Inspection on 28/09/07 for Regents House Rest Home

This inspection was carried out on 28th September 2007.

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.

Other inspections for this house

Regents House Rest Home 12/08/09

Regents House Rest Home 15/08/08

Regents House Rest Home 22/03/08

Regents House Rest Home 01/02/07

Regents House Rest Home 27/02/06

Regents House Rest Home 12/12/05

Regents House Rest Home 16/02/05

Regents House Rest Home 18/10/04

Regents House Rest Home 09/03/04

Regents House Rest Home 16/01/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Winton House

Newbeech House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Regents House Rest Home 206 Regents Park Road Southampton Hampshire SO15 8NY Lead Inspector Annie Kentfield Key Unannounced Inspection 28th September 2007 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 Regents House Rest Home DS0000012319.V344376.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. Regents House Rest Home DS0000012319.V344376.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Regents House Rest Home Address 206 Regents Park Road Southampton Hampshire SO15 8NY 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) 02380 322 101 Mr Ian Newson Mrs Jean Newson Mrs Sandra Pearl Anaszko Care Home 17 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (17), Mental disorder, excluding learning of places disability or dementia (3), Mental Disorder, excluding learning disability or dementia - over 65 years of age (17), Old age, not falling within any other category (17), Physical disability (3), Physical disability over 65 years of age (7) Regents House Rest Home DS0000012319.V344376.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users in the DE, MD or PD categories may not be accommodated under the age of 55 years A total of not more than 7 service users may be accommodated in the PD and PD (E) categories Not more than 3 service users in total may be accommodated under the age of 65 years 1st February 2007 Date of last inspection Brief Description of the Service: Regents House is a large period property that has been adapted to provide residential care for up to 17 older people. The accommodation is both single or shared bedrooms available on the ground and first floors with a passenger lift to the first floor. None of the bedrooms have en-suite facilities but do have a wash hand basin. There is a lounge, dining room and garden with patio area for residents to use. The building is accessible. The home is close to local shops and amenities. The home currently charges local authority rates of approximately £395 per week. There are no additional charges. Regents House Rest Home DS0000012319.V344376.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is a summary of information received about the home since the last inspection visit of 1st February 2007. An unannounced visit to the home was made on 28th September 2007, by one inspector, who was in the home from 10am to 5pm. The inspector spoke to most of the residents, either in the communal areas or in the privacy of their own rooms, and also met with two care staff, the registered manager, two visitors, and the registered owner’s representative, who lives in a flat adjoining the care home. Some comment cards were received from residents and relatives. The registered manager also provided information in this report before the inspection visit, in the Annual Quality Assurance Assessment (AQAA). This is an annual self- assessment form that all services complete that focuses on how well outcomes are being met for people using the services. It also provides some numerical information about the service. Feedback about the service was also sought from health and social care professionals who visit the home and the inspector spoke to two health and social care professionals on the telephone. What the service does well: What has improved since the last inspection? The home were required to make sure that all staff had received up to date training in safe moving and handling procedures, this has been addressed and staff updated their training in April 2007. Carpet has been replaced in the communal areas of the home and in some of the bedrooms. Some work has been carried out to the floor of the laundry room in the basement. The home have reviewed their policy on smoking in the home in line with current legislation and there is now a designated smoking room for residents with a no smoking policy for any other areas of the home. Regents House Rest Home DS0000012319.V344376.R01.S.doc Version 5.2 Page 6 In consultation with the residents, the home has applied for, and will be given, a grant to upgrade some of the facilities in the home, for the benefit of the residents. 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. The summary of this inspection report can be made available in other formats on request. Regents House Rest Home DS0000012319.V344376.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 Regents House Rest Home DS0000012319.V344376.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 (standard 6 is not applicable because the home does not provide intermediate care) - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager ensures that residents move into the home only after their needs have been assessed or they have received a copy of the care needs summary from the relevant health and social care professionals. EVIDENCE: The manager reports that prospective residents are encouraged to visit the home for a few hours and have a meal so they can get a better feel of the home. The manager ensures she receives a care manager’s assessment prior to doing her own assessment. She visits the prospective resident in hospital or at their home and gathers information to create a short-term care plan that can be reviewed once they know the person better. The assessment form that the home uses gathers basic information about resident’s health and care needs but should also gather more information about prospective residents’ emotional, social and spiritual needs. This would provide evidence of the Regents House Rest Home DS0000012319.V344376.R01.S.doc Version 5.2 Page 9 home’s stated commitment to providing a holistic approach to caring for residents. We spoke to one relative who had visited the home before their relative moved in. The relative was not sure what information had been received about the home but thought this was because the information had been given to another relative to deal with. The manager said that she was in the process of updating the information about the home for residents and their relatives. Since the last inspection training for care staff in some areas has been updated, however, the home is not carrying out thorough recruitment checks before new staff start working in the home. This has the potential to put residents at risk of harm and does not support the home’s stated commitment to putting the needs and safety of the residents first. This requirement is addressed under the section on ‘Staffing’ in the report. Regents House Rest Home DS0000012319.V344376.R01.S.doc Version 5.2 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. 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. The home does not have a clear system for compliance with the administration, safekeeping and disposal of controlled drugs and the manager and staff are unclear of what is required. Improvement is needed to the storage of all medicines to ensure that systems are safe and medication is appropriately stored. Individuals are not encouraged to keep and administer their own medication where this may be appropriate. Individual care plans do not adequately record all of the health care issues of the residents, particularly when care needs change and higher levels of care are required. EVIDENCE: The medication for residents is stored in the kitchen in domestic style kitchen cupboards that have been fitted with a clasp and padlock. Guidance for Care Homes from the Royal Pharmaceutical Society does not recommend that medicines be stored in a kitchen because of the possible detrimental affect of heat and humidity on medicines. In addition, the clasp and padlock is not totally secure and could be unscrewed or forced open. The home are not providing storage for controlled drugs or appropriately recording the Regents House Rest Home DS0000012319.V344376.R01.S.doc Version 5.2 Page 11 administration of controlled drugs that meets the requirements of the Misuse of Drugs (Safe Custody) Regulations, 1973 and will be required to meet these regulations. The home must also ensure that medication that is prescribed to be given ‘as and when needed’ (PRN) is appropriately recorded with specific written guidance for staff on each PRN medicine. Good practice in the home should ensure that residents are able to manage their own medicines where this has been assessed and agreed to be safe. There are lockable cupboards in each bedroom for residents to use. The manager trains care staff in the safe administration of medicines in the home and two of the care staff said that they were currently doing a distance-learning course in the safe administration of medicine. It is recommended that the registered manager ensures that her own training in medication procedures is regularly updated to make sure that practice in the home is safe and that she has up to date knowledge in the area of medication. Each resident has an individual plan of care based on the information gathered by the manager in the initial assessment of care needs. Care staff sign to say that they have read the care plans. There are also separate records of the care provided each day and records of visits by GP’s and District Nurses. The care plans record basic information but could contain more detail about how the health care needs of residents are monitored. There were some gaps in the information recorded and not all of the residents have an up to date moving and handling assessment. Where risks have been identified, the management plan for reducing or minimising that risk should be regularly reviewed and updated. For example, the risk assessment for one resident who likes to go out on their own had not been updated for over 12 months and although the manager confirmed that the risk assessment had been agreed with the resident’s relatives and others, there was nothing recorded or signed to this effect. Feedback about the care provided by the home was mixed; comments from residents and relatives were very positive and residents were full of praise for the manager and care staff. It was evident from observation of practice in the home that care staff know the residents well and care is provided with regard for individual privacy and personal preferences. However, concerns about the care provided to two residents with a high level of care need were expressed by community health and social care professionals and it was reported that on some occasions, staff have needed prompting to provide the appropriate care needed, such as regular bathing, recording fluid intake, and monitoring the administration of appropriate pain medication. These concerns were discussed with the registered manager. The manager said that she was looking at current guidance in order for the home to develop a planned programme for palliative care when this was identified as the appropriate care plan. There has been one complaint about the care of a resident and this complaint is currently being investigated with the full co-operation of the manager, by a multidisciplinary team led by Social Services. The outcome of this is as yet unknown. Regents House Rest Home DS0000012319.V344376.R01.S.doc Version 5.2 Page 12 The last inspection noted that the home were having difficulty finding dental services for some of the residents and during this inspection, the manager reported that they were having difficulty accessing chiropody services for the residents. These difficulties should be highlighted to the relevant health care body to ensure that the health care services that residents need are made readily available. Regents House Rest Home DS0000012319.V344376.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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. The manager ensures that residents can please themselves as to how they spend their time and welcomes their visitors. Residents can bring their own possessions into the home. Meals are varied and the home can cater for special diets. EVIDENCE: Meals are prepared daily by the care staff on duty and meals are served in the dining room that is large enough to accommodate all of the residents. Residents spoken to say the food is good and they could choose alternatives whenever they wanted to. The manager discusses the menu with the residents and makes sure those individual preferences and special diets are catered for. The home does not have a programme of social activities although the manager does try to offer different activities now and again and was planning to try out a musical entertainer who will come into the home. Residents spoken to say that they were happy with the routines in the home and either preferred their own company or watching TV. The smoking policy in the home has been changed and a downstairs room has been designated the smoking Regents House Rest Home DS0000012319.V344376.R01.S.doc Version 5.2 Page 14 room. The home, in consultation with the residents, has applied for and will be given, a grant, to improve facilities in the home for the residents. It is planned to spend the grant on new dining room and lounge furniture, a shower facility, and a new large screen television. The home has a regular volunteer visitor from a local church who has been visiting the home for a number of years. During the inspection, other visitors were made welcome if they were visiting residents and were able to see residents either in their bedrooms or in the lounge. There is also a garden area that is accessible for residents and has seating for use in the warmer months. Regents House Rest Home DS0000012319.V344376.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 - Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure and responds appropriately to any complaints or concerns. Staff are aware of the procedures to follow for protecting residents in the event of an allegation or suspicion of abuse. However, the procedures for staff recruitment and carrying out preemployment checks on new staff are poor, and this has the potential to place residents at risk of harm. EVIDENCE: Two residents and one relative returned a comment card and all of these indicated that they knew how to complain in the event of having a concern or complaint. Discussion with some of the residents demonstrated that they felt confident in speaking to the manager if they had any concerns. The manager reported that there have been two complaints since the last inspection, one was resolved by the home using their complaints procedure and one is still being investigated by the local authority Social Services under their ‘Safeguarding Adults’ procedures, the manager reported that she has cooperated fully with the investigation and the outcome has yet to be discussed with the home. The two members of care staff on duty were clear that they knew their responsibilities to report any allegation or suspicion of abuse of residents and Regents House Rest Home DS0000012319.V344376.R01.S.doc Version 5.2 Page 16 were aware of the agreed procedures for this, having covered this in their training for the National Vocational Qualification (NVQ) in care. However, poor staff recruitment practice in the home has the potential to put residents at risk of harm. The home has recruited two new staff members who are working in the home without any pre-employment checks. Although the manager reported in the Annual Quality Assurance Assessment (AQAA) that the home meets the current regulatory requirements for staffing and recruitment checks – records show that written references and police checks have not been requested for the two new members of staff. The manager and owner’s representative agreed that this would be addressed immediately and that the new staff would be supervised until all checks are received and are satisfactory. Regents House Rest Home DS0000012319.V344376.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, 22 and 26 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally the home environment is clean and comfortable for the residents and there are plans to improve the furnishings in the near future with the aid of a grant. The home would benefit from a regular maintenance programme to ensure that minor repairs and checks are ongoing and proactive. The home must ensure that suitable hand washing facilities are provided to maintain good hygiene and reduce the risk of cross infection. EVIDENCE: The use of cloth towels is not considered to be good practice in maintaining good hygiene and reducing the risk of cross infection. Although washing areas had liquid soap there were no paper towels for the use of staff or residents. Staff do not have separate toilet and washing facilities and have to wash their hands in either the laundry or the kitchen, neither of these areas had paper towels. The basement and sluice/laundry area had a cloth towel and the Regents House Rest Home DS0000012319.V344376.R01.S.doc Version 5.2 Page 18 residents’ bathrooms had no towels at all. This has been an issue of concern at previous inspections. During the inspection visit a number of minor defects were noted that should be part of the home’s regular inspection and maintenance programme: • Leaking cistern in the ground floor bathroom • Door lock broken in first floor bathroom • Broken tiles in both bathrooms (these were also broken at the last inspection) (The manager said that the upstairs bathroom is due to be refurbished and a shower will be fitted) Although the manager has been recording hot water temperatures in baths and washbasins, no action had been taken when these were too hot. The proprietor’s representative adjusted the thermostatic control valves when the concern was pointed out, but this should be regularly checked for the safety of the residents. The laundry floor has been patched up but is still awaiting the refurbishment that was planned at the previous inspection. The laundry in the basement is in a poor state of repair and decoration and there is a hole where the tumble dryer outlet goes outside and this is dirty and covered in laundry fluff. Previous inspections have highlighted the lack of private office space for the manager. The proprietor’s representative explained that currently there is no available area for this, however, it remains a concern, as the manager has no area to take confidential phone calls, keep records up to date or speak to staff in private. The manager has a desk in the residents’ dining room, and confidential records are kept in the basement area that residents do not have access to. The home has a hoist that is used by one resident and the manager confirmed in the Annual Quality Assurance Assessment that this is regularly serviced and staff have been trained to use it safely. Regents House Rest Home DS0000012319.V344376.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 poor. This judgement has been made using available evidence including a visit to this service. Residents in the home are not being protected by robust or thorough staff recruitment procedures. There is no comprehensive staff training plan and a lack of evidence of regular staff supervision and monitoring of practice in the home. This may mean that staff in the home are not skilled and experienced to meet the physical and emotional care needs of the residents at all times. EVIDENCE: Two care staff have started working in the home before police checks and references have been applied for. The home is legally required to operate a thorough staff recruitment procedure to protect residents from the risk of harm or abuse. Although the manager reported in the Annual Quality Assurance Assessment that they were meeting regulatory requirements, inspection of records in the home found that practice in staff recruitment is poor; this has the potential to place residents at risk. The manager and representative of the registered provider confirmed that they would address this immediately and ensure that new staff would be supervised until all satisfactory checks were in place. As well as ensuring that pre-employment checks are satisfactory before new staff start working in the home, the home must improve their recruitment practice to include a fully completed application form, ensure that they have a full work history, obtain two satisfactory and written references, and ensure Regents House Rest Home DS0000012319.V344376.R01.S.doc Version 5.2 Page 20 that they have a satisfactory medical history to ensure that staff are fit to work in the home. The home must also carry out satisfactory checks on volunteers who visit the home to ensure the safety and welfare of the residents. Records in the home of staff training are poor. There was no written record of new staff following an induction programme that meets nationally agreed standards for induction to care. There is no staff-training plan and records of staff supervision are not up to date. The lack of a staff training programme and inconsistent supervision records may mean that staff do not have the skills and experience to meet the particular and specialist physical and emotional needs of the residents. Some of the staff have not had sufficient training to enable them to work safely in the home at all times. Regents House Rest Home DS0000012319.V344376.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 poor. This judgement has been made using available evidence including a visit to this service. The practice in the home for the recruitment, training, and supervision of staff is inconsistent and this may mean that residents in the home are not adequately protected or safe from harm. The health, safety and welfare of residents and staff is not consistently monitored and promoted. EVIDENCE: The registered manager has worked in the home for a number of years and is experienced and working towards achieving the National Vocational Qualification in Care – level 4. Comments from residents, staff, and visitors demonstrate that the manager has a caring approach to managing the home that is appreciated by the residents. However, the home does not have a clear management structure and there is no deputy manager or senior carer to be in charge of the home when the manager is not there. This means that the Regents House Rest Home DS0000012319.V344376.R01.S.doc Version 5.2 Page 22 monitoring of practice in the home to ensure the safety and welfare of residents and staff is inconsistent and has the potential to put residents and staff at risk. The home does not have a system for quality assurance that measures how well the service meets the needs of the residents. The quality assurance or quality audit should seek regular feedback from the residents, staff, and visitors and be part of the home’s development plan. The quality audit should also provide evidence that there are good systems of organisation and management in place that promote the residents and staff safety and wellbeing. The quality audit should also regularly measure how well the service is meeting the National Minimum Care Standards and ensure that the service is compliant with the Care Homes Regulations 2001. The registered manager has identified in the Annual Quality Assurance Assessment that the home needs to develop a good quality assurance system but this has not yet been addressed. Discussion with staff during the inspection visit indicated that the previous inspection report and the statutory requirements had not been discussed with staff. Requirements and recommendations are made where practice in the home must improve to ensure the safety and well being of the residents. The registered manager also has a legal obligation to ensure that statutory requirements are met, within the timescales given. The Annual Quality Assurance Assessment (AQAA) that was completed by the manager could contain more information to provide evidence of what the home does well and what improvements are planned. The AQAA says that the home addresses issues of equality and diversity by “promoting the holistic approach to care, and provides courses for staff to understand service users rights and their responsibility to promote”, however, the inspection found no evidence of this in practice and the home lacks a comprehensive training plan for the care staff. One of the barriers to improvement that the manager has identified is “lack of time to spend on paper work” and this would suggest that a review of the staffing and management structure is needed so that the manager has time to put improvements in place and meet the statutory requirements. Regents House Rest Home DS0000012319.V344376.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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 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 1 2 X X 3 X X X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 2 Regents House Rest Home DS0000012319.V344376.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 OP8 Regulation 13 (4) Requirement Residents must be protected from unnecessary risks. Any risks to residents must be assessed and risk management plans recorded and reviewed as to how risks will be minimised or as far as possible eliminated. The recording and storage of controlled drugs in the home must comply with the Misuse of Drugs (Safe Custody) Regulations 1973. Timescale for action 06/11/07 2. OP9 13 (2) 14/01/08 3. OP18 13 (4) 4. OP29 19 and Schedule 2 5. OP33 24 Residents must be protected 06/11/07 from the risk of harm by carrying out satisfactory pre-employment checks on all new staff before they start working in the home. Staff recruitment procedures 06/11/07 must ensure that staff are suitable to work in a care home. These must include at least a full job history, two satisfactory written references and satisfactory criminal record and protection of vulnerable adults checks before the post is agreed. There must be an effective 14/01/08 DS0000012319.V344376.R01.S.doc Version 5.2 Page 25 Regents House Rest Home system of quality assurance that measures how well the service is meeting the needs of the residents and monitors compliance with the home’s legal and statutory requirements. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations Obtain a copy of the guidance document on the safe administration of medication in care homes from The Royal Pharmaceutical Society to inform practice in the home for the safe storage and recording of medicines for residents. Regents House Rest Home DS0000012319.V344376.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 Regents House Rest Home DS0000012319.V344376.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!