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Inspection on 04/05/06 for North Court Residential And Nursing Home

Also see our care home review for North Court Residential And Nursing Home for more information

This inspection was carried out on 4th May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The atmosphere in the home is welcoming and friendly. All residents spoken with said staff were always willing to help and answered bells quickly. Care was offered in a sensitive way at the pace of the resident. Staff spoken with said they enjoyed their work and got on well with each other and the residents.

What has improved since the last inspection?

What the care home could do better:

Some fire doors on residents` bedrooms are still being wedged open posing a fire hazard to the resident. Fire exit signing needs to be rationalised and all fire exit doors fitted with push bars. Some MAR sheets are not being correctly completed and some medication was treated as CD unnecessarily. The Control of Substances Hazardous to Health regulations (COSHH) were not being fully observed on the day of inspection.In the main kitchen one freezer needed defrosting to enable it to work efficiently and some prepared food that was stored was not labelled to identify it or dated. In one of the kitchenettes in the units a packet of cigarettes and a lighter were found in a kitchen cupboard. The new residents` files seen did not contain a recent photograph of the resident and a number of MAR sheets did not have identification photographs attached. Staff files did not have recent photographs of the staff member either and one file did not contain any references. The protection of vulnerable adults (POVA) folder is not the most up to date guidelines issued by the Vulnerable Adult Protection Committee of Suffolk. The complaints policy seen still refers to National Care Standards Commission (NCSC) and not the Commission for Social Care Inspection (CSCI).

CARE HOMES FOR OLDER PEOPLE North Court Residential And Nursing Home Northgate Street Bury St Edmunds Suffolk IP33 1HS Lead Inspector Jane Offord Key Unannounced 4th May 2006 09:15 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 DS0000024456.V293958.R01.S.doc Version 5.1 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. DS0000024456.V293958.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service North Court Residential And Nursing Home Address Northgate Street Bury St Edmunds Suffolk IP33 1HS 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) 01284 763621 01284 725980 Four Seasons Homes (No 4) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Elspeth Anne Nicol Care Home 65 Category(ies) of Dementia (6), Dementia - over 65 years of age registration, with number (23), Old age, not falling within any other of places category (42) DS0000024456.V293958.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One Place with the category Physical Disability (PD) The home is registered for one place under the category Physical Disability (PD) for the named individual specified in the letter dated 25th November 2003, for the duration of their residence. 12th January 2006 Date of last inspection Brief Description of the Service: North Court is located on the main road leading into the town centre of Bury St. Edmunds. The home was originally purpose built by Suffolk County Council as a home for older people but was sold in 1994 and purchased by the current owners, Four Seasons Health Care Ltd. in December 2000.The home is set well back from the roadway and accessed by a circular driveway with ample car parking spaces available. There are landscaped gardens to both the front and rear of the property with appropriate seating areas for service users. The home is registered to provide both nursing and residential care for up to 65 older people. The ground floor is divided into four units. Fern provides care for ten frail elderly residents while Primrose, Rose and Heather provide care and accommodation for 23 older people suffering from dementia. The remaining units are sited on the first floor of the home and provide care for 32 frail elderly people who require either nursing or residential care. DS0000024456.V293958.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection focussing on the core standards for Older People. It took place on a weekday between 9.15 and 17.00. On the day a tour of the premises was undertaken, several residents and visitors were spoken with, a number of the home’s policies were seen and the duty rotas and menus were inspected. Three residents’ files, care plans and daily records were looked at, as were three staff files and the training matrix. The lunchtime meal and medication round were observed; medication administration records (MAR sheets) and the controlled drugs (CD) register were checked. The manager was available throughout the day to assist with the inspection process and a number of staff on duty spoke with the inspector. On the day of the inspection the home was tidy and clean. Residents looked well dressed and comfortable. Interactions observed were friendly and appropriate. Staff were seen offering choices to residents and spending time chatting and singing with them. What the service does well: What has improved since the last inspection? What they could do better: Some fire doors on residents’ bedrooms are still being wedged open posing a fire hazard to the resident. Fire exit signing needs to be rationalised and all fire exit doors fitted with push bars. Some MAR sheets are not being correctly completed and some medication was treated as CD unnecessarily. The Control of Substances Hazardous to Health regulations (COSHH) were not being fully observed on the day of inspection. DS0000024456.V293958.R01.S.doc Version 5.1 Page 6 In the main kitchen one freezer needed defrosting to enable it to work efficiently and some prepared food that was stored was not labelled to identify it or dated. In one of the kitchenettes in the units a packet of cigarettes and a lighter were found in a kitchen cupboard. The new residents’ files seen did not contain a recent photograph of the resident and a number of MAR sheets did not have identification photographs attached. Staff files did not have recent photographs of the staff member either and one file did not contain any references. The protection of vulnerable adults (POVA) folder is not the most up to date guidelines issued by the Vulnerable Adult Protection Committee of Suffolk. The complaints policy seen still refers to National Care Standards Commission (NCSC) and not the Commission for Social Care Inspection (CSCI). 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. DS0000024456.V293958.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000024456.V293958.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6. People who use this service can expect to have their needs assessed and been assured they can be met by the service prior to entering the home. The service does not offer intermediate care. EVIDENCE: Three new residents’ files were seen and they all contained an assessment of need that had been completed. Areas such as Past Medical History, medication, diet, oral health and sensory needs were addressed. The Activities of Daily Living (ADLs) included continence, personal hygiene, sleep, social interests and a cognitive assessment. The Next of Kin and contact details were recorded and any input the family had had in caring for the prospective resident. A social assessment covered daily routine, likes and dislikes, anxieties, religious persuasion and interests, ‘flower arranging and romantic songs of the 30s and 40s’ were recorded for one resident. One assessment had included all the names of the children, grand children and great grand children as the resident had said their family were important to them. DS0000024456.V293958.R01.S.doc Version 5.1 Page 9 One file did not have evidence of a pre-admission assessment as the resident had moved from another part of the country. There was a social service assessment and a hospital report. This was discussed with the manager who said they had been happy that the resident’s needs could be met from the information in the two documents. If they had had any doubts they would have contacted the nearest home within their group (Four Seasons Homes) and asked the manager there to do an assessment of need on their behalf to ensure they could meet that person’s needs. DS0000024456.V293958.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. People who use this service can expect to have a care plan drawn up to help meet their health needs and that staff will treat them with respect, however they cannot be assured that the present medication administration procedures will protect them. EVIDENCE: The care plans of three recently admitted residents were seen. They covered areas of care such as personal hygiene, mobility, safe environment, nutrition and social interaction. The interventions to meet the identified needs were explicit and appropriate. Not all the care plan interventions had been evaluated by the recorded date e.g. monthly. There was documented evidence that health needs were met and other health professionals involved in care. All the files had the name of the resident’s GP and contact details and in some there were records of appointments with health professionals such as an optician or dentist. There were records of blood tests and swabs being done. Assessments were done to cover moving and handling needs, nutrition and a Waterlow score for tissue viability assessment. DS0000024456.V293958.R01.S.doc Version 5.1 Page 11 One resident spoken with told the inspector that they were being hoisted as they had difficulty standing. They were very unhappy with the use of the hoist and preferred to use a standing frame. A relative present during the conversation agreed that the resident was more comfortable with the frame but said they thought the manager was going to arrange an assessment by the moving and handling trainer. This was discussed with the manager who said an assessment had been done and the hoist was the safest way to move the resident for both them and staff. The manager said they would request a further assessment as the resident was so unhappy with the procedure. The lunchtime medication round was observed in the special needs unit. Many of the MAR sheets did not have resident identification photographs with them. A number of ‘as required’ (PRN) medication prescriptions were not being completed with the number of tablets administered. In several cases the code ‘F’ was not defined and one chart had no code used for paracetemol that was prescribed four times a day but routinely refused by the resident at lunchtime. One prescription was for a medication to be administered in the morning. The nurse explained that the resident was always asleep during the early drug round so the medication was given at lunchtime. This meant the wrong coloured blister pack was being used and the prescription needed changing. The CD register was checked and found to have a series of entries for Clonazepam for one resident. This medication does not fall into Schedule 2 drugs and so does not need to be treated as a CD. The nurse checked for the outstanding balance of the medication and realised that the resident was still receiving it. The blister pack was found but the contents did not tally with the signature record on the MAR sheet. One box had been signed and then an ‘F’ imposed over the signature indicating that the nurse had signed prior to the resident taking the tablet. DS0000024456.V293958.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. People who use this service can expect to be encouraged to maintain contact with family and friends and have choice about how they spend their time however, they cannot be assured that the written menus reflect the meal being offered or that food is always stored safely in the kitchen or transported hygienically around the building. EVIDENCE: As noted in an earlier section residents’ files seen all contained contact details for Next of Kin and other family members. A number of visitors were seen at the home during the day and when questioned confirmed that there was no restriction on visiting and that the staff always made them feel welcome. One resident told the inspector that they had been visited by a relative that morning and had their hair done. A member of staff said the relative was a hairdresser and came regularly to do their hair and give hand care to the resident. Another resident was spending time in their room happily talking to a toy cat. They said they enjoyed their own company and liked cats. The room had several lovely pictures and photographs of cats. DS0000024456.V293958.R01.S.doc Version 5.1 Page 13 The home has appointed an activities co-ordinator who is organising regular sessions for residents of craftwork. Unfortunately the inspector did not manage to speak with the co-ordinator during the day. The home has a work experience placement person who is also helping with craftwork sessions. The day of the inspection was a beautiful spring day and a number of the residents took advantage of the weather to sit in the sun in front of the home. One resident confined to a wheelchair due to recent surgery was transferred from their armchair into the wheelchair so a relative could take them out into the sun. The carers who undertook the transfer did so competently and carefully. The menus were seen and work on a four-week rotation. The menu for the day of inspection was to be ‘tarragon chicken or sausage casserole with vegetables’. The tarragon chicken was not served instead it was pork casserole. The manager said residents had been told of the change the previous evening and it had been done as a number of residents were refusing chicken products due to anxiety about avian ‘flu. The menus showed a limited range of vegetarian options. On most days it would have been a salad, omelette or jacket potato. One resident said the desserts were ‘boring, fruit and cream every other day’. People who needed help with their meal were assisted sensitively. Special cutlery and plate guards were available to help maintain independence. A trolley of plated meals was observed being taken to residents who had remained in their rooms. The meals were covered with a length of kitchen paper not proper meal covers. The main kitchen was seen after lunch and had been cleared away and left clean and tidy. One kitchen helper was preparing for tea. It was noted that one small freezer was very iced up and needed defrosting. There was a large selection of fresh, frozen and dry stores. Some prepared food in the refrigerator and a cake in the store cupboard were not labelled for identification or date. DS0000024456.V293958.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. People who use this service can expect to have any concern taken seriously and investigated but cannot be assured that, although staff are aware of their duty of care to residents, they have got access to the most recent guidelines for managing a POVA issue. EVIDENCE: CSCI have not received any complaints regarding this service since the last inspection. The complaints policy was seen and looked robust with timeframes for responses and information about taking a complaint further if dissatisfied with the initial outcome. One part of the policy still refers to National Commission for Social Care (NCSC) and needs to be amended to CSCI to avoid confusion. Several staff were asked about how they would manage any concerns they might have about potential abuse situations. Carers and domestic staff were all clear that they would report any concerns they had for senior staff to deal with. Most staff spoken with had not had formal POVA training but one carer said it had been covered during their NVQ level 2 programme. The POVA policy was seen and although comprehensive does not reflect local guidelines for referral. The local POVA folder was not the most recent and the manager agreed to obtain the Inter-Agency Policy Operational Procedures and Staff Guidance dated June 2004 as reference for staff. DS0000024456.V293958.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 26. People who use this service can expect to live in a home that is kept clean, has a programme of refurbishment and specialist equipment available to help maintain independence, however they cannot be assured that the gardens will be maintained, that all bathrooms will be in functioning order or that specialist pressure relieving equipment will be in order. EVIDENCE: During the tour of the home it was noted that two bathrooms were out of commission. Both bathrooms were being used as storage rooms for hoists and wheelchairs. The laundry was visited and the member of staff responsible for the laundry on that day was spoken with. The member of staff explained the procedure for managing soiled linen to prevent cross infection and said the washing machines had sluicing cycles. Throughout the day it was noted that there were wheelchairs, hoists, slings, standing frames and pressure-relieving mattresses and cushions available to help residents’ mobility and protect their pressure areas. DS0000024456.V293958.R01.S.doc Version 5.1 Page 16 The motor of one pressure-relieving mattress that was in use was bleeping an alarm constantly. The nurse said the mattress was still pressured and the rental firm had been contacted to replace the motor but they did not know when that would happen. The matter was discussed with the manager who agreed that constant bleeping was unacceptable and they would exchange the motor for one that was functioning properly. The manager said the home is about to undergo a major refurbishment. Some changes are proposed to the layout of the lounge and dining room in the special needs unit and a proportion of the residents’ bedrooms will be redecorated and have new furniture and soft furnishings. Two or three rooms have already been completed and an empty one was seen. It was very attractive with oak furniture and co-ordinated soft furnishings. The home is set back from a main road into Bury St. Edmunds and has grounds all round it. The grounds have the potential to be lovely but were unkempt on the day of inspection. The courtyard in the middle of the building offers safe access for residents in the special needs unit but in spite of the day being sunny and warm no residents were taking advantage of the fresh air. One or two residents sat in the front of the house but one resident said they would like staff to offer to take them outside sometimes, as they were unable to do so unaided. DS0000024456.V293958.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. People who use this service can expect to have their needs met by competent staff who are rostered in adequate numbers for the service however they cannot be assured that all recruitment checks are made and kept in staff files. EVIDENCE: The staff rotas were seen and showed that there is a trained nurse on duty on each floor on an early, late and night shift. The special needs unit has six carers on an early, five on a late and two for night duty. The home employs a registered mental nurse (RMN) who does night duty exclusively on the special needs unit. The older peoples’ unit is staffed with five carers on an early, three on a late and two at night time. The manager said they have some vacant residents’ rooms at present and staffing has been reduced for the time being. This has meant that there is no overtime not that staff’s hours have been reduced. Staff spoken with said that they felt the staffing was enough to meet residents’ needs. Residents and visitors all said that staff responded quickly to any request for assistance and it was observed during the day that buzzers did not ring for long periods. Three new staff files were inspected and each contained an enhanced criminal records bureau (CRB) check taken before the member of staff commenced in post. Copies of identification documents were in the file as was the application form that had been completed for the post. Two files had two references but the third had none. The manager said references had been received but they were unable to provide them on the day. DS0000024456.V293958.R01.S.doc Version 5.1 Page 18 None of the files seen contained an up to date photograph of the member of staff for identification purposes. The files are kept securely in the manager’s office under lock and key and the manager and deputy are the only people with access to them. The manager said that the work experience placement person had also had all the required checks done prior to commencing in the service. They were unable to show the file on the day but said they would forward copies of the evidence to CSCI. A new member of staff was spoken with and confirmed they had had an induction into the service that covered health and safety, fire awareness, moving and handling and infection control. Other members of staff also talked about updated training in essential areas. Some staff have attended workshops at Bradford University for working with people with dementia and the home has a comprehensive training and reference folder as a resource for staff working in the special needs unit. DS0000024456.V293958.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. People who use this service can expect that it is managed by a fit person and that their rights are protected however they cannot be assured that their health and safety is promoted. EVIDENCE: The manager is a trained nurse who worked many years in the NHS. On leaving the NHS they took the post of Nurse Manager at North Court and held that successfully for seven years before undergoing a fit person’s interview to be manager. They were appointed to the post in 2003 and have since completed the Registered Managers training. As noted in the previous report the policy of Four Seasons is to ‘pool’ residents’ money in the same bank account. Individual transactions are traceable but interest is not paid on the account so residents’ money is not working for them while in the account. DS0000024456.V293958.R01.S.doc Version 5.1 Page 20 During the tour of the home two cupboards were noted to be unlocked and both contained cleaning agents that are covered by control of substances hazardous to health regulations (COSHH). One domestic was seen to be looking for their trolley, which they had left unattended in an empty resident’s room. Some residents’ bedroom fire doors were wedged open. This practice was noted during the previous inspection and was subject to requirement. The manager was asked if self-closures were due to be fitted on the doors during the imminent refurbishment. The manager had some discussion with the estates person for Four Seasons and said it did not seem to be planned. Staff were aware, the manager said, that if a fire alarm went off they should remove all wedges before leaving for the assembly point. One member of staff who was asked about fire procedures did not mention anything about removing wedges as standard procedure. In one lounge downstairs a fire door was identified with the correct notice but lead into a conservatory area used as a nurses’ station. The exit door to outside from the conservatory was not labelled as a fire exit and was locked. The code pad to unlock the door was obscured by a blind on the adjacent window. The manager said this area will be part of the refurbishment and the exit doors will be changed. DS0000024456.V293958.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 DS0000024456.V293958.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? YES. 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. 2. Standard OP9 OP9 Regulation 13 (2) 13 (2) Requirement All residents’ MAR sheets must have identification photographs with them. All Mar sheet signature boxes must be signed when a medication has been administered or completed with an appropriate, defined code. Where a medication has a choice of dose i.e. one or two tablets, the number administered must be recorded each time. If administration of medication is varied from the prescription for any reason the prescription must be updated to reflect the new routine. Checks must be made to ensure that only Schedule 2 medication is recorded in the CD register. Procedures must be put in place to ensure that prescribed medication is administered and the MAR sheets reflect any left in blister packs. Food that has been prepared and is stored in the kitchen area must be labelled for identification and dated. DS0000024456.V293958.R01.S.doc Timescale for action 31/05/06 04/05/06 3. OP9 13 (2) 04/05/06 4. OP9 13 (2) 04/05/06 5. 6. OP9 OP9 13 (2) 13 (2) 04/05/06 04/05/06 7. OP15 16 (2)(i) 13 (4)(c) 04/05/06 Version 5.1 Page 23 8. OP15 16 (2)(i) 13 (4)(c) 9. OP18 13 (6) 10. 11. OP19 OP21 23 (2)(b)(o) 23 (2)(j)(l) 12. 13. OP22 OP29 16 (2)(c) 19 (1)(b)(i) 14. OP38 12 (1)(a) 13 (4)(c) 15. 16. OP38 OP38 12 (1)(a) 13 (4)(c) 13 (4)(a) Plated meals that are transported around the home must be properly covered with rigid plate covers for maintaining temperature and hygiene. An up to date folder of Suffolk guidelines compiled by the Vulnerable Adult Protection Committee must be obtained. The grounds of the home must be maintained so the residents can enjoy spending time outside. Bathrooms must be accessible and not used for storage of equipment. If they are not required and the home has sufficient bathrooms for residents’ needs then they must be decommissioned but until that happens water checks must continue. Action must be taken when equipment malfunctions to replace it immediately. Evidence of recruitment checks made must be kept in staff files and available for inspection by CSCI inspectors. This is a repeat requirement. Door wedges must not be used to prop open fire doors. Fire doors that are required to be left open must be fitted with a self closure mechanism. This is a repeat requirement. Fire exit routes must be clearly indicated and fire doors must have panic bar mechanisms. COSHH regulations must be complied with at all times. 04/05/06 30/06/06 30/06/06 30/06/06 04/05/06 04/05/06 31/05/06 30/06/06 04/05/06 DS0000024456.V293958.R01.S.doc Version 5.1 Page 24 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 DS0000024456.V293958.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 DS0000024456.V293958.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!