Inspection on 24/09/07 for Farm Lane Care Home

This inspection was carried out on 24th September 2007.

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

Other inspections for this house

Farm Lane Care Home 19/01/09

Farm Lane Care Home 21/04/08

Farm Lane Care Home 11/09/06

Farm Lane Care Home 09/02/06

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Farm Lane Care Home 17 - 25 Farm Lane Fulham Broadway London SW6 1PX Lead Inspector Ffion Simmons Unannounced Inspection 10:30 24 & 25 September 2007 & 11th October th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Farm Lane Care Home DS0000064137.V342854.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. Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Farm Lane Care Home Address 17 - 25 Farm Lane Fulham Broadway London SW6 1PX 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) 0207 386 4180 manager.farmlane@careuk.com manager.burroughs@careuk.com Care UK Community Partnerships Ltd Bright Tendekai Gurupira Care Home 66 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (24), Old age, not falling within any other of places category (40) Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registration be for: Care Home with Nursing Ground Floor - 14 Older People First Floor - 25 Older People Second Floor - 25 Older People First and Second Floor 1 Younger Adult per Floor 11th September 2006 Date of last inspection Brief Description of the Service: Farm Lane is a care home providing accommodation and nursing care for older people, people with dementia and people in need of rehabilitation before returning home after a stay in hospital. The home opened in September 2005 and is located in a residential area of Fulham, close to shops and other local facilities. Accommodation is provided on the ground, first and second floors and there is a large attractive roof garden and conservatory. Passenger lifts enable people living in the home to use all parts of the building. The weekly fee for the service ranges from £650 to £892.50 Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection took place over three days and lasted a total of 20 hours. The inspector spent time talking to the Registered Manager and Deputy Manager, and staff. Residents, relatives, staff and visiting professionals were given the opportunity to feedback on the quality of the service in person and/or by completing satisfaction questionnaires. A range of documentation was checked during the inspection, which included staff and residents’ records, complaints documentation, health and safety documentation and medication records. Two hours of the inspection were spent observing the care being given to a small group of people using the Short Observational Framework for Inspection (SOFI) methodology. What the service does well: What has improved since the last inspection? The home has successfully met a number of requirements since the last inspection. Residents with pressure sores now have their wounds mapped and photographs are taken to show changes in the condition of the wound. Preadmission records are completed thoroughly. Improvements were noted in the provision of staff training. Staff are now upto-date with manual handling mandatory training and food hygiene training. Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 6 A photograph of the resident is now included on the Medication administration record sheets The Manager has successfully registered with the Commission as the Registered Manager of the home. An annual quality assurance survey for the home has been produced, that contains all relevant information. 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. Farm Lane Care Home DS0000064137.V342854.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 Farm Lane Care Home DS0000064137.V342854.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): 3, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A full needs assessment is undertaken prior to admission by a competent person. EVIDENCE: “All staff from senior to junior are friendly, efficient, and helpful. They have made my stay pleasant and improved my mobility from my arrival” “with the help of staff I am able to walk a little bit more. Some staff are very nice and very sweet” (Comments form residents) The home has an admissions policy, which outlines that following the initial referral and receipt of care management assessment, the home arranges to visit the prospective resident to carry out a full needs assessment. Assessments were on the files of the residents tracked during the inspection process. There has been an improvement noted in this area. Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 9 The home offers physical rehabilitation support to residents on one of the units within the home. This unit is staffed by specialised staff including Occupational Therapists, Physiotherapists and rehabilitation assistants. The average length of stay within the unit is six weeks, where an intensive programme is drawn up with the involvement of each individual. The unit is well equipped with specialist equipment for promoting independent in activities of daily living to enable residents to return home. Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs are well assessed and outlined in their care plans, which are regularly reviewed. Improvements are needed in the management of medication in the home. There is a need to improve the monitoring of residents’ health and respond by referring concerns to the appropriate health care professionals. EVIDENCE: The care records of eight residents were checked during the inspection. Each resident had individual care plans in place that were regularly reviewed and updated as necessary. Since the home’s last key inspection, a new computerised care planning system has been introduced to record their health, personal and social care needs. Each resident has an allocated key worker and support worker for promoting continuation of care to the residents. The needs of residents were well assessed. The assessments included manual handling, continence, sensory, risk of falls and Waterlow (for assessing risk of developing pressure sores). Night care assessments were also completed outlining preferred times for going to bed and getting up. Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 11 The home has a contract with a GP who visits the home twice weekly. Good support is also provided by the physiotherapists and occupational therapists, which are based on site. The inspector noted that where a resident has a wound including pressure sores, these are now mapped and photographs are taken as per the requirements of the last inspection report. The inspector noted that specialist advice had been sought from the Tissue Viability Nurses. It is a recommendation that when specialist advice has been provided by the Tissue Viability nurse, that this is included in the residents’ care plan. Steps should also be taken to note down on the wound charts the dressings used when redressing the wounds. Each resident’s nutritional needs are assessed and the risk of malnutrition is also assessed. The inspector noted that some residents had been identified as being at high risk of malnutrition. There was no evidence in all cases that the input of the dietician had been sought. It also remains a requirement that when a service user food and fluid intake is poor that the staff are monitoring and taking daily records. The medication management was checked on two of the four units during the inspection. Medication is received into the home mainly in blister packs. On both units, medication was securely stored. The room temperatures were monitored daily in both units and these recorded correctly. Fridges were available on both units and the minimum and maximum temperatures within the fridge were being recorded and were within correct temperatures. It is a requirement that the date of opening is noted on all liquid medication. The medication administration records (MAR) were checked on both units. The MAR charts were well completed on one unit but there were gaps noted in the MAR charts on the other unit. The inspector also noted that some medication had been signed for when they remained in the blister pack. There was also a discrepancy between the frequency of dose for a controlled drug on the MAR chart and the dispensing information on the medication’s label. The manager was asked to investigate the discrepancy. Some of the MAR charts were difficult to read on one unit as it appeared in some cases that a symbol was used and a signature appeared in the box as well. There is also a need to ensure that when the letter F is used in the medication administration records for when medication is not administered, this must be defined. The inspector noticed that a picture appeared with the MAR charts, which is an improvement from the last inspection. The inspector also noted that where allergies were known, these were noted on the MAR charts. It is recommended that the medication policy is kept with the MAR charts to enable staff to refer to the policy easily and quickly. One of the resident currently receives a variable dose of Warfarin. When the inspector asked to see the latest International Normalised Ratio (INR) blood results, it could not Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 12 immediately be found. It is a requirement that the latest blood results are kept with the MAR charts for ease of reference. Controlled Drugs were in use in one of the two units. A controlled drugs register was in use in the home and correct entries were made in the book. It is a requirement that the index page of the controlled drugs register is kept up-to-date so that the correct page can be found easily. Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to be involved in meaningful daytime activities of their own choice and according to their interests. Mealtimes are unhurried and relaxed. EVIDENCE: Designated activities staff are employed in the home to arrange group and 1:1 activities. Information regarding residents’ interests and participation in activities are recorded by the activities staff. During the inspection, the inspector noted that a bingo session was taking place on one of the units, which involved a resident calling out the numbers. The inspector also noted residents being supported to use the sensory room. Information taken from the Annual Quality Assurance Assessment (AQAA) completed by the Registered Manager outlined that an in house hairdresser is available on a fortnightly basis and residents are able to choose to have their hair done within the home or are accompanied to the local hairdressers. The AQAA also outlined that the home has established links with the Metropolitan Police (Safer neighbourhoods team), a church singing group and with a local school (Fulham Primary) for the provision of activities and links to the community. Checking the visitor’s book and observation during the inspection provided the evidence that many visitors visit the home and are welcomed. Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 14 Mealtimes in the home were observed on two of the three units. The tables were nicely laid out and the atmosphere was a pleasant and relaxed. If residents required prompting, it was carried out in a quiet, encouraging and patient way. Residents commented that on the whole they were very pleased with the quality of food. A varied menu is offered and residents’ cultural needs are ascertained and a meal of their choice is provided. The Manager has agreed to look into the comments received from a resident that “the vegetables are cooked to death”. The home has Kitchenettes on each of the floors where residents and visitors are able to access hot and cold drinks on the units. Nutritional assessments are carried out on all residents and there is a need to ensure that when residents are identified of being at risk of malnutrition that the input of the dietician is sought. It also remains a requirement that when a service user food and fluid intake is poor that the staff are monitoring and taking daily records. Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that meets the standards and regulations. The procedure is up to date and accessible in the home. Policies and procedures for safeguarding people who use the service are in place but referrals are not always made due to inconsistent knowledge and practice within the service. EVIDENCE: The home has a clear complaints policy and this is displayed on notice boards on each unit. There is also a suggestions box available at main reception where residents and visitors may suggest ways for improving the service. The complaint records were checked during the inspection and the inspector noted that computerised complaint records are now being kept. The complaints records were well completed and a summary log of all complaints received is in place for ease of monitoring. The home has an adult protection policy in place and staff have received abuse awareness training. The inspector however noted that on one occasion an incident had occurred which fell under the adult protection policy. This was not reported immediately as per the local multi-agency policy for the protection of vulnerable adults. The inspector also noted that an allegation had been recorded as a complaint, and the incident was not identified as an adult protection issue. The inspector could not see evidence that this allegation had been reported immediately to the local authority’s adult protection team and the CSCI had not been notified as per the requirements of regulation 37. These incidents were discussed with the Manager and the Deputy Manager during the inspection. Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides excellent standards of accommodation. The home is well-maintained and clean. EVIDENCE: “maintenance is very good and always sees to it that service users concerns are mostly met” “gives the freedom to family and friends of service users to always feel at home”. (Comments from questionnaires) The home is a purpose built, modern building, with all parts of the home being wheel chair accessible. The home is safe and secure and security cameras are in place at both entrances to the home. Entry to the home is via video telecom system to enable staff to identify visitors prior to allowing access. There is a good amount of private and communal spaces for residents and Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 17 their relatives to enjoy. These areas include a sensory room, library and there is also a roof top garden available. There are also sufficient lounge and dining areas available. The home is well furnished and well maintained providing an excellent standard of accommodation. The inspector noted that the home was very clean and free from any malodours. Domestic staff are employed. There are two sluice rooms on each floor, which are situated on each wing of the building. A laundry service is available. Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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. People using services are generally satisfied that the care they receive meet their needs, but resident and staff commented there are times when the home seems short staffed. Recruitment policy and practices are thorough and the provision of staff training has improved. EVIDENCE: Each unit has a rota in place outlining the staff on duty. On each unit, there is a Registered Nurse on duty during the day and night. On Tuesday and Friday of every week, this number is increased to 2 Registered Nurses on duty on each unit between 08:00 and 14:00 to assist with the General Practitioner’s visits. The following comments were received with regards to the staffing in the home: “The unit rota are usually in place to ensure that the shifts are covered with staff but there are cases staff might be sick or have an emergency and calls the shift off, there may be a replacement staff or the shift may be short by a staff”. “I don’t need them often. Home appears short staffed quite often” “provide more staff since service users demands are more than staff on duty during the day.” “could be more staff” Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 19 “In a nursing unit of 26 service users, one qualified nurse is not adequate to meet their nursing needs” “More nurses to work in the units” (Comments from residents and staff) These comments were shared with the Manager during the inspection and the Manager is asked to keep the staffing levels under review to ensure that residents’ needs are fully met. Information taken from the Annual Quality Assurance Assessment (AQAA) documentation completed by the Registered Manager prior to the inspection, confirmed that 54 of care staff have an NVQ2 qualification or its equivalent. A further 12 of care staff are currently enrolled. The Manager confirmed that all new staff are undertake a 6week induction programme which covers links to the NVQ2 programme. New computerised training programmes are in use in the home enabling staff to access training any time of the day. The home has worked hard to improve the provision of training in safe working practices, including manual handling and food hygiene. The homes’ recruitment procedures were checked during the inspection and the personal files of five staff were checked. The staff files were in good order and there was evidence that the necessary pre-employment checks including enhance Criminal Records Bureau checks and checks against the Protection of Vulnerable Adults List are completed. Two employment references are obtained; past employment history and all gaps in employment are examined and discussed during a face-to-face interview. Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager is competent and qualified and is of good character. Improvements are needed in the provision of formal staff supervision. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The home has a Manager in post, who has successfully registered with the Commission as the Registered Manager. He has a Diploma in Dementia Care and has completed the NVQ 4 Registered Managers Award. The Manager is also a certified trainer and has worked in both residential and nursing care settings at senior levels within the company for the last 7 years. In support of the Manager, there is a Deputy Manager with RGN qualifications and has a minimum of 25hours per week of clinical management time. The Annual Quality Assurance Assessment (AQAA) completed by the Registered Manager as part of the inspection, outlined that each of the three Nursing units is managed by an experienced Lead Nurse (Unit Manager). The information also Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 21 confirmed that the Unit Manager for the Dementia Nursing Unit is RMN qualified. The inspector found both the Manager and the Deputy Manager to be friendly and accommodating throughout the inspection process. They were open and responsive to the inspector’s feedback and set about to improve on some areas of practice immediately. Residents and staff commented positively on the Management arrangement and felt that the Manager always had time for them and was approachable. The home’s quality assurance system includes the distribution of annual satisfaction questionnaires to all residents, relatives and/or advocates. Residents on the short stay rehabilitation unit, are asked to complete questionnaires when they leave the home following their period of rehabilitation. The Manager confirmed that information from these questionnaires is collated and used to improve the service. The Manager also confirmed within the AQAA that quality improvement plans and target dates are developed following inspections within the home. The inspector noted that a suggestion box is in use where residents are visitors are invited to comment and suggest improvements to the home. The inspector, in discussion with the Manager noted that these suggestions are taken into account. Visits on behalf of the registered provider take place on a monthly basis to assess the quality of the service as per the regulations. Copies of these reports are shared with the Registered Manager and forwarded to the CSCI. The home has an up-to-date policy for managing residents’ money, valuables and financial affairs. Lockable drawers are available in all rooms for resiedents to keep their money securely. Should residents require assistance with managing their money, a safe is available in the home for safekeeping and records of all transactions maintained. During the inspection, the personal files of five staff working in the home, were checked. Supervision records were held within these files showed that not all staff are receiving regular supervision and an appraiasal of their work. It remains a requirement of the last two inspection reports that staff receive regular formal supervision. The documentation relating to the management of health and safety in the home was checked during the inspection. The health and safety records were up-to-date, showing that equipment is regulaly serviced and checked. There are two maintenenance staff employed in the home , who are responsible for maintaing standards in health and safety. Improvements were noted in the training provision for staff in safe working practices, inluding manual handling, food safety and Cardio Pulmonary Resucitation. Accidents and incidents are reported and monitored. Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 4 4 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 23 Yes 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 OP8 & OP15 Regulation 13 Timescale for action Steps must be taken to ensure 01/11/07 that residents receive the input of a community dietician and the GP when they have been identified of being at high risk of malnutrition and where concerns about their nutritional and fluid intake have been identified. The Manager to make sure when 01/11/07 care plan shows that a service user food and fluid intake is poor that the staff are monitoring and taking daily records. Original timescales of 28/02/07 nit met, this is a repeat requirement. The date of opening of all liquid 01/11/07 medication must be recorded. All medicines must be given as 01/11/07 prescribed and must be recorded accurately when administered. If not administered the correct endorsements must be used. When the letter F is used in the 01/11/07 medication administration records for when medication is not administered, this must be defined. DS0000064137.V342854.R01.S.doc Version 5.2 Page 24 Requirement 2 OP8 & OP15 17 3. 4. OP9 OP9 13 (2) 13(2) 5. OP9 13 (2) Farm Lane Care Home 6. 7. OP9 OP18 13 (2) 37 The index of the controlled drugs register must be kept up to date. 01/11/07 The Registered person shall give 01/11/07 notice to the Commission without delay of any allegation or event in the home, which adversely affects the well-being or safety of any resident. The Manager must ensure that 01/11/07 all incidents and allegations of abuse are reported as per the multi-agency policy and procedures for the protection of vulnerable adults. The Manager and Unit Managers 01/11/07 to make sure all staff are receiving regular supervision sessions. Original timescales of 28/02/07 This requirement is repeated for the second time. 8. OP18 13 [6] 37 9. OP36 18 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 OP8 Good Practice Recommendations When specialist advice has been provided by the Tissue Viability nurse, this should be included in the residents’ care plan. Steps should also be taken to note down on the wound charts the dressings used when re-dressing the wounds. The medication policy should be kept with the MAR charts to enable staff to refer to the policy easily and quickly. The latest INR blood results should be kept with the MAR charts for ease of reference. The Manager should keep the staffing levels under review to ensure that residents’ needs are fully met. DS0000064137.V342854.R01.S.doc Version 5.2 Page 25 2. 3. 4. OP9 OP9 OP27 Farm Lane Care Home Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Farm Lane Care Home DS0000064137.V342854.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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