was a good introduction to the home and the job. All staff spoken to said that the senior nurses are great and they all work well as a team. One resident said that the staff were wonderful and knew how to care for her specific needs. Another residents’ comments included “ the staff know how to look after me I would not want to be any where else”. “The staff are marvellous and they look after me very well”, Recruitment files were viewed and were found to have all the relevant information required to safeguard the residents. There was evidence of health questionnaires, Criminal Record Checks, two references, a resume of previous employment and work permits where necessary. All the paperwork is kept in a lockable facility within a locked room. Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 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, 32, 36, 37 and 38. The Registered Manage has the necessary experience and qualifications to run the home effectively. Clear professional leadership is apparent in the home. The ethos is one of kindness and caring. The residents are well cared for in the home. Staff are supported to carry out their duties and ensure that their work is focused on the residents. Policies and procedures in place support an efficient and effective service ensuring the health, welfare and safety of residents. EVIDENCE: Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 Page 21 The Registered Manager is a Qualified Registered General Nurse and has the experience to run the home effectively with support from the Registered Provider. The feedback from residents and staff indicated that they felt supported and were able to approach the manager at any time. The ethos of the home is to focus on the residents and staff were observed doing this. The Registered Provider confirmed that the employment policies and procedures, induction training and informal supervision have been implemented. It was evidenced that formal supervision is in place via a planned programme of six times a year, informal supervision is on going. Regulation 26 visits take place and are sent to the CSCI area office. All records required by regulation for the protection of the residents are in place and accurate. Individual records and home records are kept secure and up to date and are maintained in accordance with the Data Protection Act 1998. The staff are issued with certificates yearly for Manual Handling, twice yearly for Fire Safety and Food and Hygiene. The home has a comprehensive set of policies and procedures, which govern the running of the home. All relevant legislation and procedures are in place in respect of Health and safety. Good practice was observed throughout the inspection in respect of the safety of residents when being moved and transferred. Fire precautions were seen to be adhered to and staff showed a good knowledge of the mandatory training that is required. Recommendations were discussed regarding the chair used for one disabled service user; contact with the necessary professionals was to be made. Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 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 3 3 2 3 3 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x x x 3 3 3 Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 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 OP3 OP7 Regulation 14 (1)(a) (b) 15(2)(b) (c)12(1) Timescale for action That all service users have a pre- 19/09/05 admission assessment completed in full before admission. That a comprehensive plan of 19/12/05 care is generated from a comprehensive assessment and drawn up for/with each service user, and it is reviewed at least once a month, ensuring that they are all dated and signed. That all documentation relating 19/09/05 to the service users specific needs are recorded accurately and reviewed regularly. Risk assessments for those not able to use a call bell to be completed. That all medications are signed 19/09/05 for and that any changes are recorded ,signed and dated. That oxygen bottles are appropriately stored. Requirement 3 OP8 12(1)(a) (b) 4 OP9 13 (2) Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 Page 24 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 12 Good Practice Recommendations That leisure and social activities are subject to review and further development, taking in to account the service users personal references. Ersham House DS0000013983.V253029.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. 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