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Inspection on 11/05/06 for St John`s Wood Care Centre

Also see our care home review for St John`s Wood Care Centre for more information

This inspection was carried out on 11th May 2006.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home always provides a warm welcome for friends and relatives of the service users. Relatives said that staff are approachable and there is a senior person available to speak to. They were pleased that they could visit as often as they wanted to and that visiting times are very flexible. A relationship of trust exists between the staff and service users and their relatives. This enables service users and relatives to express their needs and wishes openly. Concerns are always listened to and acted upon. The staff team are very good at meeting the health care needs of the service users. They receive the necessary training to develop their skills. The home is well equipped with aids and adaptations to ensure the safety, comfort and dignity of the service users. Health care needs are well documented on care records, which are known to staff. The home continues to deploy sufficient staff to meet the needs of the service users. Staff are encouraged to work as a team and to be flexible in how they organise their work to ensure that service users are given choices and are able to follow their preferred lifestyle. Although the home is large it is well presented with good hygiene standards. Service users benefit from having single rooms with ensuite facilities and they are able to personalise their rooms according to their tastes.

What has improved since the last inspection?

The statement of purpose and service user guide have been updated with the changes to the registration and the details of the new manager. There has been an improvement in the care planning process and it is more person centred; taking into account the personal preferences of the service users. Areas of the home have been earmarked for further improvement.

What the care home could do better:

Generally service users and relatives felt that they had enough information about the home prior to moving in. However not all this information is documented and there is a tendency to rely on word of mouth. The home could produce relevant information such as a service user guide in formats, which are appropriate to the needs of the service users. Although service users feel confident to raise their concerns with members of staff, they do not have a copy of the full complaint`s procedure. These need to be distributed and again need to be in an appropriate format. The manager is keen to improve the social care aspects of the home. Generally the values of privacy and dignity are upheld however there are some staff that need further training and development to ensure that these values are being promoted throughout the home. The catering staff have made great efforts to accommodate the different cultural and dietary needs of the service users. This needs to be developed further to include personal preferences. Care staff can support this by an ongoing process of asking service users about their likes and dislikes. This information will keep the catering staff constantly updated.

CARE HOMES FOR OLDER PEOPLE St John`s Wood Care Centre 48 Boundary Road London NW8 OHJ Lead Inspector Pippa Canter Unannounced Inspection 11th May 2006 10:00 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 John`s Wood Care Centre DS0000010324.V287257.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 John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St John`s Wood Care Centre Address 48 Boundary Road London NW8 OHJ 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 7644 2930 020 7644 2940 Lifestyle Care PLC Care Home 100 Category(ies) of Old age, not falling within any other category registration, with number (86), Physical disability (14) of places St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. For the provision of General Nursing Care for up to 86 people aged 60 and over. For the provision of General Nursing Care for up to 14 young people aged 18 to 65 years with physical disabilities (No more than 6 beds to be used in this Unit for people over 60. People over 60 placed in this Unit should be mentally alert and produce a written letter or equivalent not to be placed in the Frail elderly unit The staffing Notice From the day that the home receives the certificate of variation that a registered nurse be on duty for all shifts, viz (24 hours). 29th November 2005 3. 4. Date of last inspection Brief Description of the Service: St Johns Wood Care Centre is a registered care home providing 24-hour support and nursing by registered nursing staff and trained carers. . The home is owned by Lifestyle Care who are established in the development and management of Nursing homes and is the Registered Provider for St Johns Wood Care Centre. . St Johns Wood Care Centre is purpose built and was first registered in February 2001. The home provides nursing care for up to 100 residents. The home is situated in a prime residential area approximately ten minutes walk to local amenities and public transport. . The home is set out as follows: * Lower Ground Floor - up to 14 Younger Adults (18 - 65yrs) with physical disabilities - YPD Unit (Nursing). * Ground Floor - up to 23 Older People (OP) Nursing Care. *First Floor - up to 27 Older People - Nursing Care. This includes one double bedroom for a couple, but used as a single room only. *Second Floor - up to 18 Older People - Nursing Care. * Third Floor - up to 16 Older People - Nursing Care. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report reflects the outcomes of the first key inspection of the nursing home under the new inspection process “Inspecting for Better Lives”. This key inspection took place over three days and was initially organised on an unannounced basis. There were two inspectors, the lead inspector who spent three days inspecting the older persons’ facilities and standard of care; and the second inspector who spent one day inspecting the younger persons’ physical disablement unit. In total ten service users were case tracked, two from each unit. Out of these 10 people, eight agreed to meet with the inspectors. Relatives who were visiting over the three days of the inspection were also spoken to as well as interviews with staff and the manager. Their views underpin the content of this inspection report. The lead inspector has also received feedback from service users through the use of “Have your say” questionnaires. A variety of records were looked at including care plans, personnel records, training records and policies and procedures. What the service does well: The home always provides a warm welcome for friends and relatives of the service users. Relatives said that staff are approachable and there is a senior person available to speak to. They were pleased that they could visit as often as they wanted to and that visiting times are very flexible. A relationship of trust exists between the staff and service users and their relatives. This enables service users and relatives to express their needs and wishes openly. Concerns are always listened to and acted upon. The staff team are very good at meeting the health care needs of the service users. They receive the necessary training to develop their skills. The home is well equipped with aids and adaptations to ensure the safety, comfort and dignity of the service users. Health care needs are well documented on care records, which are known to staff. The home continues to deploy sufficient staff to meet the needs of the service users. Staff are encouraged to work as a team and to be flexible in how they organise their work to ensure that service users are given choices and are able to follow their preferred lifestyle. Although the home is large it is well presented with good hygiene standards. Service users benefit from having single rooms with ensuite facilities and they are able to personalise their rooms according to their tastes. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 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 St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Older Persons:1 & 3 : Younger Adults 1 & 2 The quality of this outcome area is considered adequate. The information about the home does not always give service users and their relatives sufficient detail to inform them that the service can meet their needs. EVIDENCE: Manager said that the service user guide is sent out as part of the enquiry process and prior to admission. She feels that only relatives get a chance to look at it. A new admission was spoken to and could not recall receiving a guide. Copies were not available in the service users bedrooms. Staff and service users said that they did not know what a service user guide is however, the comment cards reveal that service users and/or their relatives consider they had enough information about the home prior to moving in. One said they knew a person who worked there and had received a valuable insight into the home. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 9 The service user guide does not inform a referral to the physical disablement unit as to the philosophy of the unit or what rehabilitation may be available. One service user in the PD unit requested that any information about the home should be larger print because of his failing eyesight. A copy of the service user guide was available for inspection. as there are no comments from service users included in it. It is incomplete A copy of the statement of purpose is available in the main foyer of the home. It has been updated as required from the last inspection however further development work is needed. The document reads in a stilted way. Although it mentions the Physical disablement unit, it does not give any further information about it. A care needs assessment is available but in some instances it is poorly recorded. Staff are completing these at a very early stage in the admission process and the information is not being updated. Two service user said they would prefer more stimulation and would like to meet other service users with similar interests. Some aspects of social care needs are reflected in the newer care plans and also seen in service users’ lives. There is a need to develop the social care needs assessment so that it remains a “live” document and to ensure that all key workers are completing the key worker journal. A couple were found with no entries in at all. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Older Persons: 7, 8, 9 & 10 : Younger Persons 6, 19, 20 & 18 The quality in this outcome area is considered good. Although further work is required on the care plans in the older person’s units, there is a great deal of improvement and the care plans are beginning to be more individualised. EVIDENCE: In the physical disablement unit, seven care plans were inspected. These were found to be reviewed regularly with monthly updates, or as needs change and yearly reviews. All the care plans looked at showed action plans to meet service needs, which were detailed. However the assessment documentation did not detail background or significant others relationships. In the older persons units evidence was found of more person centred planning for the most recent admissions. The manager confirmed that care plans are being developed to be more person centred but this approach has not spread throughout the home as yet. Some key worker journals are not being kept updated or not completed at all although other key worker journals were found to be completed on a regular basis. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 11 Health care needs were well documented in all files both in the physical disablement and older persons units. Files show dates of professional visits to service users and appointments. A chiropody service is now available. The MARS sheets were checked and found to be accurate and reliable. There is correct ordering, storage, recording and administration of medication. Fridge temperatures are checked and recorded. Where the air conditioning temperature is different to the room temp, the engineer has been called to regulate air conditioning. The Controlled Drugs’ cupboards are alarmed. The records of administration were found to be accurate. Updated BNF books are available. The home does have guidance and support from both a Pharmacist and General Practitioner. It would be appropriate to develop the medication profiles to become part of the care planning process. This will enable care staff to have access to information that includes the side effects of medication, and the consequences if doses are missed. Agency staff are rarely used. The home has own bank staff to cover, which ensures continuity of care. Both service users, spoken to complimented care staff on how they delivered their care in the Physical Disablement unit. Another service user in OP unit complimented the staff and said that they could not do enough for the service users. Relatives said that staff are always available and from their point of view there seems to be sufficient staff on duty. However two service users did not feel that care staff respected their privacy. This was proved when the inspector was present when three care staff walked into bedrooms, two without knocking and one of whom wanted to know why the bedroom door was closed. The comment cards from six other service users showed that privacy and dignity is upheld. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Older Persons 12, 13, 14, 15 : Younger Adults 11, 12, 13, 14, 15, 16, 17 The quality in this outcome area is good. Service users are able to have a fulfilling life despite frailty. Choices are available and the food is good however the menu should be expanded to reflect dishes that are nutritional, meet cultural needs and some personal favourites of the service users. EVIDENCE: There is a good balance amongst the staff of age and social mix. The care plans reflect the cultural needs of the service users in the physical disablement unit. Visitors to the home confirmed that the policy around visiting is very flexible. Relatives a said that they are always made to feel welcome and that there is a senior person on duty if they have any queries about the care of their elderly relatives. The visitors appreciated the courtesy of using the buttery on each floor to be able to make themselves and their relative a drink. Service users confirmed that they are able to visit their families at home. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 13 Service users were very complimentary about the activities co-ordinator. They felt very supported by her community activities, which are detailed in the care plans. An activities schedule is displayed in all the units. Activities notes are in files, which show what activities the service users have engaged in. However social care assessments are not consistently written in sufficient depth nor kept updated. These need to be more informative and continually updated in order to feed into the person centred care planning process. One service user spoken to would like an advocate and there is a friend from church who could possibly be an advocate. The home is aware of this. He feels he has as much control of his life as he can have and this is a sentiment echoed in the comment cards from other service users. Staff confirmed that they deploy themselves according to the preferences of service users. Those that like to rise early are attended to first. The “thank you” cards from relatives also reflect the skill and caring attitudes of the staff. Relatives said that they are always made to feel welcome. One service user confirmed that Halal meals are offered. The menu is compiled by a relative; however the food is not always prepared in the home the way he likes it so relatives usually bring food in. Alternatives are available and the meals provided generally reflect the cultural needs of the service users. However several older Jewish people would like to see their particular food likes on the menu. This is an area that needs to be developed further and would probably come out of a more person centred approach. In two units the menu had not been recorded on black board or not it had not been updated from the previous day. A full range of alternatives are not recorded for service users to see therefore this does not invite service users to make a choice. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Older Persons: 16 & 18 : Younger Adults 22 & 23 The quality of this outcome area is considered good. Service users know that their concerns will be listened to and acted upon. They are protected and safeguarded from harm by the home’s policies, procedures and practices. EVIDENCE: Overall a good grasp of the importance of listening to service users and relatives. Staff in the Older Person’s units said that their first response to a relative or service user making a complaint would be to sit and listen to try to resolve the matter, otherwise pass it on the NIC. The complaints procedure is not accessible to one service user in the physical disablement unit. Deteriorating eyesight did not enable him to read it and he was a fairly new resident in the unit. The complaint’s procedure is not available in any other format. There is no service user guide in the rooms therefore the service users do not have access to the full complaint’s procedure. Service users said that they would speak to the person in charge on the floor or relatives said that they would approach the manager. Issues and concerns are recorded in a weekly managers meeting report. Copies of these are available for inspection and show that the manager is ware of this feedback. Relatives are made aware of the complaints procedure. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 15 The home has policies and procedures relating to the protection of vulnerable adults (POVA). POVA training is available. Staff explained the content of the training and their understanding of what constitutes abuse. Staff were clear that it was important to report any allegations or incidents at once. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Older Persons: 19 & 26 : Younger Adults 24 & 30 The quality in this outcome area is considered good. The providers offer an environment that is attractive comfortable for service users and meets their needs. EVIDENCE: All service users have a single room with an ensuite facility consisting of a washbasin and toilet. Rooms were equipped with the necessary aids and appropriately furnished. Each room was personalised according to the service users’ tastes. The home has all the necessary equipment to ensure that service user’s privacy and comfort, including special mattresses, hoists and special bathing equipment. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 17 The manager confirmed that there is sufficient monies in the budget to redecorate several areas in the home. Two areas have been earmarked and in particular the lounge-cum-dining area in the Physical Disablement unit. The manager acknowledges that this room requires updating to reflect the younger age group that use it. The fencing around the roof garden was considered unsightly in the previous inspection report. In response to this natural planting is being used to conceal it. It is planned that when the ivy and other plants grow, the fence will be hidden. There is a tendency to use the bathrooms as storage areas and generally this area could be made more homely. On one floor it was noted a poster was on display advertising a particular wound dressing. This was in a public area used by service users and relatives. It was not considered appropriate. The manager is considering changing the location of a dining room and lounge on one of the floors to improve the layout and offer interest to the service users. Infection control procedures are in place and all staff have attended appropriate training. Hibi-scrub is available, along with protective measures such as gloves and disposable aprons. The environment was noted to be clean and hygienic. There were no noxious odours. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Older Persons: 27, 28, 29, 30 : Younger Adults 32, 33, 34, 35 The quality in this outcome area is good. Service users are safeguarded by the home’s policies and procedures relating to recruitment and selection and training. EVIDENCE: The home is meeting the staffing notice. A training and development plan was available for inspection. The plan includes the following training areas:• Person centred planning Nov 06 • Appraisal training May 06 • Phlebotomy Dec 06 • Wound Care ongoing • NVQ 2 & 3 ongoing • Continence care May – ongoing • Medication training Dec 06 • POVA & statutory training 2006/2007 Training records are available and these show that some but not all staff have had elder abuse training. However those spoken to a good grasp of adult protection procedures even if they had not attended. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 19 On each floor there is a supervision folder with dates of supervision of each member of staff. The supervision file was not complete in the Physical Disablement unit. The manager confirmed that nurses are playing catch up with supervision sessions. Care staff confirmed that they had supervision and they found it useful. Recruitment procedures are in place and were noted to be thorough. Staff spoken to confirmed their experience of recruitment. Personnel files checked and there did not appear to be a consistent approach around validating references. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Older Persons 31, 33 , 35, 38 Younger Adults 37, 39, 23, 42 The quality in this outcome area is considered good. The home has a history of being well managed and the management structure is suitable for the size of the home. Service users’ welfare is protected by the home’s polices and procedures regarding safeguarding personal finances. Health and safety is observed by staff in the home, which provides a safe environment for service users and staff. EVIDENCE: Manager has an appropriate RMN nurse qualification and an NVQ 4 in management. She has management skills underpinned by relevant training. The current manager has been in post since 5th December 2005. She is aware of the requirement to register and will be submitting an application. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 21 Service users’ personal monies are kept with administrator who maintains the financial records. The nurses sign for it. One service user goes to the bank and then hands money to administrator, and gets money when he asks for it and feels that he has control over his own money. The providers have a system of regular auditing to ensure standards are maintained. A quality audit file is available for inspection. Feedback is obtained via service user and relatives` meetings are held. Expression of concern and comments are fed back to the manager through a monitoring form. The provider ensures that regular visits are made to the home and a report compiled as to its’ conduct. Health and safety training is available. Staff are aware of the health and safety policy and procedures for maintaining a safe environment. The maintenance of the building and equipment is kept up-to-date. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 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 2 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 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 OP1 Regulation 4(1)(a-c) Requirement The Registered Person must revise the Statement of Purpose to reflect both the older persons and the younger physically disabled services. The Registered Person must supply a service user guide to each service user. Guides must be in an appropriate format and language to meet the needs of the service users. The Registered Person must ensure that the values of privacy and dignity underpin the practice of all staff. The Registered Person must ensure that from the menu, the service users are able to choose from a range of meals that reflect their cultural needs, nutritional needs and their personal preferences. The Registered Person must ensure that a complaints procedure is given to each service user and is appropriate to their needs. The Registered Person must DS0000010324.V287257.R01.S.doc Timescale for action 30/11/06 2. OP1 5(1)(a-f) 30/11/06 3. OP10 12(4)(a) 30/06/06 4. OP15 16(2)(i) 30/07/06 5 OP16 22(2) 30/08/06 6 OP18 19(1)(c) 30/07/06 Page 24 St John`s Wood Care Centre Version 5.1 ensure that there is a consistent approach to validating references. 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 OP9 Good Practice Recommendations It is strongly recommended that the medication profiles be developed as part of the care planning system. The profiles should include useful information for care assistants e.g. the name of the drug, what the drug is used for and any side effects that care staff should look out for and report. St John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Camden Local Office Centro 4 20-23 Mandela Street London NW1 0DU 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 John`s Wood Care Centre DS0000010324.V287257.R01.S.doc Version 5.1 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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