Inspection on 17/09/07 for Ingham House Ltd

This inspection was carried out on 17th September 2007.

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

Ingham House Ltd 07/08/06

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Ingham House Ltd 10-12 Carlisle Road Eastbourne East Sussex BN20 7EJ Lead Inspector Gwyneth Bryant Key Unannounced Inspection 08:30 17 September 2007 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 Ingham House Ltd DS0000067336.V346108.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. Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ingham House Ltd Address 10-12 Carlisle Road Eastbourne East Sussex BN20 7EJ 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) 01323 734009 01323 734471 Ingham House Limited Post Vacant Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. That a maximum number of service users to be accommodated must not exceed thirty-seven (37). That service users must be aged sixty-five (65) years or over on admission. That one named service user with a mental disorder under sixty-five (65) years of age to be accommodated. That one named service user with a dementia type illness to be accommodated. 7th August 2006 Date of last inspection Brief Description of the Service: Ingham House is registered to provide care and accommodation for up to thirty-seven older people. The home is close to Eastbourne town centre, shops and the seafront. It comprises two Victorian properties linked together on three floors and a rear extension. There are well maintained gardens to the front and rear of the property. Service user accommodation comprises thirty-five single bedrooms and one double bedroom. All bedrooms have at least a hand wash basin. There are two lounges, a large dining room and a conservatory. Level access to all floors is facilitated by the provision of stair lifts and a passenger lift in the extension. There are five communal bathrooms all of which are assisted. Grab and hand rails are provided as required. Both respite and long term care is provided. Nursing care is not provided. The service provides prospective residents with a copy of the homes brochure and an offer to visit in the first instance. A copy of the service users guide, the statement of purpose and a contract is supplied at the time of the pre-admission assessment process. The range of fees charged as from 1 April 2007 is from £420-650 inhouse activities and toiletries are included in the fees. Additional charges are made for hairdressing, chiropody, newspapers and dry cleaning. Intermediate care is not provided. The homes lynn@inghamhouse.co.uk or paul@inghamhouse.co.uk. Currently the home does not have a website. Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place over seven hours. The purpose of the inspection was to check compliance with the requirements made at the last inspection and inspect additional standards. There were 36 people in residence on the day of which four were spoken with individually, in addition to two visitors. The Registered Manager and one carer were also spoken with. A tour of the premises was carried out and a range of documentation was viewed including care plans, personnel and medication records. Twenty surveys were returned to the inspector and were, in the main positive with people praising the level of care given. The only area that was less positive was the activities, with a number of people asking for more outings or specific activities being requested. Prior to the site visit information was requested from the provider; this was given and information detailed is used in this report as necessary. Comments in returned surveys included: ‘All staff very caring and helpful.’ ‘The staff are very good and listen to us, what we say’. ‘I have been here 5 years and been happy all the time’. ‘My mother is well looked after, good food & clothes always clean and fresh as is her bedding and room’. ‘Staff usually listen and act on what is said by service users’. ‘So far care & support really very good’. ‘Staff are very helpful and always willing to oblige’. ‘So far not reason for complaint’. ‘Senior staff are very helpful’. ‘My sister has individual and special needs at this time of her life and they are always met’. ‘I would recommend it (Ingham House)’. ‘Ingham house gives me and other family members peace of mind and comfort in the knowledge that my sister is well looked after and cared for at all times’. ‘Its an excellent place, its very clean, very good service, lots of good things’. ‘My Nan’s happy’. What the service does well: People living in the home were seen to be treated with care and respect by staff and daily routines are flexible ensuring that people using the service have the opportunity to maintain control over their daily lives. A range of activities are provided during the morning and afternoon with additional activities provided in the homes day centre providing mental and physical stimulation. People are encouraged to bring their own possessions in order to personalise their individual rooms and many have done so. The home is well maintained Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 6 throughout as are the rear and front gardens which endure the home is a comfortable and attractive place to live. Meals remain good ensuring that those living in the home have a varied and well balanced diet. Systems for dealing with complaints are satisfactory ensuring that any concerns are listened to and acted upon. 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. The summary of this inspection report can be made available in other formats on request. Ingham House Ltd DS0000067336.V346108.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 Ingham House Ltd DS0000067336.V346108.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): 3 and 4. Standard 6 is not applicable. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Improvements need to be made to the pre-admission process to provide documentary evidence that Ingham House can meet the needs of people admitted to the home. EVIDENCE: Pre-admission documentation was viewed for recent admissions and not all parts had been completed, nor did they include how the home will meet assessed needs. Discussion with the Acting Manager found that she is in the process of reviewing and expanding the pre-admission assessment record to ensure a comprehensive assessment is made for each individual admitted to the home. Returned surveys and those people spoken with confirmed that an assessment was made prior to moving into the home and that their needs were considered and met. One comment in a survey was: Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 9 ‘On a visit to Ingham House I was shown around and felt it was just right for me as I wanted to stay in Eastbourne’. At the time of admission a copy of the complaints procedure is included with the service users guide to ensure they are aware of how to make a complaint. Intermediate care is not provided. Ingham House Ltd DS0000067336.V346108.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 and 10. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care planning systems need to reflect the current needs of people living in the home and improvements need to be made to the risk assessments process and the handling, recording and administration of medication. EVIDENCE: Five care plans were viewed and while they included all aspects of care needs they did not include clear direction to staff as to how to meet those needs. In addition care plans had not been updated to reflect the current care needs for all individuals. Three people were noted to spend the entire day in wheelchairs, as they are unable to weight bear. These increased needs were not identified in their care plans and nor was there clear direction to staff in meeting these additional needs. The one person admitted for respite care did not have a care plan at all therefore it is difficult for staff to know how best to meet his needs. Each person in the home has a designated key worker to ensure they have named carer to speak to and receive consistent care and it is the key worker who is responsible for informing the care planning process and Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 11 liaising with both the individual and their families. Daily notes are maintained and these could be improved if they included more details and did not repeat information held elsewhere. An example is that daily notes stated that medication was given and this information is already on the medication administration (MAR) charts. People spoken with said they felt their care needs were met but the daily notes do not include care given, thus there is no record of the work carried out by staff to meet needs. Basic risk assessments had been carried out for all but they need to be expanded to include sufficient detail for the management of risks. This is in particular for risks associated with tissue breakdown, falls and evacuating the premises in the event of fire. Care plans showed that a number of people had lost weight but there was no information to guide staff on how to ensure these people ate a balanced diet. One person was seen to be just sitting at the breakfast table holding half a banana, with her toast left on a plate to go cold. This was discussed with the Acting Manager who explained that the individual should be assisted to eat and this was addressed during the lunchtime meal as this person was assisted with her meal. The senior carer on duty also explained that this lady has now been prescribed meal supplements to ensure she remains well nourished. Staff training records showed that all staff who administer medication have received appropriate training however, it is not put into practice on a daily basis. Medication administration practice was observed and although storage of medication and the recording of controlled drugs was good there were shortfalls in respect of other medication procedures. On the day medication was potted up into individual pots to be taken to people living in the home later in the morning and this practice needs to be reviewed as medication must be administered on an individual basis. In addition a piece of paper with the room number of the recipient was put into each pot and this puts people at risk as medication is contaminated. A number of people are prescribed a particular medication and this is distributed from one pack. It is not acceptable to give medication to an individual other than whom it is prescribed for as an audit trail of medication administered cannot be maintained. MAR charts were viewed and a number of signatures had been overwritten to show medication had been refused, this suggests that staff are signing the chart prior to the medication being administered. Throughout the site visit staff were seen to treat people living in the home with care and respect and this was confirmed by those spoken with. Comments from surveys and those spoken with included: ‘the staff are very kind’ ‘I can’t fault them’ ‘they (staff) look after me very well’. ‘staff are very good and so kind’. ‘I am very impressed with the standard of care given to my sister’. ‘Residents are given day and night care and their needs are always catered for’. Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 12 Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 13 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 and 15. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People in the home have the opportunity to experience a lifestyle that matches their expectations, choice and preferences in respect of leisure activities and meals. EVIDENCE: There is a varied daily programme of activities for both the morning and afternoon periods in which individuals are actively encouraged to participate. Returned surveys indicated that more outings would be appreciated and comments included: ‘I would like more outings’. ‘I am surprised they don’t have knitting’. ‘Staff have said there will be more activities’. ‘usually something to do but would like more arranged’. ‘Always make their residents feel at home, and relatives always get a warm welcome’. ‘Residents are treated as individuals and their individual needs are always met and catered for’. Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 14 Those spoken with confirmed that they go out into the community with family and friends and to attend local clubs. Visitors spoken with said they were always made welcome and offered refreshments. During the site visit people living in the home were seen to take the opportunity to walk in the gardens either alone or escorted by staff. Discussion with the Acting Manager found that she is in the process of identifying additional activities that can be provided in the homes day centre and the possibility of employing an Occupational Therapist to ensure the leisure needs of all those living in Ingham House are met. Food was a topic that is highly praised by those spoken with as all said that the food was excellent and that they are given a choice at each mealtime. Each meal chosen by individuals is recorded to enable staff to check meals remain well balanced and varied. The days menu was seen and confirmed that people had chosen different meals based on their preferences. On arrival some people were in the dining room having breakfast while other were given breakfast in their rooms demonstrating that preferred daily routines in respect of meals are catered for. Ingham House Ltd DS0000067336.V346108.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure with evidence that those living in the home feel that their views are listened to and acted upon. People living in the home are further protected by satisfactory adult protection systems. EVIDENCE: The home has policies and procedures on complaints and two complaints have been received by the CSCI with the home being asked to investigate. This was carried out in line with the homes policies and procedures on complaints and resolved satisfactorily. Internal complaints were recorded in the complaints book with actions taken and outcomes. There is an additional complaints book for staff to raise any issues and these are also recorded and include actions taken to resolve the matter. Since the last inspection the manager has introduced a number measures to actively encourage communication with people living in the home and their relatives so that they feel at ease to raise any concerns directly with management. People spoken with said they would be happy to speak to staff or the manager should they have any concerns. Comments in surveys included: ‘There was an issue which was addressed and resolved. I am happy with the outcome’ ‘So far not reason for complaint’. Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 16 One visitor expressed concern that a scarf had been taken from their mother, this was passed to the Acting Manager who investigated and found that staff had taken it to be washed. The scarf was duly returned. This same visitor also requested that his relative be moved to another home and as one of the Directors of Ingham House Ltd was on site she undertook to deal with this in line with the homes discharge and consultation procedures. The home has policies and procedures on adult protection and staff are expected to be familiar with this document. There is a staff training programme to ensure all staff are trained in the Protection of Vulnerable Adults. The carer spoken with confirmed that she had received this training and was familiar with the action to take in the event of an allegation. Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 17 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 and 26. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The standard of decor within the home is good, providing people living in the home a safe, homely and comfortable environment. EVIDENCE: A tour of the premises was carried out and a random selection of rooms inspected. The home continues to provide a safe and comfortable place in which to live. One person approached the Responsible Individual in respect of a necessary minor repair and this was addressed on the day. In addition some water delivery temperatures were a few degrees above that recommended and again this was addressed on the day demonstrating that minor repairs are dealt with quickly and effectively. Individuals’ bedrooms were well maintained and pleasingly decorated and it was evident that people are able to bring in their own possessions in order to personalise their bedrooms. One room was Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 18 malodorous but this was due to an event earlier in the day and a member of the management team was already dealing with this. The laundry facilities are satisfactory and washing machines are able to wash clothes at temperatures that control the risk of infection. Staff are trained in infection control and the Acting Manager has a copy of the ‘Essential Steps to Infection Control’ as a point of reference to ensure the service complies with the latest guidance. Information provided prior to the site visit indicated that there is an on-going maintenance and refurbishment programme for all parts of the home including long-term plans to renovate the laundry area, provide a wet room, shower and treatment room. Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 19 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 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are sufficient staff with the skills and competency to meet the needs of people living in the home and recruitment practices are robust ensuring that people using the service are protected. EVIDENCE: Recruitment records for the last three people to be employed were viewed and these showed that all the required information had been provided including Criminal Record Bureau and Protection of Vulnerable Adults checks, two written references and proof of identity. There is a comprehensive staff induction and foundation training programme in place that meets the Skills for Care requirements and ensure staff are familiar with working practices at the home. The one carer spoken with confirmed that there was an induction period. She said she was impressed with how comprehensive it was and that it enabled her to become familiar with the home, other staff and the people living there. There is a designated senior carer who conducts the induction period for all staff and has weekly meetings to ensure they fully understand good care practice in line with the induction programme. Comments in surveys included: ‘Staff are very helpful and always willing to oblige’. ‘So far not reason for complaint’ ‘Senior staff are very helpful’. Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 20 ‘Sometimes they (staff) are under pressure – at change over time at 8pm’. Returned surveys indicated that sometimes there are not enough staff, therefore staffing levels need to be kept under review, based on the dependency levels of people living in the home. Information provided prior to the site visit indicated that of the 21 care staff, nine have gained National Vocational Qualification level 2 in care and three are in the process of gaining this award. In addition two other staff have credentials equivalent or exceeding this qualification, therefore the service exceeds the target of 50 of staff with this qualification. Discussion with the Acting Manager and examination of staff training records showed that all staff have been trained in fire safety, first aid and safe manual handling techniques. Further discussion with the Acting Manager found that she is in the process of developing a rolling staff training programme to ensure they all remain up-to-date on training. Ingham House Ltd DS0000067336.V346108.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service is well managed and all aspects of the welfare, safety and health of people living in the home are protected and promoted. EVIDENCE: The Acting Manager has a number of years experience in the care industry giving her a wide knowledge of the care needs of people. She is in the process of gaining National Vocational Qualification level 4 in care to ensure she has up-to-date knowledge of current care practices. Throughout the site visit both people living in the home and staff were seen to approach her with concerns, indicating that she is open and accessible to deal with any issues. Comments in surveys and those spoken with included: Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 22 ‘The care manager is always available to answer any queries on questions one might have’. ‘(name of Acting Manager ) has explained how to go about making a complaint’. The one carer spoken with confirmed that the management are approachable and supportive and in their opinion ‘a good place to work’. Since the last inspection regular resident meetings are carried out and the minutes from these meetings showed that people living in the home are encouraged to raise any issues. These meetings are carried out prior to staff meetings to ensure there are good lines of communication and any concerns can be discussed and rectified. There are also suggestion boxes for both people living in the home and staff to enable them to make suggestions on improving the service, anonymously, if they wish. In addition a copy of the complaints procedure is displayed in the hallway of the home. The Acting Manager collates the suggestions and ensures they are addressed as soon as possible. Small amounts of money are held for people living in the home and all transactions are recorded and receipts provided as necessary. Information provided prior to the site visit showed that regular safety checks are carried out on all equipment, electrical and gas appliances and systems. All accidents are recorded and monitored by one of the directors as part of the monthly visits to the home and the subsequent reports are available for inspection. While the Acting Manager has created a number of avenues to check the quality of the service, it is recommended that they be formalised into a detailed quality assurance system to ensure all aspects of the service are monitored. All staff receive regular fire safety training and a fire risk assessment has been carried out and all recommendations met in line with the set timescales. Regular fire drills are carried and fire alarm systems regularly tested ensuring neither staff nor people living in the home are at risk in the event of fire. A tour of the premises found that some fire doors did not close properly and the Responsible Individual agreed to ensure the maintenance person dealt with matter on the day. Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 23 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 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 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 Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 24 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. Standar d OP7 Regulation 13 (4) (b) (c) Requirement Risk assessments for those at risk of falls or tissue breakdown need to include the management of the risk and be regularly reviewed. Service users need to be involved in the compilation and review of care plans. That care plans reflect current care needs of service users. That care plans include action take when service users are noted to have lost weight. That prescribed medicines be used only for the person intended. That medication is not potted up prior to administration and that it is not contaminated by paper . That signatures on medication charts are not overwritten. Timescale for action 17/11/07 2. 3. 4 5 6 7 OP7 OP7 OP8 OP9 OP9 OP9 12(1)(2)( 3)21(1) 15(1) (2)(b)(c) Schedule 3(o) 13 (2) 13 (2) 13 (2) 17/11/07 17/10/07 17/11/07 17/10/07 17/11/07 17/10/07 Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 25 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 OP27 OP33 Good Practice Recommendations That staffing levels be kept under review, based on dependency levels of service users. That the plan to implement formal quality monitoring systems be implemented. Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Ingham House Ltd DS0000067336.V346108.R01.S.doc Version 5.2 Page 27 - 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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