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Inspection on 27/07/06 for Jansondean Nursing Home

Also see our care home review for Jansondean Nursing Home for more information

This inspection was carried out on 27th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

Recruitment and retention of staff is well addressed in this home. Many of the staff have been in post for several years, which gives a good framework for a consistency of care. Several staff with whom the inspector met were generally happy in their work and felt supported. Most staff felt that the training opportunities were sufficient to equip them with the skills to undertake the work that they perform.

What has improved since the last inspection?

What the care home could do better:

The home must ensure that only residents within the category "older persons" are admitted, as this is the only category for which the home is registered. Residents with diagnosis of dementia are not included in the registration category. Further work is required to ensure that care plans are reflective of need with supporting risk assessment and health care documentation in place. The building layout makes it difficult for staff working between floors. Narrow staircases and a slow lift compound the problem of looking after frail elderly residents. Furniture and fittings are looking "tired" but it is understood a programme is in place to remedy this. Quality assurance measures in this home are in the main absent and these need to be implemented, particularly the Regulation 26 visits.

CARE HOMES FOR OLDER PEOPLE Jansondean Nursing Home 56 Oakwood Avenue Beckenham Kent BR3 6PJ Lead Inspector Miss Rosemary Blenkinsopp Unannounced Inspection 27th July 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Jansondean Nursing Home DS0000010138.V300165.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. Jansondean Nursing Home DS0000010138.V300165.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Jansondean Nursing Home Address 56 Oakwood Avenue Beckenham Kent BR3 6PJ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8650 7810 020 8325 8008 jansondean@btinternet.com Sage Care Homes Limited Mr David Walters Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Jansondean Nursing Home DS0000010138.V300165.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing Notice issued 28 April 1997 Date of last inspection 31/01/06 Brief Description of the Service: Jansondean is a large, detached, older building, situated in a pleasant residential area of Beckenham. It is near to local facilities and shops, and is close to a main road, bus routes and train stations. The Providers (Sage Care Homes), have several other homes for the care of older people at different locations around the country. Accommodation is provided on 3 floors (ground, first and second), and a passenger lift facilitates access to all floors. A new build extension was completed at the rear of the property about 12 years ago, and this incorporates a lounge/dining room on the lower ground floor, which leads out into a large garden; this is mostly laid to lawn, and has mature trees and shrubs. Jansondean Nursing Home DS0000010138.V300165.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted unannounced by one inspector. A second visit was undertaken; this was by arrangement. The pre inspection questionnaire was received late, the original one having been lost in the post, hence the comment cards were not sent out until after the first day of the inspection. The comment cards were sent out to professionals involved with the residents who were part of case tracking, including the GP, Care Managers and next of kin. Five residents’ comment cards were sent out. The comments received were generally favourable regarding their stay in Jansondean. Other comments received included the lack of staff particularly at weekends and the lack of information provided in the absence of the Manager. One person commented upon the lack of ambience and quality of furniture in the home, whilst another referred to the lack of activities. At the time of the inspection there were 29 residents in the building. The home is using some of the double bedrooms as single. Once the refurbishment is completed the home will provide accommodation for 28 residents. What the service does well: What has improved since the last inspection? Of the three requirements arising out of the last inspection, two had been partially or fully addressed. The care plans did have reviews in place and were up to date although not sufficiently comprehensive on areas of need such as social aspects and risk elements. The Manager has investigated other assessments and care plan formats for use in the home; these are currently under consideration. Recruitment files were to a reasonably good standard and included checks on identity. Staff photographs had been taken, but they had not yet been developed – this needs to be actioned. Jansondean Nursing Home DS0000010138.V300165.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. Jansondean Nursing Home DS0000010138.V300165.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 Jansondean Nursing Home DS0000010138.V300165.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): 3 The quality relating on this section is adequate. This is based on all information including the site visit. The Manager conducts pre admission assessments although fuller details are required on areas such as social and psychological needs. There was little evidence of pre admission visits by either the resident or their family or any documentation relating to what information had been provided prior to admission. EVIDENCE: The assessment information of the last two newly admitted residents was inspected. One gentleman was diagnosed with ‘Lewy Body’ dementia – this is outside the registration category for the home. His diagnosis was not identified prior to admission by the hospital medical team, which only detailed his physical health issues. The home must ensure that residents are accommodated within its registration category i.e. Care Home Nursing - Older Persons. Any condition outside of this registration must have a variation applied for from the CSCI , and must be sought for the resident identified above. It was however noted, in another care plan, that dementia was Jansondean Nursing Home DS0000010138.V300165.R01.S.doc Version 5.2 Page 9 recorded as part of the diagnosis. Again the home must only admit those residents for whom it is registered. Admission information was reasonably well completed and it was evident that assessments are conducted by the home Manager. One document headed “pre admission assessment” required more detail and was without the date or staff signature. The home’s assessment of activities of daily living was partially completed in both of the records inspected. In the main pages two and three were incomplete, which dealt with social and physiological needs. Other information included hospital discharge letters and Community Care assessments. The assessment information revived from the London Borough of Southwark was well completed and included a Community Care plan of care. There were no records relating to pre-admission visits or details of what information had been provided prior to admission. Jansondean Nursing Home DS0000010138.V300165.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality relating to this section is adequate. This is based on all information including the site visit. Care plans are in place for all residents. The content of these are limited, mainly focusing on physical heath needs, with little on other areas. More robust risk assessments are required to minimise identified areas of risk. Medications are reasonably well managed although more attention and detail is needed around record keeping, and “as required “ directions. EVIDENCE: The care plans of the two residents involved in case tracking were inspected. The first care plan had four areas identified under the needs section. The care plan had been reviewed 2/06/06. The care plan detailed physical health problems only; there was no reference to social or psychological needs, even though this gentleman had vision impairment which would cause significant risk to his health. One care plan item was to restrict fluid intake; fluid balance charts were in place to monitor this. Other health care interventions undertaken by the multi disciplinary team were limited, except visits by the GP. Jansondean Nursing Home DS0000010138.V300165.R01.S.doc Version 5.2 Page 11 The risk assessments for this resident included a dependency assessment and waterlow score. His waterlow score was in the high-risk category although this had not been reviewed since 22/ 06/06. His care plan indicated cot sides in use. However there was no risk assessment or care plan related to this. The manual handling assessment was also limited in content. The second care plan was in relation to the resident with a diagnosis of Lewy Body Dementia. He has been admitted 7/7/06. The care plan issues included reduced cognitive awareness, eating and drinking, washing and dressing. The care plan had been reviewed in July 06, and was due for a three month review. There was no indication of the date the care plan had been generated. Again there was nothing noted in respect of other needs particularly in respect of his Parkinson’s, which causes significant problems and poses risks in many areas of daily living activities. Within the daily events there was reference to his restlessness and confusion. The use of cot sides was referenced; however no care plan or risk assessment were in place. The health care entries included visits by the GP and Parkinson’s nurse. The inspector noted that many entries in the home’s diary referred to visits by health care professionals. These should be included on the appropriate records. The medication systems were inspected. The medication charts had residents’ photographs in place. Allergies were omitted on several charts. Some medication records were not completed with the amount received into the home, date or staff signature. One resident had been refusing her medication for a number of weeks. It was noted that medications to be administered “as required” did not have full instructions in place including the reason for the medication, maximum dose and, where applicable, duration. Dates of opening were evident on eye drops; other medications checked were in date. There was no evidence of overstocking. Please see requirements 1 and 2. Please see recommendation 1. Jansondean Nursing Home DS0000010138.V300165.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. The quality relating to this section is adequate. This is based on all information including the site visit. On the day of the inspection there was little evidence of organised activities although residents were occupied with newspapers, TV’s and their radios, and no negative comments were received regarding the lack of activities. EVIDENCE: The majority of residents were in their own rooms as the inspector arrived, later some residents were assisted into the lower ground floor for lunch. In some cases fluids and call bells were out of reach for residents to access. The inspector did not see evidence of any activities taking place although TV’s and radios were playing in individual areas. There was an activities list on the wall and information regarding an aroma therapist. One resident had just returned from a week’s holiday, which the home had facilitated, through the Winged Fellowship. Rising and retiring times are flexible although routines do prevail within the home i.e. tea times, meal times, medications etc. Visiting is open and encouraged. The inspector met with three residents who gave feedback regarding their stay in the home. Residents related positive comments and expressed that staff were kind and patient. One female resident who was in her room, gave Jansondean Nursing Home DS0000010138.V300165.R01.S.doc Version 5.2 Page 13 positive comments regarding the staff, “people are very kind”. Another resident stated that staff were “kind and considerate”. One comment card received by the inspector related that they were not aware of any activities taking place. One resident indicated the food to be good, the other two residents indicated the food was “OK” and “variable”. The menu is a four week cycle with two choices of food. The choice on the day of the inspection was homemade chicken pie or spaghetti bolognaise. Juice was served with the meal. The tables were laid as residents arrived to be seated. In the kitchen there was a chef and a kitchen assistant. The chef had been in post for one year. Temperature records were in place for hot food and fridge/ freezers. Special diets are catered for. The food storage areas were tidy and all food in date. Stock rotation was stated as taking place. Deliveries of fresh food, fruit and vegetables were weekly. Please see recommendation 2. Jansondean Nursing Home DS0000010138.V300165.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 The quality relating to this section is good. This is based on all information including the site visit. Complaints procedures are well advertised throughout the home indicating an open receptive manner to complaints. Training in respect of abuse has taken place with staff members and more is planned. Staff had knowledge of the whistleblowing and adult protection procedures. EVIDENCE: The complaints file was inspected. It contained no recent complaints, the last one recorded was January 2006. The CSCI has received no complaints regarding this service. Within the complaints file there was detail of the complaint and the investigation route including where appropriate the investigation route. The information did not contain a reference as to whether the complainant was satisfied with the outcome or not. This should be added. The complaints procedure was on the walls of all of the bedrooms as well as in the hall. It is recommended that this be made available in large print. On the training matrix provided to the inspector it detailed that abuse training had been provided to thirteen staff in June 2006; another session had been conducted in February 2006 to three staff. Further training sessions on this topic were due to take place October 2006 and February 2007. Staff with whom the inspector met had knowledge of adult protection procedures and more importantly referring it on appropriately to other bodies. Jansondean Nursing Home DS0000010138.V300165.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 The quality relating to this section is poor. This is based on all information including the site visit. The home is an adapted building spread over many floors, with a very slow lift. Travel between floors is time consuming and has an impact on staff resources. The sitting area is not ideal, as it is located in the lower ground floor. EVIDENCE: There was evidence that some refurbishment and replacement of furniture had been addressed since the inspector had last visited the home. Easy chairs were available in the lower ground floor lounge area and some bedrooms had benefited from re-decoration. However the home remains unsatisfactory and in parts unsuitable for its resident population. The home was generally clean but some bathrooms and toilets had been used for storage areas. The Manager advised the inspector that three of the double rooms were being used as single accommodation. Plans have been put forward for an extension to the building and included within this are more single bedroom accommodation. Jansondean Nursing Home DS0000010138.V300165.R01.S.doc Version 5.2 Page 16 In bedroom 4 the walls and paintwork were badly marked and the carpet was stained. Several bedroom doors were held open with bricks covered with paper. There was an alarm, which was going off frequently. This maybe be quite disturbing for residents, but is an essential piece of equipment to safeguard the health and welfare of one specific resident. The external windowsill of Bedroom 23 required urgent repair or replacement. Some areas were still in need of redecoration and replacement furniture.However it is understood from the provider that a major programme of refurbishment is planned for completion over the next 18 months. The laundry is located adjacent to the lower ground floor sitting area. Window restrictors and radiator guards were in place. Portable fans were in use in communal areas and bedrooms. These need to be risk assessed. The laundry was hot and limited in storage space. The clothes for washing were on the floor and could result in cross-infection issues. It was noted that the door was opento the sluice area adjacent to Bedroom 4, and COSHH items are contained within this area. Staff were not in the vicinity at the time. This needs to be addressed. In the garden there was old furniture waiting to be disposed of. Please see requirements 3 and 4. Jansondean Nursing Home DS0000010138.V300165.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. The quality relating on this section is adequate. This is based on all information including the site visit. Staff are subject to recruitment checks including CRB, identity confirmation, and interviews. Thereafter, staff are inducted on a supernumerary basis and training provided. Staff are provided in sufficient numbers with an appropriate skill mix. EVIDENCE: On the morning of the inspection there were two qualified staff on duty and five care staff. In the kitchen there were two staff; there was one laundry assistant, a housekeeper and domestics. Three staff personnel files were inspected. They contained evidence of CRB clearance, two references and identity including proof of address. In one file there was no photograph of the employee; this was said to be because of problems downloading the photographs from the camera. An employee had been recruited to the home who was deaf – in place were risk assessments in respect of the fire alarm and fire procedures; in addition the home is obtaining quotes for a visual fire alarm. The inspector spent time with the qualified staff on duty. One had worked in the home for two and half years, previously having worked in another care home. She confirmed a two day supernumerary induction period, which included health and safety topics, as well as the environmental layout and introduction to residents. She confirmed training on health and safety topics as well as wound care, infection control and several other relevant sessions. The staff member had not received training on abuse although was knowledgeable Jansondean Nursing Home DS0000010138.V300165.R01.S.doc Version 5.2 Page 18 on this as well as whistle blowing procedures. She stated that supervision was provided through the Manager directly whilst on duty although could not confirm that formal supervision was taking place The second qualified staff confirmed that she had received a lot of training during her two years employment. A care staff member was covering a shift as a domestic. She met with the inspector. However due to her poor command and understanding of English it was difficult to elicit very much information although she was very pleasant. The inspector met with the laundry lady who had been in post for two years. She enjoyed the work and felt the amount of laundry was manageable within the stated hours. She had received very little training both in respect of those issues relevant to the work that she undertook and those relating to residents. She needs to receive training in respect of infection control as it was evident that the practice of leaving items of clothing on the floor was not in line with infection control measures. In addition items such as adult protection and whistle blowing should be provided to every staff member. Three care staff have completed NVQ 2 and five others are planned for this year. On the second visit, the inspector met briefly with a qualified nurse who worked in the home one day a week. She felt that there was a good standard of care provided and good team working made the work enjoyable. Please see requirement 5. Jansondean Nursing Home DS0000010138.V300165.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): 31,33,35,38. The quality relating to this section is adequate. This is based on all information including the site visit. There were several items under the health and safety section, which were not current. Staff training is provided on induction and at regular updates thereafter although not all is current. Quality assurance aspects were absent and these need to be addressed. EVIDENCE: The Manager has been in post for two years and has completed the CSCI fit person process. He is a qualified nurse with previous experience in the private healthcare nursing home sector. A selection of health and safety records were inspected including the LOLER checks, gas and five year electrical service. Evidence of monthly hot water checks were in place. These were satisfactory. The hot water was found to be Jansondean Nursing Home DS0000010138.V300165.R01.S.doc Version 5.2 Page 20 in normal limits when randomly tested, although the Manager advised the inspector that there were on going issues with this. The electrical portable appliance testing stickers on individual items indicated this was overdue since May 2006. Fans in use need to be risk assessed for safety. The health and safety statement for the home was not available. Records for weekly fire alarm testing and fire drills for staff were in place. The last fire drill had been 29/06/06, fifteen staff had attended this. Prior to this staff had attended a fire video session in January 2006. The training video is comprehensivefor general fire principles and care staff must be competent in the fire procedures for Jansondean. The fire risk assessments were not seen . The fire service contract had been placed with a new fire company who were due to do their first inspection within the following week. Confirmation that fire equipment and the fire panel have been serviced needs to be forwarded to the CSCI as soon as this is completed. The previous fire service inspection had been conducted in November 2005. There was no evidence that fire escape routes or emergency lighting was checked as part of on going health and safety provision. Staff training in respect of heath and safety included manual handling; however, an annual update is recommended. Four staff have attended emergency first aid training. Within the staff complement there should be staff that have completed the four day first aid training and there must be a trained first aider on all shifts throughout the 24 hour period. It is recommended that all staff attend a one day course. The Manager was unable to access the personal accounts for each resident as the Registered Provider keeps these. It is essential that all information pertaining to residents is made available for inspection and for residents to access., however, since the first day of the inspection it has subsequently been established from the Provider that no residents monies were being held by the company. The Registered Provider has not regularly produced Regulation 26 visits to the CSCI for some considerable time. These must be conducted monthly unannounced. Please see requirements 6, 7 and 8. Jansondean Nursing Home DS0000010138.V300165.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 X X 2 X X X 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 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 x X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 x 3 X X 1 Jansondean Nursing Home DS0000010138.V300165.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The Registered Manager must ensure that care plans are fully reflective of needs, completed with dates and staff signatures and where possible residents signatures to confirm the care plan. Supporting risk assessments need to be in place. The Registered Manager must ensure that all medications are fully recorded. Those medications “ as required” need to have full instructions documented. The Registered Provider must ensure that all parts of the building are maintained hazard free and in reasonable condition including furniture and fittings. The Registered Manager must ensure that all areas are risk assessed including the use of portable fans. The Registered Manager must ensure that all staff, qualified, care and ancillary, are suitably trained and updated for the work that they undertake including statutory topics. DS0000010138.V300165.R01.S.doc Timescale for action 31/10/06 2. OP9 13 31/08/06 3. OP19 16 31/08/06 4. OP19 13 31/08/06 5. OP30 18 31/10/06 Jansondean Nursing Home Version 5.2 Page 23 6. OP38 16 7. OP33 26 (5) The Registered Manager must ensure that all health and safety issues including servicing and staff training are addressed. The Registered Provider must ensure that Regulation 26 visits are conducted and sent directly to the Commission, or to keep a copy on file for viewing at the home. This is now outstanding. The Registered Manager must ensure that quality assurance measures are in place both internally and externally. 31/08/06 31/08/06 8. OP33 24 31/10/06 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 OP9 Good Practice Recommendations The Registered Manager should review the storage facilities for medication; and making a new clinical room available for storage if possible, in line with proposed structural changes in the building. The Registered Manager should review the activities available to residents in line with their needs and preferences. 2 OP12 Jansondean Nursing Home DS0000010138.V300165.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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