Inspection on 17/10/05 for Ferendune Court

This inspection was carried out on 17th October 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

Ferendune Court 11/06/07

Ferendune Court 25/04/06

Ferendune Court 25/04/05

Ferendune Court 28/01/05

Ferendune Court 21/05/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Ferendune Court Ash Close Faringdon Oxfordshire SN7 8ER Lead Inspector Carole Moore Announced Inspection 17th October 2005 09:30 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 Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ferendune Court Address Ash Close Faringdon Oxfordshire SN7 8ER 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) 01367 243834 01367 244421 Anchor Trust Samantha Bell Care Home 48 Category(ies) of Dementia (6), Old age, not falling within any registration, with number other category (48), Physical disability over 65 of places years of age (9) Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. On admission persons should be aged 60 years and over. 1 young chronically sick/disabled - Short Stay Nursing Unit. Rehabilitation, Convalescent or Respite for a period not exceeding 6 weeks - Short Stay Nursing Unit. Maximum of 18 persons with nursing needs. The total number of persons that may be accommodated at any one time must not exceed 48 25th April 2005 Date of last inspection Brief Description of the Service: Ferendune Court is a purpose built home that opened in 1992 in Faringdon. It is divided into three units, one looking after elderly residents in their own flatlets, one unit looking after residents for a short stay and one looking after the more dependent resident with long term nursing needs. Each resident in the residential unit has their own flatlet that has a bedroom, lounge, hallway and en-suite shower room with toilet and wash hand basin. Each flat has its own lockable front door, letterbox, doorbell and peephole to enable residents to identify visitors prior to opening the front door. There is one flat identified for residents coming in for short stay. The home has a nine-bedded nursing wing on the ground floor. Each room has its own en-suite facilities comprising of wash hand basin and assisted toilet. One bedroom has en-suite shower facilities. The home has a short stay nursing unit and there are strict admission procedures for these beds. There is an agreement between Anchor Trust and the primary care trust on referrals for admission. There is a good range of assisted baths and toilets in addition to the en-suite facilities. There are two ground floor sitting rooms, and access to a large pleasant dining area. A lift serves all floors. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 5 There is a patio area outside the lounge/dining room with an attractive bank of shrubs and flowers beyond. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that was conducted on Monday, 17th October, 2005 by two inspectors. An additional visit was carried out on Thursday, 13th October, 2005 by an inspector and a manager from the primary care trust to look particularly at the short stay unit where there have been some concerns expressed. The inspectors were made to feel very welcome by both staff and residents and were appreciative of the full co-operation of all the staff that were on duty that day. The purpose of this visit was to look at areas not inspected at the unannounced visit on 25th April 2005 and to look at areas where concerns have been raised in relation to the care records and care planning, primarily for those residents with nursing needs. The inspectors did not look at any areas within the short stay unit. The visit took seven hours and, during this time, the inspectors talked to several residents, some members of staff, the registered manager and her deputy and two members from the National Care Specialist Team within Anchor Trust. The inspectors looked at some written records relating to the care residents were given in both the nursing wings and the residential unit and reassessed the medication records within the nursing wing. Paperwork relating to the health and safety of the home was also inspected along with staff files. The inspectors also toured the building looking at the residential and nursing wing and, with the resident’s permission, visited several individual flats and bedrooms. The home was clean, tidy and mostly fresh smelling. Residents were seen relaxing in the main lounge or in individual bedrooms and in the afternoon residents were seen enjoying some musical entertainment. The inspectors spent time with the two members from the National Care Specialist Team looking at ways to improve the care records for residents, particularly in relation to the residents requiring nursing care. There has been a variety of complaints made by relatives and professionals and this is being fully investigated. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 7 What the service does well: What has improved since the last inspection? What they could do better: The standard of record keeping, particularly the care plans and records for residents with nursing needs, requires major changes to ensure that residents’ needs are being met and recorded accurately. Although the inspectors only found one door wedged open, it is important for reasons of health and safety that this practice does not continue. There are some rooms in the nursing wing that require bathroom cabinets to allow the residents space to put their personal toiletries. Routine stock checks of controlled drugs need to be carried out and recorded. If a doctor orders any alterations to the prescribed medication for a resident, any handwritten entries made on the resident’s medication administration Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 8 record (MAR) sheet should be checked and countersigned by the prescribing doctor as soon as possible, or by the nurse who received the instruction and checked and countersigned by a second person. Stocks of unwanted medication should be more securely stored until the contractor collects them for safe disposal. Additional storage space should be found for disability aids and equipment in the nursing wing, so that residents and staff have free access to the bathroom and hoists. Particular care needs to be taken to eradicate the unnecessary odour in parts of the nursing wing. 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. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 9 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 Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5 The home has updated its information and ensures that all prospective residents receive a copy. Care needs to be taken to ensure that full pre-assessments are carried out. EVIDENCE: All prospective residents are given a brochure highlighting the aims and objectives of the home, setting out clearly the terms and conditions. This enables prospective residents to choose the home that is right for them. Residential Unit: The area of pre-admission assessments was assessed at the last inspection. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 11 Nursing Unit/Short Stay: One resident’s care file was looked at in detail to observe the way in which the home assessed a resident’s needs before they were admitted. The person’s file contained relevant assessment information from health and social care professionals, a completed initial referral form (unsigned) and a transfer letter from a local hospital that gave pre-admission information. However, the Independent Living Agreement (ILA) drawn up after the person’s admission did not accurately reflect the needs’ assessment information. There was little evidence that staff from the home had undertaken a nursing assessment before confirming that the home could meet the person’s needs. The assessment procedure should be improved to ensure that the pre-admission information is clearly set out and comprehensive. Without this there is no assurance that resident’s care needs will be met. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 &10 On the residential unit residents generally have good care plans drawn up with their involvement, and staff respect the privacy and dignity of residents. On the nursing unit there is still room for improvement in both medication recording and care planning. Staff also respect the privacy and dignity of those residents receiving nursing care. EVIDENCE: Residential Unit: A sample of three records of care were examined and each one had the care needs clearly identified and how these would be met. There were clear risk assessments on file and evidence of reviews being carried out. It was also clear from speaking with residents that they are involved in their care planning. One resident’s care plan was not clear in relation to the mobility aspect of their records and care does need to be taken to ensure that all records are up to date. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 13 Residents also confirmed that staff were sensitive and caring and respectful of their wishes. Staff interviewed confirmed that the privacy and dignity of residents was an important aspect of good practice. The medication records were assessed at the last inspection. Nursing Units: Six care plans were inspected and it remains clear that the current paperwork is not helpful in identifying the nursing needs of the residents and what actions need to be taken in order to meet those needs. Two independent assessors arrived at the home on the day of inspection to undertake a review of various aspects of care and record keeping on behalf of Anchor Trust. The assessors said that they agreed that the ILA format of the documentation is not appropriate for recording nursing care and that they would be helping the manager and staff to devise more suitable records to ensure that this improved. They would draw up an action plan for the manager following their two-day visit and would revisit the home at a later date to monitor the improvements implemented. The inspector found that the care plans were not sufficiently detailed, for example in describing wounds or skin damage, and to what extent the wound care given by the nurses – the type of dressing or skin treatment – had improved the resident’s problem. Information was held in different folders, for example blood sugar tests for residents with diabetes were with the medication administration record (MAR) sheets, and residents’ nutritional assessments were also in a separate file. As a result, it was difficult to ‘track’ the outcome of various suggested nursing actions, such as observing a resident’s eating habits and whether the suggested changes to this person’s meals had stopped his/her significant weight loss that had been recorded (8kg in a period of five months). The staff require specific training to further improve the care plans to include more detail of the aims of the nursing care and to what extent the care has met residents’ needs and expectations. The medication administration was re-examined and there are still areas of practice needing improvement, some of which was discussed at the last inspection. There were several examples in the MAR sheets for residents in the nursing wing where a nurse had made hand written changes (following a GP’s instructions). It is good practice for the prescribing GP to check and countersign any alterations to the MAR sheet in person as soon as possible (ideally within 48 hours). If a nurse has to make an amendment, s/he should have a second nurse check and countersign the alteration at the time s/he Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 14 receives the verbal instruction from the GP. Instructions should be written out fully, without the use of abbreviations, to minimise the risk of misunderstandings and errors. The inspector and manager checked the register of controlled drugs prescribed for individual residents and found it to be accurate and complete. At the last inspection the deputy manager said that she does periodically count the number of any controlled drugs held in the home but there was no record of this. This is a good practice additional check to ensure that the records signed by two nurses at the time of each administration of a controlled drug are correct, and that the stock balance tallies. If nurses do undertake routine controlled drugs stock checks, a nurse and another suitably qualified member of staff should do these and they should both sign the controlled drugs register. The ‘returns box’ – a container supplied by a specialist waste disposal company for collection and safe disposal of unused or unwanted medication – was in the ground floor office next to the entrance hall. The box lid was not secured. The office is not always locked and the inspector was concerned that this was not a secure place to keep the medication returns box and advised it should be moved to a more appropriate, lockable cupboard. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 &15 Residents are encouraged to join in social activities and to maintain contact with their families and friends. Residents would prefer a more varied diet. EVIDENCE: The home welcomes all visitors, and there were families visiting on the day of the inspection. Residents have the choice of seeing visitors in their own rooms or in any of the communal areas. There is a new activities co-ordinator and she is keen to meet with all the residents individually to find out their specific interests and to enable them to partake in planned activities or to have some one-to-one time with her. On the day of the inspection she had planned for some school children to visit in the morning but unfortunately they had gone to the wrong venue. In the afternoon there was musical entertainment which most of the residents seemed to enjoy. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 16 Several residents confirmed that there were now more activities within the home, but that they would really enjoy more trips out into the community. Feedback from relatives indicated that their family member was bored, with little to do, or were not encouraged by staff to take part. It is hoped that activities will be more varied and suit those residents who wish to be included. Some of the residents are self-caring and they told the inspector that they were able to exercise choice over how they spend their day. This was also evidenced in their care records. Residents spoken to and the feedback received from relatives all confirmed that “The food could be better”. In discussion with the manager, this area has been addressed and new menus are to be introduced. It is hoped that the feedback from the residents will be taken into account when planning these new menus. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 There is a clear complaints procedure. EVIDENCE: There has been a variety of complaints that have been appropriately logged in the complaint book and addressed within the agreed timescales with the outcome clearly identified. There are some complaints that were forwarded to the Commission for Social Care Inspection and these are still in the process of being investigated. Residents and relatives confirmed that they felt confident that any concern would be listened to and acted upon. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24 & 26 Residents live in a safe and homely environment and there are sufficient toilets and bathing or showering facilities to meet the needs of residents. Overall, residents have access to all parts of the home and have the necessary equipment they need to maximise their independence, although there is inadequate storage space for equipment in the nursing unit. The home is clean and tidy but some areas of the home require special attention, as it is not odour free. EVIDENCE: Anchor Trust is responsible for the programme of routine maintenance and home decoration and it is planned on a yearly programme. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 19 The regulating of water temperatures is carried out by the maintenance handyman but many of the outlets have been recorded higher than the maximum ‘safe’ temperature of ‘close to 43°C’ and the maintenance handyman has had to turn off the hot water supply to those taps in order to protect the residents. The manager told the inspector that this was in hand and contractors would be visiting to investigate the problem and replace valves to enable the water supply to be turned on, and for the water to be at a safe temperature. The Commission for Social Care Inspection should be notified when this has taken place. In the nursing wing residents do not have bathroom cabinets to house their toiletries and this should be rectified before the next inspection. The inspector noted a resident’s toothbrush and urinal on the boxed-in water pipes next to the en-suite toilet. This is unsatisfactory and clearly a cross-infection hazard. In the nursing unit bathroom there is no catch on the ‘engaged/vacant’ lock for the door, so that if a resident were using the bath or toilet, it would not be possible to lock the door to protect their privacy. There is not enough storage space for disability aids such as hoists, so the bathroom is used to store this equipment between uses. The bathroom had a total of six assorted hoists, and a linen trolley in it, so that if residents need to access the bath or toilet, staff have to move all the equipment out first. The inspector considered that staff may be reluctant to use hoists to move residents if it is difficult to manoeuvre hoists and trolleys out of the bathroom. Failure to use hoists, and/or the difficulty in accessing the appropriate hoist from the bathroom, is a potential health and safety matter for staff. Alternative storage space should be found for equipment. The inspector noted that an armchair used by a resident in their room had been covered in a blanket; underneath, the fabric of the chair arm was stained and worn. This chair should be cleaned or replaced. There was no chair for a visitor - the resident said his/her visitors sat on the bed usually. It is understood that the resident’s room had been arranged so that s/he could mobilise more easily and it may be that additional furniture had been removed for this reason. This resident’s room door closer should be adjusted, as it has a very stiff closing device, making the door very heavy for the person to open themselves and which could hinder them getting in and out independently. Also the door closer shut with a series of very loud ‘clunks’ that sounded as though someone was knocking on the door. This would be disturbing to the resident and their neighbours, especially at night. The resident was not able to reach the nurse call bell from the armchair. Most of the building was reasonably clean and tidy and pleasant smelling but the nursing wing does need some attention. There was an unpleasant odour in the corridor, particularly around the bathroom area. The inspector saw evidence of systems in place to monitor the cleaning schedules for the private Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 20 rooms, but feedback from relatives confirmed that there needs to be more vigilance in the monitoring process. Aids such as a passenger lift and assisted baths/toilets are provided for residents and wheelchairs are provided to enable residents to have access to all communal areas of the home, including the courtyard. The inspectors saw several private bedrooms with the permission of the residents and they were clean, tidy and homely. Residents confirmed that they were really happy with their accommodation. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 & 30 There were sufficient staff on duty on the day of the inspection to meet the needs of the residents. The home’s recruitment procedures are robust. There is a now a clear training schedule to ensure that staff are trained and competent to do their jobs. EVIDENCE: The staffing rotas were examined and showed that there were sufficient staff on duty that day. The manager and her deputy are available during the main body of the day. The manager reported in the pre-inspection questionnaire that 20 of the care staff had achieved the NVQ Level 2 training but this does fall below the expected 50 as required. Anchor Trust has implemented new training profiles for all staff, ”Your Career in Anchor” and it is hoped that all staff will be encouraged to embark on the NVQ training and that the training needs for both care staff and nurses will be clearly identified and training provided. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 22 Training is also crucial in the writing of care records and all staff need to have a consistent approach to how records are kept. This, according to Anchor Trust, is due to take place for all staff in 2006. Several staff files were inspected to ensure that correct recruitment procedures had been followed and it was clear that the manager operates a thorough procedure, thus ensuring the protection of her residents. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 &38. The home is run in the best interest of the residents, with their health and safety protected. Residents’ finances are clearly safeguarded. EVIDENCE: There are regular residents’ meetings to ensure that the views of residents are taken into account and residents spoken to confirmed that these meetings did take place on a regular basis. Anchor Trust has produced a document “Residents’ Personal Money” which clearly informs residents and their families how they will look after small amounts of money. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 24 The inspector spoke with the administrator and evidenced the current practice in relation to residents’ personal accounts. There were clear recordings of both money in and out with signatures against all recordings. The fire logs, electrical appliance tests, emergency lighting, lift and hoists servicing and central heating are all maintained under service contracts and the supporting documentation was examined and found to be up to date. As mentioned earlier in the environmental section of the report, the water temperatures are higher than is acceptable in some outlets and, in order to protect the health and safety of residents, the manager has assured the inspector that she is dealing with this as a matter of priority. Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 25 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 X 2 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 38 Regulation OP38 Requirement The home must ensure that fire doors are not wedged open. A suitable device must be installed to allow the resident to have the door open if they wish but ensuring their health and safety in the case of a fire. Timescale for action 01/01/06 2 3 OP3 The home must ensure that a clear assessment of residents’ needs is carried out prior to their admission. 01/12/05 Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 27 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 OP7 Good Practice Recommendations Residents’ care plans must be in sufficient detail, particularly those with nursing needs, to provide clear guidance to staff on the actions that need to be taken to ensure that their health and welfare needs are met. It is again recommended that routine checks of controlled drugs are recorded. The ‘returns box’ for unused medications should be stored in a secure, lockable area. If a nurse makes handwritten alterations to the MAR sheets on the instruction of a doctor, the doctor should check and countersign the entry at the earliest opportunity. If this is not possible, a second nurse or appropriately trained member of staff should check and countersign the first nurse’s amendments. Names of medication should be clearly written and abbreviations should not be used in the administration instructions. It is recommended that residents’ views be listened to and acted upon in relation to meals. En-suite rooms should have wall cupboards fitted for residents to store personal toiletries. Adequate storage areas should be provided for aids and equipment in the nursing unit(s). The standard of housekeeping and cleaning should be consistently maintained to ensure that all areas of the home are kept clean and free from offensive odours. The Commission for Social Care Inspection should be advised when the valves have been fitted on those water outlets that are higher than the recommended maximum of close to 43°C Automatic room door closers should be adjusted so that they operate quietly and effectively and do not impede residents’ ability to use the doors independently. 2 OP9 3 4 5 6 7 OP15 OP21 OP22 OP26 OP38 Ferendune Court DS0000027147.V252501.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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