Inspection on 04/09/06 for Hayes Cottage

This inspection was carried out on 4th September 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

Hayes Cottage 16/07/07

Hayes Cottage 09/01/06

Hayes Cottage 22/08/05

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 Mrs Clare Henderson Roe Key Unannounced Inspection 4th September 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 Hayes Cottage DS0000010933.V310436.R02.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. Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hayes Cottage Address Grange Road Hayes Middlesex UB3 2RR 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 8573 2052 020 8573 5593 HAYES COTTAGE NURSING HOME Limited Ms Ani Grace Manayin Care Home 52 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. As agreed on 23/03/06, the six Palliative Care beds that are already registered can be used for service users aged 60 and over 9th January 2006 Date of last inspection 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 52 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 52 beds. There are 46 single rooms and 3 double rooms. 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 day-to-day basis. 49 service users were accommodated at the home on the day of inspection. The home fees range from £524.41 to £650 per week, dependent on the service users assessed needs. Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 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 21 hours was spent on the inspection process. The Inspector carried out a tour of the home, and service user plans, medication records, staff records, financial records, management records, administration records, maintenance and servicing records were viewed. 13 service users, 11 visitors and 12 staff were spoken with as part of the inspection process. The pre-inspection questionnaire given to the home at the time of inspection, plus additional information provided by the Responsible Individual following the inspection, has also been used to inform this report. What the service does well: What has improved since the last inspection? What they could do better: Although generally well completed, more attention to detail is required with the service user plans, especially with updates and wound care documentation. Several shortfalls in the staffing were noted, and the home must address this Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 6 as a matter of priority and ensure that the home is fully staffed throughout at all times to meet the needs of the service users. Staff training and updates in some areas of health & safety training was out of date and this needs to be addressed promptly. Records within the home need to be reviewed so additional paperwork can be archived and the records can be streamlined. Whilst it is acknowledged that the systems for quality assurance are overall good, the Responsible Individual has not arranged for Regulation 26 monthly unannounced visits to be carried out for some months, and this needs to be rectified. It is noted that since the inspection the Responsible Individual has written to CSCI with information to show how these shortfalls are to be addressed. 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 DS0000010933.V310436.R02.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 Hayes Cottage DS0000010933.V310436.R02.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): 1, 2, 3 & 4. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with the information they need to make an informed choice about the home. Written contracts are in place, thus ensuring information regarding the homes terms and conditions are understood. Service users are fully assessed prior to admission to the home, to ascertain that the home is able to meet their needs. EVIDENCE: The home has a Statement of Purpose and a copy of the Service User Guide is in each bedroom. These documents were up to date and informative. There is a written contract/agreement with the Primary Care Trust and local Social Services for service users being funded by these departments. Contracts were available for service users funded privately. The Registered Manager carries out a pre-admission assessment on all prospective service users in order to ascertain that the home can meet the Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 9 service users needs. The home also obtains copies of the Social Services or Primary Care Trust assessment. The home has 6 beds to provide palliative care. Staff have received training in various aspects of palliative care in order to provide them with the skills to care for service users specialist needs. The home receives ongoing input and support from the Hillingdon Palliative Care Team, with weekly routine visits from both the Palliative Care Consultant and the Macmillan Nurse Team, with additional visits arranged if necessary. Hayes Cottage DS0000010933.V310436.R02.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): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the service user plans were up to date, thus providing staff with a picture of the service users needs. Shortfalls should be easily addressed. Medications are generally being well managed at the home, thus protecting service users, and shortfalls should be easily addressed. Staff care for the service users in a gentle and courteous manner, thus respecting their privacy and dignity. EVIDENCE: One Inspector viewed 4 service user plans. These had been completed promptly following the service users’ admissions to the home. Monthly updates had been carried out and care plans had been formulated when a new need was identified. One of the service user plans viewed required reviewing as changes in the service users condition had not been reflected fully. There was evidence of input from service users and/or their representatives to state that they had read and agreed with the service user plan. Risk assessments for falls had been completed, but it was not always clear how the total score is calculated, and this needs to be addressed. The Registered Manager said there had not been any falls for some time in the home. Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 11 Wound care documentation was viewed. For one service user a dressing chart was in place, but a care plan had not been formulated. For another service user for whom a protective dressing was being used, no care plan documentation for this was in place. These shortfalls were discussed with the Registered Manager at the time of inspection. Pressure relieving equipment was seen in use in the home. Assessments for moving & handling, continence care and nutrition had been carried out, and relevant care plans formulated where a need had been identified. For one service user who had not been weighed for two months the registered nurse explained that it had not been possible to do so due to the service users condition, and this needed to be recorded on the weight record chart. Other weight charts viewed were up to date. Bedrail assessments had been carried out and signed consents for their use obtained. The home has weekly visits from the GP and also weekly visits from the palliative care Consultant and also from the Palliative care nursing team. There was evidence of input from other healthcare professionals. The CSCI Pharmacist Inspector carried out an inspection on 04/09/06 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. Staff were seen speaking with and caring for service users in a gentle and courteous manner. Service users and visitors spoken with expressed their satisfaction with the care provided at the home. Service users clothing is individually labelled, and the home is exploring the most appropriate labelling system for future use. Service users can bring in personal possessions in line with health & safety. There was a good atmosphere throughout the home. Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity input for the home is good and reflects the interests of the service users. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. Information regarding advocacy services is freely available, thus ensuring the service users right to independent representation is respected. The food provision in the home is good, offering variety and choice, to meet the service users needs. EVIDENCE: The home has a full time activities co-ordinator. There is an activities programme displayed throughout the home. The activities co-ordinator said that she tends to do one-to-one sessions in the mornings with service users, and then have group activities during the afternoon. Outings take place, and service users spoken with said that they are offered the opportunity to join in activities, and their wishes are respected. The activities co-ordinator keeps an individual record for each service user, recording their interests and a monthly review of their participation. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are always made welcome at the home and Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 13 refreshments are offered. Service users can choose to receive visitors in their bedrooms or in one of the communal areas, as they so wish. Leaflets providing information about Age Concern Advocacy services were clearly on display in the home, and service users representatives are aware of the service available. The food provision in the home is good. Generally service users spoken with expressed their satisfaction with the meals. The need to ensure alternatives to sandwiches are provided for evening meals at the weekends was discussed, and the Responsible Individual has since confirmed that this has been addressed. The home has a 4 week menu, and a choice of meals is offered, with alternatives being available to meet the service users wishes. Service users are asked about the menu and their choices for the following day, which are recorded and given to the kitchen staff. Service users spoken with confirmed the fact they are offered choices, and if they do not want either option on the menu, an alternative will be provided. The Inspector viewed the lunchtime meal. Some of the service users have lunch in the dining room, which was quite a sociable occasion. Others have their lunch in their rooms, and staff were available to help with serving and assist service users with their meals as necessary. The kitchen was clean and tidy and records were up to date. A recent Environmental Health Inspection had taken place and the home had received a commendable report. Drinks and snacks are available throughout the 24 hour period. Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by service users and their visitors. The system in place for protection of vulnerable adults is robust, thus safeguarding service users. EVIDENCE: The home has a clear complaints procedure and complaints documentation is maintained. One Inspector recommended an index for complaints be maintained with outcomes recorded, and the Responsible Individual has since confirmed this is to be introduced. The home had received 3 complaints since the last inspection. The home has its own Adult Protection policies and procedures, which dovetail with the Hillingdon Safeguarding Adults documentation. One POVA investigation had taken place and been concluded, and one was in process. Staff spoken with were clear that they would report any concerns, and also understood Whistle Blowing procedures. The Responsible Individual was very clear to report any concerns of this nature. Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Work is ongoing with redecoration and refurbishment of areas of the home to maintain an attractive and safe environment for service users to live in. Equipment and facilities are available to meet the needs of the service users and the home. Bedrooms are personalised, thus providing service users with a homely environment to live in. Clear infection control procedures are in place and being adhered to, thus safeguarding service users. EVIDENCE: One Inspector carried out a tour of the home. Overall the home is maintained to a good standard and there are redecoration and refurbishment records in place for each room in the home. The Responsible Individual was aware of some areas of carpet that need to be replaced. A repairs book is completed by staff and checked promptly by the maintenance man. The home has a small sitting room on the first floor. On the ground floor there is a conservatory with another sitting area next to this. There is also a dining Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 16 room, which is spacious. There is one room where service users can smoke, plus in the garden. The garden is well maintained and garden furniture is available for service users and their visitors to use. Several service users were sitting out in the garden on the day of inspection, and enjoying the clement weather. The home has adequate assisted bath and shower facilities to meet the needs of the service users. Several of the bedrooms have en suite facilities and there are toilets situated near communal and dining areas. There home has three hoists, and staff spoken with said that these meet the needs of the service users. Handrails are available in some corridor areas, plus grab rails were seen in toilet facilities. The home has a call-bell system in place, and the Responsible Individual said that this is being reviewed as it is not always possible to identify the order in which bells had been activated. Overall, call bells were being answered promptly. The bedrooms are individualised in shape and size, and several of those viewed were very personalised. Adjustable beds are provided for all service users. Flooring in bedrooms is either carpet or wood effect non-slip flooring. Bedroom door locks are fitted and are accessible to staff in an emergency. Screening is provided in double rooms. The home was clean and tidy throughout. All bed linen and towels are laundered off the premises. Personal laundry is done at the home. There is one washing machine with a sluice programme and one tumble dryer in use. The home has an infection control policy in place. Protective clothing to include gloves and aprons was available in the home. Electronic disposal units are situated in each of the sluice rooms. Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Shortfalls in the staffing levels at times could potentially place service users at risk. Staff had received training to provide them with the skills and knowledge needed to meet the needs of the service users, thus maintaining good standards of care. Robust recruitment and vetting procedures are in place, thus safeguarding service users. EVIDENCE: Staffing levels had been reviewed last year when the home registered 6 beds for palliative care. On viewing the staffing rosters, several shortfalls were identified for August 2006, for both day and night shifts. This included the Registered Manager working as one of the registered nurses when she should be supernumerary. Shortfalls in the numbers of care staff on duty were also noted. The Registered Manager said that at times the home receives extremely short notice from staff, which presents difficulties covering the shift. The Registered Manager said that she covers shortages on a day-to-day basis, and forward planning for this must be introduced. These issues were discussed with the Responsible Individual and the Registered Manager and the importance of ensuring that the home is appropriately staffed at all times was emphasised. Comment regarding the home being short staffed at times was also received from people spoken with at the time of inspection. The Responsible Individual has acknowledged these findings, and is addressing them. Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 18 Three sets of staff employment records were viewed. These contained all the information required under the Care Homes Regulations 2001. The home has a core team of long-serving staff, and the majority of care staff are trained to NVQ level 2 or 3 in care. The induction and foundation training for care staff reflects the Skills for Care core standards. The home has made an application as a facility for overseas nurses to undertake supervised placement training to qualify to work as registered nurses in this country. There was evidence that staff undertake periodic training in topics relevant to the needs of the service users. Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 19 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): 31, 33, 35, 36, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the qualifications and experience to manage the home. Systems for quality assurance are in place, thus providing an ongoing process of system and practice review. Service users monies are well managed, thus safeguarding service users interests. Staff supervision sessions take place, providing a forum for individual discussion and reflection on practice. Systems for the management of health and safety are good, however shortfalls in the provision of health & safety training could potentially place service users, staff and visitors at risk. 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 18 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. Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 20 The home has a quality assurance system in place. The Responsible Individual was aware of the need to carry out Regulation 26 visits and complete a report. No reports had been received by CSCI since March 2006. Feedback questionnaires are undertaken every 3 months and the views of family, friends and stake holders are sought. Results of these questionnaires were available and evidence was available that these results had been discussed with representatives and service users within the home. Staff meetings, service user meetings and relatives meetings take place and minutes are recorded. The Responsible Individual has confirmed that management meetings for heads of department are to be re-introduced. A quarterly newsletter is produced for service users and visitors, and is very informative. Small amounts of personal monies are managed for each service user. Records of these were viewed and were clearly and accurately recorded. In some instances receipts were not available. One Inspector recommended that this be recorded. The home also has a residents account with individual numbered accounts for any service users who have significant funds. One Inspector viewed supervision records for staff. It was clear that staff had not been receiving regular one-to-one supervision. The home has in place an annual appraisal system, which had been carried out. A system to ensure staff receive supervision every 2 months must be put in place. Generally the records viewed were up to date. Service user plans are stored in service users rooms, for ease of access, and a signed agreement for this is available in each file. One Inspector noted that several records with regard to office administration were being duplicated, and in some areas those available were not up to date, although others viewed were. The need to review the documentation to ensure that all copies of records are up to date, and that only necessary duplication takes place, was discussed. A sample of servicing and maintenance records were viewed and found to be up to date. It was clear that the maintenance man has a good understanding of his role and maintains the home to a good standard. Risk assessments for equipment and safe working practices were available. Clear risk assessments are available for the laundry & kitchen, and the Responsible Individual has confirmed that the system for recording updates has since been reviewed for clarity. Shortfalls were noted in the health & safety training records, to include moving & handling training and fire awareness training. This was discussed with the Responsible Individual who said he would arrange for a moving & handling trainer to attend the home and provide training and updates for all staff as a matter of priority. Confirmation of such arrangements being put in place has since been received by CSCI. There was evidence of fire drills having taking place, and the importance of ensuring all staff take part in fire drills at the required intervals was discussed. Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 21 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 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 3 17 X 18 3 3 3 3 3 X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 3 2 Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 22 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. 2. Standard OP7 OP8 Regulation 17(1)(a) 17(1)(a) Requirement Service user plans must be up to date and reflect the service users current condition. Where a service user has wound care needs, these must be clearly documented and a care plan put in place. The date of receipt of controlled drugs must be recorded in the CD register The home must be staffed appropriately at all times to meet the needs of the service users and the home. Regulation 26 visits must be carried out in accordance with that regulation. Copies of the reports from these visits must be forwarded to CSCI. There must be a system in place for all staff providing care to receive supervision a minimum of 6 times per year. Staff must undergo health & safety training to include moving & handling and fire safety training at intervals in line with current legislation and guidance. Timescale for action 01/10/06 15/09/06 3. 4. OP9 OP27 13(2) 18 14/09/06 01/10/06 5. OP33 26 01/10/06 6. OP36 18(2) 01/11/06 7. OP38 13(5) 23(4) 18 01/10/06 Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 23 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. 2. 3. 4. 5. Refer to Standard OP7 OP8 OP9 OP9 OP37 Good Practice Recommendations It is strongly recommended that the risk assessment for falls document be reviewed to clearly show how the total score is calculated. It is strongly recommended that where it is not possible to weigh a service user, this information be clearly recorded on the weight chart. That attention be given to the organisation of controlled drugs and injections on the first floor That copies of current prescriptions are kept in the home It is strongly recommended that records in the home be reviewed and out of date information archived. Hayes Cottage DS0000010933.V310436.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 DS0000010933.V310436.R02.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!