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Inspection on 11/01/07 for Home Of Comfort Nursing Home

Also see our care home review for Home Of Comfort Nursing Home for more information

This inspection was carried out on 11th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

A good pre admission process that includes providing the prospective service user with detailed information and assessment of that person. This results in the service user knowing what to expect when moving into the home and being confident that the home can meet their needs. A range of suitable activities is available for the service user to participate in if wished. Meals are varied and nutritious; staff assist service users at meal times with sensitivity. Service users are protected by a work force that is aware of adult protection issues as well as being equipped with the skills to meet the needs of the service users through good training programmes. Robust recruitment practices protect the welfare of service user. Service users are confident that complaints and concerns will be dealt with promptly and effectively. Service users live in a home that is well maintained, clean and homely. The manager of the home is highly competent to run the home and meet its stated aims and objectives.

What has improved since the last inspection?

The home has abandoned a computerised care planning process. Care plans are now done on paper and are accessible. They detail the action to take to meet service user`s assessed needs and are reviewed on a regular basis. The home has changed the pharmacy that supplies medications to the home. This has resulted in prompter delivery of medications, accurate documenting of the date of administration of medications to service users, auditing by the pharmacist of the homes medication procedures and the opportunity to access training. The documentation of incidents affecting the wellbeing of service users has improved allowing for instant access to such information and audits of falls and incidents. This results in action to reduce the incident of falls and to improve the wellbeing of service users.

What the care home could do better:

Reasons for medications not being administered to service users are not being clearly documented; this must be improved. Action taken as a result of service user surveys is not documented; recording of this will give improved evidence that the home is responding to service user surveys.

CARE HOMES FOR OLDER PEOPLE Home Of Comfort Nursing Home 17 Victoria Grove Southsea Portsmouth Hants PO5 1NF Lead Inspector Gina Pickering Unannounced Inspection 11th January 2007 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 Home Of Comfort Nursing Home DS0000011514.V326230.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 Of Comfort Nursing Home DS0000011514.V326230.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Home Of Comfort Nursing Home Address 17 Victoria Grove Southsea Portsmouth Hants PO5 1NF 023 92 730063 (023) 92 730063 hocomfort@aol.com 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) The Home of Comfort Charity Mrs Patricia Irene Evans Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Terminally ill (8), Terminally ill over 65 of places years of age (30) Home Of Comfort Nursing Home DS0000011514.V326230.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: Home of Comfort is a care home providing nursing and personal care for 30 ladies over the age of 65 years. The home is also registered to accommodate service users with life limiting disease with the condition that only 8 may be accommodated between the ages of 55-65 years. The registration also has a condition that one male may be accommodated at any one time, providing he is the spouse of a service user. The home is owned and administered by The Home of Comfort Charitable Trust and is represented by a management committee, one of whom is the named responsible individual stated on the certificate of registration. The home is located in the pleasant residential area of Southsea, close to Portsmouth city centre and in walking distance from the sea front and local amenities. The home is two converted Victorian houses on three floors with a purpose-built three-storey wing added in the 1960s. A newer conservatory lounge has been added in recent years. The home has a well-maintained garden that surrounds the home and is accessible to service users who make use of it in the finer weather. All rooms are single accommodation. There are two shaft lifts installed. Fees for the home are from £490 to £525 per week. Home Of Comfort Nursing Home DS0000011514.V326230.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process took into account information provided by the service and a site visit on 11th January 2007. During the visit to the home the inspector spoke with the deputy matron, care staff, the cook, nine service users and four visitors as well as looking at documentation. The inspector also toured the environment. Information gained from the pre inspection questionnaire was also used and included in this report, as was information received by the commission about the home since the last inspection. What the service does well: What has improved since the last inspection? Home Of Comfort Nursing Home DS0000011514.V326230.R01.S.doc Version 5.2 Page 6 The home has abandoned a computerised care planning process. Care plans are now done on paper and are accessible. They detail the action to take to meet service user’s assessed needs and are reviewed on a regular basis. The home has changed the pharmacy that supplies medications to the home. This has resulted in prompter delivery of medications, accurate documenting of the date of administration of medications to service users, auditing by the pharmacist of the homes medication procedures and the opportunity to access training. The documentation of incidents affecting the wellbeing of service users has improved allowing for instant access to such information and audits of falls and incidents. This results in action to reduce the incident of falls and to improve the wellbeing of service users. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Home Of Comfort Nursing Home DS0000011514.V326230.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 Of Comfort Nursing Home DS0000011514.V326230.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6. 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 good information to make an informed decision about the suitability of the home for them and to help them settle into the home. Good assessment processes ensure the home is able to meet the needs of service users when they move into the home. The home does not provide intermediate care. EVIDENCE: Prospective service users and their representatives are provided with information about the service provided by the home in the form of a home brochure, statement of purpose and a resident’s guide. Several service users and their relatives said that they had received information about the home prior to making the decision to move into the home. One of the nurses from the home visits the prospective service user to assess needs and discuss life at Home Of Comfort Nursing Home DS0000011514.V326230.R01.S.doc Version 5.2 Page 9 the home. Service user’s care planning files include the assessment made prior to them moving into the home; this includes all details of a person’s holistic needs including personal care, health care and social and leisure needs. Speaking with service users and relatives confirmed that the assessment process had taken place prior to them moving into the home. One service user who had moved into the home the day prior to the inspectors visit was observed to be at ease in the home, was comfortable with the care staff and the other residents suggesting that she had been informed about the life at the home during the assessment process. Each service user is provided with a statement of terms and conditions of residency at the home; this sets what is included in the fee, by whom it is payable, the role and responsibility of the provider and the rights and obligations of the service user. Service user’s documents evidenced that these are revised regularly and service users and/ or their representatives are informed of changes in fees. Home Of Comfort Nursing Home DS0000011514.V326230.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that each resident’s plan is reviewed regularly. The plan is updated to reflect any personal, health or social care changes. Staff work hard to ensure all service users have access to all health care services. The home works to good medication procedures that protect the health and wellbeing of those living at the home. The aims and objectives of the home reinforce the importance of treating residents with respect and dignity. EVIDENCE: At the last inspection in January 2006 the care planning process had been computerised. Difficulties accessing information and care plans resulted in this system not working to meet the needs of service user. As part of the case tracking process four care plans were looked at. These are now completed on paper and kept in individual service user files. Care plans are comprehensive Home Of Comfort Nursing Home DS0000011514.V326230.R01.S.doc Version 5.2 Page 11 detailing the action needed to meet the individual’s needs. Risk assessments are in place for moving and handling, skin integrity, and the use of bed rails. Care plans are reviewed at least every two months or more frequently if needed. Service users have access to the multidisciplinary heath care team including advice from district nurses. A record is made of all contact that service users have with health care professionals. Service users and relatives said that health care needs are attended to; GP’s are contacted promptly if a service user is unwell. Concern was raised by both the deputy matron and a relative that dental care is difficult to obtain for those service user’s that still have some of their own teeth. Service users have to access the community dentist by referral by their GP. This results in service users have to wait a long period before any dental work can be carried out. The deputy matron said that the home was continuing to look for a better dental service for service users. The home uses a local pharmacy that specialises in providing medications to care homes. The pharmacy provides a dedicated link pharmacist for the home, who can offer a variety of training and supports the home’s quality auditing process by auditing the medication processes at the home. The deputy matron said that the service provided by the pharmacy has resulted in a prompter delivery of medications, greater support and advice from the pharmacist, and improved documentation of the administration of medications. Four medications administration record sheets were looked as part of the case tracking process. It is clearly documented at what time and on what date medications are administered to service users. But for some medications not administered to service users there was no reason documented as to why they had not been given. The service must document reasons for medications that have not been administered to service user. Safe administration of medications was observed. Medications are stored in a safe and orderly manner. The ethos and management of the home encouragers all service users to be treated as individuals. Service users said that staff treat them as individuals respecting their wishes and acknowledging how their life experiences make them the person they are. Staff were observed to interact with service users in a friendly respectful manner. Home Of Comfort Nursing Home DS0000011514.V326230.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. 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. Service users are able to choose to participate in leisure activities that are planned to meet their needs and wishes. The service recognises that different people have different social and leisure needs ranging from group activities to time spent with a service user on a one to one basis. Service users can receive visitors as they wish. Practices and attitudes of the staff team give service users the opportunity to remain as independent as they can be and make their own choices about daily life. Food is considered to be highly important and meal times are considered to be a social occasion. The menu is balanced and nutritious. EVIDENCE: Service user’s hobbies and leisure interests are recorded in their care plans. Home Of Comfort Nursing Home DS0000011514.V326230.R01.S.doc Version 5.2 Page 13 The home employs an activities co-ordinator who arranges activities for two afternoons a week; these can include bingo, quizzes, armchair exercises and skittles. On the day of the visit to the home the activity coordinator was on leave. A member of the care staff was facilitating a bingo and chat session in the afternoon. Staff said that activities are based on the needs and wishes of service user and that due to the increased frailty of many of the service users they appreciated one to one activities such as looking at newspapers and chatting rather than group activities. Staff were observed chatting with service users during the visit to the home. Service users said that they could choose whether to join in with activities or not. Religious needs are met by visiting clergy from various Christian denominations. Other religious denominations would be accessed if the need arises. Service users are able to choose where they take their meals, though they are encouraged to take meals in the dining room. The cook who speaks with all service users about their dietary needs develops the menu plans. Lunchtime was observed to be a social occasion: staff were assisting service users with sensitivity. Service users spoken with said that they enjoy the meals at the home. Service users are made aware of the menu for the day by staff discussing it with them and by it being displayed. Service users confirmed that they are able to have an alternative meal if they do not want the menu planned for that day. The home caters for special diets including diabetics, pureed meals and will cater for diets of different social/ religious needs after seeking advice. The home is able to care for service users that required tube feeding, though there were no such service users at the time of the visit to the home. During the visit to the home several people were visiting residents. All visitors said that they are always welcomed into the home and that they can see their relative/friend in one of the communal areas or in the person’s own bedroom. Service users said that they are able to make choices about their daily lives and activities. Staff said that the choices and wishes of the residents have great influence over the general and daily running of the home. Home Of Comfort Nursing Home DS0000011514.V326230.R01.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. 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. Service user and others associated with the home demonstrate a good understanding of how to make a complaint and are confident that their concerns will be addressed promptly. Service users are protected from the effects of abuse by a work force that has a clear understanding of the issues about the protection of vulnerable adults. EVIDENCE: A robust complaints procedure is in place. Service users and their representatives are informed of it by information provided prior to moving into the home. The complaints log book showed that no complaints had been received by the home since the last inspection. Service users, due to their memory problems, were unable to recall whether they had been given information about how to complain at the home. But all them spoken with said that they would put any concerns or complaints to any member of the staff at the home and that they believe that these will be dealt with promptly. Visitors also spoken with stated that they would be confident to express concerns or complaints to any staff members and they believe that these would be dealt with effectively and promptly. Home Of Comfort Nursing Home DS0000011514.V326230.R01.S.doc Version 5.2 Page 15 Polices and procedures are in place about the protection of vulnerable adults. Staff have received training. Staff spoken with were able to discuss different types of abuse and the correct action to be taken if they suspect abuse has happened. The deputy matron was able to discuss the correct procedure for investigating allegations of abuse. Home Of Comfort Nursing Home DS0000011514.V326230.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home that has a well-maintained environment, which provides aids and equipment to meet their needs. The well being of those living at the home is protected by good hygiene and infection control practices. EVIDENCE: Home of Comfort is situated in a residential area of Southsea within easy access to local amenities and the seafront. All bedrooms are single occupancy and have a hand basin. No bedrooms have en-suite facilities; this is made clear within the information provided to service users prior to moving into the home. Service user’s rooms looked clean and cheerful and contained many Home Of Comfort Nursing Home DS0000011514.V326230.R01.S.doc Version 5.2 Page 17 personal items such as pictures and ornaments. All bedroom, bathroom and toilet doors have suitable locks fitted, allowing service users privacy when required. Communal areas consist of a large lounge area, smaller lounge area and dining room. The dining room is utilised for afternoon activities as well for meal times. Accessible and well-maintained garden areas are used by service users during the warmer months, one service user said that she liked to use the garden area daily when the weather is suitable. There are two shaft lifts to access the first floor. The design of the building results in some bedrooms being located via a small flight of stairs. During the assessment process service users are offered these rooms if their mobility is suitable; the home does have a mobility aid to assist service users up and down these stairs if needed. Sufficient bathing and toileting facilities are provided. Good processes for reporting maintenance issues ensure that the home is kept well maintained. The home was clean and free from malodours during the inspectors visit. A team of cleaning staff are responsible for the cleanliness of the home. All laundering is done in the homes own laundry. The laundry area was clean and tidy on the day of the visit to the home. Service users were wearing clean laundered clothes during the visit to the home. Suitable hand washing facilities are provided for staff and service users, protective equipment such as gloves and aprons are readily available for staff members. Home Of Comfort Nursing Home DS0000011514.V326230.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. 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. Service users have confidence in the staff that care for them. The service ensures that staff receive relevant training that is targeted on meeting the needs and improving the wellbeing of service users. Good recruitment procedures protect the welfare of service users. EVIDENCE: The home employs the matron (registered manager), a deputy matron, trained nurses, and care staff. Separate staff are employed for administration, catering, laundry, domestic and maintenance duties. Rotas seen indicate that on a morning shift six care staff and one nurse is on duty, in the afternoon four care staff and one nurse and during the night two care staff and one nurse. Staff, service users and relatives spoken with said that they believe there are sufficient numbers and skill mix of staff on duty at any one time. More than 50 of the care staff team have achieved level NVQ level 2 in care or above, with other staff in the process of studying for NVQ qualifications. A training matrix illustrates what training staff have received and training they Home Of Comfort Nursing Home DS0000011514.V326230.R01.S.doc Version 5.2 Page 19 require. The deputy matron said that the organisation is committed to providing training or staff. Staff spoken to said that they receive training needed to enable them to fulfil their role and meet the service users holistic needs. Service users said that they believe staff at the home have the skills to care for them; this comment was also made by visitors. Recruitment polices and procedures are in place. Sampling four staff member’s files evidenced that recruitment procedures are followed. This includes ensuring two satisfactory references and satisfactory CRB clearance are received before a person commences employment at the home. Home Of Comfort Nursing Home DS0000011514.V326230.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service benefits from a competent manager who has a clear vision that the service should be run to maintain and improve the welfare of those living at the home. There is strong ethos of being open and transparent in all areas of the running of the home. The service responds to suggestions by service users, their representatives and staff members. Clear procedures protect resident’s finances. The home has a good record of meeting relevant health and safety requirements and legislation. EVIDENCE: Home Of Comfort Nursing Home DS0000011514.V326230.R01.S.doc Version 5.2 Page 21 There have been no changes in the management structure at the home since the last inspection. The manager, Mrs Pat Evans, has the required qualifications and experience, is highly competent to run the home and meet its aims and objectives. She is supported by the deputy matron who is in the process of completing her registered managers award. Staff expressed satisfaction with the management of the home and the support given to them by the manager. Staff said that they are able to put forward ideas about the running of the home that are considered and acted upon if possible. Staff meetings are held. Auditing of the service provided by the home is achieved with the use of several tools including a service user survey, auditing of the environment and reviewing care plans, pharmacy inspections, one to one discussion with service users. The annual service user survey is done anonymously not involving any of the care staff. The results are collated and the deputy matron said the results are acted upon. It is recommended that the action taken as a result of these surveys is documented with the report from the surveys. Staff said that the running of the home is greatly influenced by the wishes and needs of those living at the home. The home will look after small values of resident’s monies. Accurate records are kept of all money received and spent by the resident. Polices and procedures are in place about health and safety issues. The fire logbook indicates that all staff receive the relevant fire safety training as recommended by Hampshire fire and rescue services. Fire risk assessments are in place. Fire safety checks are performed to the fire and rescue services recommended intervals. All incidents affecting the wellbeing of service users are documented in the care notes and on the relevant accident forms. A regular audit of these records takes place and action is taken accordingly to reduce the risks of falls and incidents to service users. During the visits to the home the kitchen was a clean and tidy. A recent food hygiene inspection carried out by the environmental health department had described the food hygiene practices at the home as excellent. A sample of records was seen evidencing that services and equipment are serviced at the manufacturers recommended intervals. Home Of Comfort Nursing Home DS0000011514.V326230.R01.S.doc Version 5.2 Page 22 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Home Of Comfort Nursing Home DS0000011514.V326230.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2)17(1 a) Requirement The registered person must ensure that the reason for medications not administered to service users is clearly documented. Timescale for action 30/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP33 Good Practice Recommendations Actions taken as a result of quality audit findings should be documented. Home Of Comfort Nursing Home DS0000011514.V326230.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Home Of Comfort Nursing Home DS0000011514.V326230.R01.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. 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