Inspection on 17/02/06 for Old Well House

This inspection was carried out on 17th February 2006.

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

Other inspections for this house

Old Well House 10/01/07

Old Well House 30/06/05

Old Well House 15/01/05

Old Well House 21/07/04

Old Well House 02/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Old Well House Frognal House Frognal Avenue Sidcup Kent DA14 6LS Lead Inspector Maria Kinson Unannounced Inspection 17th February 2006 09:35 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.V278055.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. Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 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 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 Mrs Elaine Ferris Care Home 44 Category(ies) of Dementia (44) registration, with number of places Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 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 shower facilities. Some of the bedrooms are called ‘companion suites’ as they include a shared area where service users 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 Mary’s hospital, which is within walking distance of the home. There are car parking facilities within the grounds. Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 17.02.06 between 09:35am and 17:35pm. The inspector spent time on both floors of the home assessing care documentation, health and safety and complaint records. Lunch was observed on the first floor of the home and feedback was obtained from residents during this time. The inspector had a brief discussion with one relative and spoke with five members of staff. Seven comment cards were returned to the commission. Since the last statutory inspection two additional visits had been made to the home. On 30.01.06 an unannounced inspection was undertaken to assess compliance with previous requirements. The inspector was accompanied by Ms L Oxford from The Health Protection Agency. A copy of the letter that was sent to the Registered Person following this visit can be obtained upon request. On 09.02.06 a CSCI Pharmacy Inspector carried out an unannounced inspection to assess the management of medication in the home. A summary of the findings from this visit can be found in this report. What the service does well: The home was well maintained, clean and tidy. Resident’s bedrooms were extremely spacious, allowing room for favoured possessions and a significant amount of their own furniture. Staff facilitated a regular programme of activities, entertainment and outings. This provided daily stimulation and variation for residents. The arrangements for keeping relatives informed about residents health and welfare needs were good and regular meetings were arranged to agree and discuss care plans. All of the relatives that completed comment cards about the service were satisfied with the overall standard of care provided in the home. The arrangements for obtaining regular feedback about the service and for commenting about the management of the home were excellent. Staff took action to maintain resident’s privacy and dignity and to promote choice and independence where possible. The home complaints procedure was easy to follow and senior staff viewed concerns and complaints in a constructive manner. Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 6 The food provided in the home was well balanced and nutritious. Meals were presented in an appetising manner and residents were encouraged to choose their preferred meal from a varied menu. All of the residents that the inspector spoke with said they enjoyed the food provided. Staff worked hard to meet resident’s needs when their health declined. End of life care was provided in the home, where possible, with support from other agencies such as district nurses. The home had a good quality assurance system, which included regular reviews and audits and an annual satisfaction survey. Regular fire safety checks and inspections were carried out and a detailed risk assessment had been undertaken. What has improved since the last inspection? Since the last statutory inspection a new manager had been appointed. The Manager has now been in post for seven months. This has provided some stability for residents, relatives and staff. The new Manager was working hard to address staff and care issues. The Statement of Purpose, Service User Guide had been reviewed and updated. Both documents were well presented and informative. The assistance and support provided for residents at mealtimes had improved. The time of the midday meal had moved forward to provide a bigger gap between breakfast and lunch, and arrangements had been made to provide additional staff during the lunch period. The cleanliness of the Laundry rooms had improved. Arrangements were in place to refurbish these areas this will provide more space, improved storage and easier to clean surfaces. Staff awareness of hand washing and infection control matters had improved. Soap and hand towel supplies were provided in appropriate areas. Action had been taken to address maintenance issues such as the missing flaps on the air conditioning units and damaged refrigerator seal. Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 7 What they could do better: 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. Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 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.V278055.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 4. (Standard 6 does not apply to this home). The written information provided for residents and their representatives about the service had improved. Some additional information must be added to the Service User Guide. Some staff required additional training and supervision to ensure that they can meet the needs of people with dementia. Training to address this issue was planned. EVIDENCE: The homes Statement of Purpose and Service User Guide were reviewed and updated in February 2006. Copies of the updated documents were forwarded to the commission. The Statement of Purpose includes all of the information outlined in the Care Homes Regulations. The manager was advised that some additional information must be added to the Service User Guide. See requirement 1. The inspector was told that the requirement to provide specialist dementia training for staff had been arranged through the Alzheimer’s Society. The Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 10 manager said that funding for this training had been agreed. See requirement 2. Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11. Residents looked well cared for but there was insufficient evidence in some care documents to show how personal, health and welfare needs were met. Some aspects of medication were poorly managed. This could compromise resident’s safety. Staff ensured that resident’s privacy and dignity was maintained. Documentation indicated that the home had made provision for end of life care. EVIDENCE: Two sets of care notes were examined. The home had obtained extensive information about resident’s health, social and personal care needs prior to admission. Senior staff and the Wellness Team completed a number of assessments when the resident first moved into the home and on an ongoing basis. This included nutritional assessments, moving and handling assessments, risk assessments relating to falling and risk of developing pressure sores. Recent changes had been made to the care plan format. The changeover from the old to the new format was in progress. The new style care plan provides clearer information for staff and relatives. The new style plan includes specific Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 12 notes and information about the best way to approach the resident, issues for staff to be aware of and a summary of the resident’s background. A number of concerns were identified about the documentation maintained in the home. Some care plans were not reviewed at regular intervals, there was extensive duplication of some records, staff left gaps between some entries in the progress notes and some care plans did not reflect residents current needs. For instance one care plan indicated that the resident could feed himself, had a normal diet and was mobile. This resident was fed at mealtimes with a soft /lump free diet and was chair bound. Staff had initialled the records to indicate that they were providing the care outlined in the plan, even though it was apparent that the plan did not reflect the resident’s needs. Some files were poorly organised and difficult to follow. The manager said that all files would be reorganised. There was a section on the records for the resident or their representative to sign and agree the care plan, but this part of the form was not always completed. Progress notes and care plans did not always provide adequate information. For instance one record indicated that a resident had a “skin tear” and “sore buttocks”. This issue was referred to the wellness team and district nurses but no further reference was made to the sores in the care plan or progress notes for several weeks. Staff must provide evidence that they are monitoring these issues. Feedback from four health care professionals that visit the home was mostly good. All of the professionals that completed a questionnaire were satisfied with the overall standard of care provided in the home. Two respondents expressed concerns about staffing and in particular the availability of senior staff to confer with during visits. The manager should address this issue. A CSCI pharmacy inspector carried out an unannounced inspection in the home on 09.02.06. The findings from this visit are outlined below. The home had comprehensive policies and procedures relating to medicines. The policy for medicines for residents on leave was in development. There was a system to audit staff adherence to medication policies and procedures. The Wellness Team conducted spot checks on the medicine trolley each month. Records of receipt were not always kept for medicines received mid month. When medicines were carried forward from the previous month, the balance carried forward was not recorded. The date of receipt and quantity were not recorded. There were some gaps in administration records where either nonadministration codes had not been used, or where administration had not been recorded. Administration of some creams was not recorded. When variable doses were prescribed, the amount actually administered was not always recorded. One medicine had been signed as given but was still in the Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 13 monitored dosage system. When administration charts were handwritten, they were not checked and initialled by a second member of staff. The home had good facilities for storage of medicines. Each floor had a lockable medicine trolley and a medicine cupboard and refrigerator were on the ground floor. However, the medicine trolleys were not secured to the wall and internal and external medicines were not always completely separated in the trolleys and cupboards. The temperature of the refrigerator was monitored but minimum and maximum temperatures were not recorded. The CD cupboard was secured to a partition wall. No rawl bolts were used. Staff had received training on medicine management from an outside agency and six monthly updates were also provided. A PCT pharmacist conducted regular medicine reviews. See requirements 3, 4 and 5 and recommendation 1. Staff communicated with residents and relatives in a polite and courteous manner. Interaction between staff and residents during mealtimes had improved and some senior staff were excellent role models. Staff indicated that residents could choose to spend their last days in the home if their needs could be met. Several residents had been transferred back to the home for end of life care recently at the relative’s request. The home had received good support and advice from district nursing staff during these periods. One relative expressed satisfaction with the care, attention and support he had received during his family members recent illness. The home had policies and procedures about death and dying. Some files included specific information about resident’s wishes should they become terminally ill or die in the home. Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. A regular programme of activities and entertainment were provided in the home and community. The arrangements for obtaining feedback from relative’s was good. Staff encouraged residents to exercise personal choice and retain control over their lives, where possible. The standard of food provided in the home was good and the arrangements for supporting residents at mealtimes had improved. EVIDENCE: The Registered company employed an Activities and Volunteer Coordinator to work across the whole site. The Coordinator was responsible for ensuring that care staff provided appropriate activities in Old Well House, in line with the company’s policy. A review of activities had recently been undertaken and various changes were planned. This included purchasing and labelling new equipment for each floor of the home, providing training and guidance for staff and developing a new programme of activities. A weekly tea dance and twice weekly exercise class was held in the home and entertainment was provided every two to three months. Other social events and entertainment took place regularly in Chestnut House. Staff or relatives escorted some of the residents to these sessions. The home had a mini bus. Some residents were able to visit local places of interest and attend shopping trips. A monthly church Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 15 service was held in the home and the minibus provides transport to a local church on a Sunday. There were no records about the activities or outings that residents had taken part in. This made it difficult to track individual residents and assess whether their individual social needs were being met. See recommendation 2. Written feedback about the service was obtained from three relatives. All of the relatives were satisfied with the visiting arrangements, said they were kept informed about significant issues and were happy with the overall standard of care provided in the home. The home holds monthly support meetings for residents and their families. This provides an opportunity for relatives to raise concerns and make suggestions about the management of the home. Discussions with one relative indicated that suggestions and concerns made during meetings were considered and addressed. Speakers were invited to some of the meetings and the manager provided feedback about inspections and quality assurance work. Copies of the minutes were sent to relatives that could not attend the meetings. Relatives also received written information about social and charity events. Every six months relatives were invited to attend a meeting to discuss their family members care plan and other issues or concerns. Relatives were able to request more frequent meetings if necessary. The arrangements for obtaining feedback from relatives and encouraging relatives to participate in their family members care were excellent. The inspector observed staff serving lunch on the top floor of the home. The home had recently changed the time of lunch to ensure a longer gap between breakfast and the midday meal and had rearranged staffing rotas to provide more staff during this period. Some staff had received training from dining services staff that worked in other parts of the community. Lunch was served from heated trolleys and residents were able to choose what they ate. Staff provided appropriate support for residents that required assistance or prompting. The starter, main meal and dessert choices looked appetising and all of the residents that the inspector spoke with said they liked the food provided in the home. Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. The home had a comprehensive complaints and adult protection procedure for responding to complaints or allegations of abuse. The records maintained about complaints were variable. This made it difficult to assess if all complaints were managed effectively. EVIDENCE: The home had a comprehensive complaints procedure. The procedure provided information about the timescale for responding to concerns and contact details for the commission. A record of all complaints received in the home was maintained. Three complaints had been received in the home since the last statutory inspection. All of the complaints were addressed in a timely manner. It was not possible to track some of the complaints as some information could not be located or was not recorded. The inspector did track one complaint about resident’s personal property. This complaint was investigated thoroughly and a detailed response and apology was sent to the complainant. A copy of this complaint was sent to all staff to avoid a similar issue occurring again. See requirement 6. The homes adult protection procedure had recently been reviewed and updated. The procedure indicated that allegations of abuse would be referred to Social Services, CSCI and the Police if necessary and staff would be suspended whilst the allegation was investigated. The Manager reported significant issues and accidents to the commission. A significant number of staff had attended abuse awareness training sessions. Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 17 During the past nine months two incidents that had occurred in the home were referred to Bexley Social Services for investigation under their adult protection procedure. These issues did not involve staff. Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23 and 26. Action had been taken to address maintenance issues identified during previous inspections. The standard of cleanliness in the laundry rooms had improved and hand washing facilities were provided in appropriate areas. This home provides a high standard of comfort and personal space for residents. EVIDENCE: A full tour of the home was undertaken during the additional visit on 30/01/06. Three bedrooms, communal areas and laundry rooms were viewed during this inspection. The amount of personal space provided for residents exceeds the National Minimum Standards for Older People. Residents were able to bring a significant amount of their own furniture and belongings into the home making the rooms welcoming and homely in appearance. Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 19 The home was clean, tidy and odour free. All parts of the building, excluding the laundry rooms were maintained to a satisfactory standard. Since the additional visit the laundry rooms had been thoroughly cleaned and tidied. Work to provide more space and easier to clean surfaces in these rooms was planned. A supply of soap and hand towels was provided in the laundry rooms, toilets and most en suite areas. Foot operated clinical waste bins were on order. The manager was researching hand towel dispensers to find a style that was in keeping with the other parts of the home. The Manager had provided staff with a copy of the homes infection control and hand washing guidelines and some staff watched a video about hand hygiene. The missing air conditioning slats had been replaced and the commission was advised that covers would be fitted to the air conditioning units. A new refrigerator was on order. A local environmental health inspector had visited the main kitchen in October 2005. The report from this visit indicated that the kitchen was well organised and that staff demonstrated excellent knowledge of food hygiene and safety issues. Five requirements were made as a result of this inspection. Discussion with the maintenance manager indicated that all of the requirements had been addressed. The kitchen was awarded a bronze clean food award. The maintenance manager had contacted Thames Water to assess the homes compliance with the Water Supply Regulations. See recommendation 3. Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29. Staffing levels were satisfactory. Some shifts patterns had changed to provide increased staffing levels during peak periods, such as mealtimes. The homes recruitment procedure did not provide adequate protection for residents. EVIDENCE: The off duty roster for the week following the inspection was assessed. The roster indicated that there was one senior carer and three care staff on each floor of the home during daytime shifts and two care staff on each floor during the night. The Manager and Deputy Manager were supernumerary. There was an on call system outside office hours for supporting staff and reporting significant issues. Staff recruitment was assessed during the additional visit on 30.01.06. The Registered Person had not obtained adequate documentation prior to allowing staff to commence work in the home. This requirement was not assessed, as the timescale for compliance had not expired. It was evident that some work was in progress to address this issue. See requirement 7 and 8. Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37 and 38. The management of the home was improving but further work must be undertaken to ensure that staff are appropriately supervised and health and safety issues are identified and addressed promptly. There were good systems in place for monitoring the quality of care provided in the home. EVIDENCE: This home has been subject to frequent changes in management during the past two years. Since the last statutory inspection a new manager had been appointed. The new Manager’s application for registration was assessed and agreed by the commission in December 2005. The Manager advised the inspector that she had completed the Registered Managers Award. A copy of the certificate was requested. The Manager was advised at interview to undertake a care qualification at level four or above. Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 22 The new manager had addressed some longstanding issues since her appointment and was communicating effectively with the commission about significant issues. The manager acknowledged that further work was required to meet some standards. Staff were satisfied with the approach of the new manager and indicated that many of the changes that had been introduced did improve residents quality of life. Staff said the manager was approachable, fair and helpful. The home had a structured quality assurance system that includes internal audits and quality reviews. Managers from other homes and senior staff from within the company undertook these assessments. The home was provided with a copy of the findings from audits and areas for improvement were identified. The Manager was required to prepare an action plan if the overall score was below a certain level. The Manager told the inspector that the homes score had improved in recent months. Charts to support this were displayed in the office. Some of the homes quality review reports were difficult to interpret. See recommendation 4. The Manager had worked hard to ensure that this information was presented in user-friendly format at family support meetings. An independent satisfaction survey was undertaken annually. Unannounced visits to comply with legislation were taking place, but the Manager and the commission had not received copies of some reports. See requirement 10. Discussions with staff and assessment of records indicated that formal supervision was not always taking place regularly. See requirement 9. Fire safety equipment was serviced at regular intervals and good records were maintained about in house fire safety checks. A fire risk assessment had been undertaken. All fire doors and exits were accessible. The fire extinguisher in the first floor office was placed on the floor. Failure to provide adequate storage for heavy equipment could result in injuries to staff or visitors. Some of the homes health and safety records were viewed. All of the records seen excluding the frequency of the mains electricity installation were satisfactory. The inspector was told that the mains electricity installation was last checked in 1999. There was no evidence that bedrails and window restrictors were checked regularly. The inspector was told that the weighing scales were calibrated annually; records relating to these checks could not be located. See requirement 11. One of the residents had a bedrail fitted to one side of her bed. A risk assessment had been carried out and the issue had been discussed with the relatives. Guidance issued by the Medical Devices Agency indicates that if Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 23 bedrails are used they should be used on both sides of the bed. A copy of the guidance was sent to the Manager to consider. Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 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 X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X 4 X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 2 2 2 Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 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 Timescale for action 01/05/06 2. OP4 12 3. OP9 13 4. OP9 13 The Registered Person must ensure that the Service User Guide includes terms and conditions of occupancy and a standard form of contract. The Registered Person must 01/03/06 provide specialist dementia training for staff. This training must include communication skills. This requirement was carried forward from a previous inspection. The requirement was not assessed during this visit, as the timescale had not expired. The Registered Person must 09/06/06 ensure that the controlled drug cupboard is secured to a solid wall with rawl bolts. The Registered Person must 09/06/06 ensure that • Medicine trolleys are secured to the wall • Internal and external medicines are stored separately • The minimum, maximum and current temperature of DS0000006787.V278055.R01.S.doc Version 5.1 Old Well House Page 26 5. OP9 13 6. OP16 22 7. OP29 19 8. OP29 19 the refrigerator is recorded daily The Registered Person must ensure that • Records of receipt are kept for all medicines, including those received mid month. (The record must include the date and the quantity of the medication received) • Administration records are kept for all medicines including creams and ointments • When variable doses are prescribed, the amount actually administered is recorded • Hand written administration charts are checked and initialled by a second member of staff The Registered Person must ensure that the complaints file includes details of the action that was taken to address concerns or complaints. The Registered Person must not employ a person to work at the care home unless he/she has obtained a satisfactory written explanation of any gaps in employment. This requirement was carried forward from a previous inspection. The requirement was not assessed during this visit, as the timescale had not expired. The previous timescale of 01/01/06 was not met. The Registered Person must not employ a person to work at the care home unless she has obtained two written references and written verification of why the applicant left their previous job, if it involved working with DS0000006787.V278055.R01.S.doc 09/06/06 03/04/06 05/03/06 05/03/06 Old Well House Version 5.1 Page 27 9. 10. OP36 OP37 18 26 11. OP38 13 vulnerable adults. This requirement has been carried forward from a previous inspection. The requirement was not assessed during this visit, as the timescale had not expired. The Registered Person must 01/05/06 ensure that staff receive formal supervision. The Registered Person must 01/05/06 ensure that regulation 26 visits are undertaken at monthly intervals and that copies of the reports compiled as a result of these visits are supplied to the commission and the Registered Manager. 17/04/06 The Registered Person must ensure that: • The fixed electrical installation is inspected by a competent person (The commission must be notified of the timescale for completion of this work by 17/04/06) • Heavy equipment such as fire extinguishers are stored appropriately • Window restrictors and bedrails are inspected at regular intervals RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The Registered Person should ensure that the balance of medicines carried forward each month is recorded on the DS0000006787.V278055.R01.S.doc Version 5.1 Page 28 Old Well House 2. 3. 4. OP12 OP26 OP33 administration record. The Registered Person should ensure that a record is maintained about the activities that residents have taken part in. The Registered Person should provide the commission with evidence of compliance with the Water Supply Regulations 1999· The Registered Person should ensure that quality assurance information is presented in a user- friendly format for residents, their representatives and staff. Old Well House DS0000006787.V278055.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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