Inspection on 25/07/06 for Harts House Nursing Home

This inspection was carried out on 25th July 2006.

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 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

Harts House Nursing Home 03/10/07

Harts House Nursing Home 27/10/05

Harts House Nursing Home 18/04/05

Harts House Nursing Home 12/10/04

Harts House Nursing Home 13/05/04

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 Harts House Nursing Home Harts Grove Woodford Green Essex IG8 ODP Lead Inspector Ms Gwen Lording Key Unannounced Inspection 25th July 2006 10:00 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 DS0000025955.V305037.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. DS0000025955.V305037.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Harts House Nursing Home Address Harts Grove Woodford Green Essex IG8 ODP 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) 0208 502 9111 0208 502 9444 www.bupa.co.uk BUPA Care Homes (GL) Ltd Mr Jonathan Hoyle Care Home 61 Category(ies) of Old age, not falling within any other category registration, with number (61) of places DS0000025955.V305037.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 2 beds may be used for respite care for residents aged between 50 and 65 years To include one named person under 65 years of age. Date of last inspection 27th October 2005 Brief Description of the Service: Harts House Nursing Home is owned and operated by BUPA Care Homes. The home is registered to provide care with nursing for up to 61 elderly people over the age of sixty-five years. The home is situated in a quiet residential area of Woodford in the London Borough of Redbridge. There are good transport links and the home is close to shops and other amenities and community facilities. All the rooms have en-suite facilities and the premises have been fully adapted to accommodate service users with a range of physical disabilities associated with old age and are suitably equipped. The external grounds and the premises are well maintained and secure. The home employs activities co-ordinators, catering, domestic, maintenance, laundry and administrative staff, as well as registered nurses and care staff. On the day of the inspection the range of fees for the home was between £500.00 and £1,400.00 per week. A copy of the Statement of Purpose and Service User Guide to the home is made available to both the resident and the family. Copies of both of these documents are available at the main reception. Copies of the most recent inspection report are available on request from administrative staff. DS0000025955.V305037.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 10am. It took place over six hours during the late morning and afternoon. The registered manager was available throughout the visit to aid the inspection process. This was a key inspection visit in the inspection programme for 2006/2007. Discussion took place with the registered manager; several members of nursing and care staff; the person in charge of the kitchen; and the person in charge of the laundry on the day of the visit. There was also an opportunity to speak to administrative and activities staff. The responsible individual for the service was also visiting the home and she was able to join the inspector’s discussions with the registered manager at the end of the inspection. Nursing and care staff were asked about the care that residents receive, and were also observed carrying out their duties. The inspector spoke to a number of residents and visitors. Where possible residents were asked to give their views on the service and their experience of living in the home. All parts of the home were visited and a number of staff, care and home records were looked at. The inspector would like to thank the staff and residents for their input and assistance during the inspection. What the service does well: The standard of the décor, furnishings and fittings are maintained to a very high standard and provide residents with an attractive and comfortable place in which to live. There is an attractive and accessible secluded garden, which many of the residents and their visitors gain much pleasure from. The nutritional needs of residents are well considered so that food and mealtimes are seen as being important for all residents. Those residents spoken to said that they enjoyed the “quality and variety” of meals available to them. The home fully supports residents to exercise control and choice over their lives and offers a range of activities to suit individuals expectations, preferences, interests and capacities. DS0000025955.V305037.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. DS0000025955.V305037.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 DS0000025955.V305037.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive assessments are being undertaken for all residents prior to them moving into the home. Care plans are drawn up from the information in this assessment, ensuring that the needs of the residents are identified, understood and met. The home does not offer intermediate care. EVIDENCE: Individual records are kept for each resident and a total of ten files were examined. All records inspected have assessment information recorded and the information had been used to continue assessment following admission to the home and develop written care plans. The records showed that residents and their relatives/ representatives and all relevant professionals are involved in the assessment process. The Care Homes Regulations 2001 have been amended with effect from the 1st September, 2006 for new residents, and for existing DS0000025955.V305037.R01.S.doc Version 5.2 Page 9 residents with effect from the 1st October, 2006, so that more comprehensive information is to be included in the service users’ guide. Details of information to be included are contained within the amended regulations. Therefore, the service users’ guide must be reviewed and amended by the stated timescales. Prospective residents and their relatives are provided with an information pack and there is always the opportunity to visit the home prior to making any decision to move in. DS0000025955.V305037.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9,10 & 11. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal care and social care needs are set out in individual care plans and provide staff with the information they need to satisfactorily identify and meet resident’ needs. However, care plans must reflect any changes identified at reviews so as to accurately record changing and current needs. There are clear medication policies and procedures for staff to follow. However, there are some inconsistencies in the recording of medication, which may result in unsafe practices. EVIDENCE: A total of ten residents were case tracked and their care plans and related documentation inspected. All residents had comprehensive care plans, which covered health and personal care needs. Whilst it was evident that care plans were being reviewed/ evaluated on a monthly basis, some of the care plans examined did not reflect the changes which had been identified at the review. All care plans must be updated to reflect changing and current needs. This DS0000025955.V305037.R01.S.doc Version 5.2 Page 11 could be incorporated in the home’s system for updating/ reviewing individual residents holistic care “Resident of the Day”. One resident is identified each day and all elements of their care are reviewed, including meals and activities. As part of case tracking the documentation/ health records relating to wound management; the management of a resident with diabetes; a recently admitted resident and a resident admitted for a period of respite care, were examined. These were detailed and being adequately maintained. Risk assessments are routinely undertaken on admission for all residents around nutrition, manual handling, continence and pressure sore prevention; and reviewed on a regular basis. Turning regimes and fluid monitoring charts were all being maintained up to date. Records indicated that residents are seen by other health professionals such as tissue viability nurse, diabetic nurse specialist and the home has a very good relationship with a local GP. Nutritional screening is undertaken on admission and records maintained of nutrition, including weight gain or loss with appropriate action being taken where necessary. There was no evidence in the files of “End of Life” care plans and the importance of developing these was discussed with the manager and the nurses, during the inspection. However, from conversations with staff and entries in care plans and the inspector’s experience and knowledge of the home it was apparent that staff dealt with a person’s dying and death in a sensitive manner, both for the individual and relatives. Staff were observed to treat residents with respect and the arrangements for their personal care ensure that their right to privacy is upheld. On the day of the inspection the weather was hot and fans were in evidence in communal areas and residents rooms. Staff were observed throughout the inspection offering and encouraging fluids/ iced drinks and ensuring residents were comfortable. There are policies and procedures for the handling and recording of medications. An audit was undertaken of the management of medication on each floor of the home and a random sample of Medication Administration Record (MAR) charts were examined. The following issues were discussed with the manager and the nurses’ in charge: • Handwritten entries on MAR charts must be signed and dated by the person making the entry. The entry must also include the source of the information i.e. GP, registered nurse. • When directions for administering medications are variable e.g. one or two tablets, then the dose given is to be entered on the MAR chart. DS0000025955.V305037.R01.S.doc Version 5.2 Page 12 Risk assessments are undertaken for residents wishing to take responsibility for their own medication, where appropriate. A record is maintained of current medication and a lockable facility is provided in which to store the medication. DS0000025955.V305037.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 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. There is a varied programme of activities available, which suit individual interests, preferences and capacities. The programme provides daily variation and interest for people living in the home. The meals in the home are very good, offering both choice and variety for residents living in the home. The nutritional needs of residents are well considered so that food and mealtimes are seen as being important. EVIDENCE: The home employs one full and one part time activity co-ordinator. The full time person has recently taken up post and is in the process of meeting with residents individually to record their particular interests, preferences and expectations. He is keen to resume community contacts and provide more outdoor activities for individuals; or small groups of people with similar interests. A forthcoming event is “Proms in the Garden”, a classical concert, which will be held in the home’s attractive, secluded garden. Residents and DS0000025955.V305037.R01.S.doc Version 5.2 Page 14 their family/ friends will be entertained by professional musicians and be able to enjoy a picnic and refreshments together. A marquee will be available if the weather is not suitable. Those residents spoken to were very much looking forward to this event. Comments included: “It’s a marvellous idea, my family and I are looking forward to it”……….” It’s nice to experience something again which I enjoyed when I was younger and more independent”. From observation and talking with several residents it was evident that the routines of daily living are flexible and varied to suit the differing needs and preferences of residents. The inspector observed members of staff allowing time for residents to express their wishes and supporting individuals to make choices in their daily lives, for example choosing a drink, where to sit or where they wished to take their meal. Relatives are encouraged to visit the home and there are no restrictions on when relatives and friends can visit. Visiting can be undertaken in the lounges or in the privacy of the resident’s room. On the day of the inspection several residents were entertaining their visitors in the garden. Relatives are encouraged and welcomed to be involved in activities/ special events in the home, in line with residents wishes. The serving of the lunchtime meal was observed and provided residents with a varied, appealing and nutritious meal. There is a wide variety of meals/ snacks for residents to choose from. Residents can choose to eat in one of the dining rooms or in their rooms according to their individual needs and choices. Meals served to residents in their rooms were served on trays laid with tray cloths and were nicely presented. Dining tables were laid with cloths, cutlery and glasses and the settings were very congenial. Pureed meals were presented in an attractive and appealing manner and residents who required assistance were not hurried. Staff were seen to offer assistance where necessary and this was done discreetly and individually. A visit was made to the main kitchen and the inspector discussed the storage and preparation of food and menus with the chef in charge. As part of the “Resident of the Day” catering staff met with the resident and their keyworker to discuss any issues relating to nutrition, choice of food etc. DS0000025955.V305037.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and staff make every effort to sort out any problems or concerns and makes sure that residents and their relatives feel confident that their complaints and concerns are listened to and will be acted upon. Staff working in the home have received training in Adult Protection/ Abuse Awareness to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a written complaints policy/ procedure and the records inspected indicated the number of complaints received and included details of investigation and any action taken. From viewing the complaints records and discussions with the manager it was evident that all complaints/ expressions of concern, whether made formally in writing, or verbally, are taken seriously and dealt with effectively and to the satisfaction of the complainant. Those residents spoken to were aware of how to complain and to whom. There is an in house training programme for all staff in adult protection and this has been extended to include all administrative/ ancillary staff and for all DS0000025955.V305037.R01.S.doc Version 5.2 Page 16 new staff during their induction. Those staff spoken to during the inspection were aware of the action to be taken if they had concerns about the safety and welfare of residents. DS0000025955.V305037.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 23, 24, & 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents at Harts House enjoy a very attractive, safe and comfortable living environment, which with the high standard of cleanliness and maintenance adds considerably to their quality of life . EVIDENCE: A tour of the whole home was undertaken by the inspector. The standard of the décor, furnishings and fittings are being maintained to a very high standard. Two maintenance staff are employed and there is a very effective system in place for staff to report items requiring replacement or minor repair. There is an ongoing programme of refurbishment and re-decoration. DS0000025955.V305037.R01.S.doc Version 5.2 Page 18 There are a number of rooms throughout the home in which a variety of activities can take place. All the lounges have a different atmosphere, to suit individual preferences, needs and interests. For example small, quiet rooms and larger lounges with televisions and music. The external areas of the home are equally well maintained and there is a secluded garden which is fully accessible and well used by many residents and their visitors. From discussion with residents it is evident that they gain much pleasure from the garden, which includes a very attractive sensory garden area. Residents are very much involved in the choice of plants and tending of the garden. All areas of the home were clean, tidy and free from odour. Handwashing facilities are prominently sited and staff were observed to be practising an adequate standard of hand hygiene. The laundry was visited and this was found to be clean, with soiled articles, clothing and foul linen being stored appropriately, pending washing. Personal protective clothing and equipment were available and in use. Two new washing machines and one new dryer have recently been purchased. Adaptations and equipment are in situ which are capable of meeting the needs of all residents. Call alarm systems are provided and were accessible and within reach of residents whilst in their rooms. DS0000025955.V305037.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual assessed needs of the residents. The procedures for the recruitment of staff are robust and provide safeguards for people living in the home. EVIDENCE: Staffing rotas were inspected and the staffing levels and skill mix of qualified nurses and care staff, on all floors of the home, was sufficient to meet the assessed nursing and personal care needs of residents. The home has a relatively stable staff team and effective team working was observed and evidenced throughout the inspection. Staff interacted well, both with each other and residents. At the last inspection three residents commented that they “felt rushed by staff at night”. A requirement was made for the registered providers to review the night time staffing arrangements and ensure that there were sufficient night staff on duty that reflected the number and needs of residents; DS0000025955.V305037.R01.S.doc Version 5.2 Page 20 and the layout of the home. This review has been undertaken and it is evident that the issue is related to staff working practices and not staffing levels. However, two residents spoken to during this inspection commented: “Staff at night don’t take so much time”……….”During the night staff do not respond as quickly to the alarm”. Following discussions with the registered manager and the responsible individual, the inspector was satisfied that the manager is actively and urgently addressing these ongoing concerns with the staff concerned. Several other residents were asked about the care they receive in the home Comments included: ”I have everything I need. Staff are kind, thoughtful and helpful”………….”They are wonderful to me”……….”I am well cared for at Harts House”. An organisational audit was recently undertaken by the Human Resources department which included staff employment files and recruitment procedures. An audit report is provided with details of any actions required by the manager. The inspector is satisfied that the home is undertaking all the necessary checks to ensure the protection of residents. 65 of care staff are qualified to NVQ level 2 or above and a further cohort is planned. The manager has recently successfully negotiated for two students undertaking nurse training to have placements in the home. This will commence in September this year and two of the Registered Nurses have completed Mentorship Training in preparation for the placements. The staffing levels of nursing staff have increased by one since the last inspection and the role of senior nursing assistant has been developed specifically to work alongside care staff. One of the senior sisters has been designated as the Training and Development Co-ordinator and will take the lead on all training issues. There is a welldeveloped and comprehensive training programme for both nurses and care staff. Staff had received training in essential areas such as fire safety, moving and handling, health and safety and first aid. Training for all staff in infection control and basic food hygiene is undertaken through the use of workbooks. DS0000025955.V305037.R01.S.doc Version 5.2 Page 21 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): Standards 31, 32, 33, 34, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The manager of the home is a well qualified and experienced person and residents benefit as the home is run in their best interests. Monitoring visits are undertaken regularly by the responsible individual to monitor and report on the quality of the service being provided in the home. EVIDENCE: The registered manager has been in post for approximately six months. Prior to his appointment the home had been without a registered manager for DS0000025955.V305037.R01.S.doc Version 5.2 Page 22 almost a year, due to prolonged ill health of the then registered manager. During her absence time the home was well managed by the Head of Care. All staff spoken to throughout the visit, spoke very positively about how well supported they felt by the manager Mr Hoyle and the Head of Care, Mrs Mitchell. The manager has an open and inclusive management style and staff commented that he is very approachable. Comments included: “If you have any ideas to improve things, he will listen to you”……..” l feel we have a good staff team, we are all working together for the benefit of the residents”. The manager sets high standards for the home and is committed to provide an excellent quality of life for all residents in Harts House with the support of staff. The home benefits from the quality assurance procedures adopted by the registered organisation, BUPA Care Homes. Regulation 26 visits are undertaken regularly by the responsible individual and a copy of the report is sent to the Commission. On the day of the inspection the responsible individual was visiting the home to undertake such a monitoring visit. The visit covers records and systems in the home including, complaints; accident/ incidents; finance; maintenance; health and safety and fire safety. A tour of the home is also undertaken with notes taken of discussions with staff, visitors and residents. The visit is thorough and a comprehensive report is produced. Such records were therefore not looked at by the inspector during this visit. There are small fridges situated in the servery kitchens on each floor. It was noted that some items of food being stored were past their use by date or not labelled. The manager must be clear whose responsibility it is to check and clean the fridges and introduce an effective system for monitoring any food items stored in these fridges. DS0000025955.V305037.R01.S.doc Version 5.2 Page 23 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 X 3 3 4 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 3 3 3 3 X 3 2 DS0000025955.V305037.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 All care plans must be updated to reflect changing and current needs identified at care plan reviews All handwritten entries on Medication Administration Records (MAR) charts must be signed and dated by the person making the entry; and include the source of the information. When directions for administering medications are variable e.g. one or two tablets, then the dose given is to be entered on the MAR chart 3. 4. OP11 OP38 15 16 “End of Life” care plans must be 30/09/06 developed for all residents. The manager must implement an 25/07/06 effective monitoring system for checking items of food stored in the servery fridges. Requirement Timescale for action 30/09/06 2. OP9 13 31/08/06 DS0000025955.V305037.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000025955.V305037.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000025955.V305037.R01.S.doc Version 5.2 Page 27 - 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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