Inspection on 16/11/06 for Quenby Rest Home

This inspection was carried out on 16th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Quenby Rest Home 10/01/08

Quenby Rest Home 16/05/07

Quenby Rest Home 03/11/05

Quenby Rest Home 28/06/05

Quenby Rest Home 05/01/05

Quenby Rest Home 12/08/04

Quenby Rest Home 09/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Quenby Rest Home Brightlingsea Road Thorrington Colchester Essex CO7 8JH Lead Inspector Sara Naylor-Wild Key Unannounced Inspection 10:35 16th November 2006 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 Quenby Rest Home DS0000017915.V320537.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. Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Quenby Rest Home Address Brightlingsea Road Thorrington Colchester Essex CO7 8JH 01206 250370 01206 250787 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) Mr A Sandhu Mr Avtur Singh Sandhu, Mr Sukvir Singh Sandhu, Mr Surinder Sandhu Ms Alison Simmons Care Home 26 Category(ies) of Dementia - over 65 years of age (11), Old age, registration, with number not falling within any other category (26) of places Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 26 persons) Persons of either sex aged 65 years and over, who require care by reason of dementia (not to exceed 11 persons) The total number of service users accommodated in the home must not not exceed 26 persons 3rd November 2005 Date of last inspection Brief Description of the Service: Quenby is a former domestic dwelling located on the main Colchester Road to Brightlingsea. The property is among established houses of similar age and design. The premises have been extended to the rear to provide the current accommodation comprising of mainly single rooms, most of which have ensuite facilities. There are four lounge/dining areas located to the front, centre and rear of the building providing varied and accessible space. The front garden is mainly laid to hard standing for vehicle parking. The rear garden is mainly laid to lawn with shrubs and trees. The ranges of fees charged by the service are between £367.00 and £495.00 per week. There are additional charges for hairdressing, chiropody and staff and some activities. The provider provided this information to the Commission in August 2006. Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Key inspection visit was carried out over two dates on the 16th November 2006 and 21st December 2006. During the visits the inspector had opporintity to speak with residents, staff, managers and the proprietor. Documents and records such as care plan, staff records, residents and relatives CSCI questionnaire returns. What the service does well: What has improved since the last inspection? What they could do better: Residents have care plans, but these do not reflect all the information known about how to provide the care they require. Medication administration did not adhere to specialist guidance and safe practice. Aspects of staffs practice did not fully uphold residents’ rights to dignity and respect. Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 6 Staff need to develop their skills in engaging residents in activities, which should from part of the individual residents everyday routine with staff supporting them to be involved in the tasks to the best of their ability. Whilst the service had policies in complaints and protection of vulnerable adults these were not always adhered to by staff. Staff training was basic and training in topics that provide staff with additional skills in meeting residents needs development. The location and overall layout of the home is satisfactory although examples of outstanding repair and maintenance detracted from the homeliness of the environment. 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. Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 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 Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are only admitted to the home once they have established they can appropriate meet their needs. EVIDENCE: The residents files sampled during the inspection contained an assessment format by which the service gained information about the residents needs. The information contained in these documents was varied in the level of detail it provided, and in order to begin to form a picture of the individual and how their needs could be best met there should be greater commentary attached to the indications of needs. Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 9 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 Poor. This judgement has been made using available evidence including a visit to this service. Residents have care plans, but these do not reflect all the information known about how to provide the care they require. Medication administration did not adhere to specialist guidance and safe practice. Aspects of care practice did not uphold residents’ rights to dignity and respect. EVIDENCE: During the inspection the records of four residents were sampled to provide an understanding of how the service supports individuals in their care. These all contained care planning documents that appeared to follow the information gathered from the residents’ assessment. However, from discussions with the management team and staff it was apparent that there important information known to individual staff about residents preferences and the best way to provide aspects of their care was not contained in the documents and therefore Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 10 was not always shared amongst the staff group. As an example a staff member discussed how they had developed an approach to a resident that created a calmer atmosphere and therefore a more successful outcome. As the individuals plan of care did not include any of this information the resident and staff did not routinely benefit from this knowledge and this did not demonstrate a person centred approach to the planning and provision of care. As a service with a specialist registration of dementia this is expectation of good practice that was discussed fully with the proprietor, manager and deputy manager during the inspection. The residents files contained reference to individuals health care and visits from health professionals, although outcomes from these visits or observations were not always used to update care plans and the action staff needed to be aware of. The practice in Medication administration was considered during this inspection and included observation of practice and recording by staff. There were significant gaps in both recording and the understanding of staff in ensuring that the appropriate medication was administered. For example staff were using one residents’ named prescription to dispense to all the residents taking that prescribed medicine. These shortfalls were raised with the person in charge on the day of the inspection and a requirement to review the practice immediately was given by the inspector. The way in which residents are respected as individuals is measured throughout the ethos and delivery of the service and includes issues such as, understanding the individuals needs through care planning, good communication between staff, enabling resident choice and ensuring the service engages with residents and their families in the care provided. As reported earlier in this report the service has some development required in care planning to ensure they are truly person centred and reflect how the individuals wishes in respect of their care should be included. This also demonstrates gaps in communication between staff, and discussions with staff on duty indicated that care plans are not in regular use. During the inspection there was opportunity to observe how staff interacted with residents. Generally staff were kind and attentive to residents and addressed them with respect. However some actions of staff during the period of inspection did not support an ethos of dignity and respect, such as a member of staff assisting two residents to eat at the same time, the removal of table cloths when residents sat down to eat and inappropriate music choices being played without consultation with residents in the room. The lack of awareness of staff in this area of their delivery of care was raised with the manager. Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 11 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 adequate. This judgement has been made using available evidence including a visit to this service. The residents receive a varied level of support for their social needs. EVIDENCE: The service has appointed an activities coordinator at the last inspection and although that post holder had resigned they had reappointed to the post. During the inspection it was possible for the inspector to observe the impact of this post on the resident group. When the inspector first entered the communal areas, the activities co-ordinator was not in the building and other care staff were responsible for providing occupational stimulation to residents. Staff did make attempts to provide stimulation and activity to residents in one lounge for example music was turned on. However they did not appear to be clear how individuals’ wishes should be considered nor did they involve residents in making choices in issues such as music. This resulted in a choice of loud modern club music whilst leaving the television on as well. When asked by the inspector, residents stated they did not know why this was on or who had chosen it. In contrast when the activities co-ordinator arrived they responded Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 12 directly to service users asking them about preferences and reminding them of previous experiences, i.e. when they had sung to a favourite music choice. They were also able to demonstrate an intimate knowledge of residents and were responsive to their emotional needs. This was particularly evident in their interaction with a resident who had suffered a personal loss and was distressed. The resident commented that other staff “fussed” over them, by repeatedly asking if they were alright as they passed by. The resident found this frustrating and complained to the activities coordinator. In contrast the activities co-ordinator listened and demonstrated empathy with their feelings. Whilst the initiative of a dedicated post to ensure there is provision of activities and occupation for residents, it is less effective if when the post holder is absent other staff do not interact with residents appropriately. Activity should from part of the individual residents everyday routine with staff supporting them to be involved in the tasks to the best of their ability. It was noted that there were large scale planned activities such as parties and entertainment planned in addition to the daily routine. The proprietor and manager reported that they had recognised the shortfall in this issue and had engaged the services of a specialist consultant in dementia care mapping and activities to assist in developing the provision of activities and review the daily routine. The visitors policy remains unchanged and provides arrangements to support and welcome relatives and visitors. The lunchtime meal was observed. Overall the response from service users was positive; a number of residents were spoken with regarding their satisfaction of the food served. They made comments such as “It is good food”, “I always eat everything, it is very tasty” and “it is not always cooked the way I like it, but you cannot always please everybody” Alternatives were provided to those residents who did not want the main meal. Staff were observed assisting residents to eat their meal, and whilst this was generally carried out with patience, staff were observed to assist two people at the same time, a practice that does not support the dignity of residents. Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Whilst the service had policies in complaints and protection of vulnerable adults these were not always adhered to by staff. EVIDENCE: The service has a complaints policy that meets the expectation of the NMS and provides residents and their supporters with an understanding of how to access the complaints procedure. The service had not developed different formats that supported and enabled residents with dementia to express their satisfaction with the service. Within the care planning documents there was a small mapping tool, however it was clear from discussions with staff that there had not been any formal training in the use of the tool and therefore its impact in understanding residents emotional response to their delivery of care is limited. Prior to the inspection the Commission was copied into a letter sent to the manager in respect of a residents ceasing to live at the home. There was also information sent in survey returns sent out to residents and their supporters as part of the inspection methodology residents. On this occasion the inspector received a detailed response identifying dissatisfaction with aspects of the service. The letter had not been responded to by the service, nor had the details been entered into the complaints log. This does not adhere to the services complaints policy and does not meet the expectation of the NMS. Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 14 The issues raised in the survey response had not been copied to the manager previously and the inspector explored these with the manager whilst maintaining the individuals confidentiality. The discussions highlighted a need to develop a more robust approach to understanding individuals dissatisfaction and how the service listened and reacted to these. In addition to these discussions the inspection officer considered the items raised in these communications in the inspection processes. The services policy on protection of vulnerable adults contains information in respect of the services procedures when allegations of abuse are reported. This meets the “No Secrets” and Essex Vulnerable Adults Guidance documents. However following the inspection visit the manager reported an allegation of possible abusive conduct to the CSCI. It was clear from the information received that whilst some aspects of the services procedures had been adhered to, the full reporting procedures, including referral to the POVA list had not been instigated. Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. The location and overall layout of the home is satisfactory although examples of outstanding repair and maintenance detracted from the homeliness of the environment. EVIDENCE: At the time of the first inspection visit the premises was generally not in a good state of repair. This was especially the case in the front older portion of the building where décor, carpets and furnishings were worn and tired in appearance. Additionally a planned extension to provide an office adjacent to the main corridor had not been completed from the last inspection with the area temporarily boarded up. The proprietor and management staff explained that the long term planning was for a major refurbishment of the whole area. Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 16 However the appearance gave the impression of a lack of care and respect for those residents who use the facility and the premises should not be allowed to deteriorate. Additionally the use of communal rooms had been changed with the front lounge being “swapped” with the dining room at the rear of the building. The reason given for this move was to enhance the appearance of the home to visitors to the building. Residents stated, “There is nothing to look at outside anymore” and felt they were shut away at the back of the building. The two environments were not similar and whilst the dining room had been comfortably accommodated in the rooms that had previously made up the lounges at the front of the building, the previous dining room had been a large rectangular room that did not lend it self to the intimacy of a lounge space. At the second visit efforts had been made to the décor and condition of the communal dining room and this had resulted in a marked improvement in the appearance of the area. Additionally the manager reported that the rooms were reverting to their original use. There was not an odour in the building at the time of the inspection, and discussions with the staff indicated an understanding of the principles of maintaining a hygienic environment. Although the service had details of their policy in safe hygiene and infection control, the staff files did not contain evidence of staff having received training in Infection control. Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 17 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 service ensures staff recruited have a suitable background to support vulnerable adults. Training in topics that provide staff with additional skills in meeting residents needs require development. EVIDENCE: The staffing numbers maintained by the service are arrived at following a calculation against the assessed residents needs. On the day of inspection there was the person in charge, 4 care staff, plus housekeeping and catering staff. There appeared to be sufficient opportunity for staff to spend time with residents in communal areas of the home, although as previously stated there needs to be further consideration made in how staff utilise this time. The evidence gathered from speaking with staff and examining staff files indicated that there was a robust system for the recruitment of staff. This included gaining two references and carrying out CRB checks. A number of staff are foreign nationals and their recruitment checks are carried out by specialist companies in their own country. Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 18 The staff record contains mandatory training such as first aid and food hygiene. The staff had undertaken dementia training through the Alzheimer’s Society yesterday, today and tomorrow programme, and the manager indicated that future training plans included more in depth dementia training. The service states that 8 of the 15 care staff hold NVQ level 2 or above, or equivalent. Staff files examined contained certificates for courses staff had attended. The need to develop the training programme and the variety of skills staff develop was discussed with the manager. The inspector’s discussions with staff indicated they had a varied understanding of the needs of older people and particularly those with dementia. The inspector was interested to understand from staff how their approach to providing support to those residents with cognitive impairments, differed from other residents. The staff spoken with were not all able to evidence a specialist knowledge of dementia care and explain the techniques they used to offer choice to those residents, or how the care plan assisted them in understanding their needs. From this information the impact of induction processes and the specialist training on offer to staff in dementia does not appear to provide them with sufficient guidance in delivering the homes statement of purpose. Both in discussions during the inspection and in surveys returned to the Commission the employment of overseas staff and their competence was raised. In particular the comments stated that the language skills of those staff inhibited their ability to communicate with residents. The majority of staff currently employed by the service are from overseas and the inspector discussed with both the staff and the managers how the process of recruitment and induction was undertaken. The manager and deputy reported that the varied cultural background of the staff employed at the home, was taken into account during the induction programme and additional information was provided in respect of the ethos and expectations of a care setting, a view supported by staff spoken with. The manager was clear that the competency of staff in supporting residents was the priority in employment and that they had terminated individuals employment where this was not the case. Those staff spoken with during the inspection had good communication skills and were clearly understood by residents they were supporting. Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 19 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): 31,32,33,35,36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the service creates a positive atmosphere within the home, although there are developments required in systems and procedures to ensure residents benefit fully from living there. EVIDENCE: The Manager, Alison Simmons is a qualified Nurse, and has appropriate levels of management experience in care settings. Based upon observation, discussion with Ms Simmons and care staff, the management regime, overall, enabled an open and positive atmosphere. Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 20 As identified elsewhere in this report there are developments in the management of the service required to ensure that residents are gaining from a service that is operated in their best interests through consultation and provides them with protection. This is particularly so in enhancing daily life through care planning and occupation, the listening and proactive response to residents satisfaction and complaints and the development of staff skills. The home does not directly hold individual service users monies, and instead operates an invoicing system whereby these monies are held centrally and audited by an external account manager. The home uses a float system to purchase items requested by service users and these are then billed to the individuals’ accounts. Running records of individual service users’ expenditure, income and totals held are then provided to the home. This accounting system is acceptable and secure, provided service users are fully able to access monies as required. The staff files contained reference and records of supervision sessions with line management. The format of these met the expectations of the NMS and identified not only the individual’s performance, but also how training should be offered to support their role. There is an ongoing development of the supervision skills in the management team and the techniques used to create quality of the experience for staff. The connections between supervision and the development of the staff training programme are not clearly defined and this element of staff development was discussed with the manager. The service operates a quality assurance programme that involves a questionnaire being sent to residents and their supporters, with an audit of the responses carried out. As a proportion of the residents by reason of their capacity, would not be able to complete a survey questionnaire, the inspector was informed that the service also intended to train staff to carry out dementia care mapping. This would provide additional tools to understand the satisfaction levels of those residents with dementia. The measurements of quality must also include all feedback received from resdents and their families and the survey results cannot be taken isolation. The issue raised with the response to complaints detracts from the work carried out in this area. The documents relating to the maintenance and safety checks for equipment and systems operated in the home could not be located during the inspection visit. The certificates for fire safety were seen and evidenced that the fire alarm systems and emergency lighting had been annually maintained and checked. The opportunity to provide additional information was given to the service, and copies of these documents were sent to the Inspector and were satisfactory. The manager must ensure that documents required for inspection by the CSCI or other authorities are readily available in the service. Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 21 Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 x 3 2 X 2 Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 23 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 OP7 OP8 Regulation 55 Requirement Service user plans of care require further development to ensure that the instructions to staff in meeting individual needs reflect all the information known about them. This is a repeat requirement since July 2003. 2. OP9 12 The registered person must ensure that the medication practice in administration and recording meets the Royal Pharmaceutical Society guidelines. The registered person must ensure that staffs practice adheres to the statement of purpose upholds residents rights to be treated with respect and dignity. 01/03/07 Timescale for action 01/03/07 3. OP10 OP14 12 01/03/07 4. OP12 OP14 16 The registered person must 01/03/07 ensure that service users are able to exercise choice in relation to social, recreational and leisure interests. DS0000017915.V320537.R01.S.doc Version 5.2 Page 24 Quenby Rest Home This is a repeat requirement since August 2004. 5. OP18 13 The registered person must ensure that the policy and procedure for protection of vulnerable adults is understood and followed. The premises remain in need of minor works and attention to environmental hazards. This is a repeat requirement since July 2003. 7. OP28 OP30 19 The registered person must 01/03/07 ensure that a training programme that reflects the assessed needs of residents is undertaken by staff. In particular the development of skills in supporting residents with dementia. The registered person must 01/03/07 ensure that record required by legislation are available for inspection. 01/03/07 6. OP19 16 01/03/07 8. OP38 17 Schedule 3 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 OP3 OP11 Good Practice Recommendations The registered person should ensure that pre admission assessments gather full information about the individual as possible It is recommended that the registered person gains further information in respect of service users wishes at the point of dying and following their death. This standard was not assessed at this visit and will be Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 25 3. OP16 OP33 4. OP36 revisited at the next inspection. The registered person should ensure that the service develops tools to gather the views of resident with dementia and that this is included in the consultation such as the complaints and quality assurance system. The registered person should develop the staff supervision to ensure the elements set out in good practice are incorporated. Quenby Rest Home DS0000017915.V320537.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Quenby Rest Home DS0000017915.V320537.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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