Inspection on 25/05/07 for Maurice House

This inspection was carried out on 25th May 2007.

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 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

Maurice House 30/05/08

Maurice House 12/09/06

Maurice House 06/03/06

Maurice House 17/10/05

Maurice House 07/03/05

Maurice House 14/07/04

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 Maurice House Callis Court Road Broadstairs Kent CT10 3AH Lead Inspector Tina Thomas Key Unannounced Inspection 10.00 25 and 29th May 2007 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Maurice House DS0000037465.V337361.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. Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Maurice House Address Callis Court Road Broadstairs Kent CT10 3AH 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) 01843 603323 mwarburton@britishlegion.org.uk www.britishlegion.org.uk The Royal British Legion Post Vacant Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (47) of places Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. To admit one (1) Service User, under the category of MH, whose date of birth is 18.09.1911. To admit one(1) Service User, under the category of DE, whose date of birth is 15.01.1917. To admit one Service user D.O.B 08/03/1942 under the age of sixty five years old not falling into any other category. 12th September 2006 Date of last inspection Brief Description of the Service: Maurice House is a large detached purpose built care home, which is set in accessible attractive grounds in a semi-rural location. Nearby towns and amenities are only a few minutes drive away. The Home is registered to provide nursing care and therefore employs a number of registered nurses. The Home has a hotel type atmosphere. The Home has a number of shaft lifts to access all levels of the Home. The grounds have had pathways built so that service users can access them and appreciate the views over the sea. The fees are: £490.00 residential; £600.00 low nursing; £700.00 medium nursing; £760.00 high nursing per week. Maurice House DS0000037465.V337361.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 unannounced inspection. The inspection process took place over a period of time, information was gathered, and it concluded with a site visit conducted over two days. Judgements were made by taking into account evidence from a range of documentation, a tour of the home, discussion with people that live in the home, their visitors, staff and the manager. What the service does well: The home is a purpose built care home, which is well maintained and benefits from extensive grounds; which are fully wheelchair accessible. All bedrooms are en-suite and consideration to maintaining privacy and dignity in the finishing details, such as screening around the bathroom doors. There is a licensed bar which is open daily and a large activities room, which is supported by the activities person. A variety of nutritious meals are cooked everyday with personal preferences being catered for, some service users choose to eat their meals in their own room. The home is support by a charity and therefore has benefited from the provision of equipment etc. The manager has recognised the strengths and weaknesses of the home and has produced a plan to address them. Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home should improve their statement of purpose and service user guide so as to meet the Care Home Regulations and to give people the information they need so as to be able to make an informed choice before deciding to move into the home. The contract should be reviewed in a timely manner so as to meet with the requirements of the National Minimum Standards and Regulations and the Office of Fair Trading. Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 7 Care planning has improved, however staff need to ensure that they understand and implement the instructions included in them so that they can meet peoples needs and look after them in the way that the person has chosen. Staff should ensure that when nursing people in bed that they have access to their own belongings and fluids, so that people feel comfortable and remain hydrated. Staff should ensure that they respond in a timely and pro-active when people need access to specialist nurses to ensure that people have all the support and expert advise they require. The manager should ensure that the medication policy and procedures are reviewed. Staff administering medication should ensure that they adhere to the homes policies and procedures and general good practice to ensure the safety of people living at the home. The Registered Person must ensure that when complaints are dealt with by people other than the manager that they are dealt with in a timely manner so as to ensure that people in the home are not unduly concerned. The manager should ensure that all staff working in the home understand the homes own policy regarding the protection of adults, and ensure that they adhere to in practice. New staff should be supported in a suitable induction and foundation training. Staff should receive suitable supervision. The homes internal quality assurance systems need to be strengthened. The health and safety of staff and people living in the home need to be protected at all times. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Maurice House DS0000037465.V337361.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 Maurice House DS0000037465.V337361.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The statement of purpose and service user guide continue not to provide all the information required to enable prospective service users to make an informed decision. Progress continues not to be made with the review of the contract. Pre-admission assessments have improved and are performed so as to ensure that peoples needs can be met. The home does not provide intermediate care. EVIDENCE: Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 10 The Statement of Purpose and Service User Guide have both been reviewed and updated. They are both informative documents, which give an indication as to what can be expected in day-to-day life at Maurice House. It was required at the last inspection that the Statement of Purpose and Service User Guide be reviewed to comply with the National Minimum Standards & Regulations. These documents continue to require some amendments to meet this standard. At the last inspection it was required that the Service Users terms and conditions must be reviewed to comply with the National Minimum Standards and Regulations and the Office of Fair Trading. A timescale of 31/12/06 was agreed for this to be completed. Previous timescales of 21.12.04, 30.09.05, 31.03.06 & 31.07.06 regarding this matter had not been met. This requirement continues not to be met. The document has been produced in draft. It needs to be implemented in a timely manner. Information gathered prior to people going to live at the home was found to be of good quality. This ensures that the home can meet people’s needs. Relatives and people living in the home agreed that the home conducts a pre-admission assessment. Documentation was found to be good and the home continues to work towards improving this further. The home does not provide intermediate care as described in Standard 6 of the National Minimum Standards, therefore it was not assessed. Maurice House DS0000037465.V337361.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning has improved, however, they are not always adhered to by staff. Standards of care are not always consistent. Medication practices by some staff are unsafe and place service users at potential risk. People living at the home feel that their privacy and dignity is observed, however staff approach is not consistent. Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 12 EVIDENCE: Each person living in the home has a plan of care. The home has developed a new format for care planning, which is based on a person centred approach. One of the new plans viewed gave in depth information on how the person would like staff to look after them and meet their needs. It was written with the involvement of, and agreement signed by, the person receiving care. Generally the care plans were well reviewed. Care plans contained risk assessments, however they did not always give sufficient information. For example: One nutritional risk assessment viewed, had a key piece of information omitted. Manual handling risk assessments did not detail which sling was to be used with a specific hoist or how the sling was to be used. Daily records written by staff do not always reflect that they have given the care required in the care plan. Care is not always delivered as described in the way in which it is described in the care plan. An example of this is that one well-written plan of care, which gave specific instructions for a person’s care and specific instructions on how to deal with certain behaviour was ignored by staff. People that live in the home were spoken with, as were four relatives. They all believed strongly that either their own or their relative’s needs were very well met. There was evidence in care plans that people had access to G.P’s and other health care professionals as and when they needed them. However, conversation with one person showed that staff had not been pro-active in resolving one persons issues through a specialist nurse. Whilst most people appeared generally well cared for, there were occasions over the two day inspection where it was observed that people being cared for in bed did not have access to fluids or their belongings such as spectacles as their bedside table had been left out of their reach. The medication policy and procedures have been reviewed, however they do not cover all eventualities, an example of this is that sometimes staff collect medication from the chemists. Procedure regarding this practice is not referred to. Staff do not always adhere to the medication policy. The medication fridge was found to be unlocked. Medication administration record charts (MAR) were found not always to be signed when medication had been given. Handwritten entries into MAR charts had not been signed. There was no explanation when medication had been cancelled. Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 13 People that live at the home and a number of relatives expressed that they believed that the privacy and dignity of people in the home was always very well observed. There were some things such as privacy curtains around the bathroom doors that reinforced privacy and dignity. Most staff were observed to be polite to people living in the home, however, one agency staff was observed to be speaking to a person living in the home in an inappropriate manner and not in line with their plan of care. Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has improved processes for ensuring that the home meets people’s social and recreational interests. People are supported and encouraged to maintain independence and contact with relatives and the local community. Meals are of good quality and variety of meals are offered on a daily basis. EVIDENCE: The programme of activities gives thought and consideration to those people who are being cared for in their own rooms. People in the home and some relatives expressed that the home met or exceeded their expectations of a care home. Several people commented that it was ‘like a first class hotel.’ Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 15 The home has a varied and vast activities programme. It also has a house bus, which takes people on regular trips out. A house car has been purchased to take people out for example to hospital appointments. The home has a large dedicated activities room, which is well equipped, and a bar where people are currently welcome to smoke. People at the home expressed that they did not feel pressured to join in activities if they did not choose to and if they preferred were left to enjoy the privacy of their own rooms. People are kept up to date with information about the home in a monthly newsletter produced by the manager. Visitors expressed that they were always made to feel welcome at the home. People living at the home agreed that visitors were welcome to visit at all times and they could interact with their visitors in either the communal areas of the home or in the privacy of their own rooms. People in the home are encouraged to make choices about the way they live. A life history questionnaire has been included in the pre-admission assessment so that the home can gather information regarding the things people have enjoyed being involved in their past and explore things they may like to do in the future. With the exception of one person, all people living at the home and visitors spoken with thought that the food at the home was ‘excellent’. An effort was made by the kitchen staff to work with the person who was not finding the food to their liking, to produce food in the manner the person preferred. People living at the home have a choice of menu daily. People at the home and their visitors agreed that mealtimes were a social occasion and very much enjoyed by people living at the home. Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People at the home and their relatives feel confidant that they can complain and that their complaints will be taken seriously. The response to some complaints continues to be slow. Procedures are implemented to protect service users from abuse but these need to be reinforced to ensure that they occur in practice. EVIDENCE: People living in the home and their relatives knew how to complain through the homes own complaints procedure and agreed that they would feel comfortable to do so or would feel comfortable to speak directly with the homes manager. One person who had complained formally to the Committee of the Royal British Legion had an initial response to their complaint but it had not been followed up with a resolution in a timely manner. The adult protection policy has been updated. Staff have training in the prevention of adult abuse. As previously mentioned one agency member of Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 17 staff was heard to speak with a person living in the home in an inappropriate manner. Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The building is clean, comfortable and well maintained providing a hotel style environment for service users. EVIDENCE: The Home is purpose built, with substantial sized gardens, which have paths ways wide enough for wheelchair users. The Home has a variety of communal space that includes activity rooms, bar, dinning room, lounges and conservatories. All of these areas are furnished to a high standard; all areas of the Home and grounds are accessible to those with mobility problems. Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 19 A new entry system has been installed to enable residents to enter the building independently. The home has an in-depth fire risk assessment, which is due for renewal. The Home exceeds the minimum number of required bathrooms and toilets. All bedrooms are en-suite and some also have showers. The shared bathrooms are good in size with shower curtains fitted around the doorways to maintain privacy and dignity. The types of baths are varied and are appropriate to the category of service users. The bathrooms contain aids to enable people to remain as independent as possible. The home has suitable storage space for equipment but staff sometimes do not store equipment appropriately. On the two days of inspection hoist were found to be placed in a bathroom potentially blocking access to a toilet and sink. This limits people’s choice of the bathrooms they may chose to use and also poses a health and safety risk. Peoples own rooms meet their needs. All rooms are comfortable and well decorated and furnished. All rooms have a nurse call system. Rooms have been personalised with people’s own belongings. All bedrooms have keys and people can lock their own door if they choose. Pipe work and radiators are covered or have cool touch surfaces so as to prevent scalds and burns. The home is extremely clean throughout. The home does not have unpleasant odours. The home has suitable infection control procedures. The home has purpose built sluices and a purpose built laundry. Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home does not put into practice the induction and foundation training that it has purchased. It cannot therefore ensure that new staff understand the policy, procedures or ethos of the home. The homes recruitment procedures are not adhered to and this could put people in the home at risk. EVIDENCE: The home has held a recruitment drive to provide the home with permanent staff. The manager acknowledges that the home has needed to use a number of agency staff recently, but has endeavoured to have the agency supply staff that know the home and the people that live in it. Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 21 People that live in the home and visitors expressed that the home was generally adequately staffed but there were times when the staff were very busy. Domestic staff are employed in sufficient numbers and for sufficient hours to ensure that the home throughout is kept clean. More than the required 50 of staff are trained to NVQ level 2 in care. The manager has ensured that the home has an induction which is in line with skills for care, however there is no evidence that staff have undertaken this induction and their workbooks have not been signed off. The home has suitable policies and procedures regarding the employment of staff. However, staff do not always adhere to them. This puts people living at the home at risk. Staff files were found not to contain all the required documentation listed in Schedule 2 of the Care Home Regulations for example a photo of staff employed at the home. One member of care staff did not have a reference from their previous employer. Whilst induction and foundation training is not suitably in place, staff are provided with mandatory training and some service specific training. Dementia training was tailored to educate staff in one persons needs. Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home now has a manager. The manager listens to people that live and work in the home and tries to meet their needs. The homes internal quality assurance has shortfalls. The homes policies and procedures protect the people that live there from financial abuse. Staff do not have suitable supervision. The health and safety of people in the home is not always protected. Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 23 EVIDENCE: The home has employed a new manager. The manager has the appropriate qualifications for the position but is yet to make a formal application to become the registered manager and to be assessed through the fit persons process. The manager has introduced a number of methods of communication in the home. The home has regular meetings for the people that live there and staff members. At the beginning of every shift there is a handover period so that staff on duty are always aware of the current situation and any changes. The manager has introduced a newsletter for the people that live in the home. The manager provided the Commission with honest, in-depth, welldocumented pre inspection information. It demonstrates that she is aware of the strength and weaknesses of the home. She has put in place plans to continue to maintain, or improve further, areas of strength and has developed strategies to address the weaknesses. This has provided the base of a good development plan, which now needs to have realistic timescales. The homes internal quality assurance processes need to be strengthened. Staff induction and supervision has not taken place, and was not identified through quality assurance checks. This is clear evidence that the system of quality assurance does not work effectively. The manager needs to ensure that work that has been delegated to senior staff is completed. The QA system, including Regulation 26 visits which are conducted on behalf of the Registered Person, are not rigorous enough to detect such matters. The home actively encourages feedback from people that live in the home and their visitors. The home produces quality assurance questionnaires for people that live in the home and their visitors. Policies and procedures are not always reviewed in a timely manner, although the manager is not autonomous regarding this and policies and procedures are reviewed by a team that do not work within the home. An example would be that the medication policy remains in draft form despite two previous requirements made at other inspections regarding this matter. Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 24 Action is not always progressed within agreed timescales to implement requirements identified in CSCI inspection reports, examples would be the medication policy and the resident’s terms and conditions. Therefore there remain a number of requirements outstanding and this means that the home is not meeting all minimum standards and therefore potentially putting people in the home at risk. The procedures for managing service users finances are sound. The home keeps receipts of transactions. The home has a format for supervision. The manager has delegated the duty of supervision of carers to some of the trained nurses. Staff supervision has not been conducted regularly and the nurses involved had not made the manager aware that they were failing to provide supervision in line with minimum standards. The home has employed a Head of Care to assist the manager in some of her roles pertaining to the management of the home and staff training and supervision. It was generally expressed amongst staff that the head of care who also works ‘on the floor’ does not have suitable ‘management hours’ to conduct all the tasks that are required of this role. The actions of the staff within the home do not always protect the health and safety of people that live in the home; examples would be the way staff store equipment and leaving drinks out of peoples reach. Any accidents are suitably recorded and reported. Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 25 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 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 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 2 17 x 18 2 4 4 4 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 x 3 2 x 2 Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 26 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 5 Requirement Required to update and review the service user guide to comply with the National Minimum Standards & Regulations PREVIOUS REQUIREMENT WITH TIMESCALE OF 30/11/06 NOT MET 2. OP2 5 31/07/07 The Service Users terms and conditions must be reviewed to comply with the National Minimum Standards and Regulations and the Office of Fair Trading. PREVIOUS REQUIREMENTS WITH TIMESCALE OF 21/12/04, 30/09/05, 31/03/06 & 31/07/06 30/12/06 NOT MET 3. OP9 12-17 20 sch 3 The medication policy must be updated to provide details of current practices. Proper reviews must be conducted of the policies and procedures. PREVIOUS REQUIREMENTS WITH Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 27 Timescale for action 31/07/07 31/07/07 TIMESCALE OF 31/03/06, 31/07/06, 31/12/06 NOT MET 4. OP9 12 -14 17 sch 3 All staff must adhere to the policy & procedure for administering medicines. The manager must ensure that monitoring systems are in place and appropriate action is taken when unsafe practice is identified. PREVIOUS REQUIREMENTS WITH TIMESCALE OF 23/10/06 NOT MET The manager must ensure that 31/07/07 complaints are responded to quickly. The manager and the registered individual must ensure that the findings of an investigation following a complaint and the action plan is implemented as soon as reasonably possible, ensuring all staff are aware of the content and action required. PREVIOUS REQUIREMENTS WITH TIMESCALE OF 23/10/06 NOT MET Recruitment procedures must 31/07/07 show recorded evidence of exploring gaps in employment history and include references from last care employer. PREVIOUS REQUIREMENTS WITH TIMESCALE OF 23/10/06 NOT MET 7. OP30 12 18 The manager must ensure that the new induction programme is implemented The manager must ensure that DS0000037465.V337361.R01.S.doc 31/07/07 5 OP16 17 22 sch 4 6. OP29 7 9 12 19 Sch 2 31/07/07 8 OP36 18 31/07/07 Page 28 Maurice House Version 5.2 staff are suitably supervised RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Maurice House DS0000037465.V337361.R01.S.doc Version 5.2 Page 30 - 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!