Inspection on 16/10/06 for Loose Valley Nursing Home

This inspection was carried out on 16th 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

Loose Valley Nursing Home 16/09/08

Loose Valley Nursing Home 15/11/05

Loose Valley Nursing Home 29/06/05

Loose Valley Nursing Home 09/03/05

Loose Valley Nursing Home 26/08/04

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 Loose Valley Nursing Home 15 Linton Road Loose Maidstone Kent ME15 0AG Lead Inspector Maria Tucker Key Unannounced Inspection 16th October 2006 09:30 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 Loose Valley Nursing Home DS0000060403.V312804.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. Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Loose Valley Nursing Home Address 15 Linton Road Loose Maidstone Kent ME15 0AG 01622 745959 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) Nellsar Limited Janet Poole (pending) Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (34), Terminally ill (5) of places Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registration is restricted to caring for older people which can include up to five people with a terminal illness. 15th November 2005 Date of last inspection Brief Description of the Service: Loose Valley Nursing Home is situated a short distance outside the centre of Maidstone, it is on a main transport route with a good bus service. The home is set in attractive grounds overlooking the Loose valley; some bedrooms have views of the grounds and surrounding countryside. The home is registered to provide nursing care for 39 older people, 5 of whom may have a terminal illness. There are seven double and twenty-three single rooms. Accommodation is on two floors; a shaft lift provides access to the upper level. There is a main lounge, a conservatory and dining room. Registered General Nurses are on duty at all times complimented by care assistants, a chef, kitchen, domestic and laundry staff, a maintenance operative, an activities co-ordinator and fitness instructor. The fees range from £491.35 £854.75 per week. Extra charges for Hairdressing prices range from £6 for a cut shampoo and set to £27 for a perm; Chiropodist £8; physiotherapy negotiable; manicure £4.75; exercise class £5.00; aromatherapy £5.00; administration charge for finance £1.00 when applicable. Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection lasting from 9.45 am to 4 pm. Time was spent talking with the manager, deputy manager, ancillary staff and care staff. Service users were spoken with individually and collectively. Three relatives were spoken with. A partial tour of the building was undertaken. The pre inspection questionnaire has been received, as have comment / feedback cards from service users, health and social care professionals, visitors and relatives. Overall the feedback was very positive and service users, visitors and staff were relaxed, calm and engaging. What the service does well: What has improved since the last inspection? Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 6 There is a new manager in post who is in the process of becoming registered with the commission. There has been a new deputy appointed. The care plans have been sectioned and indexed for ease of use and accessibility. The changes of ownership and staffing arrangements have naturally caused a certain amount of unsettling. This has reduced with the home returning to a sense of normality and stability. 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. Loose Valley Nursing Home DS0000060403.V312804.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 Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 Quality on this outcome area is good judgement has been made using available evidence including a visit to the service. Service users are only admitted following a comprehensive assessment and consideration made as to if the home can fully meet their needs. EVIDENCE: The statement of purpose has not yet been amended to take into account the changes of staff in the home. The manager is currently working on this document. A contract was seen. The contract contained all information required. Service users and or representatives are sent an information pack and have an initial assessment conducted prior to being offered a place in the home. Prospective service users are invited to visit the home and admitted on a trail basis. The home do not write to confirm that following the assessment the home are to meet their assessed needs. The assessments contained information that forms part of the overall care plan. These are fully completed once a service user moves into the home. The home does not provide intermediate care. Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, Quality on this outcome area is good judgement has been made using available evidence including a visit to the service. Service users’ health needs are promoted and they can expect a high standard of individual care and health promotion. Service users can expect to be treated with dignity and respect. The PRN (when required) medication needs to be firmed up to ensure good practice is adhered to. EVIDENCE: The care plans have been indexed and sectioned and identified as not only being available for support staff only as recommended at the last inspection. The care plans are the RCN assessment tool and were seen to be fully completed and comprehensive and kept in service users rooms. The daily recording corresponded to the care plans, which ensured that the care is received as identified as being needed. It was discussed with the manager that as a work in progress the daily records can be expanded upon to include more personal information giving a sense of the experience throughout the day and making it more personalised. The manager stated that she is not happy with the pain assessment format currently in use and will be looking into modifying this. Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 10 Risk assessments were conducted and kept in individual files. Service users and or representatives have been given a copy of their care plan to comment upon a response was seen to have been made by a service user. Relatives spoken with while visiting expressed how “Incredibly detailed” the care plans were and that they were at “liberty to see the notes”. The home pays for a physiotherapist to visit the home and provide advice, guidance and support, a care assistant accompanies the physiotherapist. A group session for exercise is run by an external professional, which is paid for by those participating. The home is pro active in supporting service users with their health needs and promoting a healthy life style. Two relatives spoke of how vast health improvements have been made since being at the home. Evidence of health appointments were recorded and detailed in the care plans. The manager explained that the staff worked hard in “getting people to go home for good” through maximising their independence and ‘getting them better’. Two service users had pressure sores that were being treated with success. It was discussed with a relative that on returning from hospital pressure sores were noted to have occurred but the home had worked hard in their management of these so that they had almost healed. Comments made by a visiting health professional evidenced that the health needs of the service uses are supported by staff stating, “There is a very friendly and homely feel here, the staff are very attentive to the residents and always helpful”. Further comments from relatives include “My (service user) is looked after very well indeed and given excellent nursing care in this well organised and friendly home”. A comment made by a relative in a comment card evidenced that the home are sensitive to individual needs and that the care and support provided considers specific behaviours which staff are responsive to as stated by a relative “(service user) can be very determined and single minded at times. The staff are always patient, considerate caring and respectful for which I am extremely grateful”. The pre inspection questionnaire lists a range of health provision including a weekly visit to the home by the General Practitioner; direct contact to a dietician; local dentist; visiting optician and a physiotherapist and chiropodist who visit the home. The medication administration round was observed and good practice adhered to. All medication was seen to be stored appropriately and the mar sheets signed accordingly. It was discussed that the PRN (when required) medication needs to be firmed up so that more detail is given as to what dose and to what medication i.e. Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 11 pain relief is prescribed for. Currently the mar sheets record as required. It was also discussed that a front sheet would be of benefit to record extra information such as preferred name, any specific details around preferences in taking medication and a photograph for identification purposes. The home do hold photographs with room numbers so that cross referencing can be made for staff who may not as yet know all of the service users personally. The deputy manager has taken over the responsibility for medication. The home assesses and reviews compatibility for shared rooms. It was noted that the screens provided were not all fixed with overhead tracking they were free standing. This is addressed later in the report as a recommendation to have freestanding frames removed for health and safety. Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality on this outcome area is good judgement has been made using available evidence including a visit to the service. Service uses can expect to have their choices and preferences for meals catered for in a flexible way. Every effort is made to promote service users autonomy. EVIDENCE: The activities / hobbies in the personal profiles accurately reflected what the individual service user chose to do. Due to the vacancy of an activity coordinator a limited range of individual activities such as supporting with letter writing or painting are currently not on offer. The manager is actively recruiting for this position. In the interim a care staff undertakes this for 4 hours a week on 2 afternoons. During the inspection service users were enjoying a quiz. A comment received in a comment card evidenced that the home organises activities stating “Loose valley do a good organisation of events for the residents but sadly (service user) does not wish to join in which is disappointing for the owners”. Service users who were visited in their rooms stated that they were there through choice, as they preferred to spend time watching television or reading, Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 13 when asked if they joined in activities one expressed that occasionally they liked to go down for the quizzes. Meals were seen to be taken to individual rooms and in the dinning area and conservatory. Good interaction and practice was noted from staff supporting service users with their meals. One service user was being assisted to eat, the staff member was engaging the service user in conversation encouraging them to eat in a patient and understanding way. Lunch time was an active time yet staff did not rush service users and each person seen was given individual attention offered choice and staff were heard to enquire if everything was alright or if they wanted or needed anything else. There was a range of meals available again each to individual choice and need. Examples of this included finger food that a service user was eating as discussed with their relative they do not like to be fed and like to be independent; tinned salmon is purchased and there is a range of puddings to choose from. The cook explained that meals are taken at various times, suited to the individual. Examples of this were breakfast taken later and food being kept warm or cooked fresh as requested outside of the normal meal times. Service users are visited by the cook to determine preferences and choice. Service users meetings are held with notes seen to be kept. Service users are encouraged to exercise choice with what they want to do, where they spend their day and whom they have visit them. During the inspection visitors were seen to be coming and going. Visitors spoken with stated they were made welcome and felt able to visit whenever they wanted to. Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality on this outcome area is good judgement has been made using available evidence including a visit to the service. Service users can feel confident that they will be listened to and protected. EVIDENCE: The accident recordings were monitored and tracked. A service user had been having several falls that were recorded. These had been reduced through a risk assessment and the proactive response of staff in their action to support to minimise these. The home have a complaints procedure in place it was discussed that there are a few minor alterations with the wording that would make it clearer the manager agreed to amend this. A comment card received by a relative stated that they had complained to the manager whom had addressed the issues raised and contacted them to enquire if all “was well”. Another comment received by a relative evidenced that the home are proactive in managing concerns or complaints stating “It has been a time of great change for all of us. (Service user’s name) and the staff have been getting to know each other. Any concerns we have had have been addressed professionally and promptly”. Throughout the inspection staff were continually heard to be attending to service users needs and enquiring if they needed or wanted anything. Service users and relatives spoken with were complementary of the home and staff and had no complaints. There have been no adult protection alerts raised at the home. Loose Valley Nursing Home DS0000060403.V312804.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, 20, 21, 22, 23, 24, 25, 26 Quality on this outcome area is good judgement has been made using available evidence including a visit to the service. Service users live in a well-maintained homely environment that meets their individual needs. EVIDENCE: Loose Valley Nursing Home was found to be very clean and tidy. Service users and visitors were seen to be using different areas of the home for relaxing and visiting. The service users’ private accommodation was individual and to taste adding to the homely atmosphere of the home. A walking route was undertaken and some areas around the home were in need of re decoration and upgrading to the same high quality standard as the rest of the home, this included a replacement of the conservatory and hallway carpet; sluice room upgraded; bin area tidied up and general painting and decorating of tired areas such as the reception. The manager had already identified these and showed the inspector an improvement plan of what was she had identified as needed to be done. Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 16 The diffuser covers in the laundry room need to be replaced and the overhead tracking for screening in double rooms need to be put in place as free standing frames are deemed as a potential risk and are advised not to be used. The office has had a call bell fitted as the manager explained that this was requested to be fitted in order to maintain contact and awareness of what was happening in the home, such as call bells or emergencies. There is a maintenance person employed who deals with any minor repairs promptly. The front door was open for the duration of the inspection. It was discussed that as the front desk is not manned the security of the home should be reviewed to ensure a more robust awareness of security issues is undertaken and measures taken. The home have had a health and hygiene inspection and the cook detailed how they were recommended to put a shelf in a food storage area for air circulation and this had been done. A further visit is not required for 18 months. The laundry was found to be very tidy with the laundry assistant describing how they have a good clean up session every week. There is a companion assessment undertaken on the compatibility of shared rooms. A copy of this was seen evidencing that the choice of sharing is made and reviewed 3 monthly. An occupational therapy assessment report was given to the inspector this was conducted on 18th September 2006 some minor recommendations for consideration only have been made. Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality on this outcome area is adequate judgement has been made using available evidence including a visit to the service. Service users can expect their needs to be met by a good staff complement and range of staff for specific tasks and duties. Staff mandatory training needs to be made a priority. EVIDENCE: The rota detailed that the home has 6 carers on duty am and 4 on pm shift with qualified staff as extra and ancillary staff including: - a handy person; cook; laundry assistant; cleaner; 2 kitchen assistants. Extra staff are available during peak times including early morning and in the evening. There are 3 carers and 1 trained waking staff at night. The manager works supernumerary and the newly appointed deputy has an average of 2 to 3 hours a day to devote to administration tasks. The pre inspection questionnaire provides general information relating to the needs of the service users. It states that 33 service users have medium needs and that 148 staffing hours are provided every 24 hours the Department of Health residential forum calculates that a total duty hours of 826.02 are required with 649.32 care hours and a full time staffing level of 20.65. Staff files viewed contained all items as required and from discussions with the manager a robust recruitment process is in place. Staff files contained some certificates. Not all of the mandatory training has taken place for all staff. It was discussed that the home must have a staff trained in first aid on duty at all times. Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 18 Specialist training on the last 48 hours of life has taken place with the elderly nurse specialist. The pre inspection questionnaire states that the home has 28.5 of staff with the NVQ level 2 or above award. The training listed included fire training; wound care; care of a person after death. Future planned training listed included moving and handling; fire training; nutrition; health and safety and dementia. It was discussed that a staff training matrix would be a useful tool in identifying at a glance mandatory training needs, this would enable the manager to plan in advance for training that was due to expire. Supervision dates were noted to be recorded as being planned. The manager has not managed to undertake regular supervision due to the organisation arrangements of a vacancy of a deputy. The manager is currently undertaking the NVQ level 4 in management and is in the process of applying to become the registered manager with CSCI of the home. Team meeting take place the notes for the meeting conducted on July 2006 detailed how care was discussed and can be improved upon. Comments received in the comment cards were complementary of the staff with comments made such as “The staff at this home give the care users individual attention and in general are patient and understanding”. Loose Valley Nursing Home DS0000060403.V312804.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, 32, 33, 34, 35, 36, 37, 38 Quality on this outcome area is good judgement has been made using available evidence including a visit to the service. The home is run and managed for the benefit of the service users. Service users, staff and visitors are protected through safe working systems and practices. EVIDENCE: The home has had a change of manager. The new manager is currently undergoing the process of becoming registered with the CSCI as the registered manager. There is a new deputy manager in post, which has improved the organisational management arrangements as the manager had been ‘freed up’ to fully devote her time to managing the home. Throughout the inspection the manager and staff were very open and transparent, with any advice or suggestions being discussed and welcomed. Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 20 The home has been through some changes since the new ownership, from comments received by the CSCI it has evidenced that although this has been at times a difficult process things have settled down and issues relating to the changes have been raised and addressed. One such comment received was that the “Home has changed hands and become part of a group. Staff changed and service / care went down. Now has improved under the new manager”. The pre inspection questionnaire lists maintenance and associated records these include: - fire officers visit on 26/04/06; environmental health officers visit on 28/06/06; approved gas installation gas engineer 09/06/06; hoists and baths (adaptations) on 27/07/06. The pre inspection questionnaire lists the homes polices and procedures all of which have been ticked to say they have been reviewed in August 2006. As discussed earlier the complaints procedure is recommended to be reviewed. The service users are invoiced for extra activities and services such as hairdressing and aromatherapy. The inspector viewed a sample of the invoices. These contained details of monies received and outgoing expenditure with a running balance kept. A change has been made to the administration charge, reducing this cost to £1, which is only applicable if an expense occurs. No money is kept at the home on behalf of service users. The administration office manages monies kept in accounts. The inspector discussed new regulation 37 notifications, as some received by the CSCI were brief. The manager has addressed this and the last one received contained more information. Regulation 26 reports are on site the last one. Team meetings and service users meetings take place as part of the quality assurance monitoring. It is envisaged that a robust quality assurance system will be attained as the new manager settles into her role and develops this area. Supervision dates were noted to be planned to ensure that all staff receives formal supervision at least six times a year or more if required. Relatives spoken with were familiar with the care plans and records and had access as deemed appropriate i.e. with the expressed permission of the service user. Service users have their care plans accessible in their rooms. Loose Valley Nursing Home DS0000060403.V312804.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 2 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 3 3 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 2 3 3 3 3 3 3 3 Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 22 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. 1 Standard OP1 Regulation 6(a)(b) Requirement The statement of purpose requires to be updated to include the changes of staff. A revised copy of the statement of purpose is required to be forwarded to the commission. The registered person shall confirm in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service users needs in respect of his health and welfare. The registered person shall make arrangements for the recording, safekeeping, safe administration, and disposal of medicines received into the care home. In that there the PRN when required policy and procedure is firmed up as detailed in the text. That 50 of care staff to be trained to NVQ level 2 or equivalent. That all mandatory training is undertaken. That a first aid trained member of staff is on DS0000060403.V312804.R01.S.doc Timescale for action 11/12/06 2 OP3 14(c) 13/11/06 3 OP9 13(2) 01/01/07 4 5 OP28 OP30 18(1)(a) 12(1)(a) (b) 01/04/07 01/01/12 Loose Valley Nursing Home Version 5.2 Page 23 duty at all times. 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 Refer to Standard OP7 OP16 OP19 OP19 OP31 Good Practice Recommendations It is recommended that daily recordings be expanded upon so that they provide more detail. It is recommended that the complaints procedure be reviewed so that it is clear and can be easily tracked. It is very strongly recommended that the arrangements for the security of the home be reviewed. In particular the open front door. It is recommended that the programme of routine maintenance of decoration and refurbishments as identified in the body of the text be completed. It is recommended that the manager submit her application to go through the process of becoming the registered manager with the CSCI. Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Loose Valley Nursing Home DS0000060403.V312804.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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