Inspection on 26/01/07 for Ocean Swell

This inspection was carried out on 26th January 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

Ocean Swell 31/03/08

Ocean Swell 11/10/05

Ocean Swell 27/06/05

Ocean Swell 17/03/05

Ocean Swell 24/06/04

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 HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Ocean Swell Ocean Swell 33 Sea Road Westgate-on-sea Kent CT8 8SB Lead Inspector Clair Brown Key Unannounced Inspection 26th January 2007 11:45 X10029.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 Ocean Swell DS0000023511.V329537.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 and Care Homes for Adults 18 – 65*. 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. Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ocean Swell Address Ocean Swell 33 Sea Road Westgate-on-sea Kent CT8 8SB 01843 832362 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) Mr Martin Stephen Rose Mrs Denise Elaine Mary Rose Mrs Denise Elaine Mary Rose Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (17), Physical disability (15) of places Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The total number of residents shall not exceed 32. Residents who are physically disabled must be over 35 years of age. To admit one (1) Service User, whose date of birth is 14/05/1920. Date of last inspection 11th October 2005 Brief Description of the Service: Ocean Swell provides residential care for up to 17 older people and 15 people with physical disabilities, who require varying degrees of assistance. The home comprises of a large detached premises with coastal views and is located within short distances of the seafront, local shops, post office, library and public transport links. The home is a family run business, with the owners having a high level of input into the day-to-day running of the home. A team of care staff and domestic staff are employed, this includes two waking night staff. Accommodation briefly comprises of a large lounge, dining room with open smoking room, off road parking and an enclosed garden. Bedrooms are located on the ground, first and second floors with lift access to all floors. Fees are: £303.29 - £429.12 per week. Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection consisted of an unannounced key inspection visit to the home on 26th & 29th January 2007 by one inspector, duration approximately 8 ½ hours. The inspection takes account of information received from a variety of sources including written information from the registered provider and registered manager, service users and staff. All key standards were inspected. The inspector spent time observing interaction between staff & service users and talking with the staff. A tour of the premises was conducted. Documents and records were seen and service users files were case tracked. What the service does well: What has improved since the last inspection? What they could do better: The home needs to gain sufficient information about prospective service needs to make sure they only admit people they are registered to care for. The service users care plans would enhance the quality of users care if they contained more information and details about the service users needs. The written procedures for handling service users medication needs to be reviewed to cover all of the practices the home is undertaking, such as supporting service users to self administer their own medication. Staffs’ awareness of maintaining service users dignity needs to improve. The activities for the younger service users would benefit from being expanded to include more age appropriate activities and for them to be supported to have an annual holiday. Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 6 Some hot surfaces such as radiators need to be covered and the hot water needs to be checked regularly to prevent possible scalding. The procedure for infection control and the disposal of clinical waste needs to be improved to bring them inline with current practices. The home allows service users and staff to smoke, the registered persons have planned some changes for when the law changes later in the year but needs to look into this further. The procedures used to employ new staff need to be improved to include them having their POVA & CRB check before they start work. An immediate requirement was made relating to this at the inspection visit. The quality assurance work needs to be expanded and a report produced. The use of communal records needs to stop so no-ones private information is in shared records. The procedures for handling and recording service users monies needs to improve, with signatures, receipts and deficits being accounted for and if necessary reimbursed. 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. Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 346 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments are conducted. However insufficient information is gathered to enable the manager to make an informed decision and admit within the homes registration categories. The home does not provide intermediate care therefore standard 6 OP is not applicable. EVIDENCE: A service users file was viewed to assess the pre-admission process and assessment. An assessment had been undertaken by the registered manager prior to the service user being admitted. Information had been obtained relating to the service users needs but the record was brief and was not Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 9 recorded in any detail. There was no evidence of the registered manager making further enquiries into the fact the service user has a “little confusion”. The home is not registered to provide dementia care. The homes current registration is for 17 older persons and 15 with learning disabilities above the age of 35 years. The pre inspection questionnaire records that during September 2006 the home exceeded 17 older persons. The registered manager stated that she believed that there was flexibility within these numbers for each category. Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. 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. The care planning system is a good foundation but does not provide staff with sufficient information to satisfactorily meet the service users needs. The home works closely with healthcare professionals to access medical services. Service users privacy & dignity is not maintained. Medication policy & procedure does not provide staff with clear instructions & guidance. Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 11 EVIDENCE: Two service users files were case-tracked. One service user had been recently admitted and was funding this themselves. Care managers have just conducted an assessment and have now agreed to fund their placement, the home has not been provided with a copy of the assessment. The files identified the majority of the service users needs, with some instructions on how to meet them, some were well written and prescriptive about their care. This includes for one service user the management of their diabetes and provided staff with instructions on the appropriate action to take when blood sugars were above or below specified levels. Other needs were identified through assessments such as skin integrity and one of those who was at risk did have this included in their care plan, the other one didn’t. The care plan stated to monitor the persons skin condition, but the daily records showed no evidence of this being done. The daily records varied in the quality of information being recorded about the care being provided. Some provided a picture of the service users daily routine but few referred to the care needs identified in the care plan. Staff recorded a lot of the information in a communal record book. There are no nutritional assessments being conducted. There are detailed records kept in each service users file about their appointments with doctors, hospitals and district nurses. These provided evidence that the home supports service users to gain access to medical services. The details of the circumstances relating to the service user needing to see a doctor etc. are vague and if these appointments result in a change in care, this has not been cross referenced to the care plan. A carer had taken a service user to the toilet (situated on the corridor) and was assisting the service user to get on to the toilet, the door was left wide open whilst the service users clothing was lowered, exposing them. This carer is the same carer referred to under the section “Staffing”. The lunchtime medication round was observed, with the majority of the service users sitting in the dinning room. The general practices were satisfactory, however, there was a tendency to leave medicines with service users to take without observing them. The member of staff did return to check they had taken them and had remained in the dinning room for the majority of the time. The first drug round of the day is at 08.30 hours when breakfast is served, however some service users are prescribed medicines that needs to be taken 1 hour before food. One service user self-administers their medication, which is a good practice within a care home however, there is no policy & procedure Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 12 within the home for this. The homes medication policy & procedures are very brief and does not cover all aspects relating to the handling of medicines. Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The current range of activities provided are limited and does not meet the needs of all of the service users. A nutritionally balanced diet is offered. EVIDENCE: The pre-inspection questionnaire details that the activities provided includes sit & get fit, bingo, quizzes, dominoes/games etc, manicure, entertainers and sing-a-longs. There are outings to the shops, Portland centre, beach and Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 14 cinemas. There is a limited programme of activities provided for the younger service users and one young service user is supported to attend Headway and Shaw Trust rehabilitation classes. Young service users are also entitled to a weeks holiday a year but there were no records of this occurring. The homes does not employ an activities person therefore is reliant on care staff to provide these. The home benefits from a cook who prepares and cooks meals from fresh. On the second day of the visit the main meal was homemade steak & kidney pie, with fresh vegetables. During lunch service users appeared to enjoy their meal. Fresh fruit and vegetables are delivered once a week. Fresh fruit is provided for desserts but any additional fruit has to be purchased by the service user. A cooked breakfast is offered everyday. Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are confident that their opinions and concerns are taken seriously and responded to appropriately. EVIDENCE: All ten of the service users comment cards stated that they aware of how to complain and who to complain to. The Commission has not received any complaints since the last inspection. The Home has an adult protection policy and procedure. Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) 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 adequate. This judgement has been made using available evidence including a visit to this service. The building is well maintained providing a homely environment for service users. Hot surfaces are not guarded. Some infection control procedures are inadequate. Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 17 EVIDENCE: The home is a large detached building providing accommodation for up to 32 service users. The home has seven double bedrooms. Some of the double and single bedrooms have en-suite facilities. The service users bedrooms were maintained to a good standard of décor, with the service users being encouraged to personalise them with their own possessions. There is a large lounge at the front of the home. At the back of the home is the dinning room; this includes an open plan smoking area. The extractor fan had broken in the smoking area and had been removed for repair. The home has an odour of cigarette smoke throughout the ground floor of the home. The home benefits from a shaft lift to access all floors. The radiators are not guarded in the bedrooms for older persons or the rooms where the beds are placed next to the radiators. The hot water is only tested in the kitchen. None of the sinks and baths have their hot water temperatures monitored. The home has a selection of hoists and other movement & handling equipment. The lifting belts and easy-slides were seen in the laundry, these were thick in dust, the deputy manager stated that they have not needed to use them for sometime. It was noted that these had been laundered by the second day of the visit. All of the wheelchairs footplates had been removed; staff stated that a service user couldn’t use the regular footplates, however appropriate ones had not been provided. Infection control procedures did not include the use of clinical waste bags and clinical waste bins are not provided. The registered manager stated the home does have a clinical waste contract. but the paperwork did not specify the volume and category of waste the contract was for. The registered provider stated he provides silver bags for the disposal of clinical waste rather than the required yellow sacks. Used catheter bags were seen to be left in a bowl in the sluice. There is no provision of liquid soap and paper towels in areas where personal care is provided. Overall the home was clean and the bedrooms smelt fresh and did not have any offensive odours. Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the 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. At times staffing levels are low and could compromise the quality of care. Staff are attending training courses but the staff are not implementing the knowledge they have gained. The home has a low turnover of staff. Recruitment procedures do not protect the welfare of the service users. EVIDENCE: The duty rotas show that there are 4 care staff on duty between 08.00hrs and 15.00hrs. From 15.00hrs until 18.00hrs there are 3 care staff and between 18.00hrs & 22.00hrs 2 carers on duty. At night there are two waking carers. At the time of the inspection there were 26 service users, 16 older persons and 10 service users with physical disabilities. Some of the older persons also have restricted mobility and need to use hoists and wheelchairs. The registered manager/provider stated that at least 6 service users like to stay up late and Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 19 that she will stay late to assist with putting them to bed. The home employs two cooks and a domestic. The care staff also do all of the homes laundry. The duty rota only shows those staff working and not those on annual leave, maternity, sick or on training. Many of the staff have worked at the home for over 5 years resulting in a stable work force. Staff stated that they enjoy working at the home. All ten of the service user surveys completed stated that they receive the support they need and when they want it. Some service users added comments that included “care & support first class” and “very happy here”. The registered manager/person has not reviewed the home’s staff induction programme to bring it up to date with the current specifications set by “skills for care”. Ten of the fifteen care staff have completed the NVQ level 2 in care with further staff working towards this qualification. A variety of training courses have been attended by staff, recently these have included first aid, fire safety, bereavement and infection control. See the section for “Environment” for examples of staff not putting into practice training. The most recently employed carers’ file was assessed. The carer started work 2 days after applying for the job. The registered manager/person did not apply for a POVA first, POVA or CRB check. The carer provided a CRB that was 14 months old. Written references had not been obtained until after the carer had started work. The member of staff was observed to be working alone, providing personal care. No supervisor had been appointed to work with the carer. (See text for “Health & Personal Care). An immediate requirement was made relating to recruitment. Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 35 37 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The overall management of the home is not proactive. There are limited quality assurance processes implemented within the home. Procedures for the Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 21 handling of service users money do not ensure their finances are protected. Health & safety environmental checks and procedures are satisfactory. EVIDENCE: The registered provider/manager has completed the registered managers award training. The service users financial records showed that some records were kept in communal record books. Others were on spreadsheets, not all entries were signed, only some records included receipts and the totals recorded for two service users, did not correspond with the actual cash being held, both were found to have less money/cash than the balance showed. The home has policies and procedures in place, however these have not been dated or endorsed/signed by the registered provider/manager. The home records confidential information in communal books. These include some of the financial records and a book referred to as the daybook. The daybook contained confidential information about all of the service users; this should be recorded in the service users individual file. The daybook breaches the Data Protection legislation. All of the environmental certificates were in date, showing that the building and equipment is serviced and maintained. The registered provider/manager stated that they have undertaken some quality assurance work by surveying some of the service users and relatives. The information gathered from these surveys has not been collated or acted up and a report has not been produced. Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 2 4 2 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 ENVIRONMENT Standard No Score 19 3 20 2 21 X 22 2 23 2 24 3 25 2 26 1 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 2 33 2 34 X 35 2 36 X 37 2 38 2 Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP3 Regulation 14 15 Requirement The registered persons must obtain further information about prospective service users, following up possible needs that may compromise the homes registration, such as when it is stated a “little confused”. Copies of care managers assessment must be obtained. 2. OP4 12 14 18 The registered person must contact the CSCI central registration team to obtain clarification regarding the homes current registration and to have the conditions updated. The registered persons must review the care plans and ensure that all of the service users needs are identified and updated when service users needs have changed. Daily records of the care provided must be detailed and linked to the care plan. 31/03/07 Timescale for action 31/03/07 3. OP7 12 13 15 30/05/07 Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 24 4. OP8 12 13 14 15 16 17 schedule 3 12,13,14, 16,17,23 sch 3 All service users must have a nutritional assessment completed and this is regularly reviewed. 30/05/07 5. OP9 Medication must be administered 31/03/07 at the prescribed times and in accordance with the manufacturers instructions. Medicines that must be taken one hour before food in the morning must be administered at 07.30hrs. The medication policy and procedure must be rewritten to include all aspects relating to the handling of medicines in a care home. This must include procedures for selfadministration. All staff must ensure that service users dignity is maintained and respected when assisting them to use the toilet by ensuring the door is closed. (YA12) A programme of appropriate activities for the younger service users must be provided. An annual 7-day holiday for those under 65 year must be provided and funded from the fees. 30/05/07 6. OP9 12-14 16,17,23 sch 3 7. OP10 12 16 18 31/03/07 8. OP12 12 14 15 16 23 30/05/07 9. OP25 13 23 The radiators situated in bedrooms used by older persons (65 ) must be guarded. Where beds and chairs are placed in front of or next to radiators must be guarded. Radiators in bedrooms for 30/05/07 Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 25 younger adults must be risk assessed or guarded. Radiators in communal areas used by older persons must be guarded. 10. OP25 13 23 All hot water sources, (sinks and baths) must have their temperatures tested and recorded, to ensure hot water is delivered from the tap at no higher than 43’C. 30/05/07 11. OP26 12,13,16 23 The registered person must 30/05/07 obtain clarification about their responsibilities to staff, smoking & non-smoking service users and visitors due to the pending changes in the law relating to smoking. The registered manager must notify the CSCI of the date the smoke extractor is repaired and installed. 12. OP26 12,13,16 23 Infection control procedures must include the provision of liquid soap and paper towels in all areas where personal care is provided, including service users bedrooms. 30/05/07 13. OP26 12,13,16 23 The registered persons must 30/05/07 obtain clarification about their contract for the disposal of clinical waste and the category of waste their contract covers. The registered person must ensure that the homes clinical waste is disposed of in accordance with current legislation. The registered person must Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 26 inform all of their staff of the procedures to follow for the handling and disposal of clinical waste. The correct clinical waste bags and foot-operated bins must be provided and used. 14. OP26 12,13,16 23 The registered person must provide and ensure staff use the alginate bags for the laundering of soiled linen/clothing. The registered person must review the staffing levels for both the evenings and nights to ensure there are sufficient numbers of care staff available to assist with putting service users to bed and to assist those that need 2 carers during the evening and night. The duty rota must show all of the staff working at the home, the shift they are working, holiday, sick, overtime, agency training and maternity leave. 16. OP29 7,9 12 19 sch 2 Immediate requirement. All staff employed to work in the care home Ocean Swell must have a POVA first, POVA and CRB check completed before they start work. Staff employed with a POVA First check and awaiting the CRB must not work alone and must be appointed a supervisor to work with them at all times. The registered persons must ensure the welfare of the service users by taking action in relation to the carer MH employed on the 21st January 2007. 29/01/07 31/03/07 15. OP27 17,18 sch 4 30/05/07 Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 27 The registered person must adhere to thorough recruitment procedures. 17. OP33 10 12 15 24 The registered person must conduct an annual quality review of the services the home provides, obtaining the views of staff, service users, relatives and other relevant parties. The information gathered must be collated; a report of the findings produced which includes an action plan based on the findings. The procedures for the handling of service users monies must include a two-signature process. Receipts must be kept for purchases made on behalf of the service users. The registered person must audit all of the service users financial accounts; identify all that have deficits in their monies. The registered person must investigate this and take appropriate action to prevent this reoccurring and to reimburse the service users. 19. OP37 15 17 The home must not use communal records. Information about each service users must only be recorded in their individual file. 31/03/07 30/05/07 18. OP35 12 17 20 23 sch 4 31/03/07 Ocean Swell DS0000023511.V329537.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP9 OP12 Good Practice Recommendations It is recommended that a different location be identified for the storage of medications. The home should purchase a recognised medication cupboard that complies with the current specifications. To appoint a designated activities person. Ocean Swell DS0000023511.V329537.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. Ocean Swell DS0000023511.V329537.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!