Inspection on 28/02/06 for St Aubyns

This inspection was carried out on 28th February 2006.

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

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

Other inspections for this house

St Aubyns 11/07/07

St Aubyns 30/05/06

St Aubyns 11/08/05

St Aubyns 04/03/05

St Aubyns 29/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE St Aubyns 35 Priestlands Park Rd Sidcup Kent DA15 7HJ Lead Inspector Maria Kinson Unannounced Inspection 28th February 2006 09:20 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 St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 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. St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Aubyns Address 35 Priestlands Park Rd Sidcup Kent DA15 7HJ 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 8300 4285 020 8300 4285 Mr Dilipkumar Tanna Mr Kirtikumar Tanna Mrs Jean Woodcock Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. An additional five (5) day care places for people falling into the above Service User Categories 11th August 2005 Date of last inspection Brief Description of the Service: St Aubyn’s Nursing Home is situated in a residential area of Sidcup, near to a mainline rail station, bus routes and Sidcup town centre. The home was first registered in 1988. The building was extended in 1995 and is registered with the Commission for Social Care Inspection to provide nursing care for thirtynine older people. There are nineteen single bedrooms and ten shared bedrooms in the home. Twenty-two of the bedrooms have en-suite facilities. Service users have shared use of the dining room and two lounges. There is a garden at the back of the property and limited parking at the front of the home. St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by two inspectors on 28.02.06 between 09.20am - 15.10pm. The inspectors toured both floors of the home and examined care, health and safety, training and recruitment records. Staff were observed communicating with residents and relatives, serving meals and assisting residents to eat and move. Three members of staff, nine residents and three visitors were spoken with during the inspection. Two comment cards were returned to the commission. What the service does well: What has improved since the last inspection? Since the last inspection some of the homes documentation had been updated. This included the Statement of Purpose, medication administration charts and disposal of medication procedure. St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 6 One height adjustable bed had been purchased. The home had appointed an activities coordinator and developed a weekly programme of activities. Two nurses from overseas had commenced adaptation training. What they could do better: This home has been slow to comply with the Care Homes Regulations and National Minimum Standards. A number of requirements set following previous inspections had not been addressed. A meeting has been arranged with the registered providers to discuss this issue and the findings from this report. The home had developed a Service User Guide but this document did not include all of the information required. Care plans did not always provide up to date information about the action that staff should take to meet resident’s needs. Some aspects of the management of medication were poor. Residents were able to make some choices about how and where they spent their time but were not able to select their meals. Various records that must be stored in the home could not be located. The manager did not have access to a copy of the homes Statement of Purpose, copies of resident’s contracts, staff contracts, information about resident’s personal finances and copies of regulation 26 reports. Staff recruitment was poor. New staff had commenced work in the home without adequate documentation. Failure to obtain adequate documentation could compromise resident’s safety. The acting manager was working hard to maintain a good standard of care but did not have sufficient support to introduce other quality initiatives such as a staff training programme, staff supervision and quality assurance systems. There were no records of any ‘in house’ safety checks being carried out to monitor hot water temperatures or check window restrictors. Lifting equipment was not serviced at appropriate intervals and accidents were not formally reviewed. St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 7 No work had been undertaken to improve the visual appearance of the home. Some of the paintwork was chipped and decorative borders were torn. The Registered Person had advised the commission in writing that all of the bedrooms in the home would be redecorated in 2005. This work had not taken place. The off duty roster indicated that the home was not always complying with the minimum staffing notice. 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. St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 8 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 St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 9 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, 2, 3, and 4. The home did not provide adequate written information for residents. This could make it difficult for residents to make an informed decision and have an awareness of their rights. EVIDENCE: Since the last inspection the Registered Person had updated the Statement of Purpose to include all of the information listed in the care homes regulations. This document must be kept in the care home and be given out to residents and their representatives on request. The acting manager did not have access to a copy of the Statement of Purpose. The previous requirement to review and update the Service User Guide had not been addressed. See requirement 1 and recommendation 1. The inspectors were told that resident’s contracts were not kept in the home. This standard could not be assessed. See requirement 2. St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 10 The files seen included multi- disciplinary assessment papers or a preadmission assessment that was undertaken by staff. There was no evidence that the manager had confirmed in writing to prospective residents, that the home could meet their needs. See requirement 3. St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 11 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, 9 and 11. Residents looked well cared for but there was not sufficient evidence in some care documents to show how personal, health and welfare needs were met. Some aspects of medication were poorly managed. This could compromise resident’s safety. Documentation indicated that the home had made provision for end of life care. EVIDENCE: Four care files were assessed. The files seen included care plans and risk assessments such as moving and handling and risk of developing pressure sores. The standard of care planning was variable with some plans reflecting resident’s needs and others providing out of date information. For example one care plan indicated that a resident was weight bearing and would spend time in the lounge. The resident was bed bound, immobile and totally dependent on staff to meet their needs. This care plan had been reviewed monthly and staff had recorded that the resident’s needs had not changed. St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 12 Wound care plans also varied in content. Some included clear information about wound management. Other plans did not provide clear guidance about dressings, the frequency of dressing changes or the condition of the wound. See requirement 4. All of the residents seen looked clean, tidy and well cared for. A CSCI pharmacy inspector carried out an unannounced inspection in the home on 01.03.06. The findings from this visit are outlined below. Policies and procedures relating to medicines must be reviewed and updated. The policy and procedure for disposal of medicines had been reviewed and a new one drafted since the previous inspection. There was no policy / procedure for storage of medicines or for medicines for leave, or drug errors. All policies and procedures must be dated. The home had good records of ordering and receipt of medicines, which were kept on a separate sheet, but the date that medicines were received was not recorded. The home had good records of medicines received mid month but these records were not signed. The home had recently started using computer generated administration records supplied by the pharmacy. These appeared to be working well, however, on some the print was very faint. It was noted that emollient creams were not recorded on the MAR sheet and the resident’s date of birth and allergies were not recorded. On some the directions on the dispensed medicine differed to those on the MAR sheet. Hand written MAR charts were used until computer generated charts were available but these were not checked and countersigned by a second member of staff. Tippex was used on one chart. On another a dose had been signed in error but the MAR chart had not been annotated as such. When variable doses were prescribed, the amount actually administered was not recorded. The morning doses administered to residents on the first floor had not been signed, although they had been administered. Where residents had more than one MAR chart, they were not marked as “1 of 2” and “2 of 2”. A different style of MAR chart was used for respite patients, which could be confusing for staff. Records of disposal were good, but were not signed by a second member of staff. When medicines were placed in the disposal bin, patient names were not always removed. The home had a controlled drug book, which was complete, apart from dates of disposal, which were not always recorded. Systems for administration of medicines needed improvement. Lactulose was shared amongst all residents that were prescribed it. There was no medicine trolley to transport medicines securely to residents. Doses were prepared in advance into separate plastic trays, which were marked with the resident’s name. These were then taken to the residents in one go and given to each resident. The morning doses administered to residents on the first floor had not been signed by the member of night staff who had administered them before she went off duty. Morning doses were marked on the MAR charts at 6am but were actually administered at 7am. A complete audit trail of St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 13 medicines was not possible, as not all medicines had been marked with a start date. An audit was done of one “when required” medicine that did have a start date, the MAR chart indicated that no tablets had been administered but 16 tablets were missing from the box. Photographs were available to confirm the identity of residents but these were not kept with the MAR charts. Some “when required” medicines did not have complete directions including a dose and frequency. Alcohol was kept in the medicine cupboard. The home had a medicine refrigerator but the lock was missing. The temperature was monitored and recorded daily, but an accurate temperature and minimum and maximum temperatures could not be recorded with the thermometer available. An oxygen cylinder was kept in the home for one resident as a back up but the oxygen mask was not covered to protect it from dust. Staff had recently attended wound management training. There was no formal system to prompt the review of medicines on a regular basis in line with NSF requirements. See requirements 5, 6 and 7 and recommendation 2. Staff indicated that residents could choose to spend their last days in the home if their needs could be met. The home had policies and procedures about death and dying that included supporting relatives. St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 14 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 and 14. Some improvements had been made to the provision of activities. Relatives seen were satisfied with the overall standard of care provided. Feedback from residents was mostly good but some residents said they were not able to choose their meals. EVIDENCE: Since the last inspection the provision of activities had improved. A four weekly programme of activities had been developed and a designated staff member was now responsible for facilitating activities between 2pm to 4pm each weekday. Some residents said they had taken part in activities such as painting and sing along sessions but there were no records to indicate what activities had taken place and which residents had taken part. Care plans did not include adequate information about resident’s social needs. An external entertainer was due to facilitate a karaoke session in the home on the day after this inspection. Staff said that plans were being made to have regular entertainers visit the home. See recommendation 3. Four relatives provided feedback about the home. Relatives were satisfied with the visiting arrangements and the overall standard of care. One relative told the inspector that his family members well being had improved since moving into the home. St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 15 The inspectors spoke with ten residents. Residents were mostly satisfied with the care and facilities provided in the home but a number said that they were not offered a choice of meals. One resident said she had asked for porridge for breakfast and had received this for a couple of days but was now given weetabix with cold milk, which she dislikes. The lunchtime menu included one main meal and a list of alternative lighter options. Residents said they were never asked what they wanted and some said they did not feel able to ask for anything different once the meal had arrived. One resident said, “You get what you are given”. The manager advised the inspectors that kitchen staff were aware of resident’s likes and dislikes. Residents were offered a choice of juice and hot drinks and jugs of water and juice were left in resident’s rooms. See requirement 8. St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 16 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): 22 and 23. The home had adequate procedures in place to respond to complaints and protect residents. EVIDENCE: The home had a complaints procedure, which complied with the care homes regulations. A system was in place to record complaints. Since the last inspection the home had received one complaint. Records showed that the complaint was appropriately managed. The commission had received any complaints about this service in the period since the last inspection. One complaint had been investigated under the local authority adult protection procedure. The investigation had concluded that the resident had sustained an injury in the home as a result of poor moving and handling practice. The manager advised the inspectors that following this investigation staff had received a moving and handling update from an external trainer. See standard 38. St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. There has been no change to the décor in the home in the last twelve months. Although this does not pose a risk to residents it does not create a pleasing and pleasant environment to live in. All parts of the home were clean tidy and odour free. EVIDENCE: The Registered Person informed the commission in writing that all of the bedrooms in the home would be redecorated and the garden surface replaced in 2005. It was very disappointing to find that this work had not taken place. The environment was looking tired and dated. In particular the paintwork in parts of the corridors, bedrooms, and doors was chipped, some of the plasterwork on the walls was damaged and some of the decorative borders were torn. See requirement 9. The home was clean, tidy and odour free. Hand washing facilities were provided in appropriate areas. One profile bed had been purchased since the St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 18 last inspection and the Registered Person advised the inspector that plans were in place to increase the number of height adjustable beds in 2006. Staff indicated that ten residents would benefit from the provision of this equipment. St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, and 30. The home has a stable team of care staff. This ensured good continuity of care for residents. The records relating to recruitment and staff training were poor. Staffing levels did not always comply with the staffing notice. EVIDENCE: The home has a relatively stable team of care and ancillary staff; this provided good continuity of care for residents. The manager used the same agency nurses to cover vacant posts where possible. Two overseas nurses were undertaking adaptation training in the home. Staff interacted and communicated effectively with residents and their visitors. The inspectors obtained copies of the staffing roster for a two-week period. The roster indicated that there was either insufficient trained staff on some shifts or the manager was not supernumerary on these occasions. The home must provide adequate staff on all shifts. The roster was difficult to interpret in parts as some staff worked day care and nursing home shifts but this information was not recorded separately. See requirement 10. Three staff recruitment files were assessed. None of the files fully complied with the care homes regulations. The information that was missing from files included application forms, proof of identity, verification of references, staff contracts and on one file an appropriate criminal record bureau disclosure. St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 20 The acting manager advised the inspectors that the Registered Persons had some of these documents in his office. All records relating to the employment of staff must be kept in the care home. See requirement 11. All members of staff had an individual training record but there was no evidence of recent training recorded. New staff had an induction file but there was no evidence that induction was provided. See requirement 12 and recommendation 4. St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. The management structure did not reflect the size of the home and complexity of the care provided. This could place residents and others at risk. EVIDENCE: Since the last inspection the deputy manager had stepped down to resume staff nurse duties and the registered manager had retired. A senior nurse was currently managing the home but without the support of a deputy and with no administrative support in the home. This home has now been without a registered manager for three months. The Registered Person advised the inspector that the post had been advertised and efforts were being made to recruit a manager. The Registered Person must provide adequate support for the manager and advise the commission in writing about progress to recruit a full time manager. See requirement 13 and recommendation 5. St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 22 The home had no structured quality assurance system in place but some regulation 26 reports were now supplied to the commission. The commission had not received reports for November 2005 or January 2006. The manager had not received copies of these reports. See requirements 14 and 17. Staff were responsible for safekeeping some personal money for one of the residents. The resident’ money was paid by their appointee to the Registered Person and he provided a sum of money on request to the home. The home maintained a record of all money given to the resident or spent on services such as hairdressing. There were no records in the home to show how much money the Registered Person had received on the resident’s behalf or in what type of account the money was being held. See requirement 15. There was no written evidence to show that staff were receiving formal supervision. See requirement 16. A selection of safety records was inspected. Most of the records were satisfactory but hoists were not inspected six monthly and there were no records of thermostatic valve, hot water temperatures and window restrictors checks. Fire drills were held regularly but none of the drills involved the night staff. One of the bins used to dispose of sharps was not assembled correctly and was not labelled. Accident records were maintained. Three accidents had occurred whilst residents were receiving care or being assisted to move. There was no written evidence that staff had followed up the cause of these accidents and had taken action to prevent a reoccurrence where possible. Some staff were observed using appropriate moving and handling techniques. One resident was moved from a wheelchair to an armchair. Equipment was placed around the resident’s waist but staff completed the manoeuvre using by holding the resident under the arms. See requirement 18. Access to the home was restricted and the gate at the side of the building was bolted. St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 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 2 2 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 X 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 1 2 2 St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 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 OP1 Regulation 5 Requirement The Registered Person must amend the Service User Guide to include the following information: the address and telephone number for the commission, a summary of the complaints procedure and information about access to inspection reports. A copy of the revised Service User Guide must be forwarded to the Commission within 28 days of any changes being made. (See also recommendation 1) (The previous timescale of 01/12/05 was not met) The Registered Person must keep a copy of all correspondence relating to the service user in the care home. This includes contracts and terms and conditions of occupancy. (Previous timescale of 01.12.04, 01.06.05 and 01.12.05 were not met) The Registered Person must confirm in writing to prospective residents, that based on the assessment the home can meet DS0000006771.V278062.R01.S.doc Timescale for action 21/04/06 2. OP2 17 07/04/06 3. OP4 14 07/04/06 St Aubyns Version 5.1 Page 25 4. OP7 15 5. OP9 13 6. OP9 13 their needs. The Registered Person must ensure that care plans are up to date and reflect how residents current needs will be met. Plans should include up to date information about the management of wounds. The Registered Person must develop policies and procedures for storage of medicines, medicines for leave and recording of drug errors. Other policies and procedures relating to medicines must be reviewed and updated. All policies and procedures for medicines must have a review date. The Registered Person must ensure that • All records of receipt of medication are signed and dated • Allergies and date of birth are recorded on all administration records • All creams and ointments are recorded on administration records • All computer printed administration records are legible • All medicines have a dose and frequency, including “when required” medicines • Directions on administration records are the same as directions on dispensed medicines • All handwritten administration records are checked and countersigned by a second member of staff • Tippex is not use on administration records • When variable doses are DS0000006771.V278062.R01.S.doc 21/04/06 02/06/06 07/04/06 St Aubyns Version 5.1 Page 26 7. OP9 13 8. OP14 12 9. OP19 23 prescribed, the amount actually administered is recorded • Administration records are signed at the time of administration to ensure accuracy • Records of receipt and administration enable a complete audit trail to be conducted • When medicines are signed out of the controlled drug register the date of disposal is recorded The Registered Person must 02/06/06 ensure that • A secure system is available to transport medicines to residents • Medicine doses are not prepared in advance of administration • Medicines are not shared between residents • Alcohol is not kept in the medicines cupboard • The medicines refrigerator is kept locked and the minimum, maximum and current temperature of the medicines refrigerator is recorded daily • Oxygen masks are covered to protect form dust The Registered Person must 21/04/06 ensure that resident’s have a choice of meals and that this information is recorded. The Registered Person must 07/04/06 ensure that the home and grounds are adequately maintained and decorated. In response to this report the Registered Person must notify the commission of the date that the work outlined in the development plan for 2005 will DS0000006771.V278062.R01.S.doc Version 5.1 Page 27 St Aubyns 10. OP27 19 11. OP29 19 12. OP30 18 13. OP31 9 14. OP33 24 15. OP35 20 16. 17. OP36 OP37 18 26 commence. The Registered Person must ensure that the home is staffed in line with the minimum staffing notice. Day care shifts must be recorded separately to nursing home shifts. The Registered Person must ensure that adequate documentation is obtained prior to allowing staff to commence work in the home. All records relating to staff employment must be kept in the care home. The Registered Person must ensure that a record is maintained of all training undertaken by staff including induction training. The Registered Person must provide a monthly update in writing to the commission to show what efforts have been made to recruit a full time manager. The first update must be sent to the commission by 07/04/06. The Registered Person must Introduce an effective quality assurance system that includes consultation with service users and their representatives The Registered Person must advise the commission in writing where and in what type of account resident’s personal money is held. A record of all money received for the residents personal use must be kept in the care home. The Registered Person must ensure that staff receive formal supervision. The Registered Person must supply the Commission and the Registered Manager with a copy of the report that he is required to prepare under regulation 26 of DS0000006771.V278062.R01.S.doc 07/04/06 07/04/06 07/04/06 07/04/06 21/07/06 07/04/06 21/04/06 07/04/06 St Aubyns Version 5.1 Page 28 18. OP38 13 The Care Homes Regulations 2001. (The previous timescales of 01.06.05 and 01.11.05 were not met) The Registered Person must 07/04/06 ensure that • Some fire drills include the night staff • A regular schedule of in house safety checks are undertaken and recorded • Accident records are monitored and a record is kept of any remedial action taken to prevent a recurrence • Moving and handling equipment is serviced at six monthly intervals • Sharps containers are appropriately assembled and labelled RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The Registered Person should amend the Service User Guide to include the following information: a description of the communal space, the number of places provided and any special needs catered for, the qualifications and experience of the Registered Manager, Provider and staff, access to inspection reports, residents views of the home and how the home meets standards 20.4, 21.4, 22.2, 22.5 and 23.10. The Registered Person should ensure that: • Photographs of service users are kept with administration records • If service users have more than one administration record they are marked “1 of 2” and “2 of 2” DS0000006771.V278062.R01.S.doc Version 5.1 Page 29 2. OP9 St Aubyns 3. OP12 4. 5. OP30 OP31 The same administration records are used for respite as for other service users • Records of medicines sent for disposal are signed by a second member of staff • Service user’s names are removed from medicines before placing in the disposal bin The Registered Provider should ensure that resident’s social needs are assessed and met. A record should be maintained of activities provided in the home and community. The Registered Person should ensure that staff receive a minimum of three paid training and development days per year. The Registered Person should ensure that the management structure and administrative support provided reflects the size of the home and the volume and complexity of the care provided. • St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 St Aubyns DS0000006771.V278062.R01.S.doc Version 5.1 Page 31 - 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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