Inspection on 03/12/07 for Glebe Court Nursing Home

This inspection was carried out on 3rd December 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

Glebe Court Nursing Home 18/11/08

Glebe Court Nursing Home 23/10/06

Glebe Court Nursing Home 17/02/06

Glebe Court Nursing Home 16/08/05

Glebe Court Nursing Home 11/01/05

Glebe Court Nursing Home 09/08/04

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

CARE HOMES FOR OLDER PEOPLE Glebe Court Nursing Home Glebe Way West Wickham Kent BR4 0RZ Lead Inspector Miss Rosemary Blenkinsopp Unannounced Inspection 10:00 3 December 2007 rd X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000010135.V339518.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. DS0000010135.V339518.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glebe Court Nursing Home Address Glebe Way West Wickham Kent BR4 0RZ 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) 020 8462 6609 020 8462 9971 glebecourt@hotmail.com Glebe Housing Association Ms Gillian Payne Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51) of places DS0000010135.V339518.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing (CRH - N) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 51 23rd October 2006 Date of last inspection Brief Description of the Service: Glebe Court is part of the Glebe Housing Association, which provides housing and support through sheltered housing as well as warden assisted bungalows to elderly persons. The Association has one nursing home, which is Glebe Court. This is a purpose built care home for the nursing care of older people. The home is set in its own grounds on Bencurtis Park. There is car parking to the front of the home and a sheltered garden to the rear. The shops at Coney Hall are within walking distance for people with unrestricted mobility and there are various bus routes from Coney Hall or West Wickham. The fees in this home are between £553 and £749 with extra fees payable for hairdressing, chiropody, newspapers and toiletries. DS0000010135.V339518.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted by two inspectors over a one day period. The site visit was unannounced. The Manager was not on duty during the site visit hence Mr Lilly facilitated the process with the assistance of the administrator and qualified staff on duty. Prior to the inspection the home had completed the AQAA document and provided good information and identified areas that needed further investigation. Prior to the site visit comment cards had been sent out to members of the multi disciplinary team. Comment cards were also given out during the site visit as the AQAA information had been received some months previously hence data relating to residents was not current. During the site visit the inspectors met with staff residents and relatives in the home. Generally good feedback was obtained in respect of the service. A number of records were inspected including those in respect of staff recruitment and training as well as those for health and safety. Feedback was provided at the end of the site visit to Mr Lilly. What the service does well: The service provides residents with nursing care in pleasant and comfortable surroundings. The home is well maintained. As far as possible choices are facilitated in the resident’s daily living routines. Staff are provided in sufficient numbers to meet residents needs and additional time provided for completion of documentation, which can be time consuming. This is good practice. In house and external training opportunities are provided to staff to ensure that their knowledge and skills are kept updated. The home is part of the Bromley training consortium. This has been a positive move with training in customer care; first aid; dementia; moving and handling; equality and diversity; loss and bereavement, report writing and safe handling of medication. DS0000010135.V339518.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000010135.V339518.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 DS0000010135.V339518.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are subject to assessments conducted by staff in the home although additional information supplied through the Care Manager’s assessment was absent. Comprehensive assessment information must be obtained, prior to any decision regarding potential placement being made. Assessment information would help to determine the homes ability to meet the resident’s needs. EVIDENCE: At the time of the inspection there were 50 residents on site and no one in hospital. There were two residents who were suffering MRSA . The inspectors selected newly admitted residents to case track. The assessment information for the three residents case tracked was viewed. Glebe Court have developed a comprehensive assessment form to record key DS0000010135.V339518.R01.S.doc Version 5.2 Page 9 information about the individuals’ needs. Where the individual’s placement had been arranged by the Local Authority (LA), there was no evidence of the Care Manager’s assessment. Delays in obtaining Local Authority information was said to be an ongoing problem, however the home must ensure that all information is received prior to admission to enable the decision making process. Viewing of one individual’s assessment showed there to be some confusion as to whether the assessment had been completed through visiting the individual or by conversations with the hospital staff. This should be made clear on the assessment information. There was no evidence of the home confirming, in writing, that after the assessment they were able to meet their needs. Contract information for four residents were viewed. Those that are funded through the Local Authority eventually have Placement Agreements provided by the Authority. The home’s terms and conditions were comprehensive with details of fees including responsibility for payment of fees and how they are to be paid, including nursing contribution, what is included in the fees. Notice periods are also included. Where the LA are funding the care and provide a placement agreement the home must also provide details of their terms and conditions. In one file information showed the funding had changed from private funding to Local Authority funding. The contract had not been updated to show this and this needs to be addressed. The home has produced a Statement of Purpose and Resident Guide, which are made available to all residents. Please see requirement 1. DS0000010135.V339518.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are in place for each resident. These provide staff with good information on how to address the individual’s care. Supporting risk assessments are in place and kept under review. The medications are safely stored, administered correctly and have supporting records in place which provides a safe system for residents. EVIDENCE: The care plans of those residents who were part of the case tracking were selected to view. The home uses the Standex system for care planning documentation. This is a good format and covers all areas required although it can be time consuming to complete. The care plan of a resident admitted September 07 was part of the selection. The care plan included a photograph of the resident and personal details including next of kin contact. DS0000010135.V339518.R01.S.doc Version 5.2 Page 11 The care plan included an outline of the areas of need. The interventions section of this document was to a good standard, and all records included the signature of the nurse, and either the resident themselves or their advocate. The care plan included little in respect of phsycholical and social areas of care with the main focus of physical issues. Supporting risk assessments were in place including those for manual handling nutrition and skin integrity. Daily events records reflected the physical care provide but little on social aspects of care. Some entries needed to be written using more professional terms. There was a medical sheet which detailed visits made by the multi disciplinary team. This record included entries relating to GP visits and an outline of the investigations /examinations undertaken. Included in this record, were entries relating to visits by the dentist, chiropodist and district nursing service. Additional observational charts were also in place and weights were checked regularly. The second care plan was of a similar standard although this resident had a diagnosis of Vascular Dementia as well as other physical conditions. The care plan did not include any of the issues, which may be present when a resident is suffering with Dementia, and this should be reviewed to include such. The findings of the second inspector were as follows. The first care plan viewed contained information about the resident’s identified needs, including one recent care plan regarding a recent health problem. It also included issues about weight loss and indicated the actions taken by staff to ensure the resident’s nutritional needs were being met. Risk assessments had been completed for falls, pressure care, nutrition and moving and handling. All had been reviewed regularly. The pressure care and nutritional risk assessment showed there to be high risks. Both had care plans detailing the action staff were taking when pressure sores had developed. The pressure sore care plan showed the individual to have a grade two sore. There was also a wound care chart in place showing staff treatment of the sore. However, this did not contain details about the dressings to be used. This was included in the care plan, although not obvious to see. The file contained supporting information including records of multidisciplinary meetings and discussions. The records showed that staff had requested advice from the care home liaison team, GP and optician. One carer spoken to had a good knowledge of their role in the prevention of pressure sores and the subsequent treatment. DS0000010135.V339518.R01.S.doc Version 5.2 Page 12 In the allocation book was a “ bathing list “ and beside this a bedroom number was indicated. Information in respect of personal hygiene should be addressed in relation to need and resident choice and incorporated into the care plan. Throughout the tour there was evidence of appropriate equipment in use including mobility aids, hoists and pressure relieving equipment. The medication systems were inspected. The home uses the Boots system. The medication charts all had clear photographs of the individual resident, with their allergies stated. Medications received were recorded. Supporting records relating to those medications in use, were attached, for example a blood pressure chart was in use for one resident. Those medications with a short shelf life, once opened, had the dates of opening recorded. One chart had a hand transcription for a cream, which had no staff signature in place. One chart had a note indicating that if the resident was refusing medication then it should be put in her food. In the event that covert administration of medication is required then full multidisciplinary discussion needs to take place. A record attached to the medication sheet should indicate the medication, which is to be disguised, and in what form. The home should apply the guidance as set out in the UKCC medications publication and that set out by the Royal Pharmaceutical Society. The medication practice was safe. Medications were safely stored in a clinical room within a medication trolley. Records relating to those medications disposed of were in place. The controlled drugs, which were checked, were correct and supporting records in place. One relative’s comment card received contained the following information “medication is always given at the right time which is essential for Parkinson’s disease-------I have asked to be present when the Doctor is seeing my husband and this has been noted”. Please see recommendation 1and 2. DS0000010135.V339518.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A wide and varied activities programme is available which takes into consideration the limited abilities of some residents. Visiting is open which enables family contact. The menu provides a balanced diet and choice to residents. EVIDENCE: In each of the resident’s bedrooms was a communication pad which can be used for information sharing with relatives and is a two-way communication aid. This is good practice. During the inspection there were a number of visitors who were in the home. The inspectors had discussions with some of them and with residents. Visiting is open and encouraged. There was on display throughout the home the activities list. This indicated that a varied programme of activities was available throughout the week. The DS0000010135.V339518.R01.S.doc Version 5.2 Page 14 activities coordinator works hard at engaging residents with activities of their choice. One resident was in her bedroom where she preferred to stay. She did not wish to participate in the group activities, preferring her TV, magazines and visits from her family. She did however refer to the staff’s approach stating it was variable, some good other not so good. One comment card indicated that activities were arranged even for those with limited ability. Prior to lunch the dining area was nicely presented with clothes serviettes cutlery and condiments. The inspector observed the lunch, it looked appetising and portion size was good. The staff that were assisting residents to feed, sat to do so. Two hot menu choices were offered. Three types of juice were offered. It was nice to see that tea was served either in a mug or a cup, which was the resident’s choice. The lunch was an unhurried affair. Comments regarding the food were variable. Comments from residents, regarding the services provided, were good and this was also true of comments received regarding the staff. In one comment card the visitor stated, “ The carers and sisters are always ready to answer my questions and help with any problems”. Visitors who met with the inspectors were in the main fairy positive. One visitor who met with the inspector felt things in the home were reasonable although was unhappy about things going missing citing some make up which had recently disappeared. This was referred to the staff members on duty for attention. DS0000010135.V339518.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information on how to make a complaint is provided and available to residents, relatives and staff. The system of recording complaints needs to be reviewed to ensure clarity and transparency to protect residents. Staff were knowledgeable about what constitutes abuse and residents can feel safe that such allegations will be actioned. EVIDENCE: The AQAA showed there to be 22 complaints received within the last 12 months, all of which had been resolved within 28 days, 2 of which had been substantiated. This was the information provided 11 June 2007. The complaints file was viewed and found to have a higher number of complaints recorded which may have been due to the time delay between the site visit and receipt of the AQAA. Information on how to make a complaint was on display and included within the residents’ guide. This provided details of internal and external avenues for raising issues. The format for recording complaints included details of the complaint, investigation, outcome and whether the person was satisfied with the outcome. DS0000010135.V339518.R01.S.doc Version 5.2 Page 16 However, on reading the complaints record, it showed there to be some confusion over the investigation and outcome components and showed there to be a lack of records about whether the complaint was substantiated. It also required additional information in respect of the action the home is taking to address the issues identified within the complaint. There were some complaints recorded that should possibly have been referred to be investigated under adult protection procedures e.g. theft of monies and offensive written words. This was discussed with Mr Lilly at the site visit who will need to review the complaints process. The home has policies and procedures dealing with suspected abuse and complaints. Staff are provided with training in respect of dealing with abuse. Staff spoken to had a sound knowledge of what constitutes abuse and what they would do if allegations of abuse were raised. Staff also understood the meaning of “whistle-blowing” and what it means to them. Staff recruitment measures also provide safeguards to residents; please see under the section headed “Staffing” for the inspector’s findings in respect of recruitment procedures. Please see requirement 2. Please see recommendation 3. DS0000010135.V339518.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with clean, comfortable and well maintained. accommodation. A selection of sitting areas enables residents to choose how and where they spend their day. EVIDENCE: A tour of the communal areas and the individual bedrooms was undertaken. Bedrooms were found to be clean, tidy and personalised. Many had been redecorated and soft furnishing replaced. There was evidence of clocks and calendars in many bedrooms. It was noted by the inspector that there had been a lot of thought when positioning chairs and in those bedrooms where the residents remained in bedrooms. In other bedrooms the beds themselves were carefully positioned overlooking the garden for example. . The chairs and beds were usually in a position of facing the garden or where the resident could DS0000010135.V339518.R01.S.doc Version 5.2 Page 18 observe the TV. Call bells and fluids were at hand in those bedrooms inspected. Safes, for storage of valuables, were in each wardrobe. There is a ground floor quiet area, which was beautifully presented and provided residents with an alternative to watching the TV. There is a large lounge and dining area located on the ground floor. The home has undergone major refurbishment of the servery and the kitchen. The recent building work also provided a new reception area and a bedroom. There had been a new shower room toilet and WC provided on the ground floor, which was to a good standard. COSHH and other substances, which may be hazardous, were safely stored. Areas were tidy and generally hazard free. The garden was tidy with garden furniture for seating during better weather. External CCTV has been installed for better residents and staff safety. The home has a lift to all floors and most areas are wheelchair accessible. DS0000010135.V339518.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers to meet the resident’s needs. Additional time is allowed for the completion and upkeep of records. Supervision is conducted. Staff are trained to undertake the work they do. Recruitment procedures are in place, although greater attention is needed to ensure that these are fully robust to afford safety to residents. EVIDENCE: On the day of the site visit the home was staffed with a full staff team including qualified nurses, care staff, ancillary and administration staff. The inspectors viewed a selection of staff personnel files including qualified and unqualified staff. The personnel files contained standard documentation including application forms, reference request forms, offer letters, terms and conditions. In one file there was only one reference and the inspectors were unable to locate evidence of POVA or CRB checks made prior to employment. There was also a file note relating to issues with this employee. Supervision notes could not be located. DS0000010135.V339518.R01.S.doc Version 5.2 Page 20 In a second file, good evidence of recruitment procedures were noted. There was an appraisal form dated 14/9/07 although this was not signed by the employee. Standard formats are used for supervision and appraisal and these did not reflect the inclusion of the staff member’s views or indeed any of their comments. Information regarding induction, and thereafter ongoing training, was evidenced. Two other recruitment files were to a satisfactory standard except references, which were without a company stamp or compliment slip to verify authenticity. In some cases the request, on the application form, for a ten-year employment history, was not always supplied. Discussions with four staff including two care staff; one RGN and one domestic, showed that all had a sound knowledge of infection control practices but needed more information on clostridium difficile. Most staff had a sound knowledge of adult protection and how they would report or refer on to the appropriate person. Core training is provided for HCAs and RGNs with moving and handling training provided by an RGN competent to do so. There are currently two qualified nurses who provide this training. It was clear from the training matrix that staff, with the exception of domestic staff, have received training in this area during 2007. This is also true of the provision of fire training for staff with the exception of a few staff whose annual training update was overdue. Training provided in house included moving and handling; fire, food hygiene and COSHH. Some of this is in the form of videos with question and answer format. Food hygiene training is one of those using this method for the care staff, although kitchen staff undertake the food hygiene certificate. In the training summary provided by the home to the association- of the 38 healthcare assistants, 27 have NVQ 2 or equivalent. Four have a higher qualification and twelve are studying for a higher qualification. The home is also now part of the Bromley training consortium. This has been a positive move with training in customer care; first aid; dementia; moving and handling; equality and diversity; loss and bereavement, report writing and safe handling of medication. The home must however send details of the names and number of staff with first aid training i.e. that provided through an outside agency with a competent trainer. DS0000010135.V339518.R01.S.doc Version 5.2 Page 21 The second inspector met with staff throughout the site visit. One care staff was NVQ level 3 trained and was a bank staff member. She demonstrated a good knowledge on all of the topics she was questioned on including infection control, MRSA, clostridium difficile and general heath and safety issues. Please see requirement 3. DS0000010135.V339518.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by a trained and experienced nurse. Health and safety issues need to be subject to greater scrutiny to ensure all measures are in place to maintain the home safely. Receipts for all resident’s transactions should be retained. Quality assurance measures must include Regulation 26 visits, which are conducted monthly, unannounced. In addition an annual quality assurance tool which incorporates the views of residents relatives staff and all stakeholders. EVIDENCE: DS0000010135.V339518.R01.S.doc Version 5.2 Page 23 The Manager of this home is a qualified and experienced nurse. She is an RGN with a post graduate certificate in Management. Currently the Manager is doing a university course relating to caring for people with Dementia. Prior to taking up this position she managed another nursing home in the area. At the time of the inspection she was off sick following surgery, hence the inspection was facilitated by Mr Lilly and qualified staff in the home. The home has in place policies and supporting risk assessments relating to health and safety. A selection of health and safety certificates were inspected including those for gas, electrical and lifting equipment. The certificate for water chlorination was current. The PAT testing for portable electrical appliances, was last undertaken August 06. Mr Lilly stated that the maintenance staff member is due to address this in January 08. The fire alarm had been serviced March and September 07. The weekly fire alarm test was recorded although gaps were evident between 3/8/07 – 22/8/07 and 16/5/07- 8/6/07. The fire alarm must be tested weekly and records retained of that test. An audit of the personal finances of the three/ four residents case tracked was undertaken. There were records in place although the records did not show signatures for monies paid out nor were there receipts for monies coming into the home. Overall there was a lack of receipts for monies spent. All monies were cross-checked with the amounts recorded. These were accurate. Meetings take place regularly for RGNs; care staff and residents and relatives. Minutes are taken of the discussions. There was a long discussion regarding Regulation 26 visits. The discussion revolved around the fact that Mr Lilly was a frequent visitor to the home although no reports were completed. This needs to be actioned and the format must include those items as set out in Regulation 26. The Providers must also undertake a review of the quality of care provided by the home that includes consultation with residents and other stakeholders. Please see requirement 4 and 5.Please see recommendation 4. DS0000010135.V339518.R01.S.doc Version 5.2 Page 24 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 2 X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X x X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 X 2 X X 2 DS0000010135.V339518.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement The Registered Manager must ensure that comprehensive assessment information is received prior to any admission decision and other relevant details recorded including trial visits. Partially met. The Registered Manager must ensure that the complaints information accurately reflects the investigation route the action taken and outcome. The Registered Manager must ensure that all potential staff are subject to robust recruitment checks including CRB/POVA and a fully completed application form. References must be authentic and evidence of this retained. The Registered Provider must ensure that Regulation 26 visits are conducted as well as an annual review of the service. The Registered Manager must ensure that all health and safety precautions are addressed DS0000010135.V339518.R01.S.doc Timescale for action 30/03/08 2 OP16 22 30/03/08 3 OP29 19 30/03/08 4. OP33 24 30/03/08 5. OP38 23 31/01/08 Version 5.2 Page 26 including weekly fire alarm testing. This is now outstanding Previous time frame for action 31/3/07 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 OP7 2 OP9 3. OP16 Refer to Standard Good Practice Recommendations The Registered Manager should ensure that social and phsychological issues are identified in care plans The Registered Manager should ensure that specific guidance is drawn up should covert administration of medications be required. The Registered Manager should ensure that the complaint record, details if the complainant was satisfied with the outcome. All information must be securely retained. The Registered Manager should ensure that receipts are issued for all expenditures. 4. OP35 DS0000010135.V339518.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 DS0000010135.V339518.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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