Inspection on 24/08/06 for Honey Lane Care Home

This inspection was carried out on 24th August 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

Honey Lane Care Home 28/01/09

Honey Lane Care Home 01/08/07

Honey Lane Care Home 08/02/06

Honey Lane Care Home 07/07/05

Honey Lane Care Home 14/12/04

Honey Lane Care Home 13/07/04

Honey Lane Care Home 07/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Honey Lane Care Home Honey Lane Waltham Abbey Essex EN9 3BA Lead Inspector Lysette Butler Unannounced Inspection 08:45 24 August 2006 th 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 Honey Lane Care Home DS0000037535.V309531.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. Honey Lane Care Home DS0000037535.V309531.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Honey Lane Care Home Address Honey Lane Waltham Abbey Essex EN9 3BA 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) 01992 718558 01992 653463 Towertrend Limited Mrs Caroline Mary Carter Care Home 41 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (41), Old age, not falling within any other of places category (8) Honey Lane Care Home DS0000037535.V309531.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 8 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 41 persons) One person, under the age of 65 years, who requires care by reason of dementia The total number of service users accommodated must not exceed 41 persons 8th February 2006 Date of last inspection Brief Description of the Service: Honey Lane Care Home is a 2-storey purpose built home providing care for persons, of both sexes, over the age of 65. The service users rooms and communal areas are entirely situated on the ground floor with offices on the 1st floor. The home is divided in to four separate wings. There are 41 beds: 32 beds for service users who have dementia; one service user with dementia who is under 65 years of age; 8 for service users who need residential care only. (There had been no further decrease in the number of residential care beds since the last inspection.) This home does not offer nursing care. The home is located about 2 miles from the centre and main shopping area of Waltham Abbey, which is an Essex market town. It is on a main bus route and there is good access by road as the home is in close proximity to the M25. Current fees £476 to in £750. Honey Lane Care Home DS0000037535.V309531.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection started on 1st April 2006. The inspection process included: a site visit on 24th August 2006, which lasted just under eight hours; review of evidence supplied by the proprietor, residents, visitors to the service and staff; resident, visitor, healthcare professional and staff surveys; discussions with the registered manager, senior carers, care staff, ancillary staff, residents and relatives. However the level of cognitive impairment experienced by the majority of the residents of Honey Lane meant that it was difficult to determine their views directly. During the site visit the premises were inspected, including inspection of the grounds. Samples of records and residents care plans were also reviewed. The home was clean, malodour free and well maintained. The overall care and well being of the residents was the focus of the inspection. Staff and residents were welcoming and happy to speak to the inspector at the site visit. This inspection covered all twenty-two key standards and four of the remaining standards. The manager and her staff approached the inspection in a positive and cooperative manner that was focused on achieving best practice to meet the needs of the residents. What the service does well: What has improved since the last inspection? Regular weight and bathing charts are now kept for each resident to ensure nutritional and personal care issues are addressed as necessary. All bathrooms have been cleared of unsuitable items since the last inspection; and everything is now stored appropriately. Honey Lane Care Home DS0000037535.V309531.R01.S.doc Version 5.2 Page 6 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. Honey Lane Care Home DS0000037535.V309531.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 Honey Lane Care Home DS0000037535.V309531.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): 1, 2, 3 & 6 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. Prospective families are given both written and verbal information that allows them to make an informed decision as to whether Honey Lane is the right place for them to reside. EVIDENCE: The statement of purpose and service users guide for this home had been reviewed within the last year and all relevant name changes had been made. There had been no major change to the information they contained. The manager or her deputy using Carebase paperwork undertook all preadmission assessments. Resident files showed evidence of comprehensive assessments and relevant information about their needs, which had been undertaken before they had been admitted to the home. Both the manager and her deputy demonstrated a good understanding of what was needed regarding the assessment criteria. This home does not offer intermediate care. Honey Lane Care Home DS0000037535.V309531.R01.S.doc Version 5.2 Page 9 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 & 11 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. The health and personal care offered by this home to the residents is generally very good, however some aspects of documentation needs to be improved to ensure continuity of care. EVIDENCE: Three care plans were reviewed during the site visit of this inspection. The plan was divided into sections, which made it easy to follow. There has been a general improvement in the content of these plans although the files themselves are starting to look a bit worn and could do with some review and renewal. However all three plans had been regularly reviewed up until April 2006, but then the reviews had become more spasmodic. One care plan for a resident, who had a pressure sore, contained no current information about care of the area. Changes made were clear and mostly dated. There was some good written information, including on one file details of the residents wishes not to take part in the civic process. In another residents file their Honey Lane Care Home DS0000037535.V309531.R01.S.doc Version 5.2 Page 10 deterioration in health including details of their smoking allowance, was a well documented. Two of the three plans had been signed, to agree with the content, by the relatives of the resident. A number of pictures of residents on the care plans were out of date and the inspector was informed that the staff were in the process of renewing all resident photographs, both on the care plans and on the medication sheets. Risk assessments and input by specialist services were detailed and well laid out. All plans reviewed had an infringement of rights form signed by the residents relative regarding the outside doors being locked at all times. Regular weights, and other observations as necessary, were contained within the file along with basic information about activities undertaken. None of the plans reviewed contained information about procedures to be undertaken when the residents’ health deteriorated or they died. The health and personal care or of all residents is well documented and they are offered all regular health checks, most of which are offered within the home. District nurses attend the home as required and feel that the staff only call them when needed. There is still a weekly consultant visit to the home, when all residents are reviewed in rotation to ensure that treatment and medication are up-to-date and to prevent unnecessary hospital admissions. Medication policies and procedures were good; there was no evidence of over prescribing or sedation of the residents. There was no evidence of overstocking and all medications administration records were reviewed demonstrating that there were no omissions. Where medication had been discontinued the medication records had been properly crossed out, an explanation written and the date of discontinuation added, however the individual discontinuing them had not signed them. On the day of the site visit the outdoor temperature was average for the time of year, but the medication room temperature was quite high. However room temperatures are not taken on a daily basis and there was concern that the room was above 25°C. The area manager was informed of this problem at the time and she asked the manager to order an air-conditioning unit as soon as possible. It was also recommended that daily temperatures were taken of the room to ensure that the temperature stays within normal limits. Fridge temperatures were taken daily that the evidence reviewed showed that the fridge had gone above 8°C on a number of occasions during the previous month, but there was no written record of what had been done to rectify this. Verbally the staff were able to tell the inspector that this had been investigated and had been fixed, the evidence showed that since the initial problem the temperatures had been within normal limits, but they were advised to document what had been done Honey Lane Care Home DS0000037535.V309531.R01.S.doc Version 5.2 Page 11 about temperature rises in future. Staff were advised to read medication boxes to ascertain the correct storage place for medications, as one medication was being incorrectly stored in a fridge. The senior care assistant spoken to had a good understanding of the medications given each day and who was taking what medication. It was also discussed with the senior care assistant the importance of reviewing incident forms and medication, in relation to a deterioration in their health that could be related to the medication they are on. The privacy and dignity of the residents is generally respected, although some agency staff do not have the same view of what was required, as did the regular staff. As already highlighted the documentation of the residents’ wishes concerning deterioration in their health or death within the home, is poor. However staff verbally expressed a very caring attitude to these aspects of care and a commitment to the principle of ‘a home for life’ for the residents in their care. Honey Lane Care Home DS0000037535.V309531.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 is good; this judgement has been made from evidence gathered both during and before the visit to this service. The residents of this home had choice in their daily lives and social activities. Families were encouraged to maintain links with the residents even though their cognitive abilities were poor. EVIDENCE: The manager in conjunction with the activities coordinator has recently agreed a new activities programme that was due to start during September 2006. The new programme will be looking at each resident individually their likes and dislikes, then tailoring activities to cover all resident needs. The programme will include more one-to-one time for residents. The home was in the process of expanding its list of activities outside of the home. However there are only a limited number of residents who are suitable to go out of the home and the manager is anxious that they find other suitable activities that all of the residents can undertake. During September the residents and staff of this home are undertaking a sponsored walk for National Alzheimer’s Day. The manager was arranging for all residents to take part, even if their walk is once/twice round the grounds or car park. Visitors and people from the local Honey Lane Care Home DS0000037535.V309531.R01.S.doc Version 5.2 Page 13 area have also been invited to join in. Documentation of activities is basic and not entered on a regular basis. Local community contract remains good, a number of the residents attend a local Day Centre and links with local hotels and schools continue. All residents of this home were on the electoral register and were given the opportunity to vote by post. However due to their levels of cognitive impairment, very few choose to take part in the procedures. The home operates an open visiting policy, which creates no problems for the staff or the residents. Visiting can take place in the residents’ room or in shared areas. Visitors spoken to during this inspection process felt that they were always welcome and could talk to the staff if they need to. On arrival at the home for the site visit, breakfast was being served, which evidenced that each resident chose what they wanted; choices included porridge, cooked breakfast, cereals, toast, fruit, hot and cold drinks. Lunchtime menus always contained two choices and signs up around the home demonstrated a commitment to giving further choices if the residents did not like either all of that days meals. At both breakfast and lunch staff were observed helping and communicating with residents in an appropriate way that preserved their dignity. The kitchens were clean and tidy; cupboards, fridges and freezers were full. There was evidence that there were a lot of fresh vegetables and fruit in the home and the inspector was told that they were offered at least one fresh vegetable with each meal. The last environmental health officer visit had not particular problems. The relief chef was on duty on the day of the site visit and she told the inspector that the menus are on a four-week turnaround, but she was not sure when they had last been changed. The relief chef had originally started at the home as a kitchen assistant and had now been fully trained as a chef. She was also a senior care assistant and enjoyed working at the home in both roles. Honey Lane Care Home DS0000037535.V309531.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 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 from evidence gathered both during and before the visit to this service. Policies & procedures in this home ensure the safety of the residents and staff are aware of their responsibilities under POVA. EVIDENCE: There had been no complaints forwarded to the Commission for Social Care Inspection since the last inspection. There had been some minor concerns made to the manager and staff within the home, all staff had followed procedure. Review of previous handling of complaints by the present manager demonstrated a positive attitude to the complaints, following the homes policies and procedures. The manager also used the information gained during any investigation to improve the care of the residents generally. The manager provided the commission with information about any complaints or problems within the home on a regular basis. All staff had undertaken POVA training and those staff spoken to understood the principle of all POVA procedures. There was a general commitment within the home to protect the residents in their care. During the site visit an issue was raised by a resident concerning the conduct of one of the staff. The manager dealt with it quickly and appropriately. There was no need for follow up once she had completed the appropriate investigation. Honey Lane Care Home DS0000037535.V309531.R01.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 & 26 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. Overall the home is well maintained, safe, accessible and clean. EVIDENCE: A tour of the home was undertaken at the beginning of the site visit. This was at the time that the majority of the residents were being got out all stayed and personal care was being offered. There had been no change to the fabric of the building since the last inspection. The security of the front door was good and the inspector was unable to gain access until a senior care assistant, who asked for identification, opened the door. In the entrance hall where visitors signed in there was hand rub to be used and a polite sign asking that it be used for infection control purposes. The senior care assistant who answered the door, apologised for the length of time it took, because she had needed to lock away the medications whist opening the door. Honey Lane Care Home DS0000037535.V309531.R01.S.doc Version 5.2 Page 16 The inspector immediately toured the home and spoke to the laundry person and chef. The laundry has separate dirty in, clean out doors. The laundry itself was fully in use at this time of the day, but one of the dryers was not working and they were waiting for a part to be delivered. This home use red bags that are put straight into the washing machine, where the seam disintegrates and at the end of the wash they are taken out and disposed of. There were three housekeepers in the home on the day of the site visit and all CoSHH procedures were being followed throughout the home. During the original tour of the home there were a number of unpleasant odours detected, however by the end of the day of these had been completely eliminated and personal care procedures ensured that this was generally the case. There is a smoking room in the home, but it does not have an extractor fan, which means one end of the unit constantly smells of smoke. When discussed later with the manager she stated that there were plans to improve the situation in the near future. All but three hoists and electric baths, in the home had stickers on stating that they had been last checked in July 2006. However during the day servicing contract invoices were reviewed and the three without stickers had also been serviced on the same day. The manager was going to follow up the lack of date stickers with the servicing firm following the site visit. The number and range of hoists in the home was adequate for the dependency of the current residents. Infection control procedures throughout the home were good; soap, hand towels and hand rub were sited at all sinks used by staff. The home was generally well decorated and well maintained. The grounds were tidy, accessible and safe for the residents. Honey Lane Care Home DS0000037535.V309531.R01.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 from evidence gathered both during and before the visit to this service. Staff skill mix and levels of training ensured that the needs of the residents were met within this home. EVIDENCE: Staffing numbers in the home were appropriate to the number and dependencies of the present residents. On duty during the site visit there was one senior care assistant, four care assistants, the deputy manager, three housekeeping staff, one laundry person and one chef. Rosters reviewed during the site visit demonstrated a good skill mix and in enough staff to cover duties. There had been a recent change in senior care assistants that the staff spoken to felt had been very positive. The day following the site visit two new care assistants were due to start on the permanent staff and five further care assistants were awaiting the return all of appropriate identification and checks before commencing work at the home. The home operates its own bank staff, using of very few agency staff, to ensure continuity of care. Due to a number of personnel changes recently, this home no longer has 50 of the staff with National Vocational Qualifications at level 2 or above. Added to this the manager and five of her staff were registered to undertake National Vocational Qualification’s with a company that has recently gone into Honey Lane Care Home DS0000037535.V309531.R01.S.doc Version 5.2 Page 18 liquidation, which means that all six will have to redo any work they have already undertaken with a new firm when the manager has accessed one. Three personnel files were reviewed during the site visit. All files were complete, tidy and very easy to follow. The manager is very clear about the different types of work permits and ensures that all staff have all appropriate paperwork available before they commence at the home. Supervision and appraisal records are kept separate from the personnel files. The manager double-checks all references whether verbal or written. Training records were reviewed and evidence showed that current staff were up-to-date with all statutory training. The majority of the certificates seen had been signed and contained a list of the content of the particular training. A lot of the training sessions included a test quiz at the end and copies of these are also kept on file. Most training was undertaken through a local firm, but other specialist companies were utilised as necessary. Honey Lane Care Home DS0000037535.V309531.R01.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 & 38 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. The management and administration in the home protects residents’ and ensures they’re safety. EVIDENCE: The manager of this home has been registered with the Commission for Social Care Inspection since the last inspection. As highlighted earlier she had started her registered manager award, but has now got to find a new firm through which to undertake this. She demonstrated a good knowledge base during the site visit and throughout the whole inspection process. Staff spoken to were happy that they could approach her and talk to her whenever needed. Honey Lane Care Home DS0000037535.V309531.R01.S.doc Version 5.2 Page 20 Quality assurance questionnaires had been recently sent out by the home and no evaluation was yet available. A copy of the evaluation will be forwarded to the local offices of the commission when available. Commission for Social Care Inspection resident and relative surveys were given out at the time of the site visit. The proprietors of this home follow a ‘key point’ auditing system, which is ongoing throughout the year and the manager informed the inspector that this was up-to-date. The yearly plan for the ‘key point’ auditing was to be forwarded to the local offices of the commission following this inspection process. The manager or her staff are not appointees to any of the current residents. Resident allowances are no longer kept on the homes premises all services and items required by the residents are paid out of petty cash then the relatives are invoiced for payment. During the site visit the manager, deputy manager and inspector discussed, in general terms, issues surrounding financial abuse and both managers demonstrated a good understanding of their responsibilities regarding this aspect of the residents’ care. The regularity of supervision had improved since the last inspection. The manager and deputy manager were currently undertaking everyones supervision. A number of senior care assistants had recently undertaken a supervision course and the manager was planning to cascade some of the supervision down to these seniors in the near future. Staff spoken to about supervision felt that the sessions were useful and helpful when problems arose. All appraisals were due in October 2006. In the staff office there were a number of books that contained personal information about multiple residents. The use of these books was discontinued on the day of the site visit, following discussion with the inspector about how they broke data protection guidelines. Senior care staff were also briefed to ensure that they did not come back into use. The inspector and manger discussed what could be used instead of the books. All certificates and servicing records seen at this inspection were up-to-date and appropriate for this home, ensuring the health and safety of the residents. Honey Lane Care Home DS0000037535.V309531.R01.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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 3 2 3 Honey Lane Care Home DS0000037535.V309531.R01.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. Standard 1 OP7 Regulation 15(2b-c), Schedule 3(1b) 15(1) (2a&c-d), Schedule 3(1b) 15, Schedule 3(1b) 12(2-4), 13(2)(4), 17(1a), Schedule 3(3i) 13(2), 17(1a), Schedule 3(3i) 12(2) Requirement The registered person must ensure that all care plans are reviewed regularly. (This would normally be once a month.) The registered person must ensure that all changes/reviews made to care plans are dated & signed. The registered person must ensure that all care plans reflect the residents’ current care needs. The registered person must ensure that all changes made to medication records are signed and dated appropriately. The registered person must ensure that all medicines are stored at 25°C or less, according to the requirements of the Medicines Act 1968. The registered person must ensure that all care plans contain information about procedures to be followed for individual residents if their health deteriorates or they die within the home. The registered person must ensure that all documentation in the home about the residents comply with data protection guidelines. DS0000037535.V309531.R01.S.doc Version 5.2 Timescale for action 31/10/06 2 OP7 31/10/06 3 4 OP7 OP9 31/10/06 31/10/06 5 OP9 31/10/06 6 OP11 31/10/06 7 OP37 17(1-3) 31/10/06 Honey Lane Care Home 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 Refer to Standard OP9 OP12 Good Practice Recommendations All staff should ensure that they understand the storage requirements of all medications in their care. The registered manager should ensure that all activities undertaken by the residents are individually documented. Honey Lane Care Home DS0000037535.V309531.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Honey Lane Care Home DS0000037535.V309531.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. 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!