Inspection on 04/12/07 for Quaker House

This inspection was carried out on 4th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Quaker House 01/12/06

Quaker House 16/02/06

Quaker House 02/08/05

Quaker House 26/10/04

Quaker House 14/06/04

Quaker House 24/02/04

Quaker House 30/06/03

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Quaker House 40-44 Barton Court Road New Milton Hampshire BH25 6NR Lead Inspector Pat Trim Unannounced Inspection 09:00 4 December 2007 th 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 Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Quaker House Address 40-44 Barton Court Road New Milton Hampshire BH25 6NR 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) 01425 617656 New Milton Quaker Housing Association Limited Mr Paul John Abbott Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2006 Brief Description of the Service: Quaker House is set in a residential area on the outskirts of the town centre of New Milton. It provides residential care for up to 40 older people. Many of the residents require a very limited degree of personal care and the support provided is more akin to that within warden controlled accommodation. All forty bedrooms are single and all of these have an en-suite toilet. There are three communal bathrooms and a shower on the ground floor and three communal bathrooms, two of which have toilets and a separate shower on the first floor. There are gardens to the front and rear of the property, which include a patio and water feature. The fees given at the time of the inspection were £295.00 per week. Items not included in the fee were given as hairdressing, chiropody, newspapers and personal toiletries. Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information for this report has been obtained from the following sources: A review of the home’s recent history, including the last inspection report. The Annual Quality Assurance Assessment (AQAA), which was completed by the home. This is a document that gives information about what the home is doing to make sure it meets the regulations. Eleven survey forms completed by people who use the service and their families and two completed by health care professionals. A key unannounced inspection of the home carried out by one inspector over a period of six hours. During this inspection we tracked three residents to assess their experience of moving into and living in the home. Time was spent talking with eight residents and sitting with others in the communal areas of the home, observing daily life. There was also an opportunity to speak with the registered manager, cook, five care staff and a visitor to the home. A partial tour of the home was carried out and a random selection of documents was viewed. There were five requirements resulting from the last inspection. These had been met. There were three requirements resulting from this inspection. The registered manager requested the term ‘resident’ be used to describe people who lived in the home and this term has been used throughout this report. What the service does well: The people who live in the home are very happy with the service they receive. Comments included: ‘Quaker House is an excellent home and I enjoy living here.’ ‘I am very happy with the care I get.’ ‘This is the best there is.’ Families are also very satisfied with the care and support given to their relative. Comments included: ‘Staff meet their needs in every possible way.’ Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 6 ‘I cannot speak more highly of Quaker House. The care given and especially the food is first class.’ ‘Staff always put the care and the needs of residents first.’ Many of the staff have worked at the home for a long time and know how each resident likes to have things done. Residents said they get to know staff as they do not continually change and feel confident their needs are known and met. Residents are supported to remain as independent as possible. Residents gave examples of what they like to do and staff said they felt it was very important to let them do whatever they could for themselves. Residents are supported to manage their own medication, personal care and daily living if they are able to. Communication is good. Staff said they were kept informed of the changing needs of residents through handovers and team meetings. Families said staff contacted them when they needed to and involved them in caring for their relative. Residents said the food provided was very good. Comments included: ‘The food is first class.’ ‘We have lovely home cooked food.’ Residents are offered a choice of meals. All meals are cooked from fresh and home made puddings and cakes provided. What has improved since the last inspection? What they could do better: Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 7 There must be a system in place to make sure all care plans are regularly reviewed and amended to reflect the changing needs of the people who live in the home. The current system used to give medication to people who live in the home must be reviewed to make sure it complies with the Royal Pharmaceutical Guidelines and minimises the possibility of error. Evidence that Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks have been completed before new staff begin work must be available to demonstrate everything has been done to minimise the risk to residents. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are given enough information to enable them to make an informed choice about whether to move in. Pre admission assessments have been developed that provide detailed information about residents’ needs. This ensures they will only be offered a place if the registered manager is sure the home can meet their needs. EVIDENCE: Feedback from residents, both in surveys and in speaking with them, evidenced they felt they had been given sufficient information to enable them to make a choice about moving into the home. They had all visited the home and had a two-week stay before deciding to move in permanently. They had been given a copy of the statement of purpose and service users’ guide, which gave information about what the home provided. The registered manager said he completed a pre admission assessment to identify what prospective residents could do for themselves and what they Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 10 needed help with. Completed assessments were seen on the files of three residents who have moved into the home in the last year. Each of these identified their abilities, needs and any areas of risk. The information obtained in the assessment was used in the care plan. For example, one assessment identified a problem that meant the resident needed a soft diet. The care plan also identified this as a need, but showed the resident would be able to choose an appropriate meal from the choice offered without assistance from staff. Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans contain guidance to enable staff to consistently provide personal care in the way each service user likes it, but need to be regularly reviewed and amended to make sure they reflect the current needs. The way medication is dispensed needs to be reviewed, as it does not comply with the Royal Pharmaceutical Guidance, as stated in the home’s policy and procedure and could increase the risk of error. Residents are supported to manage their medication independently if they wish to. Staff provide care in a way that promotes the service user’ rights to privacy, dignity and respect. EVIDENCE: The majority of current residents require very little support with their personal care and said that staff met their needs. They felt able to tell staff exactly what support they required. Staff were able to demonstrate their knowledge of residents’ needs and said they shared information about residents’ needs at Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 12 handover meetings. This means that staff do not rely on care plans for their information. However, the home does sometimes need to use agency staff and detailed care plans are required for them so they can easily see what assistance is required for each resident. This was discussed with the registered manager, who said he was continuing to develop more comprehensive care plans. There was some evidence that care plans were reviewed, but files did not contain a record of the review or the methods used to carry it out. Care plans had not been updated to reflect the changing needs of residents identified in the daily notes. For example, there was a concern about the dietary needs of one resident. It had been noted that her food and fluid intake should be monitored but there was no guidance in the care plan as to how this should be done. The registered manager acknowledged there was no formal system in place for reviewing care plans and agreed to look at how this could be achieved. Residents and their families felt their health care needs were well met. Comments included: ‘Any problems health wise are promptly attended to by staff and contact made to family.’ The registered manager said many residents managed their health care independently but staff supported them if necessary. The home makes arrangements for visits by dentists and chiropodists for those who wish them to. The staff work closely with local surgeries and palliative care staff. Feedback from two doctors was very positive. They felt the home asked for information and support when they needed it. They made the following comments about the home: ‘Quaker house staff always try to tailor residents needs individually.’ ‘Provides an environment where dignity and respect are paramount’. The pre admission assessment identified whether residents wished to continue to manage their own medication. Two of the residents who were case tracked managed their own medication. No risk assessment had been completed; although the registered manager said he was in the process of incorporating them into the care plans. The risk assessment required the resident to agree to store their medication safely. Medication was stored in a locked cupboard and only staff who had received training were permitted to give it out. Accurate records were kept of receipt, administration and unused medication returned to the pharmacist. Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 13 The majority of medication is pre dispensed by the pharmacist into a monitored dosage system. The current practice of the home is to put this medication into a named lidded pot in advance of the next time of administration. Staff said this was done so they did not have to take medication round the home on a locked trolley, which was felt to be an institutionalised practice. The medication policy and procedure stated that practice complies with the Royal Pharmaceutical Guidelines. This practice does not as the guidelines call this ‘secondary dispensing’ and warns that it can lead to accidental mix-ups and errors. This practice must be reviewed. Residents felt the staff worked hard to make sure their rights to privacy and dignity were upheld. Care plans record how people like to be addressed and staff were heard using these preferred forms of address. Post was distributed by putting it in personal post boxes outside residents’ rooms. Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to join in a wide range of activities that provide mental stimulation and that they enjoy. Their right to be independent is supported and they are able to maintain their links with the community. They are provided with a variety of well-balanced meals that gives them choice and they like. EVIDENCE: Feedback from residents was very positive. They felt they were able to make choices about all aspects of their daily living such as what time they got up and how they spent their day. Many of the residents remain very independent and said they liked the fact they were able to catch the local bus right outside the home. There was also a free bus to the local supermarket. Pre admission assessments record information about residents’ interests and care plans show how they can be supported to continue with them. For example, one person belonged to a local club. Arrangements were made for transport to get her to the meetings. Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 15 Staff said many residents liked to do their own washing, ironing and housework. They were able to do this with staff support if they needed it. The home has a room specifically for craft activities and residents had paintings and drawings displayed on the walls. The library visited regularly and residents had the opportunity to buy presents from various organisations that visit. The activities notice board informed residents and their families when the Christmas party was being held and also that local schoolchildren would be coming in to sing carols. Residents said they also enjoyed providing their own entertainment and like to play cards together. Visitors are welcome at any time and there is a room they can book if they wish to stay overnight. Feedback from families evidenced they felt welcome in the home and involved in the care of their relative. Residents’ religious needs are recorded prior to admission and plans put in place to meet them. A regular service is held in the home. The home has a lot of communal areas and residents were seen throughout the inspection choosing to spend time in them and in their rooms. Residents are told before they move in that they may bring personal belongings in to furnish their rooms. At 9:00 a.m. some people were in the dining room having breakfast. Others had already finished, whilst others were having breakfast in their rooms. Residents said they were expected to go to the dining room for meals, but could have them in their rooms if they wished to. Mealtimes were relaxed and lively with people chatting to each other and taking time to enjoy their food. Where assistance was required it was given discreetly and at the resident’s pace. Comments about the food were very positive. The cook said all food was prepared fresh and puddings and cakes were homemade. The menu showed there were two choices for the main and evening meal. Residents confirmed they were asked the day before what they would like to order, but that they could change their minds. Communal areas contained tea and coffee making facilities so residents and visitors could make drinks. Residents said they also had kettles in their rooms so they could make drinks whenever they wished to. Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the information they need to enable them to make complaints. Staff have the training and information they need to protect service users against the risk of abuse. EVIDENCE: Feedback from residents and their families showed they knew how to make complaints. Following the last inspection, the complaints procedure has been reviewed and now contains all the required information, such as contact names and addresses and timescales for responses. The registered manager said copies of the updated procedure had been given to everyone and residents confirmed this. The AQAA stated that the registered manager had received no complaints since the last inspection and the commission had not received any either. Following a requirement made at the last inspection, the registered manager said staff had now had training about safeguarding adults. Certificates were seen on staff files to evidence this. Staff spoken with had a clear understanding of their responsibility to report any allegations of abuse. Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a clean, safe, pleasant and well-maintained environment for the enjoyment of residents. EVIDENCE: Residents and their families said they thought the home was well maintained and kept very clean. The environment is well thought out and meets the needs of the people who live there. There are a number of communal areas so there is plenty of space for people to sit and chat with each other and visitors. There is a renovation programme and areas are kept well decorated. Residents said they enjoyed walking in the gardens, which are also well maintained. The home employs a handyman who was seen calling on residents to repair faults that had been reported. Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 18 The AQAA stated that the home provides suitable equipment to enable residents to remain independent and that bathrooms were being upgraded. The home has a Parker bath so all residents are able to bathe if they wish. The home has a policy and procedure for infection control. Staff were observed dealing with soiled linen in accordance with the guidance. The home has a laundry, which has washing machines able to disinfect linen, if necessary. Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides well-trained staff in sufficient numbers to meet the needs of residents. The recruitment procedure makes sure risks to residents are minimised, but evidence all checks have been completed must be available to demonstrate this. EVIDENCE: Residents said the staff were very good; always answering calls for help promptly. They felt there were sufficient staff on duty to meet their needs. Relatives also felt there were sufficient staff at all times. Comments included in response to what the home does well: ‘Ensures all needs in care and other aspects are met, giving the service users an excellent quality of life in their home.’ The AQAA stated that staffing levels are monitored to ensure sufficient staff are on duty to meet the needs of current residents. The registered manager said he had recently increased the care and domestic hours and changed the way the rota worked to provide better cover. He also said when agency staff were required the same two agencies were used and the same staff requested. Information about the qualifications and completed checks for these staff were seen. Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 20 The previous inspection report noted the home had well over 50 of staff with a National Vocational Qualification (NVQ). Staff said they were encouraged to undertake training qualifications and senior staff were able to complete NVQ 3. A number of NVQ certificates were seen on staff files. Feedback from staff, both in survey forms and in talking with them, evidenced they felt the employment procedure had been thorough and fair. They had been required to complete an application form, attend an interview, give references and complete Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks before beginning their employment. The previous inspection had made a requirement that these checks were completed. The files for two new staff were viewed. These contained all the required information except CRB and POVA checks. Each file contained a copy of a CRB and POVA check completed this year for a previous employer, but not one completed for the position they were applying for. The registered manager said the CRB and POVA checks had been applied for and received before the applicants had been offered a post, but the returned checks could not be found. The registered manager agreed to verify these checks had been completed and to give the information to the commission. Feedback from staff showed they felt they were able to have the training they required to provide the support residents needed. They felt the induction programme enabled them to develop the skills and knowledge they needed. The two new staff had completed an induction programme before working unsupervised. The registered manager said he was going to introduce a new workbook for staff to complete that covered the common induction standards required by Skills for Care. The registered manager said that the previous year had been spent making sure all staff had completed mandatory training such as food hygiene and manual handling. Records showed that staff had completed these courses. Since the last inspection, staff had completed in house training in safeguarding adult procedures. A record of each individual member of staff’s training was kept in their file. This showed what training had been completed and when refresher training was required. The registered manager said he had to look at each record to identify when refresher training was required. It was suggested a training matrix might make it easier to monitor what training was needed, so that this could be arranged before the training lapsed. The registered manager said he had completed an annual appraisal for each member of staff. Staff said they received regular supervision but the registered manager said this was not yet on a formal basis. He was aware of the need to introduce regular supervision and was discussing with senior staff the best way to manage this. Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and residents have the opportunity to give feedback about the service they receive. Providing training to staff and ensuring equipment is regularly serviced minimises risks to the health and safety of residents. EVIDENCE: The registered manager has been in post for two years and has just completed his Registered Manager’s Award. Residents and staff said he was competent and approachable. A number of areas that need improvement have been identified in this report. These included the development of more detailed care plans and their regular Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 22 review, the recording of returned CRB and POVA checks and the monitoring of staff training needs. The registered manager was already aware of these shortfalls and was taking steps to address them. Residents said they were able to give feedback about the service they received through the Residents’ committee. The registered manager said some changes were being made to how this operated, but there would still be a residents’ meeting where people could express their views. Residents are also able to give feedback through an annual quality audit and at any time, through a suggestion box. A representative of the provider visits the home every month to carry out a quality audit. A written report of this visit is given to the registered manager. Copies of these were seen. They identified any areas of concern, together with the action required to rectify them. The issues were reviewed on subsequent visits. The majority of residents are able to manage their own money and the home is not involved. However, some people like the home to hold small amounts on their behalf. The AQAA stated that records are kept of any money received or spent, together with any receipts. Three of these records were seen. The record of any transactions was signed either by a member of staff and the resident, or two members of staff. Records showed that staff have mandatory training in respect of health and safety, such as manual handling, food hygiene and fire safety. Staff confirmed they received this training. There were policies and procedures in respect of health and safety, such as the safe storage of chemicals and the management of clinical waste. Records were seen of a random selection of service contracts and certificates. This evidenced equipment was regularly serviced to minimise the risks to residents and staff. Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 23 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 (2)(b) Requirement The registered manager must regularly review the care plan and amend it to make sure it continues to give guidance on how staff can meet the changing needs of the residents. The registered manager must ensure that the practice of secondary dispensing of medication stops. Medication must be dispensed in a way that complies with the Royal Pharmaceutical Guidance to make sure the risk of accidental error is minimised. The registered manager must provide evidence that CRB and POVA checks were completed for the two staff discussed during the inspection as stated by the registered manager to demonstrate the employment procedure has been followed and the risk to residents minimised. Timescale for action 01/03/08 2. OP9 13(2) 01/01/08 3. OP29 19 01/01/08 Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Quaker House DS0000012160.V344426.R01.S.doc Version 5.2 Page 27 - 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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