Inspection on 02/08/06 for Ryedale Court Nursing Home

This inspection was carried out on 2nd August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ryedale Court Nursing Home 28/08/07

Ryedale Court Nursing Home 20/01/06

Ryedale Court Nursing Home 16/06/05

Ryedale Court Nursing Home 09/12/04

Ryedale Court Nursing Home 07/06/04

Ryedale Court Nursing Home 18/09/03

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Ryedale Court Nursing Home Victoria Road Barking Essex 1G11 8PE Lead Inspector Ms Gwen Lording Unannounced Inspection 09:30 2 August 2006 nd 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 DS0000015602.V300523.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. DS0000015602.V300523.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ryedale Court Nursing Home Address Victoria Road Barking Essex 1G11 8PE 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) 020 8514 2525 020 8514 2727 Avonpark Care Centre Limited Mr Selvenaden Tiagarassa Pillay Care Home 70 Category(ies) of Dementia - over 65 years of age (53), Old age, registration, with number not falling within any other category (17) of places DS0000015602.V300523.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 17 BEDS FOR ELDERLY FRAIL 53 BEDS FOR ELDERLY MENTALLY ILL MINIMUM STAFFING NOTICE To include one named person under 65 years of age. Date of last inspection 20th January 2006 Brief Description of the Service: Ryedale Court Nursing Home provides nursing care and accommodation for older people who have dementia or physical frailty due to the ageing process. The home is registered to accommodate seventy service users. The registered providers are Avonpark Care Centre Limited. The home has three separate units, two of which accommodate older people with dementia and one smaller unit for the frail elderly. The majority of the rooms are single and en suite with three double rooms on the elderly frail unit. There is a passenger lift. The home employs an activities co-ordinator, catering, laundry, housekeeping, administrative and maintenance staff. The home is situated in a residential area of Redbridge on the borders of Barking and is well served by public transport. On the day of the inspection the fees for the home were £545.00 per week. A copy of the Statement of Purpose and Service User Guide is made available to both the resident and the family. This information is also held at the main reception and on all three units. A copy of the most recent inspection report is available on request. DS0000015602.V300523.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection started at 9.30am and took place over eight and a half hours. The registered manager was available throughout the visit to aid the inspection process. This was a key inspection visit in the inspection programme for 2006/2007. An additional unannounced visit was made to the home on 27/03/06 to follow up progress on requirements made at the previous inspection. A specialist inspection was also undertaken on the 13/04/06 by the Pharmacy Inspector. Discussion took place with the registered manager, several members of nursing and care staff, the head cook, laundry, domestic and administrative staff. Nursing and care staff were asked about the care that residents receive, and were also observed carrying out their duties. The Inspector spoke to a number of residents on each of the three units, and where possible residents were asked to give their views on the service and their experience of living in the home. In addition the relatives/ visitors of fourteen residents were spoken to and asked their views and comments about care in the home. All parts of the home were visited and a number of staff, care and home records were looked at. The Inspector would like to thank the staff, residents’, and their relatives/ visitors for their input during the inspection. What the service does well: There is a relaxed atmosphere throughout the home and residents appeared unhurried and are given sufficient time and support in their everyday lives. The meals in the home are well presented and offer both choice and variety for residents living in the home with individual preferences, special religious or cultural needs being catered for. Visiting times are flexible and people are made to feel welcome in the home so that residents are able to maintain contact with their family and friends as they wish. Relatives and friends are encouraged and welcomed to be involved in activities/ special events in the home, in line with residents wishes. Staff were seen to be working effectively as a team throughout the inspection, with staff interacting well, both with each other and residents. DS0000015602.V300523.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. DS0000015602.V300523.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 DS0000015602.V300523.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive assessments are being undertaken for all residents prior to them moving into the home. Care plans are drawn up from the information in this assessment, ensuring that the needs of the residents are identified, understood and met. The home does not offer intermediate care. EVIDENCE: Individual records are kept for each resident and a total of eight files were examined across the three units. All records inspected have assessment information recorded and the information had been used to continue assessment following admission to the home and develop written care plans. DS0000015602.V300523.R01.S.doc Version 5.2 Page 9 Prospective residents and their relatives/ representatives are provided with information about the home and there is always the opportunity to visit the home prior to making any decision to move in. The Care Homes Regulations 2001 have been amended with effect from the 1st September, 2006 for new residents, and for existing residents with effect from the 1st October, 2006, so that more comprehensive information is to be included in the service users’ guide. Details of information to be included are contained within the amended regulations. Therefore, the service users’ guide must be reviewed and amended by the stated timescales. DS0000015602.V300523.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 and 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Standard 9. Not all elements of this standard were tested at this key inspection, as a specialist inspection was undertaken by the Pharmacy Inspector on the 13th April 2006. However, there are some inconsistencies in the recording of medication, which may result in unsafe practices. Residents’ health and personal care needs are set out in individual care plans but not all care plans accurately reflected the current needs and did not provide staff with sufficient information to ensure that care needs were being met on a daily basis. EVIDENCE: Individual care plans were available for each resident and a total of eight residents were case tracked and their care plans and related documentation inspected. Whilst the standard of care planning had improved overall, there was still some inconsistency in the completion of care plans across the units. New pro forma care planning documentation has been introduced but this is not yet standardised across the three units. Progress must continue with its DS0000015602.V300523.R01.S.doc Version 5.2 Page 11 implementation to ensure that a consistent standard is achieved throughout the home. As part of case tracking the documentation/ health records relating to wound management; the management of a resident with diabetes and a recently admitted resident, were examined. The records for these residents were found to be generally detailed and being adequately maintained. Risk assessments are routinely undertaken on admission for all residents around nutrition, manual handling, continence and pressure sore prevention. Records are maintained of nutrition, including weight loss or gain with appropriate action being taken where necessary. Records indicated that residents are seen by other health professionals such as tissue viability nurse, optician, speech and language therapist and diabetic nurse specialist. However, there were inconsistencies in the practice and standard of some care plans examined and the following was discussed with the manager and nurse in charge of the respective units: • • Not all care plans examined were being evaluated/ reviewed on a regular basis nor updated to reflect changing needs. One examination of two care plans it was noted that cot sides/ lap belts were indicated for use when the residents’ were in bed and being transported by wheelchair. Whilst risk assessments had been undertaken for their use, there was no record to show that discussion had taken place with the resident’s relative/ representative or permission sought. One resident had bee identified as having a non-isolated infection but there was no control of infection care plan in evidence, nor information around universal precautions. There was no evidence in files of “End of Life” care plans and the importance of developing these was discussed with the manager and some nursing staff, during the inspection. However, from conversations with staff it was apparent that staff dealt with a person’s dying and death in a sensitive and understanding manner, both for the individual and relatives. • • A number of food fluid intake/ output and turning regime charts were examined. These were being maintained adequately and up to date with the exception of charts on Oaklands Unit, which were being completed by staff retrospectively. However, the Inspector observed fluids being given/ offered to residents in all units regularly throughout the visit. Staff were observed to treat residents with respect and the arrangements for their personal care ensure that their right to privacy is upheld. However, at the DS0000015602.V300523.R01.S.doc Version 5.2 Page 12 time of the inspection an optician was conducting a surgery on Oaklands Unit. The optician was using the room of one resident to provide treatment for all other residents receiving treatment. The inspector brought this to the attention of the nurse in charge who addressed this immediately. Any consultation or examination by, health and social care professionals must take place in the resident’s own room. A specialist inspection was undertaken by the Pharmacy Inspector on the 13th April 2006. Therefore, only a random sample of Medication Administration Records (MAR) charts were examined on each unit. The following issues were discussed with the manager and the nurses in charge of the particular units: • • Handwritten entries on MAR charts must be signed and dated by the person making the entry. The entry must also include the source of the information e.g. GP. When directions for administering medications are variable e.g. one or two tablets, then the dose given is to be entered on the MAR chart. DS0000015602.V300523.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a general programme of activities available but more consideration needs to be given to planning activities, which are suitable to the needs of individual residents. This will ensure that al residents have a sufficiently stimulating and varied choice of activities. Visiting times are flexible and people are made to feel welcome in the home so that residents are able to maintain contact with their family and friends as they wish. The meals in the home are good, offering both choice and variety for residents living in the home. EVIDENCE: There is a full time activity co-ordinator and a programme of general activities available for all residents. Some of these activities are individual and some small group activities. Various functions are arranged such as the recent “Summer Fete”, and visits by visiting professional entertainers. On the day of the visit some residents were observed to be reading or watching TV, but it was apparent that some residents would not be able to do this, and generally DS0000015602.V300523.R01.S.doc Version 5.2 Page 14 were just sitting and not occupied or engaged in any meaningful activities. The activity co-ordinator was on leave and it would seem that the activities are left mainly to the remit of the activity co-ordinator and that care staff do not really participate and continue planned activities in the absence of the co-ordinator. More consideration must be given to provide meaningful activities for those residents who lack the capacity to be involved in the general activity programme for the home. Relatives are encouraged to visit the home and there are no restrictions on when relatives and friends can visit. Visiting can be undertaken in the lounges or in the privacy of the resident’s room. Visitors were observed at various times during the inspection, and the spouses of some residents choose to spend most of the day in the home. Relatives/ friends are encouraged and welcomed to be involved in activities/ special events in the home, in line with residents wishes. The Inspector had the opportunity to speak to fourteen visitors during the course of the visit. All visitors spoken to were very positive about the care provided in the home. One relative commented: “ I feel I am part of the team caring for my mother, staff keep me informed and involved in her care”. However, the relative of one resident felt that staff did not involve her in her mother’s care and did not keep her fully informed of all issues. The inspector discussed this with the manager. He is actively addressing the ongoing dissatisfaction with this element of the service being provided to the resident, and to the satisfaction of her relative. From observation and talking with several residents it was evident that the routines of daily living are flexible and varied to suit the differing needs and preferences of residents. The Inspector observed members of staff allowing time for residents to express their wishes and supporting individuals to make choices in their daily lives, for example choosing a drink, where to sit, or where they wished to take their meal. A visit was made to the kitchen and the inspector discussed the storage and preparation of food and menus with the chef in charge. Kitchen staff are aware of those residents requiring special diets, for example diabetic diet; and those residents with religious or cultural dietary needs. Several residents are provided with Halal food and the relative of one resident has provided the kitchen with recipes, to enable the staff to prepare culturally appropriate meals for a Turkish resident. The serving of the lunchtime meal was observed and provided residents with a varied, appealing and nutritious meal. Pureed meals were presented in an attractive and appealing manner and residents who required assistance where not hurried. Staff were seen to offer assistance where necessary and this was done discreetly and individually. DS0000015602.V300523.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager makes every effort to sort out any problems or concerns and makes sure that residents and relatives feel confident that their complaints and concerns are listened to and will be acted upon. Staff working in the home have received training in Adult Protection/ Abuse Awareness to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a written complaints policy/ procedure and the records inspected indicated the number of complaints received and included details of investigation and any action taken. From viewing the complaints records and discussions with the manager it was evident that all complaints/ expressions of concern, whether made formally in writing, or verbally, are taken seriously and dealt with effectively to the satisfaction of the complainant. Those residents and relatives spoken to were aware of how to complain and to whom. Whilst the relative of one resident did not consider that her concerns were being addressed effectively, in discussion with the manager and examining the complaint record, the inspector was satisfied that the manager is actively addressing her ongoing concerns. There is an in house training programme for all staff in adult protection and this has been extended to include all administrative/ ancillary staff. Those staff DS0000015602.V300523.R01.S.doc Version 5.2 Page 16 spoken to during the inspection were aware of the action to be taken if they had concerns about the safety and welfare of residents. The outcome for any adult protection referral is managed well and the registered manager works co-operatively with the Commission and the local authority to address all matters. DS0000015602.V300523.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The overall atmosphere in the home is welcoming, with access to indoor and outdoor communal facilities. The refurbishment programme for the home must be progressed to ensure that all parts of the home are well maintained and provide people living in the home with comfortable surroundings. EVIDENCE: The building was toured by the inspector, accompanied by the manager, at the start of the visit, and all units were visited unaccompanied later during the day. Some bedrooms were seen either by invitation of the residents, or with permission, whilst others were seen because the doors were open or being cleaned. There were no offensive odours in the home and generally the home was clean and tidy. However, the décor looked quite “tired” in some areas with DS0000015602.V300523.R01.S.doc Version 5.2 Page 18 chipped paint and marked walls. The carpet in the corridors and lounge on Park unit was badly stained and requires deep cleaning or replacing. There is an ongoing planned refurbishment for the home and an additional five bedrooms and one of the lounge/ dining rooms have been decorated/ refurbished since the last inspection. Developments for the dementia unit (Oaklands) includes new signage and décor; and name plates/ memory boxes for bedroom doors. The planned refurbishment programme for the home must be progressed as this will greatly improve the environment for all current residents, the specialist needs of people living with dementia and any prospective residents. All bedrooms are very personalised and residents can bring in small items of furniture and personal items, subject to agreement. Many of the bedrooms have been personalised by relatives. Those room visited during the inspection, were seen to indicate or be representative of the individuals cultural, religious or personal interests. The home has a maintenance contract with the London Borough of Barking and Dagenham for the garden. The outside communal areas of the home are attractive and well maintained and fully accessible to all residents. The laundry area was visited and this was found to be clean, with soiled articles, clothing and foul linen being stored appropriately pending washing. Personal protective clothing and equipment were available and in use. Hand washing facilities are prominently sited and staff were observed to be practising an adequate standard of hand hygiene. DS0000015602.V300523.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual assessed needs of the residents. The procedures for the recruitment of staff are robust and provide safeguards for people living in the home. EVIDENCE: Staff rotas were inspected and the staffing levels and skill mix of qualified nurses and care staff, on all units of the home, was sufficient to meet the assessed nursing and personal care needs of residents. Since the last inspection a number of nursing and care staff have left the service, two have been dismissed following disciplinary action and the remainder have resigned. However, these posts have been recruited to. In addition a new position of deputy manager has been created and there is now a person in post. Following concerns raised at the last inspection around the level of competency and training of nursing staff the registered providers have actively addressed these concerns. They have prioritised training and complemented this with internal development of staff, as part of the overall ongoing training plan. DS0000015602.V300523.R01.S.doc Version 5.2 Page 20 Training undertaken since the last inspection includes essential training on abuse awareness/ adult protection; health and safety, manual handling; first aid and oral health care. Staff have also received training specific in the management of diabetes; dementia awareness; pressure sore prevention and management; and the management of constipation. 70 of care staff are qualified to NVQ level 2 or above. Effective team working was observed and evidenced throughout the inspection. Staff interacted well, both with each other and residents. A random sample of staff personal files were inspected and these were found to be in good order with necessary references, criminal records bureau disclosures, and application forms duly completed. It was evident that the recruitment procedures are robust and in accordance with the Care Homes Regulations. DS0000015602.V300523.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is a very experienced and well-qualified person. The lines of accountability within the home have improved and are more robust to ensure that the manager is, at all times, fully appraised of any issues relating to the day to day management of the home, and of the specialist needs of residents. EVIDENCE: The manager has put in place a number of systems to improve and monitor the standard of care provided in the home. This includes regular heads of department meetings; daily visits to each unit and the completion of a ‘Management Handover Sheet’. Regular audits are being undertaken around complaints; accidents/ incidents and pressure care amongst other key areas. DS0000015602.V300523.R01.S.doc Version 5.2 Page 22 A wide range of records were looked at including fire safety, emergency lighting, water temperature checks, accidents/ incident reports. These records were found t be detailed, up to date and accurate. The inspector was satisfied that the financial interests of residents are safeguarded by the home’s financial policies and procedures. Regulation 26 visits are undertaken regularly by the responsible individual and a copy of the report is sent to the Commission. DS0000015602.V300523.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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000015602.V300523.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 12 (1) & 15(2) (b) Requirement The registered person must have in place an up to date and individualised care plan for each service that clearly reflects as to how each identified care need is to be met. (Timescale of 30/04/06 not met) The registered person must review the care plans for service users on a monthly basis or more often as and when changes are noted in service users’ condition. (Timescale of 27/03/06 not met) Where the record of fluid/ food intake, turning regimes etc; is indicated for a resident, these recordings must be accurately maintained and up to date. All handwritten entries on Medication Administration Records (MAR) charts must be signed and dated by the person making the entry; and include the source of the information. Timescale for action 31/08/06 2. OP7 15 (2) (b) 31/08/06 3. OP8 12 02/08/06 4. OP9 13 02/08/06 DS0000015602.V300523.R01.S.doc Version 5.2 Page 25 5. OP10 12 6. 7. OP11 OP12 15 16 8. OP19 23 When directions for administering medications are variable e.g. one or two tablets, then the dose given is to be entered on the MAR chart. Any consultation or examination by, health and social care professionals must take place in the resident’s own room. ‘End of Life’ care plans must be developed for all residents. The home must provide a more varied programme of activities, which are suitable to the needs of individual residents. The refurbishment programme must be progressed to ensure that all parts of the home are well maintained. 02/08/06 31/10/06 31/10/06 A programme of renewal of the 30/09/06 fabric and decoration of the premises must be produced, with timescales, and copy sent to the Commission. 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 DS0000015602.V300523.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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