Inspection on 22/05/07 for Somerset Nursing Home

This inspection was carried out on 22nd May 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

Somerset Nursing Home 18/12/06

Somerset Nursing Home 24/05/06

Somerset Nursing Home 17/02/06

Somerset Nursing Home 13/07/05

Somerset Nursing Home 09/03/05

Somerset Nursing Home 15/06/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Somerset Nursing Home Somerset Nursing Home 1 Church Lane Wheldrake York North Yorkshire YO19 6AW Lead Inspector Denise Rouse Key Unannounced Inspection 22nd May 2007 10:05 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 DS0000045154.V335080.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. DS0000045154.V335080.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Somerset Nursing Home Address Somerset Nursing Home 1 Church Lane Wheldrake York North Yorkshire YO19 6AW 01904 448313 01904 448022 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) Roche Healthcare Limited Ann Grieves Care Home 46 Category(ies) of Dementia (46), Dementia - over 65 years of age registration, with number (46), Old age, not falling within any other of places category (46), Physical disability (46), Physical disability over 65 years of age (46), Terminally ill (4) DS0000045154.V335080.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users in the category DE and PD must: (i) be aged 50 and over and (ii) require nursing care 18th December 2006 Date of last inspection Brief Description of the Service: Somerset Nursing home is a care home for older people providing personal & nursing care for up to 46 service users. The home is situated in the village of Wheldrake, approximately 8 miles from the centre of York, there are 14 elderly persons bungalows within the grounds of the home. The business is owned by Roche Healthcare Limited. The home provides both single and shared accommodation on two storeys and has a passenger lift. Fees range from social services rates to private rates of £575 per week for residential care and £675 for nursing, minus the Registered Nurse Care Contribution. Fees include all services apart from hairdressing, dry cleaning, reflexology, newspapers, chiropody and private taxi hire. DS0000045154.V335080.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence used in this report has included: • A review of the information held on the homes file since its last inspection. • Information submitted by the registered provider in the Pre Inspection Questionnaire. • Surveys received from two service users, three relatives, and three General Practitioners. • An unannounced visit to the home, which lasted five hours and ten Minutes. This included a full tour of all areas of the premises. • Evidence gained by direct observation, talking with service users, management and staff. Inspection of records, including care profiles, medication administration records, and staff files. What the service does well: What has improved since the last inspection? Consistent management from a new manager supported well by the management team. To enhance how the home provides its services. A risk assessment has been created for mowing the lawn to ensure the maintenance mans health and safety is maintained when carrying out this task. Cleaning product data sheets have been updated to ensure, on the whole that they reflect all the chemicals being used on the cleaner’s trolley. DS0000045154.V335080.R01.S.doc Version 5.2 Page 6 Kitchen repairs highlighted as being required have been undertaken this ensures that staff and service users health and safety is maintained. 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. DS0000045154.V335080.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 DS0000045154.V335080.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): Standard 3. (6 Not applicable) People who use this service experience good quality outcomes in this area. Service users are fully assessed prior to admission to ensure their needs are known and can be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Potential service users were fully assessed by the manager who would go to the service users own home or hospital to assess the potential service users, medical, mental and social status. This ensured that the home was aware of the service users individual needs and knew they these needs could be met. Potential service user and their representatives had received relevant information about the home, contained in the service user guide and statement of purpose. This ensured that potential service users and their families were fully informed about what the home had to offer. Prospective DS0000045154.V335080.R01.S.doc Version 5.2 Page 9 service users and their families were welcome to come and look round the home and even stay for lunch. To ensure that they were able to assess how the home operated and to see if they would feel comfortable in this environment. Comments received included “I received enough information about the home, it was very helpful to read the brochure, we were also shown round the home and given lots of information. All questions asked were answered to the full, we as a family were very impressed”. And “I got enough information about the care home to make an informed choice”. Intermediate care was not undertaken. DS0000045154.V335080.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): Standards 7, 8, 9, 10. People who use this service experience good quality outcomes in this area. Service users have their health care needs met, however there were some shortfalls relating to the recording of some medication. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The care plans and risk assessments for four service users who were case tracked were inspected. Since the last inspection all of these documents have been reassessed and rewritten. The format of the documentation has also changed. All were seen to be detailed and were regularly reassessed each month, over the last two months, or as the service users needs changed. Service users or their representatives had signed this documentation, if they so wished. This ensured all parties were kept fully informed. Service users who had pressure sores and nutritional needs had all relevant information documented, including nutritional assessments and waterlow DS0000045154.V335080.R01.S.doc Version 5.2 Page 11 scores. Their conditions were being monitored and corrective action was being taken and documented to ensure that service users were having these specific needs met. A lot of effort had gone into this process by management and staff; this must be maintained to ensure that there is a constant thorough up to date record of care given to service users and the outcome achieved. A new method of recording when care plans were due to be reassessed was now in operation and this had been effectively operated over the last two months since the documentation was updated. This system must be maintained to ensure that records are kept appropriately. Service users were seen as required by a local visiting general practitioner who knew all the service users well. Other relevant health care professionals were involved in the special needs of service users to ensure their needs were being fully met. Medication systems within the home were inspected. The balance of controlled medication was correct. The system was about to be replaced by a Boots Monitored dosage system. The treatment room was about to be relocated to a much larger room and this would be a benefit to staff. Presently boxes of medications were received. Case tracked service users all had a photograph present in front of their medications prescribed and their allergies were recorded. This helps to ensure that service users safety is maintained. Some of the case tracked service users balances of medication held or received was not recorded. One service user had one medication which was prescribed four times a day, but this had now become “only when requested” This was not reflected correctly upon the medication administration chart. There were also some gaps in recording if medication was given or had been refused. These issues must be addressed to ensure that the record gives a thorough picture of medications being taken by each service user to maintain their health. Comments received included “The staff meet the needs of my friend, and also the needs of others. I don’t know every one in the home so I presume they all receive the same excellent level of care”. And “The nursing staff are always quick to reassure and inform me if ever I am concerned about XXX health. If I am worried they are quick to call the doctor”. Also “Usually, the care service supports people to live the life they choose. “Nobody chooses to be in a nursing home, however the staff makes every effort to support the residents in the choices they make within the home. They support whatever is in their power to support”. And “The residents are beautifully and spotlessly dressed at all times. And the staff make every effort to ensure that everyone is as comfortable as possible. The nursing care is first class on a daily basis and especially when caring for those who are ill or recovering from operations. The nurses are diligent, careful and gentle with everyone. DS0000045154.V335080.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15. People who use this service experience good quality outcomes in this area. Service users received a nutritious diet and had their social needs met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People who used the service had their social needs and preferences fully recorded. This helped to ensure that their needs were known and could be met. There was a weekly activities programme displayed. This included in house activities as well as entertainers visiting the home. The programme of activities had been much improved recently. One to one and group activities continue to be undertaken. There was a part time activities co-ordinator who had received dementia training so that service users who had needs specific to this could still participate in a meaningful way with activities and reminiscence. There was a reminiscence table just inside reception where items relating to spring had been placed. This also helped to remind service users of the seasons. A summer fate being planned, service users were helping to create the posters and colour them in for each stand, DS0000045154.V335080.R01.S.doc Version 5.2 Page 13 they were colourful and creative. Bunting was also being made for the summer fayre by service users who wished to do so. Staff were enthusiastic and determined to make this an enjoyable day for service users, the chef was working hard to achieve a memorable event. Pitch and put, stalls and the local general practitioner for the home may also have been prepared to go into “The Stocks” for the summer fayre. This ensured those who wished to be were fully participating in the preparation for this event. The home had a programme of visiting clergy. Local bus trips were arranged, there had been a trip to the theatre to see Josephs Tecnicoloured Dream coat which had been enjoyed by service users. Visiting was open. Hairdressing and reflexology were also available within the home. Gentle reminiscence music was being played within one lounge; a library was available with normal and large print books, new books had just been received from the mobile library, which were seen to be excellent for reminiscence. There were large screen televisions available within the lounge areas. Baking was undertaken with the service users who had made scones, crispy chocolate buns. This week it was to be a quiche making session. This was popular with service users, who got to eat what they had made. Comments received included “Always there are activities arranged by the home that I can take part in”. And “Sometimes there are activities arranged by the home that you can take part in.” Due to limited mobility”. Staff were seen treating service users with dignity and respect. They knocked upon doors before entering bedrooms. Banter occurred between staff and service users who chose not to come out of their bedrooms, this was polite and friendly and gave the service user regular contact with all grades of staff and was enjoyed. It ensured a homely atmosphere was achieved. The kitchen was inspected. The chef knew each service users specific needs, took pride in his job, and was enthusiastic to improve the food service wherever possible. This was also indicated by cares held on individual’s trays. There was information held upon each service user about their specific dietary requirements. Food served looked appetizing and well presented. Portion sizes were varied to meet individual’s preferences and nutritional needs. Menus were displayed upon the tables, which were laid with linen cloths and napkins. There was also a large chalkboard in the reception area with the menu of the day recorded. This ensured that nutritional needs were being met. Service users who required assistance with feeding were attended to by patient staff who carried out this duty in an unhurried manner, and treated them with dignity and respect. Comments received included “I Usually like the meals, the chef comes round daily to what meals we want”. DS0000045154.V335080.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16, 18. People who use this service experience good quality outcomes in this area. Service users were protected and could be assured that their concerns and complaints would be listened to and acted upon. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Complaints received had been investigated and there was documentation to support this. The outcome of each complaint was recorded. The complaints policy was displayed in reception and was contained in the service user guide. Abuse training had been undertaken and on the day of the site visit the operations manager was holding two training sessions for staff. The information being taught to staff was observed and this was very thorough and helped to ensure that staff would be fully aware of the action they must undertake if ever an allegation of abuse was to be received. The policy relating to abuse was inspected and this was detailed and thorough. A copy of “No secrets” was also available in the home. This ensured that people using the service were protected by both procedures. Comments received included “I always know who to speak to if not I’m not happy”. And they “Always respond appropriately when concerns are raised”. DS0000045154.V335080.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 26. People who use this service experience good quality outcomes in this area. Service users live in a well maintained and clean home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A tour of the building was undertaken, all areas were clean, tidy and free from any malodour. The home was well presented and decorated throughout. The gardens were mature and well kept, with garden furniture for residents and visitors use. The small internal patio area was about to receive new garden furniture and be planted out with bedding plants. A refurbishment of the downstairs bedrooms was continuing. A lockable draw was to be incorporated into the new bedside chest of drawers, to allow service users to store personal items securely. The treatment room for storing DS0000045154.V335080.R01.S.doc Version 5.2 Page 16 medications was to be moved to a larger unused room, to give more storage space for medications. These changes continue to benefit the service users and staff. The Laundry was inspected there were three bags of clinical waste, which were due to be removed at the end of the shift. Hand washing facilities were available. Gloves and aprons were available for the staff to use throughout all areas of the building. This ensured that infection control measures were in operation. However one comment received from a visitors survey indicated “A hand dispenser at the entrance to control germs and bacteria. As used in hospitals, would be a good idea, just a thought”. This should be considered. One cleaners trolley was found unattended on the first floor, the cleaner had gone to deal with a delivery. This was discussed, as this must not be left unattended. Information held upon this trolley relating to the cleaning products and safety data was current and present for all products apart from the cream cleaner. This information must be added, to ensure that staff and service users continue to be protected. Comments received from surveys indicated that the home was “Always fresh and clean”. DS0000045154.V335080.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29, 30. People who use this service experience good quality outcomes in this area. Service users are looked after by well-trained staff, however there was a small shortfall in relation to fire training. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Staffing levels at the home had been reviewed by management recently, they should continue to assess service users dependency levels when calculating staffing levels, to ensure all service users continue to receive timely care. The activities co-ordinator had commenced going into the conservatory dining area after lunch to engage service users in discussion and to help pass the time before service users were all moved away from the dining tables. This was required as a lot of service users required to be moved by hoist and this process was staff intensive and took a little time. Comments received included “The staff are extremely caring, compassionate and cheerful, making a lovely atmosphere for residents and visitors”. One comment received referred to how things may improve “Perhaps they could use more staff. So many of the residents are very dependent, needing hoists to move them and someone to feed them. Sometimes people have to wait a while before they can be moved from a dining room to a lounge or their own room. There is such a queue for DS0000045154.V335080.R01.S.doc Version 5.2 Page 18 the hoists, that not everyone can be moved quickly enough. It would be good if they had more staff”. Management must consider this issue. The home had achieved over 50 of care staff who held a National Vocational Qualification in Care at level two, three or equivalent. This ensured that staff had good underpinning knowledge. Training had been extensive and was ongoing, staff commented that there had been a lot of courses available to them and they had appreciated this. Upon inspecting four case tracked staffs records, it was found that Fire training had not in line with North Yorkshire Fire Services requirements. This was due to timescales between training being longer than the stated 3 months for night staff and 6 months for day staff. More training was planned, but had not been timely to ensure some staff had achieved the training within those timescales. The home had a Fire Warden who would help ensure this was rectified. Fire training was being re taught to all staff to ensure that it was detailed in relation to fire compartmentalization, to ensure staff were fully aware of this. Training in Abuse awareness was being taught on the day of the site visit, and looked well attended. This helped to ensure staff were fully aware of abuse and how to prevent this. Staff appraisals and supervision was being undertaken to ensure that any training needs for staff were highlighted and provided to ensure staff were supported to carry out their duties. All staff had the required pre employment checks undertaken to ensure that they were suitable to work within the care industry; this helped protect the service users. Other comments received included “The home is wonderful, the staff are a dedicated team, warm-hearted lovely people who give there all for the welfare and happiness of the resident”. And “Staff are wonderful, the carers are kind, I have a banter with staff I like this, it makes it more homely”. Also “I think the staff are a bit pushed, but I would speak out if anything was wrong, the night staff are lovely. The cleaners say hello, they take the top off my lemonade, they do a good job, they always say goodbye I will see you later” “The care staff are all fantastic”. DS0000045154.V335080.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 38. People who use this service experience good quality outcomes in this area. Service users benefit from a well run home, however there were some shortfalls relating to maintaining health and safety. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home had recently appointed a full time home manager, who was experienced. She had just completed the process to become registered with the Commission for Social Care Inspection. Feedback from staff and service users stated that she was a workaholic, and was very keen to ensure that all areas of the service were running smoothly. Staff stated that things had improved since her appointment due to her style and continuity of leadership. DS0000045154.V335080.R01.S.doc Version 5.2 Page 20 Staff stated that an open door policy was appreciated and that the manager was very supportive and “Gets things done”. The home was running well on the day of the site visit and there was a pleasant atmosphere within the home. The manager was carrying out audits unannounced, relating to the kitchen, the delivery of trays and the choice of meals for service users. This was valued by the staff and ensured that the services provided by different departments were being monitored for quality assurance, and any action found to be required would be undertaken. Daily informal quality assurance was being undertaken by the manager, deputy, and staff who would walk round speaking to service users and observing the home and ensuring that any issues were addressed. There was a yearly questionnaire sent to service users and relatives the results were collated and them were made available to staff and service users. There was a detailed business plan in place, which ensured management knew the outcomes they wished to achieve for the home, and were working towards them. On the day of the site visit there was a residents and relatives meeting for residents in the home and they were being joined by the residents inform the bungalows contained in the grounds. These meetings were minuted. Regular staff meetings were also held and again these were minuted and were available to all staff. The estates manager undertook regular regulation 26 visits and a copy of this was sent to the Commission for Social Care Inspection to ensure that this information was considered when the Inspector was preparing for the site visit. This ensured that the staff and service users thoughts upon the service were being requested and monitored. The company’s quality assurance manager and operations manager also visited the homer on a regular basis, and provided training for the staff in certain subjects. This all ensured that departments were being audited and any corrective action required was being taken to ensure the service was running well. The management team were also available to meet with service users and their relatives when issues had been raised. This ensured that issues were fully discussed and had been resolved. Service users personal allowance balances were checked and found to be correct, receipts were kept, and monies were not pooled, this ensured service users were protected from financial abuse. There were some shortfalls relating to maintaining the health and safety as specified these related to the cleaners trolley being left unattended, three tiles needing to be replaced in the kitchen and a fly screen requiring repair, and DS0000045154.V335080.R01.S.doc Version 5.2 Page 21 Fire training is provided once a year with additional training for new staff. These must be undertaken to ensure that staff and service users health and safety was maintained. Comments received included “Its top of the pops here” and “We have a residents meeting each month”. DS0000045154.V335080.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 DS0000045154.V335080.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 OP9 OP38 Regulation 13 (2) Requirement Medication administration records must indicate clearly if a medication is to be given “As Required” or regularly. Signatures must be recorded after medication are administered. Recording must be made if medication is offered and refused. Medication balances must be recorded for all medication. Cleaning chemical information must be carried upon the cleaner’s trolley, for cream cleaner. Cleaner’s trolleys must not be left unattended. The frequency of fire training should be reviewed in line with the service’s fire risk assessment and in consultation with the fire prevention officer. Three tiles damaged or not adhered to the wall in the kitchen must be replaced. The fly screen must be repaired. DS0000045154.V335080.R01.S.doc Timescale for action 30/06/07 2 OP26 OP38 13 (4) (a) 30/06/07 3 OP30 OP38 18 (c) (i) 30/07/07 4 OP38 23 (2) (b) 30/06/07 Version 5.2 Page 24 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 OP26 OP27 Good Practice Recommendations Management should consider providing a hand-cleaning product for visitors. Management should continue to monitor staffing levels and service users dependency, to ensure that a timely delivery of care continues to be provided. DS0000045154.V335080.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 DS0000045154.V335080.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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