Inspection on 03/11/06 for Ersham House Nursing Home

This inspection was carried out on 3rd November 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ersham House Nursing Home 23/10/08

Ersham House Nursing Home 26/10/07

Ersham House Nursing Home 13/01/06

Ersham House Nursing Home 19/09/05

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 Key Unannounced Inspection 10:00 3 November 2006 rd 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.V317777.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. Ersham House DS0000013983.V317777.R01.S.doc Version 5.2 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.V317777.R01.S.doc Version 5.2 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). 13th January 2006 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 living 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. Copies of inspection reports and the homes Statement of Purpose are made available on request. Fees charged as from 1 April 2006 range from £490 to £790, which does not include toiletries. Additional charges are made for hairdressing, chiropody, newspapers and outside activities such as visits to the theatre. Intermediate care is not provided. Ersham House DS0000013983.V317777.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Ersham House will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health and social care professionals. This unannounced inspection was carried out on the 6 November 2006.There were forty-one residents in residence on the day, of which six were case tracked and also spoken with. During the tour of the premises ten other residents both male and female were also spoken with. The purpose of the inspection was to check that the requirements of previous inspections had been met and inspect all other key standards. A tour of the premises was undertaken and a range of documentation was viewed including the service users guide, statement of purpose, care plans, medication records and staff training files. Six members of care staff, one trained nurses, activity co-ordinator and the cook were spoken with in addition to discussion with the Registered Manager and the Registered Providers. The pre-inspection questionnaire was received back from the registered manager on the 5 October completed in full. Comment cards received from nine residents and two relatives were positive and indicated that both groups were satisfied with the services provided. Two comment cards were received from healthcare professionals, and as yet no staff surveys have been received from staff. The overall quality of care provided at Ersham House was observed to be of a good standard and the outcome for residents living in the home is one of warmth and comfort. The information contained in the returned surveys has been incorporated into this report. 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. One survey stated ‘ The information about Ersham House is informative and very helpful.’ The atmosphere of the home is pleasant with good interaction seen between residents and staff. A resident said ‘ The staff are very kind, they look after us very well’, another resident said ‘ I love living here, everyone is so kind and helpful’. The residents are enabled to exercise choice and control of their every day life. Ersham House DS0000013983.V317777.R01.S.doc Version 5.2 Page 6 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 snacks are readily available. Robust recruitment practices and a comprehensive training programme ensure the residents health and welfare are protected and promoted. The environment of the home is well maintained and comfortable with a good standard of cleanliness. The management of the home is effective and residents confirmed they are consulted and kept informed of changes in the home. 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. The summary of this inspection report can be made available in other formats on request. Ersham House DS0000013983.V317777.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 Ersham House DS0000013983.V317777.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives are provided with information about the home in order to make an informed choice about whether to live at the home. The pre-admission assessment procedures ensure residents admitted can have their care needs met within the home by experienced staff EVIDENCE: There is a range of well-documented information about the home and the services it provides. This includes a statement of purpose and service user guide. Copies of these are available from the receptionist. One survey received stated ‘ very pleased with the information about Ersham House’. A social care professional that had recently visited the home confirmed that relevant information was provided to a prospective resident. It was confirmed whilst talking to residents that the contract arrangements were clear and understood. Ersham House DS0000013983.V317777.R01.S.doc Version 5.2 Page 9 A review of the care documentation confirmed that pre-admission assessments are completed, and are currently completed by the manager or a senior nurse. The information contained in these assessments is then used to provide the basis of the care documentation in the home. The prospective residents’ are seen either in their home or hospital before admission and the manager confirmed that wherever possible the family or representative is involved. Two relatives confirmed that they were consulted about the pre-admission visit and were given the opportunity to attend. The manager was able to verbally demonstrate her knowledge and awareness of the different specialities required in the home and ensures that the Registered Nurses employed have attended relevant courses to deal with the needs of the elderly and also specialised courses for certain diseases. Trial visits/respite visits to the home can be arranged. The manager confirmed that self-funding residents are invited to a trial period to ensure suitability of the home; this is clearly stated in the Statement of Purpose and in the statement of terms and conditions. Ersham House DS0000013983.V317777.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 & 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally care plans provide a good framework for the delivery of care, however these need to provide clear guidance to care staff on all the care needs of all the residents. The home was found to be meeting resident’s health and general needs with accessed additional specialist support when needed. The policies and procedures in place for the safe administration of medication need to be followed to ensure that resident’s health needs are protected. EVIDENCE: The care documentation pertaining to five residents were reviewed as part of the inspection process. These were found to include plans of care, nutritional assessment, personal histories and risk assessments. The care documentation was full and demonstrated that the care was reviewed and evaluated on a regular basis. However, for some residents there was very little documentation regarding encouraging independence of individuals, whilst in the home for either respite care or long-term care. Another area that has little information Ersham House DS0000013983.V317777.R01.S.doc Version 5.2 Page 11 documented was how staff/visitors communicate with those residents that have speech difficulties. During the inspection it was found that fluid charts were not being filled in accurately, this was discussed with the manager at the time of the inspection. This had been previously identified at the last inspection. There are two clinical rooms, one on each floor and both were found clean and well organised. The medication administration charts were seen and were in the main competently completed. However evidence of tippex was seen, and some verbal orders needed a signature and date of when commenced. The clinical fridges are kept clean and the temperatures recorded daily. Eye drops and liquid antibiotics need to have a date of opening on to ensure that they are not used after the recommended expiry date. The midday medication round was observed and evidenced that the homes policies and procedures for safe administration were not followed. This was discussed in full during the inspection. It was also discussed that residents that are self-administrating some of their medication are appropriately risk assessed and safe practices endorsed by staff. Throughout the inspection it was observed that residents were treated with dignity and respect. One relative said that “ the staff always show respect to residents and nothing was too much trouble”. A resident remarked that” she felt the staff respected her feelings and that she never felt she was a nuisance”. Two other residents said, “the care they received was very good and the staff were always very kind and respectful”. Another relative said the “care could not be better”. One completed survey said ‘as a general comment, I have experienced the standards here to be exemplary and a great credit to the home, I would particularly praise the staff friendliness and level of care they have offered, they have been consistently outstanding’. Residents were addressed by their preferred names and staff were seen knocking on doors before entering. The staff receive training and support from the local hospice and there are policies and procedures in place for caring for those residents with a terminal illness and those dying. Ersham House DS0000013983.V317777.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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social activities and meals continue to be creative and provide daily variation and interest for people living in the home. Residents are able to make a range of choices about their lives as well as maintaining links with friends and relatives. EVIDENCE: The activity programme demonstrates that there is a varied activity programme in place offering a choice for residents on a daily basis. There are also one to one visits in the afternoons where the staff water the residents plants, read letters and take round the sweet trolley. However from direct observation on the day of the inspection little choice was given to certain residents regarding the morning activities and when they said they did not want to go, were told ‘yes you do’. Residents’ wishes need to be upheld, even if it is thought it would be beneficial for them to attend. The activity session taking place on the first floor was dominoes, where residents were observed participating and enjoying themselves, the ground floor activity session was colouring in a picture. Again it was identified that the pictures used for colouring in were perhaps a little childish for residents, and from talking to two residents this was confirmed and for that reason they did Ersham House DS0000013983.V317777.R01.S.doc Version 5.2 Page 13 not attend. It is thought that different levels of pictures offered may prove beneficial and entice residents to join. An individual social assessment for each resident is complied and written on when they attend or the co-ordinator visits them. One survey received stated ‘ various activities are frequently arranged for the residents’. From talking to residents it was confirmed 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 also confirmed that the routines of daily living experienced by the residents have a degree of flexibility; individual residents can request meals at a different time if they are going out and in their preference for getting up and for going to bed. Two residents were outside in the garden ‘helping with the gardening’ and this is something that really value. One resident said that she is getting lazy, and everybody does everything for her. 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 meals continue to be enjoyed by the residents, the feedback from the surveys received were positive, ‘ very good, always a selection’, ‘ the catering is excellent’. Menus rotate on a four-week basis and are nutritious and varied, a choice is always offered. The introduction of a menu in the dining area would be beneficial for the residents’ as many had forgotten what they had chosen. The inspector was offered the opportunity to join the residents for lunch, which was very enjoyable as it was an opportunity to talk to residents as a group. The meal was enjoyed by the residents and the staff were seen to offer assistance to those residents that required help in a dignified and respectful way. The dining area is a pleasantly furnished room, which is also used as a lounge area. It was an observation that it was a day when a large amount of residents came to the dining area to eat, and as result became quite difficult to fit everyone around the tables. Many residents were in a wheelchair, which affected how many could safely fit under the tables, however some residents were loath to leave the wheelchair because they felt it would affect their return to their bedroom. The meal service would benefit from review in this respect. Ersham House DS0000013983.V317777.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 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures in the home ensure that complaints and any allegation or suspicion of abuse made would be managed appropriately. EVIDENCE: The home has a clear complaints procedure and a copy of this is readily available in the home. A system of recording complaints was demonstrated to the inspector during her visit to the home. Residents spoken with confirmed that they knew the complaint procedure, that they had a copy in their room. Relatives and visiting professionals spoken to confirmed that they were confident that any complaints or concerns that they had would be listened to and responded to effectively. The home has relevant guidelines on the protection of vulnerable adults and staff have received appropriate training. The management team has a clear understanding of adult protection guidelines and have initiated this procedure appropriately in the past. Ersham House DS0000013983.V317777.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, 20,21, 22, 23, 24, 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, clean and safe environment for those living there and visiting. Residents are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s personalities and interests. EVIDENCE: The tour of the premises demonstrated that all parts of the home are well maintained and well furnished with good quality co-ordinated furniture. There is an on-going maintenance programme that ensures that the home is maintained to a high standard. The residents are encouraged and enabled to personalise their rooms with furniture and pictures, and two residents proudly showed their personal items. 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.V317777.R01.S.doc Version 5.2 Page 16 It is demonstrated in the care plans and risk assessments that all service users are independently assessed for individual needs and the staff are aware of where to procure specialised equipment 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 the centre of the home and was seen being used by many residents. Two smaller lounge areas also can be used as quiet areas, one on each floor, one that leads in to the garden. There is also an activity room on the ground floor for the residents use. On the day of the inspection the home was found to be warm and comfortable, with good levels of light and ventilation. Pre-set values regulate hot water supplies to areas accessible to residents. Outlets checked showed that hot water was delivered within the safe temperature range. Hot water is stored and distributed at temperatures that reduce the risk of Legionella On the day of the inspection the home was found to be clean and free from offensive odours. Staff ensure a high standard of hygiene and cleanliness and there are procedures in place to ensure that these standards are maintained throughout the home. Suitable laundry facilities are available which meet the required standard, all of which appeared in good working order. Adequate provisions of protective clothing are made available and suitable arrangements are in place for the disposal of clinical waste. There is written guidance for staff on control of infection. Staff consulted demonstrated a good and clear understanding of the risks associated with the spread of infections and diseases, and appeared knowledgeable in relation to how best to reduce such risks. Ersham House DS0000013983.V317777.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 good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements are good and suitable and ensure the needs of the residents living in the home are met. Residents are protected by the home’s recruitment policy and practices and from the training and induction programme. EVIDENCE: The staffing rota was viewed and the staffing levels were seen to be sufficient to meet the needs of the residents at this time. It was confirmed by the manager that there is flexibility of the staffing levels and they are adjusted according to the changing needs of the residents. Staff spoken to say that the levels of staff on duty were sufficient to give the care required, they also said that the trained staff always helped out. Residents also confirmed that they had no complaints regarding the amount of staff, one resident said the “staff are always helpful, they look after me very well”. Another said, “ The staff are really nice, always take time to talk to me”. The surveys received were positive regarding the levels of staff and the care received. Staff files of staff were discussed and evidenced that the home management team follow robust procedures when employing staff. The required information is collected before employment. The induction training is very thorough and staff are supervised closely during this period to ensure they are competent for job they are to undertake in the home. Ersham House DS0000013983.V317777.R01.S.doc Version 5.2 Page 18 Staff interviewed confirmed a high satisfaction with the training provided and stated that recent training was interesting and informative. Staff and records seen confirmed that they had undertaken compulsory training such as manual handling, adult protection, first aid, and food hygiene, fire safety and Infection control. In addition specialist training in understanding dementia, challenging behaviour, palliative care, wound care and catheter care updates are also provided. NVQ training is available and staff are encouraged to complete this, at present only 30 of staff have an NVQ qualification, however this is ongoing. Ersham House DS0000013983.V317777.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, 36, 37 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall management of this home is good with effective systems in place to protect residents. The ethos of the home is open and transparent enabling residents to participate in the running of the home, should they wish to. Ersham House DS0000013983.V317777.R01.S.doc Version 5.2 Page 20 EVIDENCE: The Registered Manager is a Qualified Registered General Nurse and has the experience to run the home effectively with support from the provider. A deputy manager completes the management team. The management structure of the home is strong, competent and has clear lines of accountability. The feedback from residents, relatives and staff indicated that they felt supported and were able to approach the management team at any time. The ethos of the home is to focus on the residents and the staff were observed doing this. Regular staff meetings and resident/relative meetings are held and records of the meetings are kept. The staff spoken with mentioned the staff meetings and how beneficial they were and the staff felt that areas of improvement they put forward were acted for the benefit of the residents. These form part of the quality assurance systems in the home. One resident mentioned that they attended the resident meetings and thought it gave them the opportunity to discuss the running of the home and areas that could be improved. Two other residents also spoke of meetings where they could discuss any issues or problems. They found that they could talk very openly with the staff and felt comfortable in the home. Residents’ financial interests are safeguarded by the homes policies and procedures. All staff spoken with were aware that they must not be involved in any financial matters of the residents, they also said that they would not accept money or gifts from residents. The residents spoken with said they had no worries regarding their financial status, and felt they were supported in managing their affairs efficiently. The training co-ordinator confirmed and the staff training records show that all staff are kept updated on the Health and Safety policies, the manual is available to all and clearly defined. Staff were able to discuss the training they received and said that they were kept up to date with changes to policies in connection with fire safety and health and safety. The staff are issued with certificates yearly for Manual Handling, twice yearly for Fire Safety, three yearly for Food and Hygiene, and a proposed yearly infection control update is due to be commenced. 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. Ersham House DS0000013983.V317777.R01.S.doc Version 5.2 Page 21 Evidence was seen of regular supervision sessions and all staff spoken with confirmed that they receive regular supervision. The manager confirmed that supervision sessions are now in place and will continue. Throughout the inspection good practice was observed in regards to ensuring the safety and well being of the residents when being moved around the building, however all staff including staff are to be reminded of the moving procedures of residents when moving from chair to wheelchair and vice versa. All ancillary staff are to be reminded of using foot rests when wheeling residents in a wheelchair. The accident forms were seen and had been correctly completed with appropriate referrals made as necessary. It was observed that residents did not have access to a call bell facility in the communal areas during the inspection. Ersham House DS0000013983.V317777.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 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 4 3 3 2 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 3 3 3 3 3 2 Ersham House DS0000013983.V317777.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP8 Regulation 12(1)(a) (b) Requirement That all documentation relating to the service users specific needs are recorded accurately and reviewed regularly. In particular fluid charts and communication and maintaining/encouraging independence care plans That the policies and procedures in place for the administration and storing of medication are followed. That tippex is not used on the administration charts. That all verbal orders are signed and dated as taken. That medication with a short life is dated on opening. That a call bell facility or a system of supervision on residents is available for the communal areas. That footrests are in place on wheelchairs when in use to prevent injury to service users. DS0000013983.V317777.R01.S.doc Timescale for action 31/01/07 2 OP9 14 (1) 03/12/06 3 OP22 OP38 13(4c) 23(2n) 23(2&4) 03/12/06 4 OP38 03/12/06 Ersham House Version 5.2 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 OP9 Good Practice Recommendations That a medication audit continues to ensure good practice. Ersham House DS0000013983.V317777.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. 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