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Inspection on 30/06/05 for Old Well House

Also see our care home review for Old Well House for more information

This inspection was carried out on 30th June 2005.

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.

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

What the care home does well

This home provides spacious and comfortable personal and communal space for residents. The building and grounds were maintained to a high standard and most areas were clean and free from unpleasant odours. Family members were encouraged to play an active part in their relatives care and to advocate on their relatives behalf. Family support meetings were held regularly and relatives were invited to attend charity and social events. Relatives said that they were listened to during family support meetings and their comments were taken seriously. The choice and quality of food provided was good. Three nutritious cooked meals were provided each day and additional snacks were provided between meals. Good information about resident`s social and family background, preferred routine and likes and dislikes was obtained from relatives, and other health care professionals. Some staff members demonstrated excellent communication skills and a good understanding of the needs of people with dementia. Access to induction, vocational and ongoing training for staff was good. There were good systems in place for safeguarding resident`s money and valuables. The home holds regular recruitment days to recruit new staff. The number of staff vacancies at the time of this inspection was low and temporary staff were used infrequently. This provides good continuity of care for residents.

What has improved since the last inspection?

Work to improve the physical appearance of the home had taken place or was in progress. This included a new path and lawn in the garden, new kitchen units and worktops on both floors and work to ensure a constant supply of hot water to all parts of the home. The manager had developed a standard letter that was sent to prospective residents after the assessment to confirm that the home could meet their needs. Some aspects of record keeping particularly care plans had improved significantly. Plans included specific information about resident`s individual needs and preferences and were reviewed regularly. A new system for documenting items of value that were stored on residents behalf had been introduced. The new system provides additional security for residents, some of who have difficulty recognising their personal belongings. The new manager had established good working relationships with residents, relatives and staff. Relatives said the manager was encouraging staff to "open their eyes" and were pleased that issues such as poor staff performance and sickness were being addressed. Work was in progress to introduce a Care Manager (key worker) role for all residents and a formal system for supervising staff had been implemented. The homes recruitment procedure was mostly good. Thorough checks were carried out on all applicants prior to commencing work in the home.

What the care home could do better:

Compliance with some requirements, many of which were easy to address was poor. The frequent change of management staff has led to poor communication and a lack of direction in addressing issues identified in inspection reports. The home did not provide adequate written information for residents. Some staff had a poor understanding about the needs of people with dementia, did not communicate effectively with residents and appeared to lack motivation. Staff did not always provide prompt assistance at mealtimes.The home was mostly clean but some basic hygiene and infection control issues were identified. The management of medicines was variable. Records of administration and disposal were mostly good but a number of errors were noted on medication administration charts. The home had a comprehensive complaints procedure but the procedure did not include the full contact details for the commission. Complaints were managed appropriately but some complaints about missing items were not recorded. Significant improvements had been made to the care planning system but some care plans did not reflect resident`s current needs. Recruitment was mostly good but the manager must ensure that all gaps in employment are explored and recorded.

CARE HOMES FOR OLDER PEOPLE Old Well House Frognal House Frognal Avenue Sidcup, Kent DA14 6LS Lead Inspector Maria Kinson Unannounced 30 June 2005 09:15 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 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 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 G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 15.01.05 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 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 G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on 30.06.05 between 09.15am and 17.15pm and on 04.07.05 between 10.35am and 15.40pm. The inspector undertook a partial tour of the home including the laundry rooms, bathrooms, two bedrooms and communal areas. Care, recruitment and medication records were examined. During the course of the inspection the inspector spoke with seven residents, six visitors and five members of staff. Written feedback was received from one relative and one health care professional. What the service does well: This home provides spacious and comfortable personal and communal space for residents. The building and grounds were maintained to a high standard and most areas were clean and free from unpleasant odours. Family members were encouraged to play an active part in their relatives care and to advocate on their relatives behalf. Family support meetings were held regularly and relatives were invited to attend charity and social events. Relatives said that they were listened to during family support meetings and their comments were taken seriously. The choice and quality of food provided was good. Three nutritious cooked meals were provided each day and additional snacks were provided between meals. Good information about resident’s social and family background, preferred routine and likes and dislikes was obtained from relatives, and other health care professionals. Some staff members demonstrated excellent communication skills and a good understanding of the needs of people with dementia. Access to induction, vocational and ongoing training for staff was good. There were good systems in place for safeguarding resident’s money and valuables. The home holds regular recruitment days to recruit new staff. The number of staff vacancies at the time of this inspection was low and temporary staff were used infrequently. This provides good continuity of care for residents. Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Compliance with some requirements, many of which were easy to address was poor. The frequent change of management staff has led to poor communication and a lack of direction in addressing issues identified in inspection reports. The home did not provide adequate written information for residents. Some staff had a poor understanding about the needs of people with dementia, did not communicate effectively with residents and appeared to lack motivation. Staff did not always provide prompt assistance at mealtimes. Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 7 The home was mostly clean but some basic hygiene and infection control issues were identified. The management of medicines was variable. Records of administration and disposal were mostly good but a number of errors were noted on medication administration charts. The home had a comprehensive complaints procedure but the procedure did not include the full contact details for the commission. Complaints were managed appropriately but some complaints about missing items were not recorded. Significant improvements had been made to the care planning system but some care plans did not reflect resident’s current needs. Recruitment was mostly good but the manager must ensure that all gaps in employment are explored and recorded. 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 G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 4. (standard 6 does not apply to this home) The Registered Person did not provide adequate information about the service for prospective residents. Staff had sufficient information to meet resident’s health and welfare needs on admission to the home. Some staff members require additional training and supervision to ensure that they can meet the needs of people with dementia. EVIDENCE: The previous requirement to update the Statement of Purpose and Service Users Guide to include all of the information listed in the Care Homes Regulations and National Minimum Standards had not been addressed. The manager advised the inspector that the Regional Resident Care Services Manager was assessing the Statement of Purpose and the Service User Guide would be completed within the next two weeks. Copies of the revised documents must be forwarded to the commission. See requirement 1 and recommendation 1 and 2. Part of the registration certificate was displayed. The part displayed was out of date. The most recent certificate was delivered to the home by recorded Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 10 delivery on 20.10.05. Following this inspection the registered person wrote to the commission to confirm that the up to date certificate could not be located. A replacement certificate was issued. The Manager and a Wellness Nurse assess resident’s needs prior to admission. The person undertaking the assessment uses a resident assessment form to record information about the prospective resident. Residents were not admitted to the home until staff had received a report from the residents General Practitioner. Relatives were asked to provide additional information about the resident’s family background, usual routines and interests. The manager wrote to prospective residents after the assessment to confirm that the home was able to meet resident’s needs. This home is registered to care for people with dementia. The manager and staff had attended in house training sessions about dementia. Some staff had little knowledge about the different types and features of dementia. Communication between staff and residents with dementia was variable, some staff communicated effectively whilst others interacted infrequently even when they were providing one to one care such as assisting a resident to eat. One staff member was seen escorting a resident to the dining area, the resident did not want to go to the dining area but the staff member persisted. A senior staff member intervened and was able to reassure the resident. Some staff did not appear to know very much about individual residents despite the wealth of information that had been collected during the assessment. The inspector observed some signs of well- being such as social interaction amongst residents. See requirement 2. Feedback from relatives was mixed. Some relatives were very pleased with the care provided and said, “senior staff were good”, or “excellent and the manager was “approachable and helpful”. Other relatives expressed concerns about the valuable items that had gone missing from the home, about staff that were “miserable” and about frequent changes of staff and management. Relatives said that some staff spoke amongst themselves and did not supervise or provide adequate assistance for residents. Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 9. Staff did not always have access to current information to enable them meet resident’s needs. Access to community health care services was good. Staff did not always follow procedures for the safe administration of medication. This practice could compromise resident’s health and safety. EVIDENCE: Two sets of care records were examined. Overall the standard of documentation had improved but further work must be undertaken to meet the required standard. Staff undertook a thorough assessment of resident’s health, personal and social care needs. Staff used all of this information to develop an individual care plan for each resident. Issues that were recognised as a potential risk for older people such as the development of pressure sores and difficulty moving were assessed separately. One of the plans seen did not reflect the resident’s current needs. The resident had fallen six times during the previous two weeks and had returned from hospital with a pressure sore. The care plan did not address either of these issues but the resident had been referred to the District Nursing Team. The other plan included detailed Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 12 information about the specific action that staff should take to meet the resident’s needs. Care plans were reviewed regularly. Work was in progress to provide a Designated Care Manager (key worker) for each resident. This would enable staff to provide more personalised care for residents. Access to community health care services was satisfactory. Feedback from one health care professional that was in regular contact with the home was good. The respondent was satisfied with the overall standard of care provided in the home. Fourteen medication charts were examined, three in detail. Several errors were identified where staff had not signed the chart, had signed the chart but had not administered medication or had not fully completed records of receipt of medication. The manager said she would report the errors to the wellness team. See requirement 3. A senior member of staff was observed administering medication. The staff member followed the homes procedure. The temperature in the first floor medicine room was too warm for the storage of medication. Action was being taken to address this issue. A new medication procedure had been introduced. Staff were not permitted to administer medication until they had attended medication training and completed a medication assessment. Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 and 15. A good selection of food was provided at each meal but residents did not always receive adequate support to eat. Relatives were able to continue to play an active role in their family members life. EVIDENCE: Overall most relatives felt welcomed in the home and said that they were able to visit at any time. Family support meetings were held regularly and social events were usually well attended. Relatives said they were able to raise issues of concern at meetings and felt that their ideas were “acted on”. The minutes of the last meeting indicated that maintenance; activities, food, and staffing issues were discussed. Although some residents found it difficult to provide verbal feedback about the service a number were able to comment about the food. Most residents said they enjoyed the meals provided and were able to confirm that food was hot and tasted good. The inspector observed breakfast and lunch being served. In an attempt to address the previous requirement about assistance with feeding the manager had implemented a suggestion from a relative to have two sittings at mealtimes. This provided more staff to assist with feeding. Mealtimes on the day of the inspection were rather hectic, as all of the residents had been moved to one floor whilst work to replace the kitchens was Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 14 in progress. Food was well presented and residents were offered several choices at breakfast time. Residents that required feeding were given prompt assistance to eat. Staff did not prompt, remind or assist the other residents for some time. During this period one staff member was rinsing crockery. See requirement 4. Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home complaints procedure did not include adequate information. The records maintained in the home indicated that formal complaints were addressed promptly. EVIDENCE: The homes complaints procedure was prominently displayed in the reception area. The procedure includes a timescale for responding to concerns but did not include all of the contact details for the commission. The previous requirement to amend the homes complaints procedure to include the commission’s telephone number had not been addressed. See requirement 5. The home had received two formal complaints since the last inspection about care and medication issues. Both complaints were acknowledged and investigated in line with the homes procedure. Discussions with relatives indicated that serious concerns had been raised with the General Manager about personal belongings that had gone missing in the home. These issues were not recorded in the complaints folder. Staff should establish whether relatives wish to make a formal complaint when they raise issues of concern and record this information in the residents file. The Police should be informed when valuable items go missing from the home. Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 23 and 26. The home was decorated to a high standard and was clean and comfortable. This provided a pleasant environment for residents. Some staff had a poor understanding about infection control issues. This could place residents at risk of cross infection. EVIDENCE: A partial tour of the home was undertaken including two bedrooms, communal areas and laundry rooms. The building was well maintained, tidy and odour free. New kitchen units and work surfaces were being fitted at the time of the inspection and there was evidence that issues relating to the hot water supply were being addressed. The standard of décor and furnishings was good and all areas felt homely and welcoming. A new path to reduce the risks of falls had been laid in the garden along with a new lawn. The manager said that a hand washbasin would be fitted in the ground floor bathroom and work was planned to provide electric doors at the entrance to the home. Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 17 The amount of personal space provided for residents within this home exceeds the National Minimum Standards for Older People. The bedrooms were all single occupancy but some residents share en suite facilities and a reception room. All of the rooms were clean, appropriately furnished and personalised. All of the units were spacious and provided adequate room for residents own furniture and possessions. The laundry rooms were small and dusty. Access to the washbasin and bin was difficult. Staff did not always wear protective clothing when handling soiled laundry and there were no hand towels or soap. After breakfast dirty clothing was piled on the floor in the dining area. See requirement 6. The previous requirement to monitor refrigerator temperatures had been addressed but some temperatures were above the level recommended for the storage of certain foods. Opened food was covered and labelled and freezers and refrigerators were clean. The manager was not able to provide evidence of compliance with The Water Supply Regulations but agreed to forward this information to the commission. See recommendation 3. Staff had access to a supply of alcohol hand gel on the drug trolley. Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30. Staffing levels were satisfactory and action had been taken to provide increased supervision and support for staff. Staff recruitment practices had improved and access to training was good. EVIDENCE: The home had an almost full establishment of staff and used temporary staff infrequently. Sessions to recruit new staff took place regularly. The off duty roster for the period 27th June to 31st July 2005 was examined. The roster indicated that there were three staff on the ground floor unit and four staff on the first floor unit of a morning, four staff on both units of an afternoon/evening and two staff on each unit overnight. The manager works office hours and was supernumerary. The inspector was told that a Deputy Manager had been appointed and would be responsible for overseeing care practices on the first floor unit. The layout of the home has made this difficult in the past. The commission welcomes this appointment. Three staff files were examined. Recruitment practices had improved overall providing more protection for residents. To comply with the care homes regulations in full the Registered Person must ensure that gaps in employment are explored with applicants and recorded in the staff member file. See requirement 7. The home provides a comprehensive programme of training for staff. Recent training sessions included food hygiene, COSHH, a mini management module for lead carers and star level one, two and three training. Access to vocational Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 19 training had improved. Induction records were not examined during this inspection. Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35, 36 and 38. The manager had a good understanding of the areas where the home needs to improve and was beginning to make some progress with some of these issues. EVIDENCE: A new manager was appointed in December 2004 but the commission had not received an application for registration. The manager advised the inspector that her application had been sent to the Regional Resident Care and Services Manager and would then be forwarded to the commission. Some relatives expressed concerns about the frequent change of management. It is essential that the home has a period of stability to ensure that all of the issues identified in this report are addressed and to provide consistency for staff and residents. Since the last inspection a system for supervising staff had been introduced and records were maintained about individual and group supervision sessions. The manager was responsible for supervising all staff but arrangements were Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 21 in place for this task to be delegated once senior staff had attended supervision training. An annual appraisal system was carried out and regular staff meetings were taking place. There was a good system in place for storing resident’s money and belongings. Separate records were maintained of any money received or removed from the resident’s funds and additional security measures had been implemented for valuable items. Receipts were kept for all purchases made on the resident’s behalf. Work was in progress to fit new kitchens on each of the units. Residents were encouraged to spend their time on the other unit and the area where the work was taking place was screened off. Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 3 3 x x 4 x x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x 2 x x x 3 3 x 3 Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 23 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 5 Requirement The Registered Person must produce a Service Users’ Guide, which complies with Regulation 5. (The previous timescale (01.01.05) was not met) The Registered Person must provide specialist dementia training for staff. This training must include communication skills. The Registered Person must make arrangements for the safe storage and administration of medicines. The Registered Person must ensure that service users receive prompt assistance with feeding at mealtimes. (The previous timescale (01.03.05) was not met) The Registered Person must amend the homes complaints procedure to include the telephone number for the Commission. (The previous timescale (01.11.04) was not met) The Registered Person must ensure that the laundry areas are kept clean and tidy, and that laundry is stored appropriately. Timescale for action 01/02/06 2. 4 12(1) 01/03/06 3. 9 13 23/12/05 4. 4 & 15 12 23/12/05 5. 16 22(7)(a) 23/12/05 6. 26 13 23/12/05 Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 24 7. 29 19 (The previous timescale (01.03.05) was not met) 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. 01/01/06 8. 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 1 Good Practice Recommendations The Registered Person should amend the Service Users Guide to include the following information, the qualifications and experience of the Registered Manager and staff, service users views of the home and information about how the home meets the following standards 21.4, 22.2, 22.5 and 23.10. The Registered Person should amend the Statement of Purpose to include more detailed information about the organisational structure of the care home, the number of bedrooms in the home, the percentage of rooms that are shared and the range of needs that the home can meet. The Registered Person should provide the Commission with evidence of compliance with the Water Supply Regulations 1999· 2. 1 3. 26 Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection River House 1 Maidstone Road Sidcup Kent, 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. Extracts may not be used or reproduced without the express permission of CSCI Old Well House G51 G01 S6787 Old Well House V215673 30.06.05 Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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