Inspection on 24/10/06 for Keate House

This inspection was carried out on 24th October 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Keate House 05/12/05

Keate House 21/06/05

Keate House 01/02/05

Keate House 27/05/04

Keate House 02/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Keate House Brookfield Road Lymm Warrington Cheshire WA13 0QL Lead Inspector Maureen Brown Unannounced Inspection 24 October 2006 09:50 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 Keate House DS0000027005.V307077.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. Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Keate House Address Brookfield Road Lymm Warrington Cheshire WA13 0QL 01925 752091 01925 754022 keatehouse@tiscali.co.uk 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) Mrs Avis Clarkson Mr Malcolm Clarkson Mrs Avis Clarkson Mr Malcolm Clarkson Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. This home is registered for a maximum of 48 service users to include: * Up to 48 service users in the category of OP (old age, not falling within any other category. Bedroom numbers 1 & 94 only may be used to accommodate two service users. 5th December 2005 Date of last inspection Brief Description of the Service: Care and support are provided at Keate House for up to 48 older people. The home is located in Lymm, close to the village centre shops, pubs, restaurants and banks. The home was opened in 1989 and consists of a four-storey building with service user accommodation on the ground and first floors. In December 2004 a three-storey extension was completed providing additional single bedroom en-suite accommodation. The home has forty-four single and two double bedrooms, all of which are en-suite. There are two passenger lifts. Car parking is provided at the front of the building and there is a garden to the side. The home has thirty-one staff that comprises of the Registered Managers, care and administration managers, senior care assistants and care assistants. The cook, general assistant, domestic and laundry staff and maintenance people support them in their roles. The fees at Keate House are £430.00 per week. Items not covered by the fees include hairdressing, chiropody, newspapers, magazines, toiletries, sundries and bingo. Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced visit took place over one day as part of the key inspection, which takes into account all evidence gathered from the last inspection of the service. The total time on site was seven hours forty minutes. The day was spent looking at care plans, policies and procedures and other documentation. Also discussions with service users, relatives, staff and the manager and a tour of the communal areas and a selection of bedrooms. The inspector spent three hours examining the information provided by the home before this visit. Four service users, nine relatives and two GP comment cards were received. At the time of this visit there were forty residents living at Keate House. Twenty-three out of thirty-eight standards were assessed and all were met. Feedback was given to one the registered managers and team members at the end of this visit. The overall quality rating for Keate House is good. What the service does well: The home had an established staff team who were keen for high standards to be maintained. Residents’ plans of care and individual case notes were well documented and reflected each resident’s needs. Meals were varied and reflected each person’s preference. They offered choice and variety. Residents commented that the “food was good”, “I always like the meals” and “the menus have improved and are very good and varied”. With the help of care staff the senior care staff manage daily activities and entertainments well and provide a range of activities. Residents said they were “pleased with the choices on offer”, “there is usually something I can take part in”, “the activities are good” and some residents commented “there are activities in the home but I don’t join in”. A good standard of hygiene was seen throughout the home and the standard of décor was high. Residents commented “the home is always fresh and clean” and a visiting professional commented, “the home is always clean”. Relatives said “I cannot fault the care of my relative”, “I am made to feel very welcome”, “the staff are always friendly”, “the home provides a pleasant and Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 6 caring environment for its residents”, “mum likes the meals” and “I would recommend Keate House to anyone”. Visiting professionals stated “the staff work well with me”, “I am able to see my patients in private”, “the record keeping is good” and “I have visited here a number of years and staff are good at responding to residents needs and will accommodate changes needed”. Staff said, “the training is good”, “the staff support each other well”, “the support from the management team is good”, and “the camaraderie between staff is good and it’s a very friendly home”. Observations made during the site visit included discussions between the manager and the staff. The manager gave clear direction to the staff member and spoke in a clear manner. Care staff were observed assisting residents during the day. The interactions between the staff and residents were respectful and were friendly in their manner. On observations of assisting a resident with their medication it was seen that the staff member gave the resident time to achieve this independently and stayed with them until they had taken the medication. Staff were also seen assisting residents during teatime and support was provided in a caring and sensitive way. Choices of meals were offered to each resident and during discussions staff were able to confirm their knowledge of residents personal food preferences. What has improved since the last inspection? What they could do better: To ensure that service users are cared for by well supervised staff the manager should ensure that formal supervision sessions are undertaken six times a year with the care staff team and records must comply with the Data Protection Act 1998 in regard to storage of information and confidentiality. To ensure that residents are cared for, by staff that are trained and competent to do their jobs, 50 of care staff should obtain NVQ level II in Care. Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 7 To enhance the care and support given to residents development of care plan records should include information gained by key workers during individual time spent with residents; areas of change noted on the care plan review sheets; development of residents’ life history information; and recording of activities that the residents like. To ensure compliance with the Data Protection Act 1998 the details kept in the accident book should be reorganised. To ensure that residents medication is administered appropriately name labels on the Nomad MDS boxes should be renewed; the medication lists on the Nomad MDS boxes should reflect the times medication be administered; and the excess medication should be returned to the pharmacist. To ensure that residents are protected by the homes recruitment procedures identity checks should be made on all staff employed at the home. 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. Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 8 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 Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 9 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 & 3. Standard 6 does not apply. Quality in this area outcome is good. This judgement was made using available evidence including a visit to this service. Sufficient information is provided for residents to make a decision about moving into the home. A preassessment document is available to ensure that the home can meet the residents’ needs. EVIDENCE: The statement of purpose and service users guide are produced in a bound file and include information about the facilities, services provided, fees, terms and conditions of residence. A copy of the most recent inspection report was available separately and a notice by the service user guide explained that a copy is available in the office. Residents and relatives confirmed that they were aware of the service users guide and the inspection reports. The statement of purpose and service users guide was reviewed in July 2006. Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 10 In each service users file a needs assessment had been completed. This covered the basic areas of care and support that a person may require. Relatives confirmed they had been involved in the assessment process. The manager stated that intermediate care was not provided at Keate House. Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this area outcome is good. This judgement was made using available evidence including a visit to this service. The residents’ health, personal and social care needs are met by the staff team who enable them to maintain their privacy and dignity. EVIDENCE: Five residents’ care records were seen during this visit. These were comprehensive and well presented in individual binders. Each contained basic information, all areas of personal care information, social activities, a record of visiting professionals and a copy of the daily report sheets. The care plans were drawn up in consultation with the residents and family and were based on their assessed needs. The residents signed care plans to show that they agreed with the contents. The following areas had improved since the previous inspection, care plans were now reviewed on a monthly basis, social services reviews were up to date and risk assessments had been completed. Care plans also contained residents photograph and the date of arrival. During discussions with relatives and residents they stated that they were aware of the care plans. Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 12 The key workers kept a record of individual time spent with each resident. This information indicated how time could be spent with an individual. It was recommended that this be developed and record kept in the residents plan of care. Recommendations were also made to: • Include areas of change on the care plan review sheet; and • To further develop the recording of life history information in the care plans. Daily record sheets seen showed day-to-day activities of each resident. They were written clearly, easy to follow and were signed by carers. The accident book was seen and appropriate records were kept. It was recommended that each page be filed and not left in the book. This is to comply with the Data Protection Act legislation and confidentiality of information. The medication was stored in a locked trolley and the home used the Nomad Monitored Dosage System. Some residents had controlled drugs and these were stored and administered appropriately. Medication administration sheets were seen and records were appropriate. Staff spoken to said that “the Nomad system is good and they had received medication awareness training”. Recommendations made regarding medication issues included that, name labels on the Nomad MDS boxes are renewed; the medication lists on the Nomad MDS boxes reflect the times medication should be administered; and excess medication should be returned to the pharmacist. GP comments included “I am satisfied with the overall care provided” and “there is always a member of staff available”. During discussions with the residents they said, “the care was very good” and “I like my room” also “the staff are lovely”. Other comments included “the meals are excellent” and one resident said, “I am very happy and comfortable here”. Relatives spoken to said they were “very happy with the care Mum is receiving”, “staff are very friendly” and “Mum is happy here”. Keate House DS0000027005.V307077.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 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 area outcome is good. This judgement was made using available evidence including a visit to this service. Residents’ were able to take part in a range of activities of their choosing. Personal and family relationships were encouraged by the home and the staff team supported people with this. EVIDENCE: Residents’ privacy and dignity is discussed with staff during the induction process. It is also documented in the statement of purpose and reflected in the service users guide. During the inspection a sample of bedrooms were seen and these were decorated to residents’ personal tastes. They also had their own belongings, photographs and personal mementos in the bedroom. One resident said, “my room is very nice” and “I have my own phone and television here”. Visits from family and friends were recorded in the case notes. Residents shared with the inspector the contact they had with family members and said they could choose to see visitors within their own room or in the shared lounge/dining area. Relatives said that they were always made very welcome by the staff and were offered refreshments. They said that they could visit their family in the privacy of their own bedroom or in one of the lounges. Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 14 The senior care staff oversee the daily activities within the home. They have a programme of activities, which include hairdressing, chair based exercises, dog patting service, sing-along, bingo, afternoon tea with Colin Melrose and musical instruments. External activities include alternate weekly visits to fish and chip shop, mini bus outings and canal boat trip. During the site visit residents were enjoying playing musical instruments to background music. Records are kept of activities completed by each resident and individual time is also given to each resident. Most residents confirmed there was a range of activities they joined in with. Some residents said they preferred not to join in group activities but enjoyed the individual time spent with the staff. A visiting professional commented, “the activities had improved”. A recommendation was made to add more details of activities residents like in the care plans. It was noted by the inspector that residents were able to exercise choice over many aspects of their daily life. Whether to join in activities or not; choosing when to get up and go to bed; choice of food from the daily menu, (and whether to eat in company or not); and having their own personal possessions within their bedrooms. A four-week rota of menus is provided at Keate House. Choices are offered at each mealtime. The teatime meal was seen served and was a choice of assorted sandwiches, spaghetti on toast or soup. Bread, butter and jam, potato cakes and fruit and cream were also on offer. Resident’s preferences were clearly demonstrated, for example residents made choices from meals on offer. Staff assisted the residents during the meal as required. Hot and cold drinks are provided throughout the day. Juice and water is available in jugs in each lounge. All appropriate records are kept in the kitchen including fridge temperatures and records of hot cooked foods. The kitchen was seen to be clean and tidy during this visit. Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this area outcome is good. This judgement was made using available evidence including a visit to this service. Policies and procedures are in place to ensure that residents are protected from abuse, neglect and selfharm. EVIDENCE: The policy on complaints was seen and relevant paperwork was available in the event of a complaint being received. The Commission or the home had not received any complaints since the last visit. Discussions with residents and relatives indicated that they were aware of the complaints procedure and if they had a problem then they would contact the manager. The home had policies on the prevention of adult abuse, whistle blowing and harassment. These policies were consistent with the “No Secrets” guidance from the Department of Health. The policy included types of abuse such as physical, verbal, sexual and neglect, signs and symptoms and reporting abuse. A copy of Warrington Social Services policy on Adult Protection was available within the home and was accessible to staff. Staff confirmed that they were aware of the procedures and who to contact with any concerns. All staff had undertaken training on Adult Protection. Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this area outcome is excellent. This judgement was made using available evidence including a visit to this service. The home provides a clean, comfortable and attractive environment for the people to live in. a very well maintained, safe and comfortable home is provided for service users. Service users are actively encouraged to personalise their bedrooms, which are all ensuite. EVIDENCE: The home was furnished in a domestic style with additional equipment such as grab rails, raised toilet seats and hoists provided as necessary to meet the residents’ needs. There was an excellent standard of décor throughout. Heating and lighting was sufficient throughout the home. Service users confirmed the home was always warm. The garden area is enclosed and residents are encouraged to sit outside during the better weather. Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 17 The home was clean, tidy and free from any unpleasant smells. Residents and relatives commented, “the home is very clean” and “the cleaner is very good”. A visiting professional commented, “The home is always clean”. The home has a good redecoration programme in place. All the communal areas and corridors had been redecorated since the last visit. Service user commented on the lounges saying they were very happy with them and confirming they had been redecorated recently. Also some bedrooms had also been redecorated. One of the owners stated that a rolling programme to redecoration is applied and all rooms are reviewed regularly. New plasma televisions had been provided in all the lounges and service users commented that it was easier to see the larger screen. Wooden flooring had been fitted in some communal areas The majority of the bedrooms are a good size and the furnishing and fittings are of a high quality and are well maintained. Wooden flooring has been provided in most bedrooms. The manager said that service users were given a choice of wooden flooring or carpet in their bedroom on arrival. Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this area outcome is good. This judgement was made using available evidence including a visit to this service. The manager provided clear leadership which enabled staff to be well supported in their care for service users. Staff had completed mandatory and specialist training as required ensuring that service users were cared for by well trained staff. Service users are protected by the homes recruitment policy and practices. EVIDENCE: At the time of this inspection the agreed staffing levels were met. The staff team included the co-owners, managers, deputy manager, senior care assistants, care assistants, domestic staff, laundry staff, cook, kitchen assistants, maintenance staff and administration staff. The manager said that eight out of twenty-two staff had completed NVQ level II in care, which is slightly below the recommended 50 , and a recommendation was made accordingly. However, seven care staff were undertaking NVQ level II and one staff member was due to start NVQ level II at the time of this visit. All staff had completed a two-week induction programme. Mandatory courses undertaken included manual handling, food hygiene and first aid. Other courses undertaken included adult abuse awareness, fire awareness, diabetic care, wound and pressure care and medication. A selection of certificates were seen on staff files. Staff on duty confirmed they had completed NVQ training in care and mandatory courses. Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 19 This ensures that staff are well trained and able to use the knowledge and experience gained to provide a good standard of care to service users. The recruitment procedure ensures that the staff are suitable to work with vulnerable people. Four staff files were examined and these showed that all relevant pre-employment checks were carried out. This included application forms, two references, Criminal Record Bureau checks and terms and conditions of employment. Identity checks had been made on most staff and a recommendation was made for all staff to have identity checks on file. Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected 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 area outcome is good. This judgement was made using available evidence including a visit to this service. The health, safety and welfare of the service users are protected. The views of service users are obtained to influence the running of the home. Service users are cared for by staff who are not fully supervised in their role. EVIDENCE: The deputy manager said that one to one staff supervision was given on a regular basis. Supervision notes were seen and nine out of twenty-two staff had supervision in August 2006 and prior to this nineteen out of twenty-two staff had supervision in March 2006. Recommendations were made regarding the frequency of the sessions and the method of recording. Observed day-today supervision of staff was good and the staff team confirmed they were supported by the manager and the senior staff in their role. The staff said that Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 21 formal supervision was conducted on a regular basis. Supervision records were kept in a locked cupboard with staff files, in the office. Residents and relatives said, “the home is lovely” and “it is very comfortable”. They said that the manager and staff were very welcoming and friendly. This was confirmed during this visit. Relatives said the staff worked in a very friendly manner. Residents’ surveys are conducted on an annual basis (last one August 2006). The information gathered is used to influence the future service provided. Comments from the surveys included, “very good quality of care”, “being looked after well”, “I feel the staff do their best to help me” and “I am very well satisfied with everything”. Policies and procedures seen were appropriate to the home. Polices were last reviewed in February 2006. Safe working practices included fire safety in which all weekly checks are carried out and recorded, up to date certificates for electrical safety, gas safety, portable appliance testing and tests and servicing for all equipment for moving and handling. These checks ensure that the residents are being protected by the procedures in place. Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 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 X 3 Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? 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 Regulation Requirement Timescale for action 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 3 4 5 6 7 Refer to Standard OP7 OP7 OP7 OP7 OP7 OP7 OP7 Good Practice Recommendations The registered person should develop and record information gained by key workers during individual time spent with residents in the residents’ plan of care. The registered person should include areas of change on the care plan review sheets. The registered person should continue to develop residents’ life history information in the care plans. The registered person should ensure that the details kept in the accident book comply with the Data Protection Act 1998. The registered person should ensure that name labels on the Nomad MDS boxes are renewed. The registered person should ensure that the medication lists on the Nomad MDS boxes reflect the times medication should be administered. The registered person should ensure that excess medication should be returned to the pharmacist. DS0000027005.V307077.R01.S.doc Version 5.2 Page 24 Keate House 8 9 10 11 12 OP12 OP28 OP29 OP36 OP36 The registered person should add details of activities residents like in the care plans. The registered person should produce a plan to show how 50 of care staff will be qualified to NVQ level II. The registered person should ensure that identity checks are made on all staff. The registered person should ensure that supervision sessions are carried out six times a year. The registered person should ensure that the method of recording supervision sessions complies with the Data Protection Act 1998. Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Keate House DS0000027005.V307077.R01.S.doc Version 5.2 Page 26 - 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!