Inspection on 12/02/07 for Seahorses

This inspection was carried out on 12th February 2007.

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

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

Other inspections for this house

Seahorses 23/10/07

Seahorses 30/09/05

Seahorses 18/05/05

Seahorses 12/10/04

Seahorses 25/05/04

Seahorses 10/03/04

Seahorses 26/11/03

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

CARE HOMES FOR OLDER PEOPLE Seahorses 73 Draycott Road Chiseldon Swindon Wiltshire SN4 0LT Lead Inspector Bernard McDonald Key Unannounced Inspection 12th February 2007 09:30 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 Seahorses DS0000003171.V304777.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. Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seahorses Address 73 Draycott Road Chiseldon Swindon Wiltshire SN4 0LT 01793 740109 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 Peter Coleman Mrs Shirley Cole Care Home 15 Category(ies) of Dementia - over 65 years of age (15) registration, with number of places Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than 15 services users with DE/E at any one time. Date of last inspection 30th September 2005 Brief Description of the Service: Seahorses is a private 15 bed home that provides care and accommodation for men and women aged over 65 years who have dementia. The home is situated on the outskirts of Swindon in the village of Chiseldon. Close by is Junction 15 of the M4.The accommodation is mainly on the ground floor with two bedrooms on the first floor. It consists of two shared rooms and 11 single rooms. The homeowner takes a keen and personal interest in the running of the home and resides on the premises most of the time. The homes manager has the day to management responsibility of the service. Support staff give the personal care and provide for the welfare needs of the service users. Their duties also include cooking, cleaning and administration as part of their job role. The home provides a garden with flat level access. Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visits took place over two days lasting a total of nine and a half hours. The first day of our site visit was unannounced and the second day was by appointment with the manager and registered provider. A tour of the building was made and all areas of the home including all service users bedrooms and communal living areas were seen. We met with the majority of service users and had opportunity to speak to service users in private, though it was not possible to obtain the views of all service users due to their illness. In addition five members of staff and a district nurse were spoken to in private. The manager was also available to assist throughout the site visit. As part of our inspection, comment cards were sent to service users, their representative’s, health care professionals and placing authorities. Five care plans were examined in detail. In addition medication records, staff recruitment files, training records, health and safety documents and a sample of risk assessments were also examined. Feedback on the preliminary findings was given to the manager and the registered provider at the end of the site visits. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: The home has developed a statement of purpose and service user guide that provides service users with sufficient information to enable them to make a choice about living at the home. Service users or their representatives are also able to visit the home before making any decision about moving. One service user commented they liked living at Seahorses and comment cards received from the relatives of service users had no adverse comments about the care provided at the home. Opportunities are available to enable service users engage in daytime activities. These include occasional visits from outside entertainers in addition to the daily activity programme. Observations made during the site visit found staff treating service users in a respectful manner and referring to the service user by their preferred title. The home was clean and comfortably furnished and maintained to a good standard. Staff have access to National Vocational Qualification training in care and at present over 50 of staff have completed the award. The manager is ensuring staff are appropriately supervised and one service user commented that the “staff are very nice” Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 6 The home is continuing to look at ways of improving the service provided and the appointment of an independent person who is qualified in social care to complete quality reviews is seen as good practice. 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. Seahorses DS0000003171.V304777.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 Seahorses DS0000003171.V304777.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): 1, 3, 6. The statement of purpose and service user guide provides information to enable service users to make a choice about living at the home but more attention needs to be given to ensuring the home is able to meet the needs of service users being referred. The quality rating in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The care records of three service users recently admitted to the home were examined in detail. The records of two service users demonstrated the manager visited the service users in their previous living environment prior to the service users moving in. As a matter of good practice these assessment visits should be recorded. The care records of one service user did not have evidence of such a visit. The manager reported this was due to being told not to visit the service user. The reason why this decision was made was not recorded. Discussion with the manager confirmed that any service user who is referred is invited to come and view the home. The service user would be offered the opportunity to stay for a meal or spend the day before being offered an overnight stay. This practice was reflected in the homes statement Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 9 of purpose, which states “service users can visit, join in activities to enable them to have sufficient information on whether they want to move to the home.” Records demonstrated each service users had an interim care plan which is reviewed a month after moving in. However the community care assessment of one service user was not held in the care records. The manager stated one had been received. The manager must ensure they write to the service user to confirm their needs can be met at the home. The home does not provide intermediate care. Seahorses DS0000003171.V304777.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): 7, 8, 9, 10. Each service user has a plan of care, however more attention needs to be given to ensure the care plan reflects the actual care being provided and any specialist interventions are clearly documented. Risks to service users are being identified but the action required to reduce the risk is somewhat vague. Safe medication handling is promoted in the home by training and procedures, however there are areas relating to ‘as required’ medication that could put service users at risk. The quality rating in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The care plans of five service users were examined in detail. The care plan identifies the service users needs, goals and staff intervention. The contents of the care plans were in part well written. However what was lacking were clear directions for staff to follow. For example one care plan specified staff had to maintain a service users mood level. The staff intervention was to be alert to the service users mood but there was no guidance on what staff should do or what they should look for. Another care plan recorded the need for one service user to have hourly checks at night. Another service user needed to be turned Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 11 every two hours. There was no evidence to show whether these interventions were happening. This was raised with the manager and she immediately implemented a system for recording and monitoring these interventions. In discussion with care staff it was evident they knew the needs of the service users and their role in supporting them. This good practice should be reflected in the care plan to ensure consistency throughout the staff team on how to meet the holistic needs of service users. There was opportunity to meet with the majority of service users. Where we were able to communicate with service users, comments received were positive. One service user commented the “staff are very nice” another service user commented they “l like living here” [Seahorses]. In relation to risks to service users the home had considered what the risks were. Although these were recorded they had not identified measures, which will reduce the risk to service users. We discussed with the manager the need for more comprehensive risk assessments. The manager provided a copy of a more robust risk assessment, which had been developed, for two service users. The assessment clearly identified the risk, hazard and control measure. These assessments had been reviewed each month to ensure they remain appropriate and did not unnecessarily restrict service users freedom. This format should be used for all service users. Throughout the site visit staff were observed spending time with service users and offering assistance in a respectful manner. Service users preferred form of address was clearly recorded on the care plan. All service users are registered with the local health care practice. A G.P. surgery is held at the home every two weeks. The manager reported that the chiropodist normally visits every two weeks. The pharmacist inspector looked at arrangements for the handling of medicines at Seahorses. No service users are currently self-medicating. All are assessed on admission for suitability. In-use medication is stored securely, however some excess stock is kept in a cupboard which does not lock. Records of receipts, administrations and disposals are maintained. Medication administration records are printed by the pharmacy, written additions had not been signed, dated and checked by two members of staff. All staff receive training on the safe handling of medication and information about the drugs is kept with the medication administration sheets. One eye ointment was in use but had not been dated. This could lead to it being used past its 28 day expiry period. Records were kept of the administration of all medicines prescribed ‘as required’, but these did not include the times of administration. Medication prescribed ‘as required’ must also have clear protocols for use to guide staff in when they are needed and how often they should be used. Daily notes are made of all matters concerning the residents including visits from healthcare professionals, however a system to highlight these visits would make it easier to trace GP visits and changes to medication. A list of appropriate medicines to be used without a prescription has been agreed with the GP. Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. The home is making every effort to involve service user in social and recreational pastimes. Visitors are welcome and mealtimes are relaxed and unhurried. The quality rating in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Service users care plans do contain some information on their interests and hobbies. For example one service user enjoys listening to music and one service user enjoys poetry. A list of suggested activities is on display on the notice board. As part of the morning activity staff were observed dancing with some service users in the lounge. The service users participating appeared to enjoy the activity. The manager reported that outside entertainment “music for health” visits twice a month. The records of activities being held at the home could not be found, however discussion with staff confirmed that each day staff try to have an activity planned. Service users religious preferences are recorded and at the present time only one service user receives regular communion. The manager reported that the local clergy will drop in when passing. The manager confirmed visitors are welcome at anytime though are asked wherever possible to avoid lunchtimes. Comment cards we received from relatives confirmed they were made to feel welcome at the home and were Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 13 kept informed of important matters relating to the care of their relative. To support service users to maintain contact with people who are important to them a telephone is available for their use. The manager reported that at the present time no service user has a private telephone in their room The manager confirmed that all matters relating to personal finances are either managed by relatives, the placing authority or the service users legal representative. Part of the lunchtime meal was observed. The mealtime appeared relaxed and unhurried and where assistance with a meal was required this was done in a discreet manner. The main meal of the day is provided at lunchtime. The evening tea is served around 5pm and supper is at eight o’clock. Service users weight is monitored and if necessary advice from the dietician can be accessed through the G.P. The home operates a four-week menu, which was varied, but did not offer a choice. The manager reported service users likes and dislikes are known but if they refused a meal then an alternative would be offered. Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. The home is making every effort to ensure service users views are listened to though more attention needs to be given to recruitment practices to ensure service users are fully protected. The quality rating in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Since the last inspection the home has updated the complaints procedure to provide clear timescales for responding to any complaints. The policy now states that any complaint will be acknowledged within 7 days and the home will endeavour to resolve the complaint within 28 days. An abridged version of the complaints procedures was on display at the entrance to the home. The manager confirmed no complaints had been received since the last inspection. No complaints had been recorded in the complaints book. Discussion with staff demonstrated an awareness of what action they would take to report any concerns affecting the welfare of service users. Staff who were spoken to confirmed they had no concerns about the welfare of service users and were clear they would report any concerns to the manager. Staff confirmed they had received abuse awareness training, which was also evidenced by staff training records. Three staff have still to complete the training. One service user commented when asked about feeling safe in the home, “ I love the staff and they love me”. A whistle blowing policy is in place and a copy of Swindon and Wiltshire “no secrets” guidance was available in the home. Safe recruitment practices were not being followed for all staff employed at the home. Two members of staff recruited from overseas did not have the Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 15 necessary Criminal Records Bureau (CRB) check in place before commencing work. Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 26. The home was clean, tidy, well maintained and suited to the needs of service users. The quality rating in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Since the last inspection significant improvements have been made to the overall décor and fabric of the building. For example the kitchen has been refurbished with new units and tiling. New dining room furniture has been purchased and the communal lounge has been decorated and a new carpet fitted. A tour of the building was made. All service user bedrooms have been fitted with locks allowing access to staff in the event of an emergency. Not all radiators are guarded so as to reduce the risk of accidental scalding. and one hot water outlet in a service users bedroom was in excess of the recommended 43c. A new thermostatic valve had been fitted at the second site visit. Discussion with the registered provider confirmed over 60 of radiators are now guarded and it is envisaged the remaining radiators will be guarded within the next three months. Service users individual rooms had been Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 17 personalised with effects such as photographs and small items of furniture. One service user commented that they “liked”, their room, another service user commented they had everything they wanted in their room. The laundry room is sited away from any food preparation or storage area. There is a commercial washer and dryer and walls and floors were easily cleanable. Since the last inspection red “alginate” bags have been purchased for soiled or infected washing to reduce the risk of infection. No adverse comments were received from residents about the laundry arrangements at the home. Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Staff have access to training appropriate to their role, however more attention needs to be given to ensure safe recruitment practices are followed to ensure service users are protected. The quality rating in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Examination of the rota showed that there are normally four members of staff on duty in the morning. One member of staff undertakes cooking duties and one member of staff is responsible for cleaning but can be called upon for care duties. From 2.00 p.m. there are only two members of staff on duty one of whom has to help prepare tea leaving one member of staff providing care and supervision to service users. This matter was discussed with the manager who discussed ways the rota can be changed to provide more staff around mealtimes. Two members of staff also provide waking night cover. Service users who could express a view were complimentary about the care provided. There are nine permanent members of staff employed at the home. The manager reported six care staff have completed National Vocational Qualification (NVQ) level 2 in care. A random sample of three staff training records were examined. Records demonstrated staff had received training in mandatory courses such as moving and handling, fire safety, food hygiene, and abuse awareness. In addition some staff had completed dementia care training and staff have access to “positive dementia care” training through the local college. Certificates Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 19 demonstrating successful completion of NVQ training were also evident on staff files. The recruitment records for three members of staff recently recruited were examined in detail. We found that the records for two members of staff recruited through an overseas recruitment agency did not contain a satisfactory CRB or Protection of Vulnerable Adults (POVA) check. The registered provider stated the agency had informed them all the necessary clearances had been obtained and the provider is to discuss this matter with the agency. At the second site visit the provider had received POVA first checks on the two members of staff from overseas and a full disclosure from CRB had been applied for. The recruitment records of the member of staff not supplied by the agency had a satisfactory CRB, POVA check and two written reference together with confirmation of the identity of the staff member. There was documented evidence to demonstrate staff had completed induction training and one member for staff confirmed they had been able to shadow a senior member of staff as part of their induction. The home’s induction programme is currently being updated to meet the “Skills for Care” standards. Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. The manager is qualified and experienced to ensure the home is safe and run in the best interest of service users. Quality auditing of the care and service being provided is progressing well. The quality rating in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Mrs Cole has been the registered manager for over seven years. She has completed the registered managers award and holds an NVQ 4 in care. Mrs Cole has continued to update her training in dementia care and is currently completing a food safety course. Discussion with staff confirmed the manager is approachable and will make time for them to discuss issues of concern. Staff confirmed they receive regular one-to-one supervision with the manager and a written record of the meeting is kept. Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 21 Discussion with registered provider confirmed the home has employed an independent person qualified in social care to undertake a quality assurance report. A copy of the last report dated 30 November 2006 was available at the home. The report highlighted that it was the first report for the service in the past year though four unannounced inspections had taken place. The methodology used to complete the report included observation of staff meetings, discussion with service users, a tour of the grounds and buildings and speaking with service users families. There is evidence to demonstrate the service is making every effort to ensure the quality audit is as independent as possible and in a service where people are confused this is considered to be good practice. To further extend the scope of the quality audit the service should consider how seeking the views of relevant stakeholders. The home is not holding any money on behalf of service users. The responsible individual confirmed that in all cases their families or a legal representative manages service users financial matters. The home has developed a health and safety policy that was last reviewed in January 2007. Staff records that were examined demonstrated they had received training in safe working practices, moving and handling and first aid. Since the first site visit the manager has taken steps to reduce the risk of injury to service users and has instructed a plumber to install a central hot water valve to ensure water is distributed close to 43c. In addition checks are now being made on all hot water outlets in service users rooms to ensure water temperatures are at a safe temperature. A fire risk assessment has been completed and fire safety checks are being carried out. In addition risk assessments have been completed on the service users environment. These documents have not been reviewed since March 2004 and it is recommended they be reviewed to ensure the safety of service users. Seahorses DS0000003171.V304777.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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 3 X X X 2 X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(d) Requirement The registered person having regard to the service user assessment must write to the service user to confirm the home is suitable for meeting their needs in respect of their health and welfare. A copy of the letter must be kept on each service users care record. The registered person must prepare a written plan as to how the service users needs are to be met at the home and ensure any specialist interventions are clearly recorded. The registered person must ensure any unnecessary risks to service users are identified and as far as possible eliminated and ensure risk assessments clearly record the steps required to reduce the risk to service users. The registered person must ensure all medication is stored securely. The registered person must ensure medication which has a shortened expiry date in use (e.g. eye preparations) must be DS0000003171.V304777.R01.S.doc Timescale for action 01/03/07 2. OP7 15(1) 01/05/07 3. OP7 13(4)(c) 01/05/07 4. 5. OP9 OP9 13(2) 13(2) 01/05/07 01/05/07 Seahorses Version 5.2 Page 24 6. OP9 13(2) 7. OP29 19(1)(a) (b) dated on opening to ensure that it is discarded at the appropriate time. The registered person must 01/05/07 ensure all medication prescribed ‘as required’ have protocols for their use to ensure that they are given appropriately. The times of administration must be recorded. To ensure service users are fully 01/05/07 protected the registered person must ensure all staff have a satisfactory CRB and POVA check before commencing work. 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. 3. 4. 5. Refer to Standard OP3 OP9 OP9 OP27 OP38 Good Practice Recommendations The registered person should ensure they meet with service users prior to them moving into the home. If this is not possible then the reasons why should be recorded. The registered person should ensure written additions to the medication administration record are signed, dated and checked by two members of staff. Clearer recording of doctors’ visits would make it easier to evidence medication changes. The registered person should review the staffing levels at peak times to ensure there is sufficient staff on duty to meet the needs of service users. The registered person should ensure risk assessments are reviewed annually. Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Seahorses DS0000003171.V304777.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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