Inspection on 17/05/05 for Essendene

This inspection was carried out on 17th May 2005.

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

Essendene 02/03/07

Essendene 25/10/05

Essendene 06/01/05

Essendene 29/07/04

Essendene 10/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE ESSENDENE 199 RUNCORN ROAD BARNTON NORTHWICH CW8 4HR Lead Inspector Sue Dolley Unannounced 09:30am 3rd May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Essendene Address 199 Runcorn Road Barnton Northwich Cheshire CW8 4HR 01606-781182 01606 871323 Not applicable Mr Peter Brocklehurst Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Carol Brocklehurst Care Home 13 Category(ies) of OP Old Age (13) registration, with number DE(E) Dementia - over 65 (3) of places ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of thirteen service users to include: * * 2. up to 13 service users in the category of OP (old age not falling within any other category) up to 3 service users in the category of DE(E) (Dementia over the age of 65) The care plans and placements of service users in the category of DE(E) must be subject to at least quarterly review. Date of last inspection 6th January 2005 Brief Description of the Service: Essendene is situated in the village of Barnton approximately three miles from Northwich on Runcorn Road just off the A49 and close to the M56 and M6 Motorways. The mature detached residence is set in half an acre of grounds and at the rear it overlooks the Weaver valley. It is situated close to the village centre anf to amenities such as doctors, a chemist, and post office etc. and is on the main bus routes to Northwich and Warrington. The home was registered in 1991 and offers residential care to 13 older people. Within this number up to three service users with dementia and over the age of sixty-five may be accomodated. Service users are accomodated on the ground and first floors; the proprietors use the floor above. Access between the ground floor and first floors, is by stairs or lift. The home offers accommodtion in nine single bedrooms and two shared bedrooms. Each room is well furnished and decorated and fitted with a call bell system, wash basin and television point. There is one lounge and dining room at the front of the property. The house is a non-smoking evironment except for the rear porch area. There are two bathrooms and five toilets within the house. Grab rails and handrails are provided to corridor, bathrooms and toilet areas and there is a hydraulic bath hoist and personal hoists and vvarious other items of equipment to aid independence and mobility.Service users receive individual, prompt and attentive care in a friendly environment from a courteous staff team. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection on 3rd May 2005 took more than 7 hours to assess whether Essendene was meeting the needs of the residents. A partial tour of the premises included all communal areas, communal bathrooms, toilets and the laundry. Several members of management staff and care staff were on duty, and 5 residents were spoken to. What the service does well: 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. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 6 The admission process is well managed. Needs assessments are thorough and well written,ensuring that care needs are accurately identified. EVIDENCE: Three care files showed that the information in the assessment documentation completed prior to, and shortly after, admission was very thorough. Assessment documentation from Social Service representatives was available. The senior care staff had completed their initial assessments of need, and recorded additional information to assist care staff to adequately meet the individual needs of residents. The manager meets with prospective residents , their families and others to assess whether their care needs can be met within the home. The need for long- term residential care and the home circumstances provided background information to care staff. All care needs were identified, fully recorded and explained, to give care staff sufficient information to provide the appropriate level of care. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 8 Each resident had a plan of care for daily living. Risk assessments had been completed as necessary. Referrals to specialist health care services were evident and reviews of care and placement were completed on time. The daily records of care completed by care staff, provided detailed information regarding any changes noticed and any necessary changes to care. They also provided evidence of good communication across the various staff shifts and continuity of monitoring and care, to promote the well being of residents. Prospective residents, their family members and representatives are encouraged to visit the home. Usually a trial move is undertaken before making the decision to stay. The range of fees charged is currently £330 to £373. Occasionally short periods of respite care and day care have been provided, when places have been available, to assist residents in their transition to long - term care. Unplanned admissions are avoided. Intermediate Care is not provided at Essendene. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 Individual detailed care plans were completed. Changing needs were well recorded with care needs regularly reviewed to ensure appropriate help and assistance is provided. Residents health, personal and social care needs are known and met. Residents welfare is closely monitored and their health needs are promptly met. Residents are encouraged and supported to retain their capacity for self - care to promote independence and wellbeing. Staff members are attentive and thoughtful and residents feel well cared for by kind and considerate staff. EVIDENCE: The three care files checked detailed high levels of need and the fluctuating abilities and health of residents. The residents plans of care contain a personal photograph and highlight how physical, medical, cognitive, recreational and social needs can be met. The residents, family members and representatives from Social Services and health care staff had been involved in the collection of information. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 10 The care plans provided, detailed up to - date information with evidence of regular monitoring and review. The care plans had been regularly monitored at two to four weekly intervals by the Team Leader, based on her own observations, information from colleagues and written information contained in the daily reports. All the three files identified and described changing needs, providing evidence of close monitoring and prompt referral to specialist services, e.g. General Practitioner, district nurse, continence advisor, chiropodist and optician. The outcomes of all medical visits were well documented, promoting awareness amongst the care staff. The records provided information regarding any action to be taken, to assist the residents to maintain ,or regain independence, and to address any difficulties. The care files also documented any changes to resident’s psychological health and provided evidence of regular monitoring and necessary preventative and restorative care. Appropriate risk assessments were undertaken and relevant action to minimise any risks was clearly recorded. Residents can register with a local GP of their choice. A good, responsive working relationship has been developed between visiting health care professionals and staff within the home, to promote the residents`health. The night staff document two hourly checks on residents with more frequent monitoring when appropriate. All night time activity and disturbance was well recorded to assist day care staff and to ensure continuity of care. A key worker system is in place to ensure individual personal care needs are met. A care plan review reminder is also in place to ensure dates of reviews are met and undertaken on time. The medication administration records were well maintained in general, but there were unexplained gaps on the medication records for three residents. One fortified drink was not administered at prescribed times and was given as and when required. Care should be taken when recording the administration of medication.GPs should be notified to amend prescriptions when it is thought that a change in the frequency of administering fortified drinks is necessary. See Recommendation 1. New staff members receive training on induction to treat residents with respect and maintain their privacy. Staff members knock on bedroom and toilet doors before requesting permission to enter. Staff use the preferred name when speaking to residents. The residents open their personal mail. One resident said she received and made phone calls in the privacy of her own room. Staff are provided with written guidance regarding maintaining residents` confidentiality and promoting their rights, dignity, privacy, choice, independence and fulfilment. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Social activities and meals are well managed to provide variation, choice and interest for people living in the home. EVIDENCE: Staff members undertake individual and group activities with residents. Board games and jigsaws are available. Regular activities are arranged e.g. quizzes and beetle drives. Residents talked of Christmas and Easter activities, and a luncheon trip to Smithills Coaching House, where they watched a show. A recent clothing party was particularly enjoyed as it enabled residents to select and purchase new items. Two televisions are provided for general use, many residents have televisions, in their rooms. Several residents also have their own telephones. Residents can receive visitors in the privacy of their own rooms if they wish. Representatives from two local churches visit the home regularly to offer religious support. A visitor explained that relatives and friends are often invited to participate in the home activities, special events and outings. Residents said that they had brought their personal possessions to personalise their rooms. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 12 The senior staff on duty,together with the manager are responsible for the catering and have completed training in food hygiene. The manager uses a four - week menu cycle and individual requests and alternative preferences are accommodated. The menus are nutritionally balanced, with special therapeutic diets provided as advised by health staff. Sample menus showed a wide range of traditional and home cooked foods. A selection of breakfast foods are available with lunch being the main meal of the day. A menu board is prominently displayed in the dining room and residents are consulted about their individual meal preferences. All of the residents spoken to described the food as excellent, and many positive comments regarding the food were overheard. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 A complaints policy and procedure provides residents and their supporters with a forum to raise concerns and have them acted upon. Staff members need to build upon their awareness regarding the protection of vulnerable adults to ensure they know how to safeguard residents. EVIDENCE: One complaint has been received by CSCI since the last inspection. The proprietors are currently acting on the complaint information to investigate and reach a satisfactory resolution. Progress to achieve this is being monitored by CSCI. Within the home a complaints and feedback file records concerns and complaints. Complaints forms are available together with proformas, for acknowledging complaints, together with a form to report the investigation of a complaint and subsequent action. A complaints notice is displayed and a complaints log devised by The National Care Homes Association is on file together with and the contact details of The CSCI. The home has the ‘No Secrets’ documentation together with information from Cheshire County Council regarding abuse or mistreatment of vulnerable adults. Staff are encouraged to read this and are aware of the appropriate action if there is suspicion or allegation of abuse. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 14 Staff members have seen a training video regarding the protection of vulnerable adults and have worked through the accompanying written exercises to test their understanding. Additional external training regarding The Protection of Vulnerable Adults is to be accessed in the near future to build upon current staff knowledge. The proprietors adopt a very high profile within the home and see all residents and the majority of visitors each day. Staff members are advised of the written policy on abuse both during their induction and through NVQ level 2 training. Staff are observed during their induction period to ensure they display appropriate caring and respectful attitudes towards residents. This approach is continued during their employment. A policy and procedure is available regarding the reporting of bad practice and whistle blowing. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 21 and 26 The home is very well maintained, clean and hygienic. It is decorated and furnished to a good standard and this creates a bright,comfortable and welcoming environment for residents. EVIDENCE: Essendene is located on the edge of the village within its own grounds and is separated from the road by its car parking area. The grounds are tidy,safe, attractive and accessible to residents. The home is very well maintained, furnished and equipped to suit residents’ needs. Call points are situated in bedrooms, bathrooms and toilets, with grab rails and handrails provided to aid mobility. A hydraulic bath hoist, personal hoists and a five-person passenger lift are available. A tour of the communal areas bathrooms and toilets was undertaken. As on previous inspection visits, the home was cleaned to a high standard and was welcoming, pleasant and hygienic. Residents said that high standards of cleanliness are always evident throughout the home. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 16 One of the two bathrooms on the first floor includes a toilet, with an additional toilet on the first floor and two toilets on the ground floor. The toilets and washing and bathing facilities are regularly checked by staff, and were clean and well maintained. Since the last inspection to improve hygiene, liquid soap and paper towels are now available for hand washing in the toilet areas. One bath is specially adapted for the less able. A shower is also available for use. Clear written policies are in place to ensure that the home remains free from infection. Infection control is included within the induction training. The home is very well presented and clean. The home does not have a sluice, but has a small washing machine for washing soiled linen at high temperatures. The clean, well organised laundry is situated in a small room away from the residents communal space. The manager ensures that all staff members are familiar with Care of Substances Hazardous to Health (COSHH) guidelines. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 Sufficient staff members ensure the smooth running of the home and residents are cared for in a relaxed and friendly way. Staff members are well trained, closely monitored and competent.Residents feel safe and confident in the carer’s abilities and are assured of attentive and prompt care when needed. The home’s recruitment procedures are thorough and careful staff selection has resulted in a flexible and committed staff team with low staff turnover. EVIDENCE: The manager and fifteen staff provide care and support to residents. Staff members know the residents well and work flexibly to provide continuity of care. Information provided by the proprietors confirmed that 266 care hours are available each week indicating that staffing levels are met. A minimum of two staff including a senior, work 8.00am - 10.00pm each day, and a member of waking night staff from 10pm - 8.00am. The proprietors are committed to providing staff training and supporting staff to undertake NVQ training. The percentage of staff members trained to NVQ level 2 has increased since the last inspection. Currently 8 members of staff have achieved NVQ level 2 and 1 member of staff is undertaking this. Both the manager and care Team Leader have NVQ level 3. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 18 One new member of staff has been employed since the last inspection. The recruitment file was checked and showed a thorough recruitment procedure, including a Protection of Vulnerable Adults first check and an application for a Criminal Records Bureau Check. The home has excellent staff training files, showing a thorough and wide range of training for staff . After reading training procedures and signing to indicate understanding, further understanding and competence is checked by senior staff, before the training records are countersigned. An informative induction pack showed there was evidence of thorough induction training being completed. Conditions of employment were provided along with copies of the health and safety policy and additional guidance notes to inform staff. Care training videos are available regarding manual handling, fire safety and hygiene. Other training videos are available regarding abuse, dementia, risk assessment and health and safety. Further training is being arranged for first aid and food hygiene. The staff communication book ensures important information is exchanged and provides prompts and written reminders to staff to ensure tasks are undertaken, residents` changing needs are met and the staff group operate as a team. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,36 and 38 Both proprietors have successfully run care homes for older people for over 15 years, and hold a range of qualifications. They maintain a high profile in the home, are approachable and work alongside staff getting to know the residents and their relatives well. Feedback is sought and encouraged to ensure the home is run in the best interests of residents. Accurate written records and receipts are kept of residents personal allowance, with balances being accurate. There are good organisation and recording systems in the home. Staff are closely monitored and supervised and health and safety matters are given high priority to promote the health, safety and welfare of residents and staff. EVIDENCE: Essendene is committed to providing quality services for residents, providing caring, competent and well-trained staff in a homely atmosphere. Staff members are recruited who share the owners’ values and there is a staff development programme. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 20 Assessments are undertaken to ensure risks and needs are balanced. The home involves residents in the planning and review of the services to ensure needs are met. The residents are asked about their levels of satisfaction and suggestions for improvement. Feedback forms were circulated to residents relatives in April this year. 8 forms were completed and a whole range of positive comments were provided. The Investors In People Award is due to elapse in June 2005 and Essendene has provided recent evidence to the assessors in preparation for the reassessment. The home continues to improve its services and to respond to changing needs. All the senior care staff have been allocated additional and special duties to ensure the smooth running of the home. A staff member is responsible for health and safety issues, care planning and medication. Another staff member attends to social care, whilst other staff have other responsibilities including first aid, quality and personal care. Shift - planning records and checklists ensure staff complete all domestic tasks and necessary records during their shift. This system prevents various responsibilities from being overlooked and is an example of good practice. Where the individual resident`s money is handled, the manager ensures that their personal allowances are not pooled and that accurate records are kept with receipts. Written transactions are maintained and witnessed. Random samples of personal allowance balances were checked and were accurate. Staff supervision arrangements have improved since the last inspection. Formal staff supervision is recorded and takes place approximately every eight to nine weeks. Recent staff appraisals showed thorough recording which was informative and provided evidence of keen monitoring and observation of staff. Career development needs were indicated, areas of good practice highlighted, and appreciation of work done well. Staff meetings provide good communication channels regarding important issues about the running of the home and demonstrate an open, positive and inclusive atmosphere within the home. The proprietors ensure so far as reasonably practicable the health, safety and welfare of residents and staff and a number of records were checked to indicate this. The fire precautions record book was examined and emergency contact numbers were kept up to date. The fire alarm system is checked weekly and emergency lighting checks are undertaken monthly. A fire safety officer visited on 2/11/04 and made a small number of recommendations which, the proprietor had already actioned in some areas, and was completing in others. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 21 The recommendations were to replace intumescent strips on some fire doors, provide smoke seals on fire door casings, add two smoke alarms and provide a detailed risk assessment to further improve existing fire safety measures. See Recommendation 2. The accident records were examined and provided full details of accidents and resulting action. A clear health and safety policy is made known to staff and applied on a daily basis.The proprietors ensure that staff are suitably trained in moving and handling, and fire safety. Sufficient numbers of staff are trained to administer medication and those members of staff involved with catering duties are trained in food- hygiene and food safety. Data sheets were provided regarding all cleaning substances used in the home, COSHH guidance was available to staff and all products were safely stored. ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 3 x 3 x x x x 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 Standard No 16 17 18 Score 3 x 3 x x 3 x 3 3 x 3 ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action 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 9 Good Practice Recommendations Ensure care is taken when recording the administration of medication to ensure all administration is accurately and fully recorded. Also notify the GP that a change in the frequency of administering a fortified drink is necessary, so that the prescription can be adjusted accordingly and care staff are clear about administration instructions. Liaise with the fire officer and ensure that the fire safety recommendations made on 3.11.04 are satisfactorily addressed. 2. 38 ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI ESSENDENE F51 F01 S6662 Essendene V222786 030505 Stage 4.doc Version 1.30 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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