Inspection on 02/08/06 for Time Court

This inspection was carried out on 2nd August 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

Time Court 11/11/08

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Time Court Woodlands Terrace London SE7 8DD Lead Inspector Keith Izzard Key Unannounced Inspection 2nd August 2006 09:30 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 Time Court DS0000067475.V293814.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. Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Time Court Address Woodlands Terrace London SE7 8DD 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 8301 8080 020 8301 8099 www.sanctuary-care.co.uk Sanctuary Care Ltd Mrs Laleen Grace E Scott Care Home 56 Category(ies) of Old age, not falling within any other category registration, with number (54), Physical disability (2) of places Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of service users in the home is 56, of whom 20 are in the category of nursing care, including 10 intermediate care Date of last inspection Brief Description of the Service: Time Court first opened on 28th June 2004 and is one of three new Neighbourhood Resource Centres operated by Ashley Homes and replaces four homes previously operated by the London Borough of Greenwich for older persons. The home is situated in Charlton and provides nursing care for 20 service users; 10 on Capella unit, and a further 10 in the category of intermediate care on Ross unit. This unit provides a specialist rehabilitative service prior to final discharge back into the community, residents having either been admitted from the community or direct from hospital. A further 36 service users are within the category of conventional care for older persons and are accommodated over three other units; Ursa, Orion and Carina. Within this 36, one placement is for emergency admissions and two placements for respite carer breaks. The home also operates a Day Centre in a dedicated part of the building and is generally well provided for in terms of communal facilities for service users including dining areas, hairdressing facilities and numerous quiet areas and transport for outings for service users. Meetings for residents and relatives are held on a regular basis and a League of Friends for the home has been set up. Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection completed over a period of 8.5 hours by two Inspectors on 02/08/06. The previous inspection was an unannounced inspection on 26/01/06. The inspection included a complete tour of the premises, inspecting records, talking to twelve service users, thirteen members of staff and the Deputy manager. All areas of the building were seen and were clean and free from unpleasant odour. Service users also voiced their appreciation regarding the cleanliness of their rooms. It was evident that service users had been given the opportunity to bring in personal possessions to personalise their bedrooms and overall the home had a more homely appearance as efforts had been made to hang pictures in communal areas. Maintenance and Health and Safety matters had been attended to in accordance with the Standards. Service users were seen to be comfortable and good interaction was observed between staff and service users. Service users were seen to be appropriately dressed for the very warm weather and well cared for in clean laundered clothing. Drinks were readily available and staff members were observed to be ensuring that residents were encouraged to drink fluids because of the weather. Service users spoken to stated that staff members were caring and helpful and all staff members interviewed were positive about the inspection process and assisted the Inspectors in a helpful and constructive way. What the service does well: There was a relaxed calm atmosphere on all the units visited and the home has been made more homely over the past six months. This new home provides a very bright and airy environment throughout and individual en suite accommodation of a good standard for residents. Overall, the home was very clean, tidy and safe for residents who were cared for by staff members who were both caring and professional in their relationship with residents. Health and Safety requirements had been attended to satisfactorily. The responses from residents interviewed were generally favourable and positive comments were made about the caring attitude of care staff by many Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 6 of them. Comments that were received by the Inspectors, from some residents, about the need for more activities and outings were discussed with the deputy manager. 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. Time Court DS0000067475.V293814.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 Time Court DS0000067475.V293814.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 adequate. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose, Service user Guide and contracts for service users still need to be updated and the Intermediate Care unit requires specific description in both documents and specific policies and procedures developed. Contracts for service users on the nursing unit must state that nursing is provided. Service users are assured their needs can be met by the home prior to their moving in. Residents provided with the Intermediate care service are helped to maximise their independence to return home. However specific policies and procedures should be developed for the unit and a specific Statement of Purpose and Service User Guide made available. Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 9 EVIDENCE: Standard 1. The home does not have an up to date Statement of Purpose and none of the residents are provided with up to date Service User Guides. On Capella the nursing unit, the nurse in charge said that the Service User Guide had been withdrawn. There was one copy in the lounge on Ross but this was stored under other folders and was not placed where residents would see it. The guide included out of date information about the previous registered provider and did not provide any specific guidance about the intermediate care service. Restated requirement 1 Standard 3. The arrangements for admission of new service users to all units was satisfactory, including short term carers breaks. In respect of the intermediate care unit, Ross, the Rapid Response Team sent a formal referral; assessment and care plan to staff to consider, prior to making arrangements for residents to be transferred to the unit. Additional information or investigations were requested where necessary. The manager should develop specific policies and procedures for the unit. This should include the arrangements for admission and discharge of residents. Recommendation 1 A copy of the licence agreement was kept on residents’ files. The contract provided included information about the obligation of the provider and resident but did not indicate that nursing care was provided. The resident or their representatives were asked to agree and sign the contract. Restated requirement 2 Please note that Requirement 3 from the previous report should state Capella unit, not the Intermediate Care unit (Ross.) Standard 6. The intermediate care unit was clean, tidy and spacious. The unit includes excellent facilities for rehabilitation such as an adapted kitchen, physiotherapy room and specialist equipment to promote residents independence. The aim of the unit is to provide a period of rehabilitation for residents following illness or surgery, which enables them to return to their own home. The unit holds regular multidisciplinary meetings to assess resident’s progress and review care plans. Feedback was obtained from three residents who were staying on the unit. All of the residents said they were highly satisfied with the care and assistance they had received. Some residents said they were very anxious Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 10 when they were advised that they were moving from hospital to the unit and would have appreciated more information. Staff should prepare a Statement of Purpose for the unit and consider forwarding a supply of this document to the Rapid Response Team to hand out to prospective residents. A Service User Guide for the unit must be developed and supplied to each service user. Restated requirement 1 Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 &10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs were being met based on assessment of need and with the involvement of the resident. Those care plans seen were generally satisfactory, but were incomplete in some areas especially strategies as to how to deal with identified risks and identified social needs. Medicines were not entirely well managed and a requirement was made in respect of several shortfalls identified. Residents were treated with respect and privacy afforded them. Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 12 EVIDENCE: Standard 7. Two sets of records were assessed on each unit. On all units the care records viewed were mostly satisfactory but the content of care plans was often similar and they sometimes lacked information about residents’ social needs and personal preferences. One care plan on Capella unit, about management of a wound indicated that the wound should be redressed three times a week. Discussions with staff indicated that the wound had healed and did not require a dressing. Care plans seen were agreed and signed by the resident or relative and were reviewed regularly. On the intermediate care unit new care plans had been developed in consultation with other intermediate care units in the borough. The care plans on this unit outlined what individual residents wanted to achieve and specific timescales for achieving personal goals. Staff had assessed residents’ risk of developing pressure sores, falling and nutritional status but had not always developed strategies to reduce risks. Requirements 4 & 5 One resident on the intermediate care unit said that during the recent hot weather staff were constantly filling up their jugs with cool juice, had encouraged them to drink and had provided ice lollies to keep everyone cool. Staff members were also observed on the other units providing regular liquid refreshment. It was pleasing to note that staff had followed guidance issued by the Department of Health about supporting vulnerable people during a heat wave. Standard 8. Access to community health care services was good. The records seen indicated that some residents had been assessed or reviewed by the GP, Optician, Tissue Viability Nurse and Care Managers and reviews undertaken for the provision of bedrails. On the Intermediate Care Unit staff were able to refer residents that were unwell to the medical diagnostic unit at the local hospital. This ensured that residents received prompt medical treatment. Standard 9. The management of medication was in the main assessed on the nursing units. The arrangements for storing medication were good but records indicated that the temperature in the medication room was not always suitable for the storage of medicines. Records of receipt and disposal of medication were good. On Capella records of administration of medication were satisfactory but a number of discrepancies were noted on Ross where the remaining supply of medication was often in excess or less than there should be. Staff on this unit did not always record the dose of medication that was administered to Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 13 residents where a variable dose was prescribed and did not always indicate the reason why medication was not administered. The sharps bin in the medicine room was not secured properly and should have had recorded on it the day it was first opened and usage commenced. Some of the nomad boxes on Capella were old and worn. The nurse in charge was advised to discuss this issue with the supplying Pharmacist. Staff were developing a procedure for homely remedies on the intermediate care unit and other information and guidance was accessible to staff. The risk assessment for resident that were selfmedicating did not make reference to where the resident should store their medication. It was noted also that a MAR sheet on Orion unit, one of the residential units, had not been signed or countersigned in respect of handwritten entries and medication for one resident not properly signed for, or indicate the reason the medication was not signed for. Requirement 6 Standard 10. Twelve residents interviewed said that staff members treated them with respect and maintained their dignity at all times. All staff members who were observed by the Inspectors during the inspection were seen to be interacting with residents in a professional and caring manner. All residents seen were appropriately dressed for the hot weather and appeared well groomed and cared for. Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities were provided for residents but more should be provided and the activities post made permanent. The home could benefit from having its own transport to increase outings, something a number of residents commented on. Either increased input or training should be provided for staff in activities on the nursing unit. Residents are encouraged to maintain contact with relatives and friends, and are helped to exercise choice and control over their lives. Residents receive a balanced diet in appropriate surroundings. EVIDENCE: Standard 12. One of the Inspectors interviewed the activities coordinator who is employed on a part time basis for 21 hours per week. Residents generally felt that activities had increased although a common theme for improvement stated by residents was for the number of outings to be increased. This could be better Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 15 facilitated if the home had its own transport, the subject of a previous recommendation and is therefore restated. A previous recommendation made that this post be made permanent has been acted upon and is also restated. Two care staff members were responsible for undertaking activities with residents on the nursing unit. There was no evidence of input from the activity coordinator. Records indicated that care staff had provided nail care, arranged a sing-along, bingo and played music. The type of activities provided was quite repetitive. Staff should receive activities training. Recommendations 2, 3 & 4 Standard 13. Relatives that the Inspectors spoke to said that the care provided in the home was good. Relatives said they were able to visit at anytime and were made to feel welcome by staff. Standard 14. Residents told the inspector that they were able to choose where and how they spent their time and said they were consulted about significant issues. Standard 15. Dining rooms on the individual units were nicely laid out in preparation for lunch. Napkins, juice and a flower display were provided on each table. Residents were satisfied with the choice and quality of food served in the home and confirmed that they were able to select their preferred choice of food from the menu. On the long stay nursing unit a number of residents required assistance to eat, this resulted in a delay for some residents on the other units staff members were seen discreetly assisting some residents. The Deputy Manager advised the Inspectors that staff from the Intermediate care unit would provide assistance in future. See comments about staffing Standard 27. Requirement 7 Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints to the home had been dealt with satisfactorily. Service users legal rights were protected and they were protected from abuse. EVIDENCE: Standard 16 The home has a robust complaints policy and procedure. Five complaints had been logged since the previous inspection in January 2006. All were minor in nature and had been dealt with to the satisfaction of the complainant and in accordance with the procedures. The complaints procedure is advertised strategically, however, a shortfall exists in this area because of the lack of provision of Service User Guides for all residents, these are required to contain details of the complaints procedure, highlighted in Standard 1. See Requirement 1 Standard 18. Staff members that were interviewed by the Inspectors were aware of the procedure for reporting poor practice and abuse and were confident that senior staff would act to address any issues they raised. No issues in relation to adult protection have arisen within the home. The Inspectors noted that a request that staff members read the Adult Protection Procedures was posted on the staff notice boards on each unit. It is recommended that staff members are Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 17 required to sign that they have read and understood these procedures and this information retained on their personal files. See Recommendation 5. Time Court DS0000067475.V293814.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe and well-maintained environment. The home was clean, pleasant and hygienic. EVIDENCE: Standards 19 & 26 A high standard of cleanliness was maintained throughout the home. Cleaning staff were assigned to work in specific units so were able to establish good working relationships with staff and residents and felt part of the team. Cleaning supplies were readily available and the home had equipment that enabled staff to wash carpets, treat stains and manage spillages promptly. Hand washing facilities were provided for staff and residents. On all the units equipment to assist and promote residents wellbeing and comfort was provided. This included pressure relief mattresses and cushions, Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 19 profile beds, particularly on the nursing units, hoists, raised toilet seats, grab rails and standing aids. All of the equipment provided was in working order and maintained in accordance with the required schedule. The home was well maintained and decorated throughout. The long stay nursing unit had been redecorated and a number of framed prints were displayed on the walls, as on other units, this contributed to a more homely atmosphere throughout the home. Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 20 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): 27-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standard 27. There was one qualified nurse and two care staff on duty on each of the nursing units. Discussions with staff and examination of duty roster indicated that there had been some reduction in the number of staff rostered for the morning shift on Capella. Despite this change the unit was relaxed and residents were receiving good care. During the lunch period a significant number of residents required assistance with to eat. As there were only three staff on duty some residents had to wait for help. The Deputy Manager said that additional staff from the intermediate care unit would be asked to assist with feeding. Requirement 7 Standard 28 Staff members hold a qualification appropriate to the task they perform i.e. RGN in charge of unit providing nursing care and two care assistants spoken with both held an NVQ 2 qualification. The required minimum level of 50 staff holding the level 2 NVQ was met. Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 21 Standard 29. Three staff files were examined. All of the documents required had been obtained but two files indicated that staff had commenced work prior to obtaining a criminal record bureau disclosure. Senior staff must ensure that staff files include a written explanation about gaps in employment. Requirement 8 Standard 30. Staff that the inspector spoke with were satisfied with the support and training they received. Care staff confirmed that they had received induction and foundation training and there was evidence of this in staff files. Staff received regular health and safety training updates and are encouraged to attend other relevant in house and external training sessions. Since the last inspection some staff had attended first aid, moving and handling, dementia training, continence management and catheter care, administration of medication, person centred care risk assessment, care plans, pressure relief, peg feeds, taking vital signs and fire training. Evidence was also available of training being arranged in the coming months. Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 22 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): 31,33,34,35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures are in place to monitor and develop the quality of care and the service provided in the home. Service users live in a home run by a manager who is fit for the purpose and benefit from the leadership and management approach of the home. Service users are safeguarded by the financial and Health and Safety procedures adopted by the home. Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 23 EVIDENCE: Standard 31. It was evident that both the residents and staff members interviewed felt positively about the manager and all stated she was very approachable, neither residents or staff members would hesitate to speak to her should they have any concerns regarding the running of the home or the welfare of residents. Standard 33 The home will be subject to an annual audit by Sanctuary Care and is Visited regularly on a monthly basis and a report complied on the conduct and running of the home as required under Regulation 26. These reports have been made available to the CSCI and copies are retained within the home. The home is also monitored on a regular basis by the Commissioning unit from the London Borough of Greenwich Social Services Department and the subsequent reports of these visits are made available to CSCI. The home has a good record of compliance in respect of both CSCI reports and those from the London Borough Of Greenwich. Standard 35 The system for dealing with residents’ personal finance was examined and a good audit trail was seen and no errors found in respect of the three cases that were individually examined. Receipts are obtained for service user expenditure and an ongoing ledger records all money credited and debited in respect of individual service users. Individual plastic zip wallets contain the outstanding balance of cash and receipts obtained for any purchases made and the envelopes retained in a locked safe. The system examined was accountable. Standard 38 A sample of records to do with health and safety and maintenance checks were examined and found to be comprehensive and well documented. Records seen indicated that regular maintenance and safety checks had been carried out and substantiated the dates recorded within the pre inspection questionnaire submitted by the manager. Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 24 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 2 3 X X 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 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 2 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 25 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 And schedule 2. Requirement The Statement of Purpose and Service user guide must be updated to reflect the recent change of ownership and copies sent to the CSCI as soon as possible. There must be a specific entry describing the service provided on Ross Intermediate Care unit, in both documents. Restated requirement as previous timescale of 01/04/06 not met. A copy of the Service User Guide must be given to all service users. Restated requirement as previous timescale of 01/04/06 not met. Contracts for service users on Capella, Nursing Care unit must specifically state that nursing care is provided. Restated requirement as previous timescale of 01/04/06 not met. Care Plans must be comprehensive, based on assessment of need, regularly updated to reflect residents’ needs including health welfare and social needs. DS0000067475.V293814.R01.S.doc Timescale for action 01/11/06 2 OP1 4 And schedule 4. 4 And schedule 2. 01/11/06 3 OP2 01/11/06 4 OP7 15 01/11/06 Time Court Version 5.2 Page 26 5 OP7 15 6 OP9 13 (2) Care Plans relating to wound care must provide up to date information about the current treatment regime. The Registered Person must ensure that: 01/11/06 01/11/06 7 OP27 18 a 8 OP29 19 & Schedule 2 The temperature in the first floor medicines room is maintained at 24 degrees centigrade or below Sharps containers are appropriately secured and labelled The risk assessment for residents that self administer medication should state what, if any, assistance staff will provide and the arrangements that have been discussed and agreed with the resident about the storage of medication Action is taken to improve the management of medication on Ross unit. Handwritten entries on MAR sheets must have two signatures. MAR sheets are completed fully and if no medication is given an explanatory code is completed. The staffing numbers on Capella 01/11/06 Nursing unit must be reviewed to ensure compliance and no regression from the staffing notice issued at registration and increased if necessary. The Registered Person must not 01/11/06 allow staff to commence work in the care home until all of the information and documents listed in Schedule 2 have been obtained. The Registered Person must ensure that the reason for any gaps in employment are explored and DS0000067475.V293814.R01.S.doc Version 5.2 Page 27 Time Court recorded. 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 4 5 Refer to Standard OP3 OP12 OP12 OP12 OP18 Good Practice Recommendations Separate policies and procedures should be developed for the Intermediate Care Unit. Staff on the nursing unit should receive training in respect of activities. The Activities coordinator post should be made permanent. The provision of a mini bus for the home should be considered to facilitate outings for residents. All staff members should sign a record to say they have read and understood the Adult Protection Procedures. Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Time Court DS0000067475.V293814.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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