Inspection on 25/10/05 for Magdalen House

This inspection was carried out on 25th October 2005.

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.

Other inspections for this house

Magdalen House 12/02/07

Magdalen House 24/05/06

Magdalen House 05/05/05

Magdalen House 26/10/04

Magdalen House 22/04/04

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

CARE HOMES FOR OLDER PEOPLE MAGDALEN HOUSE Magdalen House Magdalen Square Gorleston GREAT YARMOUTH NR31 7BZ Lead Inspector KIM PATIENCE Announced 25 OCTOBER 2005 9:30 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 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. MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Magdalen House Address Magdalen Square, Gorleston, Great Yarmouth, Norfolk, NR31 7BZ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01493 661598 Norfolk County Council Community Care Position Vacant Care Home 38 Category(ies) of DE(E) Dementia - over 65 (38) registration, with number of places MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home should be registered to accommmodate older people who have dementia. 2. That the home should be registered to accommodate up to 38 Service Users. 3. That the manager of the home is only responsible for the management of personal care offered to Service Users accommodated at this establishment. 4. That the management of the home ensures that thre is always a member of staff on shift who has received training in the care of people with dementia. This to be implemented by end of March 2004. 5. That the management of the home undertakes a review of staffing elvels, in view of the category of Service Users applied for and implements the result of this review by the end of March 2004. 6. That the Norfolk County Council undertakes a review of the Services and Facilities offered at this establishment and implements a programme of improvements which ensures a satisfactory level of service for the proposed life of the home. The review to be carried out by the end of March 2004. Date of last inspection 5 May 2005 Brief Description of the Service: Magdalen House is a care home providing personal care and accommodation for 38 older people who have dementia. The home is owned by Norfolk County Council and is located in a residential area of Gorleston on sea. The home was purpose built some years ago and provides single occupancy accommodation on two floors. There are two passenger lifts serving different areas of the home. Magdalen House has large gardens including a secure area suitable for safe usage for people with dementia.. MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took approximately 8.5 hrs to complete. During the inspection a tour of the premises was conducted, staff and service users were spoken with, records were inspected and observations of people going about their daily routines was observed. The acting manager, Chistopher Mallett and the newly appointed manager Sue Pennington were both present throughout the inspection and helpful in facilitating the process. What the service does well: What has improved since the last inspection? What they could do better: Nine requirements are made in this report, of those nine, seven are repeated from the last inspection. The management need to improve their response to the requirements made as they shrive to improve the quality of life for residents living in the home. Care plans must be completed in full to enable a person-centred approach to care. The medication arrangements must be reviewed in order that they protect the safety and welfare of people living in the home. MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 Page 6 The environment must be improved in order to create an enabling environment that promotes independence. The cleanliness of the home must be improved and odours eliminated. The staffing deployment should be reviewed to ensure the most efficient use of staff time. The home must have a registered manager. Staff must be provided with adequate supervision and support. The environment must be risk assessed to ensure that it continues to be safe for residents with dementia care needs. 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. MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 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 standard(s) 0 Standards not assessed on this occasion. EVIDENCE: N/A MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 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 standard(s) 7,9 Each service user has a plan of care generated from an initial needs assessment, however, the plans need to be completed in full to ensure that peoples holistic needs are taken into consideration. This home has a policy and procedure in place for dealing with medicines, however, there was evidence to suggest that the procedures were not compliant. EVIDENCE: The local authority has introduced new care plans of a good standard, that aim to provide detailed information of peoples health, personal and social care needs. Of the files inspected some of the care plans had been completed in full. However, some had not and there were gaps in the records. For example, the care plans for social interests, historic personal information had not been completed, and this is vital to the care of people with dementia. In one case, the record of medicines was not up to date and in another, risk assessments needed for the individuals behaviour had not been completed. MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 Page 10 The care plans had been reviewed and a review and action sheet was completed to reflect any changes to personal and health care needs. This is an improvement since the last inspection when it was identified that reviews were not being conducted as often as they should. In homes that care for people with dementia, it is essential that there is a person-centred approach to their care. Ensuring that care plans are completed in full and contain information that will enable staff to care for the individual in a way that is consistent with how they have lived their life so far. In addition, there is the added concern that if information relating to peoples care and health needs is not up to date then the individuals may not be able to communicate this for themselves. Care assistants may face difficulties and dilemmas when trying to meet people’s needs. A requirement is made in respect of care plans. See requirements. The medication arrangements were inspected and the practice of one senior care worker was observed. The practice observed was not in accordance with the written policy and procedure. The care worker handled medication without dispensing into a vessel before handing it to the resident. When the medication was handed to the resident it was not seen taken, even-though the medication administration record was signed. One resident was handed medication and placed it in her pocket, later she was observed trying to find it. The care worker would not have been able to say with any certainty that the medication had been taken correctly. When touring the building a tablet was found in a resident’s room and again may indicate that medication was being left with residents and not seen taken at the time of administration. This practice is of concern and could place residents at risk. The management must ensure that the correct procedures are used to administer medication. See requirements. A number of rooms entered contained prescribed creams and emollients. These must be stored in a safe, secure place. Any residents that are able to selfmedicate must have a lockable facility in which to store such medication and a risk assessment must be carried out. See requirements. Care staff with the responsibility for administering medication have attended the medication management training. However, the management must assess the competency of those administering medication and provide further training where necessary. See requirements. The storage of medicines was assessed and found to be in order. Medicines are transported to their destination in a metal lockable trolley suitable for purpose and other medicines are stored in lockable cupboards in a locked office. The medication administration (MAR) charts were inspected and crosschecked with medication contained in the monitored dosage system (MDS), supplied weekly by the local pharmacy. MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 Page 11 The records contained a list of people authorised to administer medicines with sample initials, this ensures that those people are easily identifiable. The MAR charts were clear with a photograph of each resident and the times at which doses were to be administered were highlighted. A number of discrepancies were identified on the MAR charts where it was not clear that residents had been given their medicines as prescribed. There were gaps in the records and the quantity of tablets remaining did not correspond with the number supplied and administered. The management must ensure the safe administration of medicines. See requirements. The records of receipt and disposal of medicines were included in the MAR charts, however, for medicines that were not included in the MDS system there was no carry forward figure and therefore difficult to establish the quantity that should remain. It is recommended that the management establish a clear audit trail of medicines. See recommendations. Controlled drugs were stored in a lockable metal cabinet fit for purpose and a controlled drug register was maintained in accordance with the regulations. MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 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 standard(s) 12,15 Activities are provided at the home. However, they are not necessarily meaningful or stimulating to people with dementia. Meals provided at the home are varied and provide people with diverse tastes and cultural preferences with choice. The dining area is yet to be improved to make it more suitable for people with dementia. EVIDENCE: Service users care plans were inspected and as mentioned in standard 7 there were gaps in the care planning process. The care plans in respect of personal history and social needs were not completed in some cases. This information is important in order to plan and arrange meaningful activity and stimulation for people with dementia. During the inspection, a care assistant with responsibility for activity on that day was interviewed. She stated that activities are provided daily and that two care assistants were allocated that duty on each day. The activities included bingo, exercise games and music but were not necessarily interesting to the residents, who because of their dementia, were difficult to engage at times. Another care assistant stated that most of the time the activities were meaningless and she showed a good understanding of person-centred care and the need to arrange activities that the individual could associate with, for example, reminiscence materials and links with occupation. The management MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 Page 13 must review the provision of activities in the home and demonstrate a personcentred approach to caring for people with dementia. See requirements. Standard 15 was not assessed in full. However, copies of the menus were provided and the meal served on the day of inspection was observed. The menus show that a good variety of meal options are provided over the week. Each day showed a vegetarian option and other meals included fresh vegetables or salad. People were also offered a choice of two desserts each day. Residents needs and preferences in respect of food are recorded in the care plan and likes and dislikes are monitored daily through observation. As mentioned at the last inspection, the dining area is a large room that is institutional in appearance and some consideration should be given to making the room more suitable. Research shows that people with dementia function better in smaller living units and a room of this size and number of people could be a frightening experience for some residents. A requirement was made at the last inspection to consider dividing the room into smaller areas, however, no progress has been made. The requirement is made for the second time. See requirements. MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 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 standard(s) 18 The home is committed to the protection of vulnerable people, demonstrable through its policies and procedures. EVIDENCE: The local authority has robust policies and procedures in place for the protection of vulnerable people. The policies include a whistle blowing policy that all staff are made aware of through their induction programme and in their handbook. All adult protection concerns are reported and investigated in accordance with the requirements. The home has had two adult protection investigations in the last 12 months, neither has resulted in the individuals concerned being referred to the protection of vulnerable adults list. MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 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 standard(s) 19,20,21,22,23,24,25,26 The management have made efforts to maximise the potential of the building. However, because of the age and layout of this home it is not entirely suitable for the accommodation of people with dementia and is in need of much improvement to ensure that it provides a safe, enabling environment in which people with these specific needs can live. EVIDENCE: A member of the care team assisted with a tour of the premises and was very helpful in showing the different areas of the building and discussing resident’s needs in this respect. The home has three communal lounges on the ground floor, one containing a small bar and one designated as a smoking room. On the upper floors there are a further two small lounges that are not well used. One is locked and people do not have access to it unless they ask and the other is connected to a small private kitchen/dining room. All the lounges are equipped with a MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 Page 16 television and facilities for playing music. Each is provided with seating that is suitable for older people. There is a large main dining room that is in need of some improvement, as discussed in standard 15. See standard 15 for details. Resident’s bedrooms are situated on the ground and first floors. The upper floors can be reached via the stairs or the lift. All rooms are single with a wash-hand basin. There are nine lavatories situated close to resident’s rooms and only three bathrooms. Two of the bathrooms are located on the upper floors and only one on the ground floor. This is not entirely adequate for the number of people accommodated. The downstairs lavatories are about to be refurbished and work is to begin shortly. Plans have been made to ensure that service users will have access to part of the facilities and there will be minimum disruption. In general, the home is in need of some general redecoration and refurbishment to make it brighter and more welcoming. Some of the service users rooms are also in need of redecoration to make them appear more comfortable and homely. One room contained a set of draws, which were broken. Some carpets are soiled, particularly the main dining room and the management are considering alternative flooring options. The management must assess the environmental needs and produce a plan of maintenance and renewal. See requirements. The standard of cleanliness could be improved. Some of the communal lavatories were not clean and strong stale odours were detected. A strong odour was detected in the wing named Sunnyside. The dining room had food on the floor from breakfast time. See requirements. Some health and safety concerns were identified while touring the building. It was noted that the bathrooms contained un-named toiletries, such as bubble bath and talcum powder. These products could present a risk to people with dementia if they are consumed. In addition, one bedroom contained denturecleaning tablets, which could present a risk if taken by mistake. The management must ensure that products such as these are stored safely. Where it is felt that the resident is able to manage product those products safely, risk assessments must be carried out. See requirements. Other health and safety concerns arose in respect of unlocked storage cupboards in some areas of the home. One storage room used to store laundry was unlocked and the internal light had been left on. This is a potential fire hazard. Storage room doors must be kept locked to prevent residents from wandering into them accidentally and being place at risk of harm. See requirements. MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 Page 17 A disused bathroom, highlighted on the previous inspection report, still contained some clutter and the door cannot be closed due to some distortion. This room must be made secure to prevent people wandering into it by mistake and being placed at risk. See requirements One residents room has an electrical socket beneath the sink in which a hoist was plugged. This is a potential hazard due to the position of the socket and the possibility of contact with water. The management must ensure that this socket is blanked off and made safe. See requirements In some residents rooms, prescribed creams were seen unsecured. These could present a health and safety risk to people with dementia. See standard 9 for details and requirements. The home has very little signage or cues to assist people to move about independently. Some rooms did not have resident’s names on them and a person who is already disorientated or confused would not necessarily be able to recognise where they are. One room was marked with some brightly coloured tape to aid recognition and this is good practice. However, all service users needs in this respect, should be addressed. The management need to create a more enabling environment that will support people to live as independently as possible and this is key to personcentred dementia care. See requirements. MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Staffing levels at this home are just sufficient to ensure that resident’s needs are met, however, deployment could be improved. This home has robust recruitment procedures supported by the HR department of the local authority. Staff are provided with training that includes that specific to the needs of people with dementia. EVIDENCE: The home employs twenty-six care assistants and eleven ancillary staff for domestic and kitchen duties. The staffing hours are calculated at 15 hours per resident per waking day. Six care assistants are on duty during each shift and an additional 8 hours are provided for activities each day. The manager’s hours are not included in the care hours provided. The hours provided are set at the minimum for people with such complex needs. However, the shift patterns do not assist in the overall management of care tasks, as staff start at slightly different times – thus preventing effective handover at the beginning of a shift. A recommendation is made to review working patterns to ensure an efficient use of staffing hours. See recommendations The home has had some problems with staff sickness and has needed to employ agency staff in order to provide sufficient cover. This is not ideal for people with dementia as they need continuity of care. The home are seeking to employ more care workers on a relief basis so that they can offer continuity of care in this respect. MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 Page 19 Recruitment and selection is supported by the local authorities human resources (HR) team who arrange adverts for new staff, send out application packs and oversee the process once applications are returned and people are selected for interview. All prospective employees are offered a face-to-face interview of which a record is kept. Any new staff appointed are made a provisional offer of appointment subject to completion of the pre-employment checks. HR department are responsible for applying for references and the Criminal Records checks. Once the preemployment checks are complete, the home is authorised to confirm the appointment and allow the person to commence their induction. On the day of inspection, the management were not able to produce a list containing details of each employees CRB clearance and it is recommended that they pursue this with the HR department. See recommendations. The local authority have a staff training and development policy and a rolling programme of training throughout the year. Staff are provided with a thorough induction programme and foundation training leading to an NVQ2 course. All staff have been provided with a three day dementia care awareness training that was conducted at the home to make it specific to the people that live there. MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,36,38 This home does not have a registered manager and therefore it cannot be said that it is run by a person fit to do so. The home has a developed a strategy for consultation with residents and relatives that is in its infancy. The management cannot demonstrate that staff are being adequately supported and their work practice assessed, due to the lack of formal supervision sessions. The management cannot fully demonstrate that the health, safety and welfare of residents is promoted and protected due to the evidence already provided in this report. EVIDENCE: MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 Page 21 A manager has been appointed and will be working three days a week until December at which time she can be freed from her previous post. The current acting manager will cover the remaining two days a week to ensure that the home has fulltime management. An application for registration of the new manager is to be submitted to the Commission imminently. See requirements. The acting manager has started to consult with residents and relatives as to the quality of care provided. Questionnaires had been sent to all relevant people and at the time of inspection the results had not been collated. This will be inspected on the next occasion. There is no plan of staff supervision and very little supervision has been conducted due to the absence of a permanent manager. It is hoped that this will change with the new manager appointment. Staff must be provided with adequate supervision and support particularly when this type of work can be demanding and stressful. Work practice must be monitored. See requirements. A number of significant health and safety concerns were raised in standards 19 – 26 and requirements have been made in respect of these. The management must ensure that frequent risk assessments are carried out so that risks can be identified and eliminated where possible. See requirements. Staff working at the home are trained in matters of health and safety, fire safety and first aid. MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score N/A N/A N/A N/A N/A N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 N/A 9 2 10 N/A 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 N/A 14 N/A 15 3 COMPLAINTS AND PROTECTION 2 3 3 2 3 3 2 2 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 Standard No 16 17 18 Score N/A N/A 3 1 N/A 3 N/A N/A 1 N/A 2 MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 Page 23 yes 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 7 Regulation 15(1) Requirement The registered person must ensure after consultation with the service user or representative that a written plan is prepared, as to how the service users needs are to be met. This includes the need for risk assessments.. The registered person must make arrangements for the recording, handling,safekeeping, safe administration and disposal of medicines received into the care home. The registered person must ensure that a programme of activities is arranged having regard for the specific needs of each individual demonstrating a person-centred approach to care. The registered person must ensure that the physical design and layout of the home is suitable to meet the needs of its residents. This relates to the need for signage, cues, communal areas and specialist equipment. The registered person must ensure that a plan of maintainence and renewal is Timescale for action 1/12/05 2. 9 13(2) 1/12/05 3. 12 16(2)(n) 1/12/05 4. 15 & 22 23(2)(a) 30/12/05 5. 19 23(2)(b) 1/12/05 MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 Page 24 6. 19 7. 26 8. 9. 31 36 written with timescales for improvement set. This should include those areas identified in St 19-26.. 13(4)a,b,c The registered person must ensure that risk assessments are carried out on the premises and risks posed to people with dementia care needs are identified and eliminated. 23(2)d The registered person must ensure that all parts of the home are kept clean. This relates to food on the floors and offensive odours. 8(1)a The home must have a manager who is registered as a fit person to manage a care home. 18(2) The registered person must ensure that persons working at the home are adequately supervised. 1/12/05 1/12/05 1/12/05 1/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 27 29 Good Practice Recommendations It is recommended that the management conduct a review of working patterns to enure that they are geared to meet the needs of service users. It is recommended that the management ensure that they can provide evidence that all care staff have a criminal records disclosure. MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 Page 25 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF 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 MAGDALEN HOUSE I55 S34568 Magdalen House Stage 4 V246832 251005.doc Version 1.40 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. 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