Inspection on 15/04/05 for Merok Park Nursing Home

This inspection was carried out on 15th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Merok Park Nursing Home 15/03/10

Merok Park Nursing Home 08/12/09

Merok Park Nursing Home 30/06/09

Merok Park Nursing Home 10/07/07

Merok Park Nursing Home 15/05/06

Merok Park Nursing Home 17/01/06

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 Merok Park Park Road Banstead Surrey SM7 3EF Lead Inspector Miss Marianne Barham Unannounced 15 April 2005 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. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Merok Park Nursing Home Address Park Road, Banstead, Surrey. SM7 3EF 0208 652 7702 0208 652 7702 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) Mr Soondressen Coopen Mrs Helen Arnold CRH (N) 29 Category(ies) of Dementia - over 65 years of age (DE(E)) 20. registration, with number of places Old age, not falling within any other category (OP) 29. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Two (2) beds may be used for respite care. Of the twenty-nine (29) older persons accommodated, up to twenty (20) may be in the category DE(E) (Older people suffering from dementia). Date of last inspection 17/03/05 Brief Description of the Service: Merok Park is a large detached property located within a five minute drive or fifteen minute walk of Banstead town centre and its amenities. The home currently provides accommodation and nursing care to twenty seven service users who are elderly and some of whom suffer from dementia. The home has been extended and has twenty five single and two double bedrooms. Fourteen of the single rooms have an en-suite toilet and washing facility and all other rooms have a handwash basin. The rooms are arranged over two floors and the first floor can be reached by staircase or passenger lift. There are three toilets, a bath and a shower on the ground floor and three toilets, a bath and a shower on the first floor. The toilets and bathrooms are located in such a way that all bedrooms have a toilet and bathing facilities nearby. There are two lounges and two dining rooms on the ground floor and a large kitchen. The home stands in its own large well maintained gardens and has parking to the front of the building. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out at 11.00am in response to a complaint made against the service and was the first inspection in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. It was carried out by two inspectors, Marianne Barham lead inspector for the service and Janet Daulton as a second regulation inspector. The CSCI Pharmacist inspector, Geraldine Yates had carried out a pharmacy inspection on the previous day 14th April 2005, and her findings and any requirements are contained in this report. The inspection was carried out over a period of four and a half hours, however it was necessary for the lead inspector, Marianne Barham to carry out an unannounced follow up visit lasting two hours on 18th April 2005 at 12.00. This was in order to view records unable to be seen during the inspection of the 15th April 2005. Ten staff members, twelve service users and two relatives were spoken to during this inspection. A tour of the premises was undertaken and records relating to the care of service users and the staffing and management of the home were examined. The registered manager of the home is currently under suspension from duty and the new owner, Mr Cooppen has appointed a deputy who is acting as manager in the registered managers absence. Mr Cooppen is the registered provider for the service. The acting manager was not at the home on the day of the inspection, which was the reason a follow up visit had to be made as she held the key to the staff records. What the service does well: The home was observed to be functioning well during the inspection and there was a calm and relaxed atmosphere throughout. Service users were observed to be well groomed and appropriately dressed, and were engaged in activities with staff and each other. Staff were seen to interact in a positive and respectful manner with service users. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 6 Service users and their relatives were complimentary about the staff and the care they receive. The home employs an experienced chef and service users reported that they enjoyed the meals and were given a choice of menu. Service users needs are well documented in their care plans, with daily records kept for each person detailing care provided and visits by GP, chiropodist etc. What has improved since the last inspection? What they could do better: All of the homes policies and procedures need to be reviewed and updated to reflect the new registered provider. This also applies to the statement of purpose and service users guide. The home needs to have policy in place for care of dying and death of a service user as the home does not currently have one. Some records relating to service users were not stored securely and this needs to be addressed. The home needs to implement a programme for staff training that is appropriate to the work they do, as at present there is no training plan and no record of staff training is kept. Staff should receive formal supervision on at least six occasions in any twelve months period. No formal supervision of staff has been carried out in the last six months. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 7 Accurate records of all medications administered in the home need to be kept as there were a number of errors found by the pharmacy inspector. Risk assessments for moving and handling and pressure area care had not been reviewed for some time and this needs to be addressed. The enamel on the bath in the first floor bathroom was severely cracked and needs to be repaired or the bath replaced. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5 Service users do not have their own copy of the service users guide, therefore do not have adequate information about the home they live in. Service users have a written contract stating the terms and conditions of residence. Service users are fully assessed prior to admission and their families/representatives are involved in the process and able to visit the home before the service user moves in. EVIDENCE: The home has a comprehensive statement of purpose and service user guide in place, however these need to be updated to reflect that there is a new owner/registered provider and the change from NCSC to CSCI. There was no evidence that service users have been provided with a copy of the service users guide. A requirement has been made to address this. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 10 A copy of the service users term and conditions of residence were maintained in their care plans and some, but not all, of these had been signed, either by the service user or their representative. A recommendation has been made that all contracts are signed. The nurse in charge reported that full assessments are carried out prior to service users being admitted and that people are only admitted on the basis that the home can meet their needs. Pre-admission assessments examined at this inspection were found to be comprehensive covering all aspects of the service users needs. The nurse in charge stated that prospective service users and their families are encouraged to come to the home and have trial visits prior to admission and this is reflected in the service user guide. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 and 11 Each service user has their health, personal and social care needs detailed in an individual plan of care. The home does not meet all the health care needs of service users. A review of the handling and administration of medication was undertaken by a CSCI pharmacist inspector who concluded that the systems for the administration of medication are poor and potentially place service users at risk. Service users are treated with respect, however their right to privacy is not always upheld as one of the bedrooms on the first floor may be used as a walkway to each side of the home. Service users and their family would be treated with sensitivity and respect in the event of their death, however there is no policy in place to reflect this. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 12 EVIDENCE: Service users care plans were examined. These are generated from the pre admission assessment. The care plans were well organised and comprehensive with clear details of actions needed to meet the needs of the service users. Records were kept of GP and other involved professionals visits. There was evidence of monthly reviews having been carried out. The care plans were signed, either by the service user, or their representative, where there was no representative a note was made that they were unable to sign. Risk assessments were observed for moving and handling pressure area care. These were well written and contained clear guidelines for staff to follow, however they were in need of review. Records of nursing interventions such as catheter care are maintained. Records are maintained of visits from health professionals, these include chiropodist, optician and district nurse. Service users access the local GP surgery and dentist. Detailed medication handling procedures were available but staff were not working to them. Medication stocks and records were sampled and failed to show that service users were receiving their medication as intended by their doctors. There were frequent omissions in completing the medication administration records, resulting in no record being kept of whether medication had been administered or not. A small number of service users were prescribed medication to be given ‘as needed’ with no clear guidelines as to what constituted needed. Medication was stored securely for the protection of service users but the temperature of the medication refrigerator had not been monitored in the last month. A number of requirements and a recommendation were made to address these issues. Please see relevant section at the end of this report for details. Staff were observed to interact positively with the service users, talking and listening to them in a respectful manner. Service users preferred term of address is noted in their care plans and staff were seen to observe this, addressing some service users as Mr or Mrs and their surname and others by their first name. Relatives spoken to at this inspection confirmed that service users are treated well. Staff were seen to knock on bedroom and toilet doors before entering and double rooms have privacy screens fitted. One of the double rooms has a door at each end, with one door opening by the office, and the other onto the first floor hallway. There was no sign on the door by the office to say that this was a bedroom and a recommendation has been made that this is addressed. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 13 Service users have their wishes for funeral arrangements noted in their care plan and one service user has made a living will concerning resuscitation, however there is no policy in the home for care of the dying and death. A requirement has been made to address this. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 and 15 Service users are able to maintain contact with their relatives and the local community as they wish. Service users receive a balanced diet, according to their needs and preferences in suitable surroundings. EVIDENCE: The nurse in charge reported that service users are able receive visitors at any time. Service users and their relatives confirmed that this was the case. Service users can receive visitors in their rooms or in the communal lounges. Service users reported that they are able go out to the local shops, pubs and other amenities with staff support as needed, if they wish to do so. The home employs a chef who has worked at the home for over two years. Four weekly menus are maintained which offer a variety of nutritious meals, there are two choices for each meal. The chef reported that the staff will inform him of any special diets and these are prepared as necessary. This was observed to happen during the inspection. The kitchen was found to be clean and the food storage areas well stocked with meat, fish, vegetables, fruit and general groceries. Service users’ birthdays are celebrated with a cake at tea time, this is supplied either by the home or their relatives according to the individual. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 15 Service users reported that the food was nice and that they were able to choose what they had. When asked, all those spoken to said they could have a drink or a snack if they wanted to. The home has two dining areas, with the more able service users eating in one, and those needing more support using the other. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 The home is unable to demonstrate that adequate measures are in place to protect service users from abuse. EVIDENCE: One staff member spoken to reported that they had received in house training on the protection of vulnerable adults from abuse, however there were no certificates available to evidence this. There were no records at the home of any staff having attended the Surrey training. The home has a copy of the Surrey Multi Agency Procedures, however this is now out of date and they need to acquire the most recent copy. The nurse in charge, when asked, was unclear of the procedures to follow if abuse of a service user was suspected. A requirement has been made to address these issues. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 17 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, 21, 24 and 26 The environment in the home is safe and well maintained. There are sufficient toilet and washing facilities, however one of the baths is in need of repair or replacement. Service users bedrooms are comfortable and safe and they have their own possessions around them. The home is clean, hygienic and pleasant. EVIDENCE: The home was clean and tidy on the day of the inspection. There are two lounges and two dining rooms providing ample communal sitting space. The layout of the home can be confusing owing to extensions that have been added over the years. To address this, a member of staff has recently produced signs in pictorial format for all bathrooms, toilets, lounges and dining rooms as well as the kitchen, laundry and office. These signs are simplistic and clear and service users commented that they help them find their way round much Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 18 better. All the bedrooms have a sign stating the name of the occupant and a clear photograph of them fixed to the door. It was pleasing to see that requirements made concerning maintenance in the home had been met, and the overall improvement in the atmosphere and cleanliness throughout the home. There are two bathrooms and two shower rooms, one on each floor, as well as three toilets on each floor. The enamel on the assisted bath on the first floor is quite severely cracked and needs repairing or replacing. A requirement has been made to address this. Bedrooms were seen to be well furnished and reflected service users individual tastes and interests. The rooms were clean and tidy and adaptations such as profiling beds were provided as necessary. All rooms were able to be locked but could be accessed by staff in an emergency. Screens are provided in the double bedrooms. The home employs domestic staff and a cleaning rota is maintained. As stated above the home was clean and tidy at this inspection. One bedroom was found to have malodour, however this is currently being addressed by the owner, following a requirement being made to replace the carpet in this room at the last visit to the home. The timescale for action for this requirement has not yet elapsed. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 19 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, 28, 29 and 30 The staff numbers and skill mix is adequate to meet the needs of the service users. The nursing staff have the relevant qualifications and experience to ensure the safety of service users and care staff are registered with an NVQ training body and NVQ training is undertaken by them. The homes recruitment policy and practice protects and supports service users. Staff are not receiving the training required to be competent to carry out their jobs. EVIDENCE: A requirement as made at the last inspection that there must be two qualified nurses on duty during the morning and afternoon shifts. It was pleasing to see that this has been complied with. Staff rotas were examined and were found to show adequate staffing numbers and skill mix of staff. As well as the nursing and care staff, a chef, a kitchen assistant, an activities coordinator and domestic staff are also employed by the home. Care staff spoken to confirmed that they were continuing with their NVQ training, however there is a problem with accessing an assessor, as the assessor assigned by the college is the son of the home’s previous owner. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 20 The home has a new owner, Mr Cooppen who purchased it in December 2004, and he is now the registered provider of the service. Mr Cooppen is currently in discussion with the college to arrange another assessor. A number of staff were spoken to during the inspection, many of whom have worked at the home for some years. All stated that the new owner was approachable, they were happy with the hours they work and enjoyed working at the home. One staff member who has worked at the home for some time stated that they had initially been worried about having a new owner in case they were unable to carry on working flexible shifts, however this was not the case and their working patterns have not been changed. This same staff member went on to say that they thought the changes the new owner was making were better for the service users. The nurse in charge stated that there is a request system in place and staff can request off duties and annual leave in the request book, there is not usually a problem unless it is very short notice. A new deputy has recently been appointed and is currently acting manager in the registered managers absence. The deputy previously worked at the home for three years, and staff spoken to stated that they were pleased that she was back and felt she was very supportive. The home has a recruitment policy and procedure in place, this needs to be updated to reflect the new ownership of the home. At the last inspection a requirement was made that staff personnel records were maintained in the home. This has been met. Staff personnel records were seen by the lead inspector, Marianne Barham at the unannounced follow up visit on 18th April 2005. A mixture of new staff, agency staff and long serving staff files were examined. All new and long serving staff files were found to contain two references, copies of identification such as birth certificates and passports, a statement of terms and conditions, job description, application form, NMC PIN for nurses and copies of CRB and POVA checks. Agency staff records are not kept at the home, however the agency sends written details of staff qualifications and experience and copies of their CRB and POVA checks. These were seen for two agency staff currently working at the home. The home does not have a training and development programme in place and a requirement has been made to address this. There is no consistent recording of staff training or supervision. The nurse in charge reported that she had received a verbal induction but no formal recorded induction. No staff received supervision in the last six months. The owner is currently in the process of developing a training programme for staff. Requirements have been made to address these issues. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 21 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) 32, 36, 37 and 38 The management arrangements at the home benefit the service users. Staff do not receive appropriate supervision Service users’ rights, and best interests are not always safeguarded by the homes record keeping, policies and procedures. The health, welfare and safety of service users is not adequately protected. EVIDENCE: As stated previously in this report, the newly appointed deputy is acting as manager in the registered managers absence. Staff spoken to reported that the deputy has an open and supportive style of management. Service users stated that she was kind to them and that they liked her. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 22 Staff have not received supervision for the last six months. Those staff spoken to felt that the deputy will commence supervision once she has settled in. A requirement has been made that all staff receive supervision and that it is recorded. The homes policies and procedures were examined and were all found to be in need of updating to reflect the new ownership of the home. Records are stored in the office, which is locked when not in use, however an unlocked filing cabinet containing old records of service users is stored outside the office. A requirement has been made to address this issue. Fire safety training had been arranged for 19th April 2005 and staff spoken to were aware of this. As stated previously in this report there is no training programme in place and no formal induction process. Staff reported having had moving and handling training, but this could not be evidenced and their had been no update since. Staff do not hold first aid certificates. Requirements have been made to address these issues. A maintenance programme is in place and records are kept of all maintenance issues. Mr Cooppen employs a maintenance worker to undertake minor repairs around the home. The chef holds a current food hygiene certificate and a City and Guilds qualification. Temperatures of food, fridge and freezer are maintained. Window restrictors are fitted to first floor windows. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 23 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. Where there is no score against a standard it has not been looked at during this inspection. 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 1 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 2 11 1 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x 3 x x 3 x x STAFFING Standard No Score 27 3 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 1 x 3 x x x 1 2 1 Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 24 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 1 Regulation 4 (1) (2) 5 (1) (2) Requirement The homes statement of purpose and service user guide must be updated to reflect the change of provider and details of CSCI. Each service user must be supplied with a copy of the service user guide. Assessments of risk to service users must be reviewed, updated and recorded regularly. Complete and accurate records must be kept of all medication administered to service users. Timescale for action 15th July 2005 2. 3. 8 9 14 (2) (a) 17 (1) (a) 15th May 2005 Immediate within 24 hours of inspection date 14th April 2005 12th May 2005 4. 9 13 (2) 5. 9 13 (2) The registered person must have a clear plan, giving detailed instructions to staff as to what constitutes as needed for service users following consultation with the relevant practitioner. This will ensure that medication is administered in a clear and consistent way for the benefit of service users. Daily temperature records must be kept for the medication refridgerator to ensure that it is operating within the correct range of 2 - 8 degrees 28th April 2005 Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 25 6. 11 12 (4) (a) (b) 7. 18 13 (6) 8. 9. 21 30, 38 23 (2) (b) 18 (1) (c) (i) (ii) 10. 36 18 (2) (a) 11. 37 17 (1) (b) 12. 37 17 (3) (a) centigrade and that the quality of the medication held in it can be assured. The home must produce a policy and procedure on the care of the dying and death of a service user and ensure that all staff are made aware of it. The registered person must ensure that all staff receive training on the protection of vulnerable adults from abuse and that they are made aware of the most recent Surrey Multi Agency Procedures. The cracked enamel on the bath in the first floor bathroom must be repaired or replaced. A training programme for staff, appropriate to the work they are to perform, including structured induction training must be implemented, and records must be maintained of all training undertaken. All staff must receive formal supervision at least six times in a twelve month period and this must be recorded. Service users records stored in the unlocked filing cabinet on the landing by the office must be made secure. All policies and procedures kept in the home must be reviewed and updated to reflect the change of registered provider. 15th July 2005 15th July 2005 15th May 2005 15th June 2005 15th May 2005 19th April2005 15th July 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 9 Good Practice Recommendations It is reccommended as good practice that when it is H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 26 Merok Park 2. 10 necessary to handwrite a medication onto the medication administration record chart in the home, that the member of staff signs the chart and a second carer checks the entry for accuracy and then initials the chart. It is strongly recommended that a sign be placed on the second door of the bedroom next to the office stating clearly that it is a bedroom and is not to used as a walkway to get to other parts of the home, in order to protect the privacy and dignity of the service user. Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 27 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Merok Park H58 H09 s62507 Merok Park v218979 150405 Stage 4 unn.doc Version 1.20 Page 28 - 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!