Inspection on 07/06/06 for Home Covert

This inspection was carried out on 7th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Home Covert 21/05/07

Home Covert 23/11/05

Home Covert 05/07/05

Home Covert 04/01/05

Home Covert 09/08/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Home Covert The Avenue Bentley Doncaster South Yorkshire DN5 OPS Lead Inspector Janet McBride Key Unannounced Inspection 7th June 2006 10:20 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 Home Covert DS0000032140.V297361.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. Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Home Covert Address The Avenue Bentley Doncaster South Yorkshire DN5 OPS 01302 875325 01302 822831 NONE 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) Doncaster Metropolitan Borough Council Carol Ann Morley Care Home 35 Category(ies) of Dementia - over 65 years of age (24), Learning registration, with number disability (11) of places Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2005 Brief Description of the Service: Home Covert is registered for thirty-five beds, providing accommodation and personal care to two different service users groups, learning disabilities and elderly EMI and residential care, aged 36 years to 65 years. The Registered provider is Doncaster Metropolitan Borough Council (DMBC) All accommodation is on ground floor level and is in three units; two with twelve beds and one with eleven beds, and each unit has its own lounges and dining facilities, and staffed individually. Fern Unit Provides accommodation for eleven service users ranging from 36yrs to 69yrs old with Learning Difficulties. These service users are independent and go out to centres during the day on Monday to Friday. Rose and Daffodil Unit Provides accommodation for twelve service users who are elderly mentally infirm. The unit is accessed via a secured digital locks, and it has it’s own enclosed courtyard, and CCTV is fitted to the outside of the building for security purposes. Fees range from £395:00 to£465:00 per week, as at June 2006,and additional charges are made for hairdressing, Chiropody, toiletries and magazines/newspapers The Statement of Purpose and the Service User Guide, which is available on request, this as information about the services available to residents and their families. The home last published inspection report was available in reception. Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector from the Commission for Social Care Inspection carried out this unannounced inspection at Home Covert, which was conducted on the 7th and 15th of June 2006 and took place over two days (10 hours). The home is registered for 35 beds, which were full at the time of Inspection. Pre-Inspection work was carried out for example, analysis of notifications and any other relevant documentation. During the Inspection various documentation and records were examined for example, medication records, staff rotas, staff training and also included case tracking of three-service users care plans, which were cross-referenced with other documentation. Prior to the visit twenty questionnaires were sent to residents within the home for their views on the service, nine were received back, and a number of residents were spoken to. Those residents that have difficulty with communication, and not able to comment, key workers gave feedback and observation during the Inspection enabled more information to be gathered for this report. This Inspection also included individual interviews with members of staff, and feedback from relatives and visitors on the day. Tour of the premises and direct and indirect observation of staff interaction with residents throughout the visit and information was gathered from as many different individuals as possible that had contact with the residents in their environment. The Inspector would like to thank all the staff and residents for their cooperation in the Inspection process, and any issues or concerns that were raised were discussed with the manager at the end of the Inspection. What the service does well: Home Covert provides a good standard of accommodation, with easy access to all parts of this single-storey building, the home has a good standard of furnishings throughout, and the atmosphere within the home is good. Residents that were spoken too feel they live in a safe, comfortable environment, most of the residents are able to personalise their bedrooms, and this was evidenced during the inspection, as they had a number of their own possessions around them. Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 6 Both residents and visitors spoke highly of the staff team at the home, and comments received from residents on Fern unit, stated there are always activates arranged by the home for them to take part in, and were happy with care they received and the staff group. The home has a very enthusiastic staff group that work positively with residents to improve their quality of life within the home, they were observed to carry out their duties in a professional manner and show consideration for the residents individual needs The last Inspection report was available for prospective resident to read, they can also access day care and respite care before living there permanent. 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. Home Covert DS0000032140.V297361.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 Home Covert DS0000032140.V297361.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): 346 Quality in this outcome area for standard is good. This judgement has been made using the written evidence available in care plans and discussions with staff. Prospective service users are individually assessed prior to admission to the home, this ensures that all their care needs will be met, and receive a good standard of care. EVIDENCE: The home does not offer intermediate care, only personal care for residents. Evidence was seen during case tracking that residents are individually assessed prior to admission to the home, to ensure that their needs will be met. Lots of information was available in individual care plans, and evidence that other professionals are involved. Care plans are developed based on individual needs, various assessments are carried out to ensure the home will meet the residents care needs and those care plans seen on Daffodil and Rose reflected this. Relatives also confirmed that some residents had been to the home either for day cay or respite before being admitted on a permanent basis. Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 9 Alternative day care as been arranged one resident on Fern unit, which is more appropriate to their needs. Home Covert DS0000032140.V297361.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): 7 8 9 10 Quality in this outcome area for those standard assessed is Good. This judgement has been made using available evidence including a visit to this service, examination of documents and discussion with staff and residents in the home. A few gaps were found in the medication records, but this as not effected the outcome in this area because of the improvement in documentation in both the care plans and accident records. EVIDENCE: Three service users care plans were case tracked and cross-referenced with medication records, accident records and any other relevant information, and discussed with their key worker. The care plan for all service users are developed shortly after the admission, using the initial assessment of need and any other relevant information gathered by professionals and family and friends. The resident (if capable) and family would agree the plan prior to its implementation. Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 11 Key workers spoken to were able to describe care needs of service users, and when they required the input of either GP or district nurses. Care plans showed signs of improvement and were generally found to be comprehensive, concise and easy to follow. Accident records checked which shows an improved in documentation, they were completed, legible and concise records, with the manager completing monthly analysis reports. The District Nurse provides the main link to all medical services including pressure area care, adaptations e.g. airwave and other pressure relieving mattresses, continence advice and general health checks as required by the G.P. all is recorded when either referred to outside professional or when they are seen by others. Medication policy and procedure was discussed with the deputy manager and records checked. The local chemist that supplies the Nomad system currently used at the home and visits the home periodically. The Pharmacist is responsible for carrying out audits and give advice to staff at the home. Staff responsible for the administration of medication has completed the accredited medication training. An audit of the records and stock were found to be satisfactory with two issues raised; hand written MAR sheets not signed by two staff. When medication was omitted no reason was given. Eye drops in use must have date when they were opened. During this inspection there were many examples of good practice, from the staff on duty, they were observed to knock on residents bedroom doors before entering, and interacted with respect addressing service users by their preferred name. Comments from relatives seen during the inspection mother looks clean and well dressed”.” my wife always looks neat and tidy and as her hair done every week. Home Covert DS0000032140.V297361.R01.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 for all standards assessed is Good. This judgement has been made using available evidence including a visit to this service and talking to residents and staff. The homes staff try to provide stimulation and interest for those residents on the elderly unit, but this can be dependant on staffing numbers, and therefore its difficult to assess how stimulation and satisfied those resident are, no issues were raised by relatives or residents at the time. Residents on fern unit seem to have a good choice of activates. Dietary needs of residents are well catered for, and offer a varied diet to meet resident’s tastes and choices. EVIDENCE: Staff interviewed gave examples, some attend a social evening every Wednesday evening, and at weekends they can visit relatives at home, go to the pictures and shopping. A number of resident also have holidays, some have just been to Blackpool, others are going away for a long weekend to Cleethorpes and they are going to Euro Disney in September. Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 13 Activities are organised for the residents on the two elderly units by staff, on the day of Inspection, there was a Physiotherapist who attends weekly, and she organiser’s activity to music. During both visits to the home staff had ensured that appropriate music and TV programmes were available on both of the elderly units, and residents were seen to occupy themselves by reading newspapers, watching TV or talking to others. Discussed with the manager who stated that they are implementing an activities record to provide evidence of what takes place within these units. Visiting is allowed at any reasonable time, and this was confirmed by visitors seen on the day, they also stated that their relatives came to the home for either day care or respite before being admitted and feel that’s why they settled at the home. Capacity to exercise choice within the resident’s lives was discussed with both the manager and staff that were spoken to. All residents are able to personalise their room, and this was evidenced during the inspection. Staff stated they encourage all service users to make choices whenever possible. Food and mealtimes were discussed with staff on all of the units and it was found that service users on the elderly unit have more structured meals, and the cook provides these. The meals are transported to the two units via hot trolleys and served in the dining rooms by the staff. Observations during mealtimes on the day confirmed that they were unhurried and assistance was given when required, although it was a very bust time. Residents spoken to said they had enjoyed their meal and liked the food at the home. A relative raised one issue, this was checked during case tracking and found all relevant care had been given, including a referral to speech therapist for swallowing difficulties. Service users on Fern Unit have a different routine at mealtimes, breakfast can be a little rushed, due to them leaving early for the centres, but weekends is very relaxed and they have breakfast as and when they get up and this is prepared by staff on the unit. Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 14 They also eat their main meal at the day centre and teatime is usually dependant on activities that are taking place during the evening, they have a for a takeaway night every Thursday in the home. Home Covert DS0000032140.V297361.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): 16 18 Quality in this outcome area for standards assessed is Good. This judgement has been made using available evidence seen in records, including a visit to this service. Residents and relatives are provided with information to enable them to raise concerns or complaints about the home and the care provided, robust polices are in place to protect residents. EVIDENCE: The organisation has a comprehensive Concerns Complaints procedure (DMBC View Point). There is also a monitoring form that is used to record complaints, this meets the requirements and includes timescales for complaints to be acknowledged and investigated. No recorded complaints since the last Inspection, staff demonstrated their awareness of these procedures and relatives stated that they feel happy to raise any concerns with members of staff or management. Discussion with staff confirmed they were aware of abuse polices and procedures, training records show some staff have recently had updates on adult abuse, this was confirmed by staff and they could give explanation of whistle blowing. Management are aware when incidents need the external input and who to refer the incident to. Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 16 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 23 24 26 Quality in this outcome area for standards assessed is good. This judgement has been made by visiting the premises and tour of the building and speaking to residents. Layout of the home ensures that residents live in a safe, well-maintained and comfortable environment. EVIDENCE: The home was purpose built and designed to suit the client group, corridors internally connect on two of the units, and digital locks on the entrance of each unit for security purposes and safety of residents. Tour of all units was found to be well-maintained environment, which provides aids and equipment to meet the needs of the residents. Communal rooms were found to be comfortable, bright and cheerful and looked very homely with pictures and ornaments around the home. Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 17 It was clean and tidy, with furniture and fittings being of adequate quality. The grounds were well maintained, but it was a sunny day and it was noted that the home don’t encourage residents to sit outside, as one of the units didn’t have any garden furniture for residents or visitors to sit on. The home has three sluicing facilities one for each unit and a communal laundry that is equipped to deal with all of the homes laundry. Washers meet the required safe washing temperatures to control the risk of infection. Bedrooms on all the three units were furnished and equipped to assure comfort for the residents and found to be clean and tidy, minor issues were raised in two of the bedrooms, one had wallpaper stripped off and the other had a hole in the ceiling. The home as a call system in each bedroom, call bells were left within reach of resident’s beds, and the function of the system was tested during the Inspection. Residents are encouraged to bring personal items with them and most had been personalised with pictures, photos and ornaments. All bedrooms remain locked to ensure that other residents don’t wander in them, however those residents who are capable of holding their own keys do so. Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 18 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 for standards assessed is adequate. This judgement has been made using available evidence, checking staffing rotas, training files, observation during the Inspection, taking to management, relatives and residents, including visiting the premises. The home has a very enthusiastic staff group that work positively with residents to improve their quality of life within the home, the outcome is affected by a failure of the registered provider not filling the vacant posts for a long time, therefore staff at the home continue to work above their contracted hours to ensure minimum numbers are maintained, this as effected this judgement. EVIDENCE: Staff had the competencies and qualities required to meet resident’s needs, and staffing was discussed with the manager, deputy manager, and staff on duty and examined of duty rotas. Duty rota checked which shows the home has sufficient staff when there no annual leave or sickness. Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 19 The registered manager continues to work on rota, when they are short staffed, and staff at the home covered duties over and above their contracted hours to ensure minimum numbers were maintained. One member of staff remains on long-term sick and one on maternity leave. Ancillary staff is employed in sufficient numbers to ensure that all standards relating to food, meals and nutrition are met, and that the home is maintained in a clean and hygienic state. On the day of Inspection the home had 35 residents plus 3 day care residents and staffing was adequate, and this was reflected at lunch time as one member of staff was feeding two residents at the same time which is not ideal, but at least both residents ate a hot meal unhurried. The staff team were observed to carry out their duties in a professional manner and show consideration for the residents individual needs, and are highly regarded by the residents. Recruitment was discussed with the manager, staff personal employments files are kept centrally by DMBC and have to be requested to examined in the past have always met the standards, no new staff since the last Inspection therefore not requested at this inspection, but discussed with the manager. Discussion with the manager found that the home still have three vacant care staff posts and three domestic posts. These are not being advertised at the present re closer of two homes therefore DMBC are holding these posts open for other staff in DMBC homes. Training files were examined and training opportunities were discussed with the registered manager, new staff completes a well-structured induction programme, they can access NVQ training and the (LADAF programme) Learning Disability Award Framework. Staff spoken to confirmed they have either registered or commenced their training. The home is well on its way of meeting the target for 50 of staff to be NVQ trained (45 ) roughly. Since the last Inspection access to mandatory training updates as improved, training matrix shows staff have either completed updates or are booked on courses. Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 20 Abuse and Dementia training packages have been set up by the manager and one of her deputies, these are being rolled out to staff in-house, also a number of staff are doing distance learning courses in infection control. Home Covert DS0000032140.V297361.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): 31 33 35 37 38 Quality in this outcome area is good. This judgement has been made by visiting the service, observation during the Inspection, taking to staff, relatives and residents and examination of records. The registered manager is skilled and experienced to manage the home; she promotes the safety and protection of residents within the home. EVIDENCE: The registered manager of the home has a HNC in managing care and has been in post for a number of years. The registered manager is working towards the Registered Managers award and is hoping to attain the qualification soon. She continues to work on rota, when they are short staffed, which restricts her ability to develop the service further and deal with management issue. Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 22 Quality assurance systems was discussed with the manager and deputy manager, who have devised a new questionnaire to be sent out to relatives and residents, the manager as also been proactive in devising a quality audit for nutrition and medication. Spot checks on policies and procedures show a number require updating, this was discussed with the manager. Equality and diversity was discussed with the manager, she hopes to be able to access some courses on this issue, but did confirm that basic equality and diversity is discussed with staff during induction for example, make sure residents are dressed in appropriate clothes for their gender, that residents can access their religious beliefs. Relatives and residents confirmed that the manager is very approachable, and they had recently completed questionnaires about their satisfaction with the home and care provided. Very positive comments were received throughout the whole Inspection about the home, care provided and staff members. Records required by regulation were checked and found that most records were up to date and accurate with the exception of medication records, however a big improvement in accident records and care plans, also regulation 37 notifications, have been sent to the CSCI on a regular basis. Regulation 26 visit reports are available at the home. Safe working practices was discussed with staff and records checked, and observation of staff during the Inspection. Visitors to the home sign in and out of the home as there is a book in reception. Fire records indicate that fire tests are carried out and drills had taken place, and fire training for staff had been completed, also emergency lights had been checked on a regular basis. Water certificate for legionella and records show temperatures are checked on a monthly basis. Staff has received updates in moving and handling, food hygiene and health and safety. Observation of staff using wheelchairs and movement of residents was safe and appropriate; call system was checked during Inspection and found satisfactory. Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 23 Duty rota does not identify a first-aider on duty, this was discussed with the manager, who stated that this is because all officers have completed the three year course therefore one on duty at all times. Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 X X X 3 2 X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 3 3 Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement Medication; 1) Two staff must sign Hand written MAR sheets. 2) When medication is omitted staff must state reason why. 3) Staff must date when eye drops are opened. Premises; Must be kept in good repair with regards to identified issues in bedrooms. Staffing vacant post must be recruited ASAP to ensure staffing is appropriate to meet service users needs. (Timescale of 1/12/05 not met) The registered person must ensure that 50 of the staff is NVQ trained. The registered manager must gain the NVQ level 4 in Management Timescale for action 01/07/06 2. 3. OP24 OP27 23 18(1)(a) 31/07/06 01/09/06 4 5. OP28 OP31 18(1)(c) (I) 9 01/09/06 01/09/06 Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 26 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 OP33 Good Practice Recommendations Policies and procedures should be reviewed and updated on a regular basis. Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Home Covert DS0000032140.V297361.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!