Inspection on 22/08/05 for Hayes Cottage

This inspection was carried out on 22nd August 2005.

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

Hayes Cottage 16/07/07

Hayes Cottage 04/09/06

Hayes Cottage 09/01/06

Hayes Cottage 24/02/05

Hayes Cottage 02/08/04

Hayes Cottage 15/01/04

Hayes Cottage 05/08/03

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Hayes Cottage Grange Road Hayes Middlesex UB3 2RR Lead Inspector Clare Henderson Roe Unannounced 22 & 23 August 2005 10.10am nd rd The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hayes Cottage Nursing Home Address Grange Road, Hayes, Middlesex, UB3 2RR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0208 573 2052 0208 573 5593 haycott@aol.com Hayes Cottage Nursing Home Ltd. Ms Ani Grace Manayin Care Home 54 Category(ies) of Old Age registration, with number of places Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Six of the beds currently registered may be used as Palliative Care Beds as agreed by the Commission for Social Care Inspection, on 1st August 2005. Date of last inspection 24th February 2005 Brief Description of the Service: Hayes Cottage Nursing Home was previously the Hayes Cottage Hospital. The building has been developed and extended to its present condition. The home provides accommodation for 54 service users who require nursing care. The home has a contract with Hillingdon Social Services for 12 respite care beds, six of which can be used to provide palliative care, and these are included within the total of 54 beds. There are 44 single rooms, 13 with en suite facilities, and 5 double rooms, one with en suite facilities. There are several sitting areas to include a conservatory, plus a main dining room. The garden is well maintained and has chairs, tables and parasols for the use of service users and their visitors. The home is situated in a residential area of Hayes. It is well maintained and has a good atmosphere. The Beck Theatre is within walking distance from the home. There are shops and local amenities plus Hillingdon Hospital close to the home. The home has a social activities policy, which lists many ideas for social activities throughout the year and also ideas for diversional therapy on a dayto-day basis. Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 14 hours were spent on the inspection process. The Inspector carried out a general tour of the home, and inspected administration, staffing and refurbishment records, plus 5 service user plans. 13 service users, 6 visitors and 10 staff were spoken with as part of the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 & 5. The home does not provide intermediate care. Service users are assessed prior to admission to ensure the home can meet their needs. Prospective service users and their representatives are encouraged to visit the home in order to allow them to make an informed choice. EVIDENCE: A pre-admission assessment is carried out for all prospective service users to ascertain that the home is able to meet their needs. This includes for service users being admitted for respite care. Where possible service users are encouraged to visit the home prior to admission, where this is not possible the service users representative is encouraged to visit. Visitors spoken with confirmed that they had visited the home to view it and these visits could be made either by appointment or unannounced. The home does not accept emergency admissions at this time. Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 & 11 Service user plans were not always up to date, and this can place service users at the risk of not having their needs fully met. Shortfalls in the storage of medications potentially place service users at risk. Staff are courteous to service users and personal care is provided in such a way as to promote and protect the service users privacy and dignity. Staff have received training to promote the care of service users with palliative care needs. EVIDENCE: Five service user plans were viewed. These were generally comprehensive although some needs had not been addressed. Not all the service user plans viewed had been reviewed each month. Risk assessments for falls had been completed and the Registered Manager stated that there had been no recent falls at the home. Some of the service users and representatives said that they do have involvement in the review of the service user plan. A system of evidencing this involvement needs to be formulated. Care plans to address service users oral care needs were not always in place. Pressure sore assessments had been carried out. In one instance the assessment had not identified a skin break at a time when the service user did have a wound. Documentation had been formulated for identified wounds, but Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 9 in some cases these required reviewing to clarify the condition, progress and treatment for each wound, and also to ensure that the documentation was up to date. Pressure relieving equipment was seen in use in the home. Moving & handling assessments and care plans for moving & handling needs had been completed. Care plans had not always been formulated for every care need, for example, for one service user with continence care needs, no continence assessment or care plan for continence care was seen. The risk assessment/reason for the use of bedrails needed expanding to clearly identify the need for and appropriateness of their use. Written consent for the use of bedrails is obtained from the service user or their representative. For one service user, the daily record indicated that bedrails were in use, but no assessment or written consent was seen. The shortfalls identified with the service user plans were discussed with the management at the time of inspection. The home is not registered to accommodate service users with dementia, and the Registered Manager is very clear about this. Care plans had been formulated for service users who had a level of confusion identified, and the Registered Manager said that where necessary referrals are made to the GP. Nutritional screening is undertaken and monthly weights are carried out, with increases in frequency should weight loss be identified. Food charts and fluid charts are in place for all service users. All service users are registered with a GP practice, and the GP visits weekly and when necessary. There is also a weekly visit from the Doctor from the palliative care team, to review those with palliative care needs. There was evidence of referral to and input from healthcare professionals. Some staff had undertaken training in foot and nail care and can carry out simple chiropody for service users who do not have any medical need requiring input from a qualified chiropodist. The temperature in clinical room on the ground floor was reading as 38º centigrade, despite an air cooler unit being in place. The record of temperatures indicated that for several months both the room and fridge temperatures had been well above the safe levels of 2-8º centigrade for the fridge and 25º centigrade for the room temperature. It did not appear that this situation had been being monitored. The excess temperatures are a repeat finding from previous inspections. Action was taken on the day of inspection to move the medications affected to the clinic room on the first floor, where the temperature is better controlled. The need to ensure that all medications are stored at the required safe temperatures was discussed and must be fully addressed. Registered nurses administer the medications. Records of receipts and administration are maintained, with one omission in signing noted and two findings where the stock of medication did not tally with the number of doses signed for. All other medication administration record (MAR) charts viewed were fully signed and where medication had been omitted, appropriate coding to indicate the reason for omission had been recorded. Where a variable dose of a medication is prescribed, the actual dose given was not always being identified on the MAR chart. Information regarding dosages of anti-coagulant Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 10 therapy is kept with the service users MAR chart. All medications were being stored securely. Dates of opening had been written on the liquid medications, plus on boxes of medications not issued in the monitored dosage packs. There are good practices in place for the administration of controlled drugs. Where controlled drugs are not being administered on a daily basis, a stock check must be recorded, and as good practice this should be done each day. The Registered Manager said that she does check the stocks of the controlled drugs when she carries out her monthly audit of medications. The dispensing pharmacist usually carries out three monthly medication audits, but had missed the last audit date. The home is aware of the changes in the disposal arrangements for medications and the Responsible Individual has confirmed that appropriate disposal arrangements have now been put in place. One service user on respite placement who was self-medicating was fully aware of the need to store their medications securely and lockable facilities had been provided. Where oxygen therapy is being used, clear warning signs are displayed on the door of the room. Apart from the issue with storage temperatures, medications were being generally well managed at the home, and the shortfalls identified should be easily addressed. Staff were seen caring for service users in a gentle and courteous manner, showing them respect and preserving their privacy and dignity. Service users spoken with said that they are being well cared for. There was a very good atmosphere throughout the home. Several service users have their own private telephone and service users can have access to the home telephone. The payphone was out of order and the Registered Manager said that this would be addressed. Service users were dressed in their own clothes, and their preferred term of address is recorded and respected. Visits by healthcare professionals are carried out in the service users own rooms. Screening is available in the double rooms. One service user in a double room is awaiting a single room, and the home is addressing this. The home is registered to accept up to 6 service users with palliative care needs. The service users are referred by the Hillingdon Palliative Care Team, who also manage the medical care of the service users. Input is also provided by the Macmillan Nursing Team, plus the home has access to Michael Sobell House Hospice and out of hours contact details for the palliative care services. Staff had undergone palliative care training via Michael Sobell House Hospice, with further training planned. Two registered nurses are due to commence courses in palliative care in September 2005. The service user and, where appropriate, the family are consulted about their wishes for their care. Single rooms are provided for service users with palliative care needs, and service users can spend their final days at the home unless there is a medical reason to prevent this, with friends and family visiting and staying with them as they wish. Policies and procedures are in place for care after death, and the need to formulate procedures for the care of the dying, to encompass the care and routines followed by the home, was discussed. The Nursing Director said that care pathways for palliative care had been formulated. Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and aspects of standard 15 Social activities are provided for service users, thus improving their quality of life at the home. Visiting is encouraged and this enhances the service users lives and keeps them in touch with their families and friends. Service users are encouraged to exercise their independence wherever they are able, to maintain their quality of life. The meal provision is of good quality, with alternatives being available, to meet the nutritional needs of the service users. EVIDENCE: The home has an activities co-ordinator who maintains a record of service users interests and the activities each person has partaken of. A ‘map of life’ life history document has been formulated to gather information about each service users past, to include social interests. There is evidence of outings and a programme of activities arranged. Staff work to meet the individual interests of service users as much as is possible. The home has an open visiting policy and visitors spoken with said that they are made to feel welcome at the home. Service users can receive visitors in the privacy of their own rooms or in one of the communal areas. The home has a regular newsletter to keep service users and visitors informed of life and events at the home. Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 12 At the time of inspection no service users were managing their own financial affairs. Leaflets advertising Hillingdon Age Concern Advocacy Services were on display. The service users rooms viewed had been personalised in accordance with service users wishes. Service user plans are kept in the service users rooms and a copy of the homes access to records policy is signed by the service user or their representative to agree to this method of storing the documentation, allowing easy access by service users and their representatives. The lunchtime meal sampled was well cooked and presented and was tasty. Service users spoken with were generally satisfied with the food provision, and some very positive comments were received about the quality and choices available. Service users can choose if they wish to have their meals in their rooms or in the dining room and their choice is respected. Mealtimes are unhurried, and staff were seen assisting service users with their meals in a discreet and gentle manner. The kitchen was not inspected on this occasion. Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 & 18 The home has clear complaints procedures and concerns are promptly addressed. Service users rights are protected and advocacy services are in evidence. Systems were in place for the protection of vulnerable adults. EVIDENCE: The home has a clear complaints procedure and complaints are promptly addressed. Correspondence relating to each complaint is maintained and shows the progress and outcome. Service users and visitors spoken with said that any issues raised are addressed swiftly. The home has contact details for Advocacy Services. Service users are on the electoral role and the Registered Manager said that arrangements can be made for postal votes or for service users to attend the polling station, depending on their wishes. The homes’ policies and procedures for the protection of vulnerable adults (POVA) dovetail with the Hillingdon Safeguarding Adults documentation. Staff spoken with were familiar with POVA and Whistle Blowing procedures. The home has procedures for the management of service user aggression and the use of restraint in place. Also they have policies to cover gifts to staff and management of service users personal allowances. The formulation of a procedure to cover all involvement with service user finances was recommended, so that clear procedures are available to all staff dealing with such finances. Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 26 Overall the standard of décor, maintenance and cleanliness was of good quality, thus providing a pleasant and homely environment for service users. Infection control procedures are followed thus minimising any risk to service users. EVIDENCE: The décor of the home is well maintained and the maintenance man has a redecoration and refurbishment list for each area and room in the home, with evidence of works carried out with dates of completion. There is also an annual maintenance list to cover areas of servicing and maintenance. The garden is well tended and garden furniture is provided for service users and visitors to sit out in clement weather. The home had not had any recent inspections from the Fire Safety Service or the Environmental Health Officer, and no obvious issues were noted at the time of inspection. CCTV has been installed for security purposes and covers external areas of the home only. The home was clean and tidy and smelled fresh. The laundry room was being well managed and risk assessments for equipment and products in use were Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 15 seen. In addition, safety data sheets were available for the products in use and additional safety information was available for some of the equipment in use. The laundry person has a clear knowledge of laundry management and the associated health & safety requirements. The home has sluice facilities available to include a disinfector. The washing machine has wash settings for sluice wash and hot wash facilities in line with infection control. Clothing viewed was labelled with the service users’ name. The laundering of bed linen is contracted out and the home deals with the laundering of towels and personal laundry. Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 29 The staffing levels were appropriate at the time of inspection, and are to be kept under review to ensure service users dependencies can be met at all times. Overall the systems for the recruitment of staff were robust and safeguarded service users. EVIDENCE: The home was appropriately staffed to meet the needs of the service users on the days of inspection. Copies of the staffing rosters were viewed. There was evidence of occasional shifts where there had been a shortage of staff, but action had been taken to cover the shifts where possible, and the home has since recruited new staff and this issue has been addressed. On discussion with staff it was felt that although the home is usually appropriately staffed, there are times when the needs of service users are greater, and at these times staffing levels need review. The reviewing of staffing levels on an ongoing basis, in line with service user dependencies, was discussed with the management at the time of inspection. The staff employment files viewed contained copies of the completed application form with education and employment history, medical questionnaires, 2 references, job offer letters, photographs plus terms & conditions and contracts. Two issues regarding a reference request and leave to work in the UK were clarified at the time of inspection. Evidence of POVA First and Criminal Record Bureau checks were also available. Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 & 35 The Registered Manager is appropriately qualified and experienced to manage the home. The systems for maintaining service users personal monies are robust, thus ensuring that monies held for service users is safeguarded. EVIDENCE: The Registered Manager is a first level registered nurse with both general nursing and mental health nursing qualifications. She has been in post for six months and has over two years experience as a Deputy Manager in a similar care setting. She has completed her NVQ level 4 in management and is awaiting the final result. The Registered Manager is responsible for one home only and has undertaken training in topics relevant to the service user group. The Registered Manager said that her job description enables her to take responsibility for fulfilling her duties. There are clear lines of accountability within the management structure of the home. Individual wallets are kept securely for each service user, so that cash can be accessed for each individual. Some of the personal monies records were Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 18 viewed at random and there are clear income and expenditure records being maintained, with two signatures verifying each entry made. Receipts for all expenditure are kept individually for each service user. The home is investigating the opening of bank accounts for service users with higher levels of funds. The Financial Administrator is an appointee for one service user admitted before 01/04/02, since when the home has not taken this on for any other service users. The home has a safe facility. Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x x x 3 x x x Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 17 Requirement The service user plan must be reviewed monthly and whenever a service users condition changes. A system of evidencing service user and/or representative input at reviews of the service user plans must be formulated. Assessments to include those for continence and for pressure sore risk must be completed for each service user and be kept up to date. Wound care plan documentation must be clear, up to date and accurately reflect the treatment for, and condition and progress of each identified wound. Care plans must be formulated for each identified need. Bedrail assessments must clearly identify the reason for and appropriateness of the use of bedrails for each individual. Written consent for their use must be obtained. Action must be taken to ensure that the temperature in the medication storage rooms does not exceed 25º centigrade. (previous timescale 01/06/05 Timescale for action 01/10/05 2. 7 15 01/10/05 3. 8 17(1)(a) 01/10/05 4. 8 17(1)(a) 02/09/05 5. 6. 8 8 17(1)(a) 13(4)&(7) 01/10/05 02/09/05 7. 9 13(2) 23/08/05 and ongoing Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 21 8. 9 13(2) 9. 10. 9 9 13(2) 13(2) 11. 9 13(2) 12. 13. 11 27 12, 18 18(1)(a) not met). Alternative storage must be considered if the temperature in these rooms cannot be controlled adequately. The minimum/maximum temperature must be maintained between 2-8º centigrade for the drugs fridge. (previous timescale 24/02/05 not met) Medications must be signed for at the time of administration. Where a variable dose of a medication is prescribed, the actual dose given must be recorded each time the medication is administered. There must be evidence of regular stock checks for all controlled drugs held in the home. Procedures for the care of the dying must be formulated. The staffing levels must be kept under review in line with service user dependencies. 23/08/05 and ongoing 23/08/05 26/08/05 02/09/05 01/10/05 01/09/05 and ongoing 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 18 Good Practice Recommendations It is strongly recommended that a policy and procedure be formulated in respect of the homes management and involvement with service users finances, to encompass all aspects of this involvement. Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Ground Floor 58 Uxbridge Road Ealing London W5 2ST 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 Hayes Cottage G61 G10 S10933 Hayes Cottage V214265 22.8.05 Stage 4.doc Version 1.40 Page 23 - 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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