Inspection on 24/04/06 for Swan House

This inspection was carried out on 24th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Swan House 19/05/09

Swan House 20/05/08

Swan House 06/11/07

Swan House 03/04/07

Swan House 12/08/05

Swan House 12/04/05

Swan House 25/10/04

Swan House 01/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Swan House 47 - 49 New Road Chatteris Cambridgeshire PE16 6EX Lead Inspector Elaine Boismier Unannounced Inspection 24th April 2006 8:45 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 Swan House DS0000024309.V288409.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. Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Swan House Address 47 - 49 New Road Chatteris Cambridgeshire PE16 6EX 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) 01354 696644 01354 696645 Four Seasons Homes (No 4) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40), Physical disability over 65 years of age of places (40), Terminally ill over 65 years of age (25) Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No more than 25 nursing places only No more than 25 places for terminally ill residents over 65 years of age (TI(E)) only 12th August 2005 Date of last inspection Brief Description of the Service: Swan House, close to the centre of the town of Chatteris, is a care home registered to provide care, including nursing care, for people over 65 years of age. There are 40 single bedrooms and 39 of these have ensuite facilities. Six bathrooms are also available in the home. The home is arranged on two floors that offer bedroom accommodation, dining room areas and a choice of sitting rooms. The upper floor can be reached via stairs or a lift. There is a small garden at the back of the home. Fees range from £340 to £555 and additional costs include hairdressing, newspapers and toiletries. A copy of the inspection report is available at the home or, alternatively from the CSCI website. A vacancy has arisen for a registered manager. Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This summary includes also activities carried out by the Commission following the statutory inspection of 12rth August 2005. Following the unannounced inspection of 12th August 2005 an immediate requirement was made as keys to gain access to medication were not held on the person but left unattended on a table in a communal sitting room. A follow-up inspection was carried out on 7th September 2005 and it was noted that keys to access medication were left unattended in an unlocked drawer in an unlocked room. As a result of this non-compliance with the immediate requirement, a statutory requirement notice was served against the home. A follow-up inspection was made, on the 23rd September 2005, to check compliance with the requirements detailed in this statutory requirement notice. Evidence found at this inspection indicated that the requirements of the notice had been complied with. This summary includes also activities carried out by other agencies, including the Commission, since the last statutory inspection of Swan House of 12th August 2005. These activities have been as a result of serious concerns about the health and welfare of service users living at Swan House. Following these activities the Commission reminded the Responsible Individual, representing the company Four Seasons Health Care, in a letter dated 17th March 2006, of the breaches of related regulations. An additional letter was also sent by the Commission, to the Responsible Individual for the Company, that detailed the breaches of regulations associated with reporting procedures to the commission on a monthly basis. A meeting was held on 20th April 2006 between representatives of the registered provider, Four Seasons Health Care, representatives of the Commission, representatives of the local health and social care authority and representatives of the local county council. The purpose of this meeting was to share concerns about the poor standard of care, and management arrangements of the home, with the representatives of Four Seasons Health Care, the Registered Provider. Two unannounced inspections have been carried out by the Pharmacist Inspector on 22nd March and 7th April 2006. Reference to this summary, and reference to the Pharmacist inspections, will be made in the body of this report. Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 6 This is the first statutory inspection of Swan House for 2006/7. The inspection was unannounced and carried out by two Inspectors between 8:50 and 15:00 and took just over 6 hours to complete. Staff, including a health care professional, Interim Home Manager, Care Services Director and Regional Manager, were spoken to, a tour of the building was made and documentation was examined. At the time of the inspection there were 26 people residing at the home and 8 of these people were spoken to. What the service does well: What has improved since the last inspection? What they could do better: The home could be better in the following 17 areas:- Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 7 • The Statement of Purpose must be revised, and updated, to reflect accurately the services that the home intends to provide. A requirement has been made about this. Information about the needs of residents waiting to be admitted to the home must have been carried out before the person enters the home. A requirement has been made about this. Although the home has admitted residents with mental health needs, the home is not registered to provide care for these people needs. A requirement has been made about this. Residents’ care records must be revised when the residents’ needs change. A requirement has been made about this. Residents’ care records must be reviewed at least monthly, if not sooner. A requirement has been made about this. Residents that are assessed to be at a high risk of pressure sore development, or residents that have developed pressure sores must have the appropriate care provided. A requirement has been made about this. Residents’ medication must be administered in a safe manner. A requirement has been made about this. The non-administration of medication must be investigated by the home. A requirement has been made about this. Records for the administration, or non-administration, of medication must be accurate. This is a requirement that has not been met from 31st March 2006 and carried forward to 30th April 2006. Residents’ dignity must be respected at all times. A requirement has been made about this. Residents must be allowed to be offered a choice of how they wish to live. A requirement has been made about this. A recommendation has been made to improve the way staff work in a more organised manner to meet the residents’ needs in a timely way. A recommendation has been made for the home to have 50 of care staff with NVQ level 2 qualification in care. Required information about staff must be obtained before they commence duties. • • • • • • • • • • • • • Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 8 • • • Staff must attend training in awareness of adult abuse. A requirement has been made about this. The home should be managed by a registered manager with a registered managers award. A recommendation has been made about this. The details of the monthly reports submitted to the Commission should demonstrate that residents have been consulted about their views of the home. A recommendation has been made about this. Additional requirements and recommendations made with particular regard to medication, will be assessed, by the Pharmacist Inspector, at a later inspection of Swan House, but these are included in the requirements and recommendations part of this inspection report. 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. Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 9 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 Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 & 6 The standard of information is poor and needs to be improved to assist prospective residents in the decision where to live. EVIDENCE: The home’s Statement of Purpose was seen and evidence suggests that this was reviewed in 2003 and information is out of date. Information, provided by the senior managers at the time of the inspection, indicated that interim care is provided at the home, although this is not detailed in the document (see also Standard 6 of this report). A requirement has been made. Examination of 6 residents’ care files indicated that one of the 6 residents had a full assessment carried out prior to them moving into the home. A requirement has been made. The home is not registered to care for people with mental health needs. However the home has admitted outside the categories and conditions of registration. As a result of this action residents’ admitted to the home have not Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 11 had their health and social care needs met (due to the unsuitability of the home).The Commission has received information prior to, and during this inspection, about the negative effect that this unlawful action has had on residents’ health and wellbeing. A requirement has been made. The standard associated with intermediate care has not been assessed prior to this inspection due to insufficient information provided during the previous inspections. Information provided at a POVA meeting suggested that the home provides intermediate care. This was discussed at the time of the inspection and it was made clear to the Inspectors that it is not the intention of the home to provide such a rehabilitation service. The home provides respite care and interim care although this service provision must be detailed in the Statement of Purpose (see Standard 1 of this report). This Standard has not been formally assessed on this occasion. Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 The standard of health care provided is poor although residents are generally well treated by caring staff. EVIDENCE: During this inspection 6 residents’ care files were examined and evidence suggests that the care documentation is not always revised and reviewed as specified in this Standard and related Regulations. (see also Standard 8 of this report). Two requirements have been made. Following three separate meetings, held under the Protection of Vulnerable Adults (POVA) in March 2006, it was concluded that residents with nursing needs, had not had adequate care provided to meet their changing, nursing needs. As a result of this evidence, the Commission informed in writing the Responsible Individual representing the Company, that there were breaches in the related regulations. This letter was dated 17th March 2006. At the time of the inspection there were 26 residents living at the home. Eight of these people had pressure sores; 7 of these people had pressure sores grade 2 or above; 7 of these 8 people had acquired these pressure sores whilst Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 13 living at Swan House. At the time of the inspection 2 residents’ care records, (relating to prevention and healing of existing pressure sores) were examined and care practices carried out for these people were observed. Care provided to the residents was considered inadequate i.e. residents’ seating or lying positions were changed in excess of two to three hours. The breach of the regulation, as detailed in the letter of the 17th March 2006, was not complied with, and a requirement has been made. A Pharmacist unannounced inspection was carried out on 22nd March and a follow-up inspection, also unannounced, were carried out on 7th April 2006. Following these inspections, although some improvement has been made, there remain serious concerns about the standard of medication practices in the home. Three requirements have been carried forward from the inspection of 22nd March 2006 and an immediate requirement was made at the time of the inspection of 7th April 2006 due to covert administration of medication. Due to no evidence that this practice of covert administration of medication was continuing, this requirement is considered met. There have been 4 recommendations made as a result of these 2 Pharmacist inspections. These findings were discussed at the multi-agency meeting, held on 20th April 2006, with representatives of the registered provider. Attendees were informed that since the Pharmacist inspections an audit had been carried out of the medication and that staff had received training in medication practices. During this inspection it was noted, however, that medication records were incomplete and this is related to requirement carried forward to 30th April 2006. During the tour of the premises medication had been left for a resident to take. This had not been taken although the records of administration indicated that the staff had witnessed that the medication had been taken. This is related to requirement carried forward to 30th April 2006. However, due to further evidence of poor practice, a requirement has been made as medication was left in an unsafe manner. Discussion with a health care professional indicated that a resident should have been given newly prescribed medication, 3-4 days prior to the day of the inspection. According to the health care professional this medication had not been given to the resident. Discussion with the senior managers indicated that the home had not received the medication. A requirement has been made for the home to investigate this issue as an immediate requirement i.e. 25th April 2006. Residents said that the care staff were kind and caring and it was noted that staff interacted with the residents in a caring and respectful manner. Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 14 It was noted that, during breakfast time, some residents, to protect their clothes, were wearing plastic aprons (the type normally used by staff for infection control procedures). A requirement has been made. Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Residents’ quality of life is adequate but could be improved upon. EVIDENCE: Discussion with staff and residents and examination of residents care notes indicated that activities are provided at the home. A survey has been carried out to elicit what residents would like to do. (See also Standard 33 of his report). Residents reported that they were not offered the choice of what time they would like to get up or when to have a bath. A requirement has been made. Bedrooms were seen to contain items of a personal nature. Residents confirmed that they had made the choice, for the home to keep their monies safe for them. Residents confirmed that they were able to receive their guests and this was observed also during the time of the inspection and by examination of the visitors’ record book. Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 16 During a visit to the kitchen information provided by the staff, and observation of records, indicated that the nutritional content of the food has improved due to the increase of the calorie content of the food. Following comments made by residents, staff reported that there has been a change by which beef is obtained from a different provider (see also Standard 16 of this report). The Inspectors received, favourable comments from residents, about the food provided. Surveys, seeking residents’ views about the food, were seen and these contained positive comments about the presentation, quantity and quality of food. (See also Standard 33 of his report). Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Good systems are in place for the reporting of complaints and responding to allegations of abuse. EVIDENCE: Generally residents knew who they could speak to if the wanted to make a concern or complaint known. Information provided by representatives of the Company to the Commission, indicates that the system, in responding to complaints, is good (See also Standard 15 of this report). Information of how to make a complaint was on display in the home’s front reception area. During March 2006 three individual meetings have been held under the local adult protection procedures for the protection of vulnerable adults (POVA). The home has attended and co-operated with other agencies represented at these meetings. Discussion with staff indicated that all staff have been provided with information about adult abuse although no formal POVA training, has been held for staff to attend. (See Standard 30 of this report). Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 18 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 & 26 Residents live in a homely and clean place. EVIDENCE: Swan House provides accommodation for residents on two floors. Access to the first floor is via stairs or a lift. Bedrooms are generally well furnished and decorated and throughout the home there are pictures displayed on the corridor walls. At the time of the inspection the home was clean and fresh smelling. During the multi-agency meeting of 20th April 2006 concerns were shared with representatives of the Company about poor standards of care practices with regard to infection control matters. During this inspection it was noted that staff were wearing, and changing, protective gloves and there were sufficient hand washing and hand drying facilities. Examination of staff induction records indicated staff had received instruction in infection control matter Swan House DS0000024309.V288409.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, 28, 29 & 30 Recording of attendance in staff training is good although the organisation of staff, the standard of staff training and staff recruitment procedures are inadequate. EVIDENCE: Staff and residents indicated that residents’ care needs are not always met in a timely manner. The senior managers of the home reported that there was a sufficient number of staff on duty but considered that it was how staff organised their worked might need to be considered. A recommendation has been made. Although some staff are to complete their training programmes, currently the home has less than 50 of care staff with NVQ level 2 in care. A recommendation has been made. Two staff files were examined to assess the home’s recruitment procedures. For one file all required satisfactory information was available. For the remaining file there was one (undated) written reference; no documentary proof of POVA or CRB check that may have been carried out and no satisfactory confirmation of the person’s current nurse registration status. A requirement has been made. Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 20 During the meeting held on 20th April 2006 it was reported that staff have attended training in medication and care of residents at risk, or who have developed pressure sores. Records of attendance of staff training have improved although staff have not attended formal training in POVA matters. (See Standard 18 of this report). A requirement has been made. Swan House DS0000024309.V288409.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 & 38 Residents live in a home that has been poorly managed but well-maintained. Most, but not all, good quality assurance systems are in place. EVIDENCE: Since the start of 2006, Swan House has experienced an unsettled period and this is reflected in the number of POVA meetings, multi-agency meetings and the high number of requirements and recommendations made following this inspection and Pharmacist inspections carried out during March and April 2006. Swan House is currently managed by an Interim Home Manager. Staff reported that although staff morale had been low, during the unsettled period, it was considered that this has started to improve. A recommendation has been made for Swan House to be managed by a registered manager with the registered managers award, or equivalent. Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 22 Surveys regarding activities provided (see Standard 12 of this report) and food provided (see Standard 15 of this report) have been carried out to gain the views of residents about these matters. A letter was sent to the Responsible Individual as the Commission had not received any copy of the Regulation 26 monthly reports. Copies of these have since been received although the content of these reports do not demonstrate that the residents have been asked for their views about the home. This issue was discussed during the meeting held on 20th April with representatives of Four Seasons Health Care. A recommendation has been made about this. Balances and records of residents’ monies, kept for safe-keeping by the home, were seen and these were satisfactory. Records were checked for hot water temperatures; for temperatures of fridges and freezers for food storage; for fire alarm, fire drills and emergency lighting tests and for staff training in moving and handling and fire safety matters. All of these records were satisfactory. Swan House DS0000024309.V288409.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 1 x 1 1 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 3 Swan House DS0000024309.V288409.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 4 Requirement Timescale for action 26/05/06 2 OP3 3 4 5 6 OP4 OP7 OP7 OP8 7 OP9 The Registered Person must provide a Statement of Purpose that contains the elements of Schedule 1 of the Care Homes Regulations 2001, and a copy of this to be submitted to the Commission. 14 The Registered Person must ensure that prospective service users needs are assessed prior to moving into the home and a copy of this assessment is obtained by the home. Section 24 The home may not admit outside of the the categories and conditions of CSA 2000 registration. 15(2)(b) The Registered Person must ensure that the care plan is kept under review. 15(2)(c) The Registered Person must ensure that the care plan is revised at any time.” 12(1)(a) The Registered Person must ensure that the health and welfare of service users is promoted at all times , with particular regard to prevention and treatment of pressure sores. 13(2) The Registered Person must DS0000024309.V288409.R01.S.doc 05/05/06 25/04/06 05/06/06 05/06/06 28/04/06 30/04/06 Page 25 Swan House Version 5.1 17(1)(a) Sch 3(3)(i) ensure that records of the administration (and nonadministration) of medicines are accurate. This is a repeat requirement. Previous timescale of 31/03/06 not met. The Registered Person must ensure that medicines controlled under the Misuse of Drugs Act 1971 must be recorded in accordance with the Act and associated Regulations. 8 OP9 13(2) 30/04/06 9 OP9 17(1)(a) Sch 3(3)(m) This is a repeat requirement. Previous timescale of 31/03/06 not met. The Registered Person must 30/04/06 ensure that records of the results of GP contacts are accurate and up to date. This is a repeat requirement. Previous timescale of 31/03/06 not met. The Registered Person must ensure the safe-keeping of medication. The Registered Person must investigate the incident of the non-administration of prescribed medication. The Registered Person must ensure that the dignity of service users is respected at all times. The Registered Person must ensure that service users are consulted about how they choose to live. The Registered Person must ensure that all required information about staff is obtained, and kept at the home, prior to the staff commencing duties. The Registered Person must ensure that service users are DS0000024309.V288409.R01.S.doc 10 11 OP9 OP9 13(2) 13(4)(c ) 26/04/06 28/04/06 12 13 OP10 OP12 12(4)(a) 12(2) 28/04/06 05/06/06 14 OP29 19 30/04/06 15 OP30 13(6) 05/06/06 Page 26 Swan House Version 5.1 protected from abuse by the training of all staff in POVA matters. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP9 OP9 OP9 Good Practice Recommendations The Registered Person should consider updating the policies for the safe use of medicines in line with practice developments. The Registered Person should consider the development of operational procedures for medicines handling pertinent to the practices within the home. The Registered Person should consider that hand-written changes or additions to instructions for prescribed medicines are signed and dated by the person making the entry. The Registered Person should consider recording the temperature of the refrigerator using the maximum/minimum thermometer in place and ensure a procedure is in place for its use. The Registered Person should consider ways for staff to meet the needs of residents in a timely manner. The Registered Person should consider ways for the home to have 50 of care staff, or above 50 , to have NVQ level 2 qualification in care The home should be managed by a registered manager with the registered managers award, or equivalent. The Registered Person should consider ways to demonstrate that service users have been consulted about their views of the home. 4 OP9 5 6 7 8 OP27 OP28 OP31 OP33 Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE 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 Swan House DS0000024309.V288409.R01.S.doc Version 5.1 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!