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Inspection on 31/01/06 for Prince Edward Duke of Kent Court

Also see our care home review for Prince Edward Duke of Kent Court for more information

This inspection was carried out on 31st January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

What the care home does well

The home provides a pleasant and well-maintained environment, in an attractive rural setting. Several residents spoken to particularly commented on this. Residents spoken to continued to be very positive about the range and quality of meals provided at Prince Edward Duke of Kent Court, as also noted at the last inspection. The home has a good system of volunteer drivers, who provide regular opportunities for residents to go out of the home, both individually and in groups. This enables residents, where able, to maintain their independence.

What has improved since the last inspection?

The home had made good progress in providing training for staff in the Protection of Vulnerable Adults, with the majority of staff now having attended this training. The home had implemented some good computerised databases for monitoring certain practices within the home. Examples of this were: maintenance and decoration records, risk assessments, practices, residents` financial records, and staff training records. These demonstrated some good systems for information management.

CARE HOMES FOR OLDER PEOPLE Prince Edward Duke of Kent Court Stisted Hall Kings Lane Stisted Braintree Essex CM7 8AG Lead Inspector Kathryn Moss Unannounced Inspection 31st January 2006 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 Prince Edward Duke of Kent Court DS0000017912.V281603.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. Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Prince Edward Duke of Kent Court Address Stisted Hall Kings Lane Stisted Braintree Essex CM7 8AG 01376 345534 01376 343545 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) arichards@rmbi.org.uk Royal Masonic Benevolent Institution Mrs Deborah Stevenson Care Home 47 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (35) of places Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 35 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 13 persons) The total number of service users accommodated must not exceed 47 persons 5th July 2005 Date of last inspection Brief Description of the Service: Prince Edward Duke of Kent Court is a large period house set in extensive grounds adjacent to a golf course. Although the home is in a semi rural location with limited access by public transport, Braintree town is just a short drive away and the Home has its own transport. The home has several lounges, a library and a conservatory, and also extensive grounds and an enclosed courtyard. The home provides 24 hour personal care and support, and has a through-floor lift and other equipment (e.g. mobile hoist, hand rails, etc.) to assist residents with limited mobility. It is registered to provide care to a maximum of 47 residents, and its conditions of registration allow the home to care for up to 35 older people and up to 13 people with dementia. All residents are accommodated in single rooms, and these are located on three floors of the main house, and on two floors of the annex, a converted stable block that accommodates 18 residents, including up to 13 residents with dementia (referred to in this report as the EMF (Elderly Mentally Frail) unit). On the day of this inspection there were 42 people in residence in the home. Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 31/1/06, lasting seven hours. The inspection process included: discussions with the manager, deputy manager, and five staff; discussion with five residents; the viewing of communal areas in the main house; and inspection of a sample of records. Previous recommendations were not specifically reviewed. 13 standards were covered, and 5 requirements and 7 recommendations have been made. During the inspection, staff observed were caring and patient with residents’, communicating well with them. Residents spoken to appeared positive and satisfied with their lives at Prince Edward Duke of Kent Court. What the service does well: What has improved since the last inspection? The home had made good progress in providing training for staff in the Protection of Vulnerable Adults, with the majority of staff now having attended this training. The home had implemented some good computerised databases for monitoring certain practices within the home. Examples of this were: maintenance and decoration records, risk assessments, practices, residents’ financial records, and staff training records. These demonstrated some good systems for information management. Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 6 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. Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 5 The home ensured that new residents’ needs were assessed, and that the home could meet their needs, before they moved into the home. Residents were confidant that the home was able to meet their needs, and had opportunity to visit the home before admission. EVIDENCE: The file of a new resident was inspected, and showed clear evidence that someone from the home had visited the person to carry out an assessment of need prior to their admission to the home. The home had a standard form for recording this on, covering an appropriate range of issues, and which had been signed and dated by the person doing the assessment. The resident was spoken to and said that they had not been able to visit the home prior to admission due to being in hospital, but were aware that they could have, and stated that their relative had visited on their behalf and had opportunity to view the services and facilities on offer. The resident was satisfied that the home was meeting their needs. Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 9 The home has the facilities and equipment to meet the needs of the people it aims to accommodate. Staff training over the last year showed that staff had attended a range of training relevant to the needs of the people they were caring for. At the last inspection it had been highlighted that all staff, including staff in the main house, needed ongoing dementia training. On this visit the manager confirmed that this had been explored further, and she was in the process of purchasing some Alzheimer’s Disease Association training packs for use with staff in the home. This should be progressed. It was also recommended that, in view of the number of dementia beds in the home, it would be beneficial if one or more senior members of staff complete more advanced dementia care training, in order to develop the home’s expertise in this field. Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 The home has appropriate medication procedures, but some aspects of staff practices were not satisfactory at the time of this inspection. EVIDENCE: Only medication issues were specifically inspected on this occasion. However, residents spoken to were positive about the assistance they received from staff, and felt that their personal care needs were well met. Those seen were wearing clean and well-laundered clothing, and appeared well cared for. Staff were observed to provide assistance discretely. One resident reported that they enjoyed their baths, felt that staff respected their privacy when assisting them, and were able to choose when to have their bath. Information on staff training showed that in the last year training had been provided in subjects relevant to the health and personal care needs of residents (e.g. dementia care, continence care and infection control). The home’s medication policy was viewed, and contained clear guidance on all aspects of medication administration in the home, including selfadministration. The deputy manager advised that two residents currently administered their own medication, and confirmed that risk assessments on Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 11 this had been completed (not viewed on this occasion). Arrangements for medication storage were safe, secure and well ordered, and included a controlled drugs cabinet. External medication training was provided for staff, and the deputy manager stated that they had also recently implemented an internal system for assessing and recording competency to administer medication. Staff training records showed that 14 staff in the home had attended medication training in the last two years. However, of the 17 staff currently responsible for administering medication in the home, only 7 of these appeared to have attended recent training. Medication administration records (MAR) viewed were generally well completed, with few omissions seen. The home had a system for auditing MAR sheets at the end of each month, and identifying any recording omissions and the person responsible. Medication received by the home was recorded on the MAR sheet, but it was noted that where no new supplies had been delivered, medication carried over from a previous month was not being recorded on the MAR. In one instance where the MAR for a new resident had been handwritten, the quantity of medication brought into the home had not been recorded, and the person making the record had not signed and dated the record. Bottles of liquid medication were generally dated on opening, although some bottles viewed had not been dated; a bottle of eye-drops in use were noted to be just past their expiry date, and the home needs a clear system for monitoring this. Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Practices and routines within the home supported residents to exercise control over their lives. EVIDENCE: Only Standard 14 was specifically inspected on this occasion. However, activities programmes seen showed that a good range of activities were still taking place within the home. On the day of the inspection, a group of residents were seen making birthday cards in the lounge, and reported that they had recently had a singer come in to the home to entertain them, and were due to go out on a trip later in the week. One resident particularly enjoyed the word quiz that was displayed in the lounge each day, and which clearly provided a source of discussion in the home. Residents spoken to reported that they enjoyed the meals in the home. Several residents still managed their own finances, and the home provided appropriate support as required (e.g. transport to get to the bank, support with queries over correspondence, advice on benefits, assistance to access social services’ support with funding, etc.). It was good to see the home helping some residents to maintain control over their financial affairs in this way. The home had policies relating to access to personal records for residents (not viewed on this occasion). There was information on advocacy Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 13 services available in the home, although no advocates were currently involved with any residents. Residents are able to bring their own furniture and possessions into the home with them, as noted on previous inspections. Residents were clear that they had choice over where and how to spend their time each day. Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Residents were confidant that they could raise concerns and that they would be listened to, but systems for recording and monitoring complaints and concerns required review. The home had appropriate Protection of Vulnerable Adults procedures, but these had not been satisfactorily followed in practice. EVIDENCE: The home had a clear complaints procedure, displayed within the home, which met the requirements of the Care Homes Regulations 2001. It was observed during the inspection that residents felt able to raise concerns with the manager, and were confidant to do so. There were two systems for recording complaints within the home. A standard form was used for more formal complaints: although recorded in triplicate, copies were filed on residents’ personal records and none were retained centrally in the home for monitoring purposes (there was an index of names and dates of complaints, but no details). More informal concerns and complaints were recorded on ‘complaints, concerns and incidents’ forms, which were stored in a file in the shift leaders’ office. These forms did not contain details of the investigation and outcome of each complaint, and the file contained records of general ‘incidents’ as well as complaints. The home should review its system for recording complaints, to ensure that all complaints (formal and informal) are consistently responded to, investigated, and recorded, and that a central record of these is easily available for the registered manager, provider or CSCI to review and monitor. It was recommended that complaints and incidents be recorded separately. Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 15 The home’s Protection of Vulnerable Adults (POVA) policy was viewed, and contained appropriate information and procedures for responding to suspicion of abuse, including reference to local multi-agency processes and the importance of referring concerns to social services, the police or the CSCI, as necessary. Training records showed that the home had made good progress with the provision of POVA training to staff since the last inspection, with the majority of staff having attended training, and the deputy manager was in the process of arranging further training for the few remaining staff requiring this. The home also had an Abuse Matters video training pack that was being used internally for staff training. There had been a concern raised within the home since the last inspection, which the home had appropriately referred to social services. The home had investigated this concern internally, and the incident was discussed with the manager and deputy manager during this inspection in relation to the procedures followed. It was acknowledged that this was the first incident of this nature that they had had to investigate, and also that the manager had not received any response or advice from the local authority with regard to the action the home should take. However, it was noted that the company policy had not been followed with respect to the registered provider setting up an independent investigatory panel, and that this would have been beneficial. There were also aspects of the internal investigation that were not sufficiently explored before a decision was made about the outcome (e.g. the witness had not been interviewed to discuss aspects of the accusation, and residents were not asked direct questions relating to the concerns). It was recommended that the manager review organisational POVA investigation procedures with the registered provider, to ensure clear processes and sufficient support in the event of any future concerns. Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 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 the following standard(s): 19 and 26 On the day of the inspection, areas of the home viewed provided a safe and well-maintained environment. The home was clean, pleasant and hygienic, and appropriate infection control procedures were practiced. EVIDENCE: The home has a full-time maintenance person, responsible for maintenance, decoration and health and safety in the home. There was no specific annual plan of decoration for the home: the maintenance person advised that rooms were decorated as they became vacant, or on occasions when the resident was temporarily absent, with minor repairs carried out to décor when required. Records of redecoration had been maintained, showing that over half the rooms had been decorated during the past two years, and several re-carpeted. Systems were in place to record and address any maintenance issues identified. Communal areas of the main house were viewed, and were safe and in a good state of decoration. Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 17 The home’s infection control policies were not inspected on this occasion, but it was noted that twenty staff had attended infection control training last year, and further training was planned. Communal areas of the home viewed were clean and free from any unpleasant odour, and the home had purchased a new carpet cleaning machine to ensure that carpets could be suitably maintained. Laundry facilities were away from areas where food was stored, prepared or served, and were equipped with machines and facilities that met infection control requirements (i.e. sluice wash and 75°C wash cycles). The laundry person showed good awareness of infection control procedures in relation to laundry activities. Sluice facilities were not inspected on this occasion. Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 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 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 28 On the day of the inspection, staffing levels were appropriate to the number and needs of residents. Levels of NVQ training provided evidence of satisfactory levels of competence within the staff team. EVIDENCE: The manager stated that the home was not currently fully staffed, but shortfalls were covered by existing staff or by agency staff. Details of agency staff viewed showed that several agency carers were working regular hours in the home, promoting continuity of care staff for residents. Agreed daytime staffing levels were ten care staff throughout the day, and the home generally assigned four staff to the Annex/EMF unit and six to the main house. Sample rotas viewed for December 2005 indicated that these staffing levels were generally being maintained; the manager confirmed that shift leaders were part of the ten staff on duty, and the home also has a part-time activities coordinator. It had previously been agreed that it was acceptable for afternoon staffing levels to be reduced by one person when the home was not fully occupied: staff spoken to felt that staffing levels generally enabled them to meet residents’ needs, although noted that when they were one short in the afternoons this made it more difficult to carry out some of their key worker responsibilities (e.g. to get items of shopping for a resident). It was noted that rotas did not always show the full names of agency staff, and the manager should ensure that this is addressed. Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 19 At the last inspection, staff in the annex had highlighted that there was insufficient staff cover in the EMF unit at breakfast times: the manager stated that this had now improved because no residents were eating their meals in the first floor dining area of the Annex, and therefore all four staff were free to assist with meals downstairs. Following a requirement at the last inspection, the files of two new staff were checked for evidence that CRB and POVA checks had been obtained for each person. In both cases there was evidence that a POVAfirst check had been obtained before the person started work; in one case the CRB check had also been received before the person started work, and in the other case was still outstanding due to CRB delays (the manager subsequently confirmed that this was received just after the inspection). The manager stated that details of CRB checks are now logged on a computer database, which was not viewed on this occasion. Training records viewed showed that 23 out of 45 care staff (including deputy and shift leaders) had completed NVQ level 2 or 3 in care, and that a further 7 staff were in the process of doing their NVQ level 2 in care. This meets the level of NVQ training laid out in Standard 28. There was evidence of a variety of staff training being planned for 2006. Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 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 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): 35 and 38 Practices in the home safeguarded residents’ financial interests, and promoted the health and safety of residents and staff. EVIDENCE: The home does not look after individual sums of money on behalf of residents, but maintains a non-interest Residents’ Fund Bank Account, into which residents or their relatives can pay a small amount of money. The home then makes money available to those residents on request, or pays for items on their behalf, and deducts the amount from their ‘account’. Clear individual computer based records were maintained for all monies looked after in this way, with receipts maintained for items purchased. These records were reconciled each month with the bank account statement. Several residents managed their own finances, with the home providing support as required (e.g. to get to the bank, with queries over correspondence and advice on pension credit, etc.). The home does not act as an agent or appointee on Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 21 behalf of any resident. The home does not generally look after valuables on behalf of residents, but the administrator confirmed that this would be clearly recorded if required. The home had a health and safety policy detailing employer and employee responsibilities, and policies were also seen relating to accident reporting/ RIDDOR, fire procedures, and risk assessments. The maintenance person maintained records of all checks and servicing carried out on equipment and utilities, with a good computer database showing the dates of the last servicing and checks. This provided evidence that the equipment and premises were regularly and appropriately maintained. It was recommended that the gas engineer be requested to provide written evidence of the servicing of gas equipment within the home. The maintenance person carried out regular internal checks (e.g. hot tap water temperatures, fire alarms, emergency lighting, PAT testing, etc.), with clear records kept. Fire drills took place regularly, and the maintenance person advised that they were intending to implement a system for monitoring that all staff regularly attend fire drills. The organisation had also recently implemented a new Legionella monitoring system, incorporating appropriate checks on hot water storage and distribution temperatures, water testing, checking unused outlets, etc., with a clear recording system for these. The home had implemented a good computer based risk assessment matrix for each job role, identifying any risks associated with each task, and triggering a full risk assessment where required. An example of this was viewed in relation to the maintenance person’s work, and the maintenance person advised that these had been done for each area of the home. Risk assessments were seen to be present in the laundry area, and it was recommended that these covered any risks from moving heavy containers of washing detergent, and that laundry and domestic staff should receive training in the moving and handling of loads. Accident records were not inspected on this occasion. Training records showed a good level of fire safety and first aid training attended by staff within the home, although indicated that a number of staff were due updated moving and handling training. The home has two manual handling trainers, and the deputy manager advised that plans were in progress to ensure all staff were updated. The home should progress this as soon as possible. A number of staff had completed a distance learning infection control course last year. Some staff had attended food hygiene training, but it was noted that catering arrangements within the home meant that care staff had little involvement with any food preparation activities. Records and policies required by regulation have been referred to, where relevant, under the appropriate standards. The manager was advised that the CSCI had not been receiving any reports on the monthly monitoring visits to the home by the registered provider, as required by Regulation 26. Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement The registered person must ensure that medication practices within the home include: 1. Clear records of any medication carried over from previous months; 2. Signing and dating of all records hand written by staff; 3. Recording of all medication received by the home (e.g. for new residents) 4. Monitoring of expiry dates on medication. The registered person must ensure that all staff who administer medication have received appropriate training. It is required that the registered person review current systems for recording complaints, to ensure consistent recording of action and outcomes, and that records can be easily accessed for monitoring purposes. It is required that the registered person reviews the home’s procedures for investigating any suspicion or allegation of abuse. Timescale for action 13/02/06 2 OP9 13 and 18 31/05/06 3 OP16 22 31/03/06 4 OP18 13 31/03/06 Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 24 5 OP37 26 It is required that the registered person ensure that copies of reports on the monthly unannounced visits carried out by the provider under Regulation 26 are submitted to the CSCI. 28/02/06 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 OP4OP30 OP9 Good Practice Recommendations It is recommended that dementia care training be progressed within the home, for staff in both the EMF and the main house. Medication practices should include: • The dating of bottles of liquid medication on opening • Photos of residents accompanying their individual MAR sheets The manager should ensure that the full names of staff (including agency staff) are recorded on the rotas. It is recommended that the registered person progress action to ensure that all staff are up-to-date with moving and handling training. It is recommended that ancillary staff receive training in the moving and handling of loads. It is recommended that the home maintain written evidence of the servicing of gas equipment in the home. It is recommended that laundry risk assessments cover the moving of loads (re the large containers of detergent). 3 4 5 6 7 OP27 OP30OP38 OP30OP38 OP38 OP38 Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Prince Edward Duke of Kent Court DS0000017912.V281603.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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