Inspection on 01/09/06 for The Carnarvon Nursing Home

This inspection was carried out on 1st September 2006.

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

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

Other inspections for this house

The Carnarvon Nursing Home 24/09/07

The Carnarvon Nursing Home 20/01/06

The Carnarvon Nursing Home 03/05/05

The Carnarvon Nursing Home 02/08/04

The Carnarvon Nursing Home 01/04/04

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 The Carnarvon Nursing Home 22-24 Carnarvon Road Clacton on Sea Essex CO15 6QF Lead Inspector Lysette Butler Key Unannounced Inspection 08:30 1 September 2006 st 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 The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Carnarvon Nursing Home Address 22-24 Carnarvon Road Clacton on Sea Essex CO15 6QF 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) 01255 426628 01255 426628 ANS Homes Limited Ms Carol Anne Johnson Care Home 57 Category(ies) of Old age, not falling within any other category registration, with number (20), Physical disability (14), Physical disability of places over 65 years of age (57), Terminally ill (3), Terminally ill over 65 years of age (3) The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 57 persons) Persons of either sex, aged 45 years and over, who require nursing care by reason of a physical disability (not to exceed 11 persons) Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 20 persons) Persons of either sex, aged between 60 - 65 years, who require nursing care by reason of a physical disability (not to exceed 3 persons) Three persons, over the age of 45 years, who require nursing care by reason of a terminal illness The total number of service users accommodated in the home must not exceed 57 persons 20th January 2006 Date of last inspection Brief Description of the Service: The Carnarvon Nursing & Residential Home is in the seaside town of Clacton on Sea and is accessible via public transport that passes the front of the premises. The home is a former Victorian hotel that has been extended and modified. The nearest railway station is Clacton, which is within easy walking distance, as is the seafront. The home has a small amount of car parking spaces to the front of the home. The home provides care for older people of both sexes, who need both personal and nursing care. The home is also registered to provide nursing care, for up to 14 service users, aged 45 years and above with a physical disability, within the total bed compliment of 57. There are three floors accessible by stairs and a lift. All rooms are well furnished and pleasantly decorated. Bedrooms are all 10sqm or over. There is a large combined lounge/ dining room leading out onto a small, but well maintained garden. Various outings and shopping trips are organised for service users and regular entertainment is provided. The proprietor of this home is BUPA Homes Ltd. Current fees range is: £395 to £680 The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection started on 1st April 2006. The inspection process included: a site visit on 1st September 2006, which lasted 8 hours; a review of evidence supplied by the proprietor, residents, visitors to the service or the staff; resident, visitor, healthcare professional and staff surveys; discussion with the registered manager, deputy manager, registered nurses, senior carers, care staff, ancillary staff, residents and relatives. During the site visit the premises were inspected, including inspection of the grounds. Samples of records and residents care plans were also reviewed. The home was clean and well maintained. The overall care and well being of the residents was the focus of the inspection. Staff and residents were welcoming and happy to speak to the inspector at the site visit. This inspection covered all twenty-two key standards and eight of the remaining standards. The manager and her staff approached the inspection in a positive and cooperative manner that was focused on achieving best practice to meet the needs of the residents. What the service does well: What has improved since the last inspection? Changes to the documentation and extra work by the staff have shown a general improvement in the quality and content of all care plans reviewed during the site visit. The gradual upgrading of all beds in the home is ensuring that residents are comfortable and less likely to suffer skin problems. Maintenance within the home is good and the extra roles taken on by the maintenance staff ensures that repairs are carried out in a timely fashion. The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. All staff were clear on the conditions of registration of this home, ensuring that prospective residents’ and their relatives’ were given correct information so that they are able to choose the right care home. EVIDENCE: There is a current up to date statement of purpose available in the home. Every room also contains a welcome pack, which is comprehensive and based on BUPA documentation. Both the statement of purpose and service user guide are common to all BUPA homes, however a leaflet specific to the Carnarvon is included in with both these documents. BUPA documentation is used for all preadmission assessments; the manager is clear on the registration categories of the home and admission criteria, ensuring that there are no inappropriate admissions. The manager or her deputy undertakes all preadmission assessments. Staff spoken to were happy that they had the skills to deal with the care of the current residents’. This home does not offer intermediate care. The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 9 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 & 11 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. Health and personal care is well supported for all the residents’ in this home. Residents’ looked well cared for, clean and dressed appropriately. EVIDENCE: Six care plans were reviewed during the site visit, two from each floor. All plans were in the process of being transferred to BUPA documentation called the QUEST system, which staff were generally quite enthusiastic about. Some ANS paperwork has been retained and combined with the BUPA system. However all care plans reviewed, whether of the new type or the original style, were detailed and clear; they were well laid out and contained all elements required to successfully and safely care for the residents’. Some of the plans reviewed did not have pictures of the individual resident’s on them, but all medication charts did contain a picture. There were appropriate risk assessments and details of specialist services utilised by the residents on all files. The risk assessments for bedrails were very long, but were The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 10 comprehensive and appropriate in assessing the rails in use. There were also separate wound care plans that included detailed easy-to-use charts for ongoing assessment. The health care needs for the residents’ were well documented and cared for in a holistic manner. All residents have their own GP of choice who attend the home as needed. Most regular health checks are undertaken in the home, including chiropody, dental and ophthalmic care. Staff generally attend hospital appointments with the residents if they have no family or friends’ to go with them. At the time of the site visit the home were in the process of changing the pharmacy that they used. The new pharmacy is nearer the home and is offering a complete package including training and auditing of medication on a regular basis. Medication policies and documentation were reviewed on all three floors. There were no omissions on any medication administration records reviewed, no problems with controlled drugs and no overstocking. There were only two resident’s in the home on night sedation and one resident who was self-medicating. The only documentation issue highlighted was that staff were not signing and dating medications that had been discontinued. They were stating why it was discontinued, but not when. Fridge and medication room temperatures were taken daily and there was no evidence that the temperatures were outside of excepted limits. Privacy and dignity issues throughout the home were well handled and staff were observed treating all the residents with respect. One resident had requested that pictures were not taken of their wound as it was healing and their wishes were respected. Their wishes were also documented in the care plans. Documentation of all of resident requests regarding their care during any terminal illness and/or their subsequent death was ‘patchy’. Where the information had been filled in it was done well, however not all care files contained specific details and the manager stated that she was following this up with the appropriate families. The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 11 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 - Quality in this outcome area is excellent; this judgement has been made from evidence gathered both during and before the visit to this service. Resident activities were varied and appropriate to their levels of dependency. Food offered was very good and meets the nutritional needs of the residents’. EVIDENCE: This home has two part-time activities coordinators and one volunteer who helps with the activities, on a regular basis. The activities coordinators are enthusiastic and interested in the residents. At a residents meeting prior to the site visit there was a long discussion about the different activities the home offered, including cinema afternoon is in the lounge to accommodate as many residents’ as possible, and wheelchair friendly outings that they could attend. The only complaint was that on the cinema afternoons popcorn was not available for the residents’, so the manager arranged this for to be available at the next cinema afternoon. During this meeting it was also pointed out that following the last barbecue at the home, future barbecues would be at lunchtimes instead of evenings, which suited the residents’ better. Visitors, relatives and people from the local community were also welcome at these barbecues. The barbecue a week previous to the site visit, had been well The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 12 attended and even one of the resident’s from the top floor, who does not usually come down to anything, came down and thoroughly enjoyed the day. At the time of the residents’ meeting a new initiative had been started called resident’s day’. Each resident in rotation had their own day during which all heads of departments spoke to that resident and found out what could be improved and what they liked about the home. The cook also tried to offer the resident their favourite meal on the allotted day. Any changes to care following this, or wishes that they had, were communicated to the staff through a separate file for this initiative. BUPA are very involved with activities and any money that the home raises for activities, BUPA doubles. On the day of the site visit the activities coordinator had spent the morning shopping on behalf or of some of the residents and the afternoon doing one-to-ones. Documentation of activities that residents’ take part in was also very good. The home encouraged open visiting by relatives’ and friends; the staff were pro active in arranging visits if relatives’ found this difficult. There are a number of communal areas where visitors and residents’ can meet, or they can meet privately in the residents’ room. However when there is no receptionist on duty the doors are locked and entry is gained by entry phone identification to the staff on duty, to ensure the security and safety of the residents’. All residents’ are on the electoral register and at the last election approximately ten residents’ used their postal vote and two or three went in person to the polling station with the assistance of staff at the home. Since BUPA have taken over this home the ordering of supplies has changed, however the chef is still enabled to order whatever he feels is necessary. The home now has all its milk and bread delivered directly from local suppliers, which is an improvement from having to buy these items in separately. Kitchen staff are now making all soups within the home, which the residents’ are really enjoying. Meat is sourced from London, but all fish and fresh vegetables are sourced from local suppliers. During the residents’ meeting there was a lot of discussion about food likes and dislikes, the chef was happy accommodating as many requests as possible. During the site visit the inspector observed staff communicating well with residents’ and helping where necessary. The activities coordinator was also involved with the lunch delivery and residents’ told the inspector later, that the food is generally very good and that they enjoyed mixing with other residents’ during mealtimes. The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 13 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, 17 & 18 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. The residents’ in this home are protected by the policies & procedures the service operates, being followed at all times by the staff. EVIDENCE: Since the last inspection there had been one anonymous complaint that had been dealt with very well by the manager. At the time of the residents’ and relatives’ meeting the inspector made time to speak to anybody who wished to speak to her, however the only resident who specifically asked to speak to the inspector stated that they were very pleased to be resident at this home and said that problems are always sorted out on a one-to-one basis by the manager at the time they occur. The meeting itself demonstrated that there was a good rapport between staff, the manager, residents and visitors to the home. There had been no POVA issues or referrals since the last inspection and all staff had been trained or updated in POVA policies and procedures. The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 14 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, 21, 24 & 26 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. The environment of this home was clean, tidy and well maintained, ensuring the comfort and safety for all the residents’. EVIDENCE: There have been no changes to the fabric of the building since the last inspection. At the time of the site visit the home was clean and tidy, with no malodour detected throughout. Rooms are all personalised and communal areas are made as comfortable and homely as possible. New laminate flooring has been put into the top floor dining area and on the first floor there is new lounge furniture, with new flooring in the dining area. The proprietors are intending to line all ceilings in the home to improve fire safety throughout. The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 15 Maintenance budgets are held centrally rather than with each home manager; therefore large jobs are factored into the general budget. The manager stated that this ensured maintenance was carried out in a timely manner. Maintenance support to the home was very good. Over 50 of the beds in the home are now ‘Profile’ nursing beds and there are plans to supply a further ten to the home next year. There had also been the purchase of two new hoists prior to the site visit, but these were replacements for two older hoists that had been decommissioned. All hoists had been regularly serviced under contract. The laundry was clean and tidy; surfaces are appropriate for use within a laundry. Infection control policies were generally good throughout the home with hand washing instructions above all the communal sinks. The home had recently purchased new housekeeping trolleys, which had locked areas for CoSHH products. However two of the trolleys reviewed during the tour of the home, had been left open, in unlocked areas of the home, with CoSHH products still in them. This was highlighted to the manager and they were locked immediately. The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 16 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 - -Quality in this outcome area is excellent; this judgement has been made from evidence gathered both during and before the visit to this service. Staffing numbers and extensive training ensures that the residents in this home are looked after safely and appropriately. EVIDENCE: Rosters reviewed demonstrated that there had been a slight increase in staff numbers since the last inspection and the skill mix across the home was generally good. There was a trained nurse on all floors, on each shift throughout the day. Staffing hours provided exceeded recommended guidance levels. Staff generally worked in the same areas, but are moved about depending on workloads and personal requests. Staff spoken to were happy at the home and felt that training was excellent. 53 of the care staff at this home have NVQ level 2 or above and three further care assistants were on courses at the time of the site visit. The volunteer at this home is also NVQ trained. Four personnel files were reviewed during the site visit and demonstrated good recruitment policies throughout. All staff files contained all required elements. The manager was very clear on recruitment policy and did not start any new member of staff until their Criminal Records Bureau declaration had been The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 17 returned to the home. Work permits were up-to-date and identification documentation was adequate. References were all double checked by the manager, to minimise the risk of misrepresentation. The training in the home for all staff was comprehensive. A retired nursing tutor works in the home two days per week ensuring that all staff training is up-to-date and appropriate to their role. BUPA produce a very good induction pack for staff to ‘Skills for Care’ foundation standards, which the tutor goes through with new staff. She also ensures that she is on duty on each new member of staffs first day to help with their orientation to the home. All registered nurses have now completed a Palliative Care Association course and care assistants are now having an abridged version of this course. The trainer has recently updated all kitchen staff on manual handling skills and she was organising cascade fire training with the BUPA trainers. BUPA produce a number of training tools that the trainer is using; she also produces a list of the content of all training sessions she carries out. The deputy manager has now been trained as a First Aider, along with three other staff. The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 18 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 & 38 - Quality in this outcome area is good; this judgement has been made from evidence gathered both during and before the visit to this service. Management and administration of this service is good and quality assurance procedures are followed, the information obtained is used to improve the service offered. EVIDENCE: There has been no change in the management within the home since the last inspection, although the lines of management above the registered manager have changed since BUPA took over the ownership of this home. Staff spoken to appeared to understand the lines of accountability and felt that they can approach any level of management; they felt supported and happy working at the home. The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 19 Quality assurance systems within BUPA are complex and because of this the manager has not fully implemented the system. The previous providers undertook the last audit in July 2005. However the manager is confident of that quality assurance and auditing procedures will be implemented in the near future. A full set of policies & procedures and the quality assurance manual were available to all staff and residents’. It was envisaged that resident and visitor satisfaction surveys would be undertaken every six months. The inspector reviewed the results of the last satisfaction survey, which showed very positive responses. An ongoing yearly action plan has yet to be compiled, but the manager said the copy would be sent to the commission when complete. CSCI questionnaires returned to the commission also confirmed a very positive view of the home. Financial procedures throughout the home were good. The manager and administrator were not appointee for any of the current residents, although three residents finances were managed by social services. At the time of the site visit twelve residents’ were looking after their own finances, with the help of their relatives. The issue of weekly allowances for residents’ was discussed with the manager and she demonstrated a clear understanding all of her responsibilities if a problem arose with relatives supplying enough money for the residents to choose what they did in their day-to-day lives. Each resident has individual bank accounts where their allowances are kept. The allowances are not kept on site; there is a float that pays for anything they want and then the money is transferred from the bank account into the home to replace the float. Documentation of all accounts were checked, they were clear and included enough information to undertake an audit trail if necessary. Relatives or residents’ as available signed all transactions. Supervision files were kept separately. Not all supervision programmes were up-to-date, however it is envisaged that all staff will have had a minimum of six sessions by the end of March 2007. All registered nurse appraisals were booked and when completed the nurses will undertake a care assistant appraisals. Care assistant supervision sessions are a mixture of general meetings, one-to-one’s and on the job supervision. Night staff supervision sessions are currently causing the most challenges for the manager, but she is working through this problem. All certificates and servicing agreements reviewed during this site visit were current. Public liability and employers liability insurance were both valid until June 2007. All CoSHH risk assessments were reviewed and were up-to-date. The maintenance man was leaving the week following the site visit but a new The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 20 person had been employed and was being inducted at the time of the visit. The new maintenance person is well qualified and the manager felt he would be an asset to the home. The maintenance staff at this home also service and repair all beds, wheelchairs and bedrails within the home ensuring they are rarely out of action. The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 22 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 OP9 Regulation 13(2) Requirement The registered manager must ensure that all medications are stored, administered and documented correctly and safely. The registered manager must ensure that all COSHH products are stored in accordance with current legislation. Timescale for action 31/10/06 2. OP38 13(4a) 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP11 Good Practice Recommendations The registered manager should consider storing Temazepam night sedation, in the controlled drugs cupboard, in accordance with best practice guidelines. The registered manager should encourage care staff to keep better documentation, with regard to their care wishes when their health deteriorates and if they should die whilst resident in the home. The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 The Carnarvon Nursing Home DS0000015320.V310528.R01.S.doc Version 5.2 Page 24 - 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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