CARE HOMES FOR OLDER PEOPLE
Old Well House Frognal House Frognal Avenue Sidcup Kent DA14 6LS Lead Inspector
Maria Kinson Unannounced Inspection 10th January 2007 10:00 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 Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Old Well House Address Frognal House Frognal Avenue Sidcup Kent DA14 6LS 020 8302 1600 020 8300 8204 frognal.ed@sunriseseniorliving.com 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) Sunrise Operations (UK) Limited Vacant Care Home 44 Category(ies) of Dementia (44) registration, with number of places Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 17Th February 2006 Brief Description of the Service: Old Well House is owned and managed by Sunrise Operations UK Ltd, an American based company with extensive experience of operating assisted living schemes in the USA. The home (Old Well House) is one of three buildings that are located on the same site in Sidcup. All of the buildings provide housing for older people and offer different levels of support. Old Well House is the only building on the site that is registered as a care home. The home is registered to provide personal care for forty-four older people with dementia. The home is divided into two units. Each unit has an assisted bathroom, toilet, a kitchen and a laundry room. All of the bedrooms are single occupancy and have en suite facilities. Some of the bedrooms are called companion suites as they include a shared area where residents can spend time together or prepare light snacks and drinks. The bedrooms are arranged around a central open plan lounge and dining area. The main kitchen and laundry are located in Frognal House. There is an enclosed secure garden on the ground floor and a roof garden on the first floor unit. The home is located within easy reach of the A20 and a local bus serves Queen Marys hospital, which is within walking distance of the home. There are car parking facilities within the grounds. The fees charged by the home range from £120.60 to £189.25 per day. This does not include additional charges such as the community fee (a one off payment on admission to the home), chiropody and hairdressing. This information was supplied to the commission on 02.02.07. Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over two days and was unannounced. All of the communal areas and three bedrooms were inspected. The inspector spoke with some of the people living and working in the home and three visiting health and social care professionals. Staff were observed administering medication, assisting people to eat at mealtimes, undertaking activities and supporting people to walk or change their position. Care, medication, money, health and safety and staff recruitment and training records were examined. Written feedback about the service was obtained from seven relatives and one health care professional. There were forty- three people living in the home at the time of this inspection. What the service does well:
Before people moved into the home staff spent time finding out about their individual needs, preferences and preferred routines. Relatives and other health care professionals were asked to provide information about the resident’s life and medical history. This information helped staff to understand what was important to the resident and what level of support they required. Care staff were supported by the wellness team and worked in partnership with other professionals to promote resident’s health and wellbeing. Staff supported people living in the home to undertake a wide variety of activities and visit local places of interest in the community. There were planned activities each day and regular exercise such as walks and dancing to maintain mobility and promote good health. Relatives were satisfied with the overall care provided in the home and one relative said, “activities and entertainment are outstanding”. Visiting hours were flexible and relatives and friends were invited to participate in their family members care, attend social events and comment about the service. The home was warm, clean, comfortable and well maintained. Bedrooms were furnished and organised in a similar manner to the resident’s own home and residents were able to follow their usual routine where possible. For some residents this meant staying up late and having a late breakfast for others it meant being able to potter around the home and garden or spending most of their time in their room. Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 6 Relatives said that staff kept them informed about significant issues and had a good understanding of their family members needs. Staff were polite and friendly and took action to maintain residents privacy and dignity. The staff team was stable and there was little use of temporary staff. This provided good continuity of care for residents. Staff had access to relevant training and were encouraged to attain recognised qualifications. There were systems in place to protect resident’s money and valuables. What has improved since the last inspection? What they could do better: Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 7 The information provided about the home was satisfactory overall but the ‘Service User Guide’ did not include information about the terms and conditions of occupancy. Care plans were person centred and easy to follow. Information for staff about managing challenging behaviour was not always provided. This resulted in staff adopting different approaches. The management of medication had improved but some further work was required to make it easier for staff to account for all medicines. Staff should record medication that is carried forward from the previous months supply on the medication administration record. Staffing levels were satisfactory overall but staff rotas did not take into account the need for increased staffing levels during trips and outings. Staff said they could speak to senior staff at any time and were able to raise concerns at handover or during meetings. However a number of staff had not received formal supervision and did not have an opportunity to discuss their training and development needs. Health and safety issues were well managed but some staff not received fire safety training since they started working in the home and fire drills did not involve night staff. There was no written evidence that risks to residents from bedrails or falls from windows had been assessed. Staff notified the commission about residents that had died in the home and accidents but had not kept the commission informed about other significant events such as allegations of misconduct or issues that affected the safety and wellbeing of residents. 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. Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 4. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information provided for people using the service was good overall but the Service User Guide did not include a copy of the contract. Specialist dementia training was provided and staff communication had improved. Staff obtained information about what each person considered important and what contributed to their happiness and wellbeing before they moved into the home. EVIDENCE: The Statement of Purpose and Service User Guide was reviewed and updated in February 2006. The Statement of Purpose includes all of the information outlined in the Care Homes Regulations. A requirement was made at the last inspection for information about the terms and conditions of occupancy and a
Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 10 standard form of contract to be included in the Service User Guide. This issue had not been addressed. See requirement 1. People that were interested in moving into the home completed an application form and information about medical issues and medication was requested from their family doctor. A senior member of staff and a Wellness Nurse assessed prospective residents needs. The assessments seen in resident’s files were very informative and very person centred. Additional information about individual interests, likes and dislikes and usual routines was obtained from friends or relatives. A significant number of staff attended Alzheimer Society recognised training in June 2006. Training about other aspects of care such as communication and managing challenging behaviour was also provided. Senior staff took particular care to provide the people living in the home with clear and easy to understand information and communication had improved overall. All of the interactions observed were adequate or good. Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An individual care plan was developed for each person living in the home. All of the plans seen referred to the person’s individual needs and preferences but it was not always clear how staff should approach or manage people with challenging behaviour. Staff worked in partnership with other professionals to meet people’s health care needs. The management of medication had improved but some record keeping issues were identified. The people living in the home said that staff treated them with respect and maintained their privacy and dignity. EVIDENCE: Three sets of care records were examined. Staff had developed an individualised care plan for each of the people living in the home using information obtained during the pre admission assessment or from relatives.
Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 12 Care plans were person centred and made frequent references to maintaining people’s privacy and dignity. Plans were reviewed regularly and were discussed with relatives. There was evidence that staff followed information in care plans about monitoring peoples weight and followed advice provided by the GP. The only issue that was not included in one of the plans seen was about how staff should respond to one of the people living in the home that became aggressive when staff provided personal care. Discussions with staff indicated that a number of different approaches were adopted in response to this behaviour. See requirement 2. The people living in the home were offered regular checks to identify health issues and promote good health. Wellness nurses supported staff with medication issues and assessed people that staff were concerned about or who had an accident. A GP visited the home regularly and other community healthcare professionals such as district nurses and a psychiatrist provided support. Feedback about the service was obtained from four health and social care professionals. Visiting professionals said that staff always respected and maintained people’s privacy and dignity and usually sought advice to manage and improve health care needs. Staff had carried out a number of assessments to identify risks to the people using the service and had planned strategies to avoid risks where possible. The assessments seen indicated if people were at risk of falling, had difficulty using the minibus or would be at risk outside of the home in the community. The management of medication had improved. Action had been taken to ensure medicines that were subject to special storage arrangements were stored appropriately and that lotions and creams were stored away from oral medication. Records of receipt and administration had improved. Staff recorded how many tablets they administered when a variable dose i.e. one to two tablets were prescribed and had entered a code when an individual refused or could not take their medication. It was difficult to complete a full audit trail as records of medication left over from the previous month were recorded but were not kept with the medication chart. See recommendation 1. Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provided a varied programme of activities and entertainment to stimulate interest and increase mobility and independence. Visiting times were flexible and relatives were encouraged to become involved in the home. Staff encouraged residents to exercise personal choice and retain control over their lives, where possible. The quality and choice of food provided in the home was good. The arrangements for serving meals and assisting people to eat had improved. EVIDENCE: A weekly programme of activities was arranged and displayed at the entrance to each unit. The programme provided a variety of meaningful activities that stimulated the mind, body and senses and met individual social needs and interests. The programme for the week of the inspection included group activities such as cooking, games, reminiscence, trips in the minibus to local places of interest, one to one sessions to meet individual needs and regular social events and entertainment. On the day of the inspection some people
Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 14 went on a trip in the minibus, others were playing cards and reading newspapers and there was an old film and tea dance in the lounge after lunch. Relatives were able to visit at anytime and said they were made to feel welcome by staff. Some relatives visited at mealtimes to assist their family member to eat, another provided support for staff as their family member became distressed when having any form of personal care and others joined their relatives at social events. Feedback from relatives was very positive and a number of relatives provided additional comments about their experiences and the care their family member received. Relatives said that the home provided “a first class service “staff are always respectful of my mothers wishes and are very caring”,” my relative is very happy as her needs are fulfilled”, “care is sensitive and flexible as required by each resident”. The people living in the home were able to walk around the unit unrestricted and there were plenty of things for the person to touch and handle as they walked about such as a dressing table and accessories, carpentry bench and tools and knitting basket with wool and needles. The commission had received information since the last inspection that suggested that mealtimes were noisy and the people living in the home did not have access to snacks. These issues were assessed during this inspection. Lunch was observed on the ground and first floor unit. Tables were properly laid with napkins, condiments and drinks. People were assisted to the dining room and a small number chose to eat in their room or in a comfortable chair in the lounge. Meals were served from a heated trolley. Some people were asked what they would like to eat and others were able to point out their preferred choice of food from two plated meals. Staff provided prompt assistance with feeding and encouragement and there was little noise apart from some background music. People were able to eat at their own pace and were not asked to leave their table until they were ready. People spoken with said they enjoyed their meal and one relative commented, “facilities, catering and care and support are excellent”. Each unit had a satellite kitchen where staff or the people living in the home could prepare snacks and drinks. There was a good supply of different snacks such as yogurts, fresh fruit, cereal, bread, preserves and peanut butter available for people to eat if they felt hungry between meals and staff said that other food could be requested from the main kitchen throughout the day. The menus seen indicated that the people living in the home received a wide variety and choice of nutritious food. Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints and concerns were recorded and investigated promptly. EVIDENCE: Most relatives said they knew how to make a complaint and those that had raised concerns in the past said they were usually responded to appropriately. The service had received four complaints about food, laundry and a care issue. All of the complaints were investigated and responded to promptly and action was taken to avoid a reoccurrence. The commission received an anonymous complaint about the overall management of the site in July 2006. The registered provider, Bexley Social Services and the commission jointly investigated the allegation. No evidence was found to support the allegation but it was discovered during the course of the investigation that the home had not notified the commission about some significant events. See standard 37. Two concerns identified by staff and relatives were investigated and addressed under the company’s disciplinary procedure. Some of the staff files seen during the inspection provided evidence of this. Both issues were referred to the relevant Social Service Department but there was a delay in reporting one concern. This issue was discussed with the previous and current manager of
Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 16 the service. Care staff had a good understanding of adult protection procedures and had access to relevant training. Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This home provides a safe and comfortable environment for residents with dementia. Residents were encouraged to view the home as their own. EVIDENCE: The building was well-decorated and maintained and new comfortable sofas and chairs had been purchased for the lounges. A good standard of cleanliness was maintained throughout and hand-washing facilities were provided in toilets, bathrooms and laundry rooms. Clinical waste was stored appropriately and staff had access to protective clothing. All of the bedrooms were spacious and comfortable. Some relatives had arranged for the residents own furniture and belongings to be bought into the
Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 18 home to lessen their anxiety and make their personal space feel more like their own home. Outside each bedroom door there was a memory box, fixed securely to the wall, with a small selection of photographs, cards and ornaments that were of significance to that person. This is a good orientation tool for the residents themselves, and reminds staff and visitors alike that residents are people who have led full and varied lives. An environmental health inspector visited the home in March 2006. Verbal advice was provided but the report indicated that staff had a good knowledge of food safety and personal hygiene issues. Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels were satisfactory overall but there were periods when staff were not able to meet residents immediate needs. Access to training was good and some changes had been made to the programme to help staff have a better understanding of the needs of people with dementia. The home carried out adequate checks when appointing new staff and work was in progress to introduce further safeguards. EVIDENCE: There were four staff on duty on each floor and an additional staff member was provided during the busy periods to assist residents to get up and have breakfast and to have supper and get ready for bed of a night. There were two care staff on each floor during the night. The manager and deputy manager worked some weekends and there was always a senior member of the management team on call. Staffing levels were satisfactory overall, except for one period when a number of staff left the home to accompany residents on an outing. During this time one member of staff on the ground floor unit attempted to answer call bells,
Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 20 assist the chiropodist and support residents with activities. See requirement 2. Fourteen staff had left since the last inspection but most of these posts were now filled and the use of agency staff was low. The duty roster indicated that residents received good continuity of care. 40 of care staff had attained a vocational qualification in care at level two or above. The home continues to work towards meeting the standard set by the Department of Health for 50 of care staff to attain a vocational qualification in care. Three staff recruitment files were examined. Adequate documentation and checks were obtained and carried out prior to allowing new staff to commence work in the home. Some references were not on headed paper and had not been verified. The company had recently revised the reference request form to address this issue. The company provided a regular programme of induction, mandatory health and safety and training updates for staff. All of the files seen included evidence of induction training. The induction training programme had recently been renamed to ‘your first 30 days’ and had been updated to include more sessions about caring for and communicating with people with dementia. An individual training record was completed for each member of staff. Since the last inspection some staff had attended manual handling, documentation, ageing process, continence, pressure area care, personal hygiene and eye care, activities, protection of vulnerable adults, dementia, conflict management, diabetes, team building, medication, leadership, food hygiene and first aid, training sessions. Staff were satisfied with the arrangements for training. Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team worked in partnership with relatives and other professionals to improve resident’s quality of life and wellbeing. Good systems were in place to monitor health and safety issues and improve the quality of care provided in the home. Staff did not always advise the commission about some significant events that occurred in the home. This is required to protect resident’s interests. EVIDENCE: Since the last inspection the manager had resigned and a new manager had been appointed. The new manager had worked in the service for many years
Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 22 and knew most of the staff, residents and relatives. The manager has a vocational qualification in care at level 3 and is currently undertaking a diploma in health and social care and the registered managers award. The manager was supported by a new deputy manager and senior carers. The manager had started to obtain some of the documents and information that was required by the commission for registration. Staff said that senior staff and the new manager and deputy manager were approachable and helpful. The home had various systems in place for assessing and improving the quality of care provided in the home. Unannounced visits were taking place regularly and the manager of the service received a written report about the findings. Regular medication audits were carried out and issues of concern were discussed with the relevant staff member. Regular meetings were taking place with relatives to discuss their family members care and as a group to discuss general issues. An independent Gallup survey was carried out once a year to obtain feedback about the service from staff and relatives. The results from the survey and any action planned to address concerns was fed back to relatives at a meeting. The administrator was responsible for maintaining adequate records and keeping residents money and valuables safe. Records were maintained for money received in the home or removed from the resident’s account. A number of different types of forms were in use. The administrator had identified this issue and had designed a new form to ensure that information was consistent. Receipts were kept for purchases made on the resident’s behalf or money that was used to pay for services such as hairdressing and chiropody. A record was also maintained about valuable items stored for residents. Staff were satisfied with the support they received from senior staff but it was evident that some members of staff were not receiving regular supervision. The supervision matrix showed that some staff had attended one or two sessions during the last six months. See requirement 3. During a complaint investigation at the home it was discovered that the previous manager had not notified the commission about some significant events that had occurred in the home such as allegations of misconduct and issues that may have affected the wellbeing or safety of residents. This issue was discussed with the new manager. See requirement 4. A random check of fire and health and safety records and inspections was undertaken. All of the records seen were satisfactory but fire drills did not involve staff that worked night duty and some staff had not received a fire safety training update for some time. See recommendation 2.
Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 23 The maintenance manager said that window restrictors and bedrails were checked regularly but records of these checks were not recorded. A risk assessment must be completed and strategies to reduce risks to residents should be implemented if required. See requirement 5. Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 4 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 4 X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 2 2 Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 25 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. Standard OP1 Regulation 5 Requirement The Registered Person must ensure that the Service User Guide includes terms and conditions of occupancy and a standard form of contract. Restated requirement, as the previous timescale of 01.05.06 was not met. The Registered Person must ensure that adequate staff are provided at all times to meet residents needs. The Registered Person must ensure that all staff receive regular supervision. The Registered Person must ensure that the commission is notified about all of the significant events listed under regulation 37 that occur in the home. The Registered Person must carry out a risk assessment regarding the use of bedrails and the risk of falls from windows. Timescale for action 26/06/07 2. OP27 18 29/05/07 3. 4. OP36 18 37 26/06/07 29/05/07 OP37 5. OP38 13 29/05/07 Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP38 Good Practice Recommendations The Registered Person should ensure that the balance of medicines carried forward each month is recorded on the administration record. The Registered Person should ensure that fire drills include night staff and that all staff receive regular fire safety training updates. Old Well House DS0000006787.V318722.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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
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