Inspection on 10/01/08 for Sir Jules Thorn Court and Mary Court

This inspection was carried out on 10th January 2008.

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

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

Other inspections for this house

Sir Jules Thorn Court and Mary... 14/01/09

Sir Jules Thorn Court and Mary... 21/11/06

Sir Jules Thorn Court and Mary... 09/02/06

Sir Jules Thorn Court and Mary... 15/08/05

Sir Jules Thorn Court and Mary... 20/12/04

Sir Jules Thorn Court and Mary... 10/06/04

Sir Jules Thorn Court and Mary... 15/01/04

Sir Jules Thorn Court and Mary... 21/10/03

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

CARE HOMES FOR OLDER PEOPLE Sir Jules Thorn Court and Mary Court 29-35 Prince Of Wales Drive Battersea London SW11 4SL Lead Inspector Davina McLaverty Unannounced Inspection 10th January 2008 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 Sir Jules Thorn Court and Mary Court DS0000019122.V352695.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. Sir Jules Thorn Court and Mary Court DS0000019122.V352695.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sir Jules Thorn Court and Mary Court Address 29-35 Prince Of Wales Drive Battersea London SW11 4SL 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 7738 0280 azad.mooniaruck@servitehouses.org.uk Servite Houses Mr K A Mooniaruck Care Home 31 Category(ies) of Dementia - over 65 years of age (30), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (30), Old age, not falling within any other category (31) Sir Jules Thorn Court and Mary Court DS0000019122.V352695.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One named service user is to receive personal care only by one allocated member of staff. Variation of Registration Under the High Court judgement, the service shall be named Sir Jules Thorn Court and Mary Court. The variation is for such a time until the named service user assessed needs change or they leave the home. Date of last inspection 21st November 2006 Brief Description of the Service: Sir Jules Thorn provides nursing care for up to thirty people who have mental health needs or dementia. The home provides accommodation in single rooms with ensuite facilities. Mary Court adjoins Sir Jules Thorn and has one residential bed. Sir Jules Thorn has two floors, the home is divided into three units, known as clusters, which each have their own day room. The home has a large dining area and access to a small garden. The home is situated in Battersea, close to Battersea Park. There are accessible road and bus links to north and south London. Fees range from £444-48 to £827-12 per week. Sir Jules Thorn Court and Mary Court DS0000019122.V352695.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of this service included an unannounced visit to the home on 10th January 2008 by two regulation inspectors. Documentation looked at included medication records, staff recruitment information, residents care plans and health and safety documentation. We also looked at the communal areas of the premises and saw some of the bedrooms. Prior to this inspection taking place the Manager completed an Annual Quality Assurance Assessment (AQQA), and evidence from this was used to help form some of the judgements in this report. We also sent fifteen surveys to the home before this visit for staff to complete of which four were returned. Fifteen surveys for residents to complete of which, none were returned, and fifteen for relatives /carers and advocates to complete of which, ten were returned. On the whole comments received in surveys were positive regarding the care given and the operation of the home. One visiting relative was spoken to during the inspection and again comments received were very positive. What the service does well: What has improved since the last inspection? Appropriate napkins are now provided at mealtimes for residents. Sir Jules Thorn Court and Mary Court DS0000019122.V352695.R01.S.doc Version 5.2 Page 6 Individual activities are being provided, but this still needs to be recorded in more detail and there needs to be more variety of activities offered. The medication records now detail whether residents have any allergies. 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. Sir Jules Thorn Court and Mary Court DS0000019122.V352695.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 Sir Jules Thorn Court and Mary Court DS0000019122.V352695.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): 1,2,3,5 & 6 People who use the service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The organisation has a comprehensive admission policy and admissions to the home are not made until a needs assessment has been carried out, however, copies of these reports must be available in residents’ files. Residents and their relatives are encouraged to visit the home prior to admission. Not all residents were seen to have contracts /licence agreements in place. Intermediate care is not provided. EVIDENCE: Sir Jules Thorn Court and Mary Court DS0000019122.V352695.R01.S.doc Version 5.2 Page 9 From the surveys received, eight of the relatives said that there was sufficient information available in order for a decision to be made about whether the home would suit their needs. All ten surveys stated that in their view the home always met their relative’s needs. One relative stated, “ I chose Jules Thorn Court for my husband on the basis of two visits and moved him from a commercially run home when he was offered a vacancy. Nothing arises which needs a decision. The manager and staff have been very forthcoming”. All relative surveys indicated that they are welcomed when visiting the home and feel involved in their relatives care. In discussion with the staff nurse in charge, they stated that all residents are assessed prior to and on admission. Inspectors were informed that the most recent resident admitted to the home had returned to hospital as following admission, it was found that his needs were far greater than first thought and further assessments reports had been requested. Copies of core assessments however, could not be located on four of the five files examined. Inspectors informed the staff nurse that these documents must be kept with the current file or be available to evidence that the care being provided clearly meets the residents assessed needs. Sir Jules Thorn Court and Mary Court DS0000019122.V352695.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 & 10 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Care plans are in place but must be completed more fully. Relative’s representatives continue to be involved in the planning of care. Attention is given to ensuring privacy and dignity when delivering personal care. Medication is handled safely and appropriately. EVIDENCE: All ten surveys stated that relatives were consulted about care planning and were satisfied with care provision in Sir Jules Thorn and Mary Court. Communication with many of the residents proved difficult for inspectors due primarily to the level of people’s dementia or the level of their mental health. However, four residents spoken to said that they had no complaints, with two Sir Jules Thorn Court and Mary Court DS0000019122.V352695.R01.S.doc Version 5.2 Page 11 stating that they got on very well with staff. Residents were observed to move freely around the home and those seen appeared relaxed and at home. Relatives also confirmed that they could see their relative in private, in their rooms or communally in the lounge. The relative spoken with said that they are encouraged to help themselves to tea/coffee and make drinks for their relative if they wish during their visits. Ample tea/ coffee was seen in the small kitchenettes. Due to the lack of some assessment documentation, inspectors were not able to verify that care plans lead from assessed needs. However, care plans were in place on all five files examined. The files were organised into various sections to make it easier to locate documents however, inspectors felt that in some of the areas, in particular lacked detail and must be expanded upon and completed e.g. peoples life history, their mental health needs and how the home is going to support the person. For example one file detailed the persons psychological needs which was to help the resident feel secure, staff to spend quality time with them, encourage communication, look at photos /memorabilia. However, there was no evidence in the activity file or daily records seen that this occurred. Also some documentation on files were incomplete or partially completed. Inspectors drew various examples to staff in the clusters. The care plan for the resident in Mary Court was examined and found to be very comprehensive with a detailed summary of the person’s 24-hour cycle of need. Regular meetings were also taking place with this person’s relative. Monthly evaluation was seen to be taking place although little evidence of changes. Risk assessments were seen to be in place e.g. prevention of falls, manual handling, dementia, hoist for bath and skin integrity. Also, in some of the files examined more specific risk assessments around risk of wandering out of the home was seen. As already stated, inspectors noted that residents are able to move freely around the home, although, staff stated that they are encouraged to come up from the lower ground floor to the first floor where group activities take place daily. However, on the day of the inspection no group or individual activities were seen to be taking place. Staff was seen to treat residents with respect and were aware of their differing needs, this was evidenced primarily through observation during the visit, questionnaires received and in discussion with two staff. During the inspection, staff stated that daily records were regularly discussed between shifts and staff endeavour to capture residents day. However, from the records seen notes were still too task orientated and failed to clearly detail what residents had done during the day. Sir Jules Thorn Court and Mary Court DS0000019122.V352695.R01.S.doc Version 5.2 Page 12 The medication system was sampled and found to meet the required standard. Medications are kept securely and at an appropriate temperature. The home uses a Monitored Dosage System. The Medication Administration Records examined identified no gaps with all medication being signed when given. Sir Jules Thorn Court and Mary Court DS0000019122.V352695.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 & 15 People who use this service receive good quality in this outcome area. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Visitors continue to be welcomed into the home and residents are able to maintain contact with their family. Activities are provided but must be expanded upon and recorded fully. Mealtimes are sociable and thought is given to the types of food provided. EVIDENCE: In discussion with the staff nurse in charge, she stated that there is a comprehensive activity programme in place and that staff in the units will also undertake activities with residents. An activity programme is also displayed on notice boards in the hallway as well as in the individual clusters. On the day of the inspection the Activity Co-ordinator had called in sick and despite being informed by the nurse in charge that two care staff also carry out activities, inspectors did not see any activities being offered. Many residents remained in their rooms and those in the lounge were not actively engaged in doing anything. Sir Jules Thorn Court and Mary Court DS0000019122.V352695.R01.S.doc Version 5.2 Page 14 Relative’s questionnaires however, did not raise activities as an issue and neither did residents spoken with. Relatives in their surveys indicated that they are satisfied with the care provided. All, when asked the question “ Does the care service meet the different needs of people (You may want to consider race and ethnicity, age, disability, gender, faith and sexual orientation), seven responded always and three usually. The activity programme displayed included music, reminiscence and reading. There was very little evidence of any reading materials in the home, although the staff nurse said that two residents have a newspaper delivered. The record of activities was seen and inspectors recommend that staff record in more detail e.g. how long the activity lasted, did the person enjoy it or not. The home must consider providing more variety e.g. many entries stated relaxation/music/ball games/story tape. Care notes must include activities carried out in the units. The relative spoken to confirmed that her relative did not want to participate in any activities with other residents and that this was his choice. This person visited regularly, took her husband out for walks and engaged in individual activities e.g. cards. This person said that staff tried hard with the residents who all had varying needs. One relative in their survey stated “ the carers seem benevolent and friendly and I have seen them deal competently with problems that have arisen during my visits”. Lunchtime was observed and seen to be a relaxed sociable occasion. Staff were seen to sit around tables and support individual residents to eat. Residents are encouraged to eat in the dining room but can have their meals in their rooms or in their lounge if they wish. The visiting relative confirmed that her husband had his meals in his room through his choice. The menu file has pictures of main meals to aid choice. There is a choice of hot meals and dessert at lunchtime. For supper there is a choice of a light meal or sandwiches, plus dessert. The menu has a variety of ethnic foods, such as Caribbean, curries and traditional English food. Alternatives are available at each meal. A record of meals eaten is maintained. However, inspectors observed no fresh fruit being available in the kitchenettes, which should be readily available in the home. The chef remains involved with residents and regularly seeks their views on the meals. Condiments are available and the meal was noted to be unhurried. Since the last inspection appropriate aprons have been purchased for residents who require them, otherwise napkins are provided. Sir Jules Thorn Court and Mary Court DS0000019122.V352695.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 &18 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure, which is known by residents and their representatives. Safeguarding adults procedures are also in place. EVIDENCE: Residents and their representatives are aware of the home’s complaint procedure. Copies of the procedure on display around the service and in bedrooms. The AQAA questionnaire completed by the manager indicated that there have been no new complaints since the previous inspection. The complaints book however, showed two recent complaints both made by staff against another staff member. The staff nurse stated the action she had taken in the manager’s absence but they was no audit trail available. An on- going complaint at Mary Court has been partly resolved and continues to be addressed by Servites senior managers. Sir Jules Thorn Court and Mary Court DS0000019122.V352695.R01.S.doc Version 5.2 Page 16 All relative surveys received indicated that they are aware of how to make a complaint. There have been no investigations under Protection of Vulnerable Adults procedures since the previous inspection. Induction training includes Protection of Vulnerable Adults training. Staff spoken to were aware of the steps to be taken in the event of abuse being identified. A copy of Wandsworth Safeguarding Vulnerable adults was available in the home. Sir Jules Thorn Court and Mary Court DS0000019122.V352695.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): 19,20, 21,24,25 & 26 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The home environment is generally satisfactory but communal areas require decorating to enhance the environment for residents, staff and relatives. The home is clean and hygienic. EVIDENCE: Inspectors undertook a tour of the communal areas of the premises. The home was seen to be clean and tidy and free from unpleasant odours. All surveys received commented on the cleanliness of the home. Inspectors noted that various areas in the home the paintwork was chipped and or marked in places. Damp spots/patches were seen on a number of ceiling areas. They also noted that generally there was a lack of support rails for residents use along the corridors apart from the slope leading downstairs. The magnetic door –stop on medicine room door needs to be repaired. The manager in his AQAA Sir Jules Thorn Court and Mary Court DS0000019122.V352695.R01.S.doc Version 5.2 Page 18 has stated that the home intends to redecorate all communal areas and corridors. This will enhance the environment for residents and staff. Consideration should also be given to making the cluster lounges more homely and should involved residents/relatives from the various clusters, as they still appeared institutional. Further efforts should be made to make bedrooms more homely e.g. pictures on walls, photos, possibly persons own furniture. Inspectors were informed that all bedrooms had ensuite facilities; bedrooms seen were of a good size. Bedrooms varied in the degree of personalisation, with some appearing very stark whilst others had been personalised. Staff stated that many residents refused to personalise their rooms and liked them the way they were. One visiting relative stated that her husband had to have the lock on his door removed for his own safety as that she is currently in discussion with the home as to putting on a different type of lock. The staff nurse confirmed this was in hand. Each ‘cluster’ has a day room, with kitchen facilities, which enables staff to make hot and cold drinks and light snacks for residents. Relatives can also make drinks in these kitchenettes. Sir Jules Thorn Court and Mary Court DS0000019122.V352695.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 & 30 People who use this service receive adequate quality in this outcome area. This judgement has been made using available evidence including a visit to this service. Residents and relatives report that staff is able to meet their needs. Internal and external training is provided to make sure that staff have the necessary skills to care for residents. An appropriate staff recruitment policy and procedure is in place, however, files did not clearly evidence that all the required checks had been carried out. EVIDENCE: Sir Jules Thorn operates daily with one staff nurse, 6 carers, an activities coordinator 2 domestics, laundry person and a handy man. There is usually the manager or deputy also on shift for part of the day. The nurse in charge reported that adequate staff are employed in the home and staffing levels are kept under review depending on the needs of the residents. The resident at Mary Court receives adequate support and their relative raised no concerns in their questionnaires regarding staffing and care received. Sir Jules Thorn Court and Mary Court DS0000019122.V352695.R01.S.doc Version 5.2 Page 20 Files for two new staff were examined and both did not evidence that all the appropriate checks had been carried out. The staff nurse stated that this is held at head office. Staff records kept in the home must state the date the CRB check was requested and received and the disclosure number. Another file seen had no CRB record on them. Three other files contained all the required information. The manager in his AQAA stated that all appropriate training is given to all staff to enable them to meet the needs of the residents. He also stated that over the last twelve months the organisation has been very active in all mandatory training and all staff are up to date with these. Three carers are currently undertaking their NVQ Level 2. Staff spoken to confirmed that they had undertaken numerous training courses and that regular team meetings took place. They also confirmed that they received regular supervision. Surveys received indicated that respondents thought there were suitable numbers of staff and that staff are helpful and do a good job with a vulnerable group of people. Sir Jules Thorn Court and Mary Court DS0000019122.V352695.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 & 38 People who use this service receive good quality in this outcome area. This judgement has been made using available evidence including a visit to this service. The manager has the required qualifications and experience and is competent to run the home. Health and safety systems are in place to ensure the safety of residents and staff. EVIDENCE: Relatives and staff in their surveys (with the exception of one staff) were positive about the manager and his management of the home. Questionnaires raised no concerns with relatives stating that a good standard of care is Sir Jules Thorn Court and Mary Court DS0000019122.V352695.R01.S.doc Version 5.2 Page 22 delivered to their relatives. The manager has run the home for over twenty years. Staff spoken to and in the questionnaires received, stated that they felt their views are listened to and they are encouraged during team meetings to raise any issues positive or negative. Policies and procedures are in place in respect of the management of resident’s finances. A quality assurance survey has been undertaken by an external agent in 2006 indicated high satisfaction levels with the service provided. The home has endeavoured to put recommendations made into practice. A copy of a follow up report was given to inspectors. Monthly Regulation 26 visit are taking place. Health and Safety records indicate that routine checks are made on electrical equipment, gas safety and fire alarm installations. Contracts are in place for these services as well as a clinical waste contract. Fire checks are carried out weekly in conjunction with Mary Court. First aid boxes checked in two of the clusters contained expired bandages despite being checked monthly. Expired bandages must be replaced. Sir Jules Thorn Court and Mary Court DS0000019122.V352695.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 2 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 2 3 X X 3 3 3 STAFFING Standard No Score 27 3 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 Sir Jules Thorn Court and Mary Court DS0000019122.V352695.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 OP2 Regulation 5A Requirement The home must ensure that the resident or their representative has a copy of their contract detailing terms and conditions and what is included in the fee. Timescale of 30/03/07 not fully met) The home must ensure that copies of the resident’s core assessment and the homes assessment are available on the residents file. The home must ensure that daily records detail care given and interventions needed to make sure that needs are evidenced as being met. (Timescale of the 30/03/07 not fully met). All complaints must be formally acknowledged in line with the homes procedures. The registered person must ensure that communal areas are redecorated to enhance the environment for residents. DS0000019122.V352695.R01.S.doc Timescale for action 29/02/08 2. OP3 12 (2) 31/01/08 3. OP7 17 (1) (a) & Sch 3 31/01/08 4 5. OP16 OP19 22 (4) 23 (2) (b) 31/01/08 30/08/08 Sir Jules Thorn Court and Mary Court Version 5.2 Page 25 6 7 OP29 OP38 Sch2 13(4) The home must ensure that a record of all the recruitment checks is available in the home. Expired bandages in first aid boxes must be replaced. 31/01/08 14/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP14 OP15 Good Practice Recommendations It is recommended that a wider range of activities is offered and a more detailed record kept. Fresh fruit should be readily available in the home. Sir Jules Thorn Court and Mary Court DS0000019122.V352695.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Sir Jules Thorn Court and Mary Court DS0000019122.V352695.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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