Inspection on 22/06/07 for Upton House

This inspection was carried out on 22nd June 2007.

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

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

Other inspections for this house

Upton House 31/05/06

Upton House 03/11/05

Upton House 17/02/05

Upton House 21/07/04

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

CARE HOMES FOR OLDER PEOPLE Upton House Deal Road Worth Deal Kent CT14 0BA Lead Inspector Clair Brown Key Unannounced Inspection 22nd June 2007 10:55 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 Upton House DS0000023288.V341114.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. Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Upton House Address Deal Road Worth Deal Kent CT14 0BA 01304 612484 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) triciajolin@hotmail.com Mr Peter Edward Jolin Mrs Patricia Jolin Post Vacant Care Home 20 Category(ies) of Dementia - over 65 years of age (20) registration, with number of places Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One Service User MD (E) whose date of birth is 23/05/1927. Date of last inspection 31st May 2006 Brief Description of the Service: Upton House is a large, Georgian style, listed building which is situated in a quiet rural area, near to the village of Worth, and on the main road between Deal and Sandwich. The owners of the home are Mr. & Mrs. Jolin, who live in separate premises in the same grounds as Upton House, and who have run the home for the past 20 years. Both Mr. & Mrs. Jolin take an active and visible role in overseeing dayto-day aspects of running the home, and they are very committed to caring for their service users. The home has a no smoking policy in the home but service users can smoke in the grounds. The previous manager of the home resigned earlier this year and a prospective manager has recently been appointed. The manager is Mr. & Mrs. Jolin’s daughter in law and is supported by a dedicated team of care and ancillary staff. Accommodation is provided on 2 floors and a selection of mezzanine levels, with stair lifts enabling access to rooms on the first floor. Some rooms need to be accessed via a few steps, and the level of mobility required is taken into account during service users pre-admission assessment. The style and layout of the home allows plenty of space for service users to wander around, and the well laid out and extensive grounds are secure, enabling the service users to walk or sit in the fresh air. The current scale of fees are:£377.38 - £625.00 per week. Upton House DS0000023288.V341114.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 that consisted of an unannounced visit to the home on 22nd June 2007 by one inspector and lasted over 7 hours. The inspection takes account of information received from a variety of sources including written information from the registered providers, service users and care managers. The previously made requirements and recommendation from other inspections were inspected and all key standards. The inspector spent time observing service users and the care staff. A partial tour of the premises was conducted. Documents and records were seen and service users files were case tracked. What the service does well: What has improved since the last inspection? Another new manager has been appointed, who is the registered providers daughter in law, and she had been in post for four weeks at the time of the visit. She had already started to assess the practices within the home and had identified some areas that needed improving. There was no evidence found of people being admitted to the home who did not meet the category of care the home is registered to provide. The manager has conducted a detailed pre-admission assessment of a prospective service user. The new manager has introduced supervision for staff and has held the first staff meeting. Staff have attended adult protection training. The hallway is being redecorated and new carpet is being laid. Upton House DS0000023288.V341114.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. Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1236 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 does not provide prospective service users with up to date or adequate information to make an informed decision. Prospective service users’ needs are fully assessed prior to admission to the home. The home does not provide intermediate care therefore standard 6 is not applicable. EVIDENCE: The statement of purpose has not been reviewed since the change of manager. The information on how to make a complaint within this document does not correspond with the home’s actual policy and procedure. A service user who had been admitted just a few days prior to the inspection had had a full assessment of their needs conducted by the manager, who had recorded these in detail. She had also obtained a copy of the care manager’s Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 10 assessment. The manager confirmed the home does not provide intermediate care. Only privately funded service users have a written contract for living at the home. Those funded by Local Authorities have not been given contracts by the home. Upton House DS0000023288.V341114.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans vary significantly in their content, with gaps in identifying service users’ needs. Service users are supported to access health care services and medication practices ensure that medicines are administered safely. EVIDENCE: Two service users’ files were assessed. One was of the most recently admitted service user and the other was for a person who had lived at the home for a longer period of time. The service user who had only been at the home a few days file contained a basic care plan, which had been produced from the information gathered through the pre-admission assessment process. The manager had also obtained a detailed life history from their family to support the care plan and to give a more personal insight into the service users life and personality. Some assessments had been conducted relating to specific needs, Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 12 however the findings of these assessments had not been cross-referenced into the care, an example of this is the nutritional assessment. There were no sections in the care plan for areas that are essential to acknowledge when caring for those with dementia, such as communication and mental health. The second file selected was for a service user who had a mixture of needs, the service user was met and their bedroom visited. When met, the gentlemen was unshaven and seen to be wearing dirty clothes, he informed me that he dressed himself and that his family are not happy for him to wet shave and so now has an electric shaver and the girls (carers) would help him shave later, (time 11.00hrs). The manager stated that she had conducted a basic audit of the care plans and had discovered that a number of them only had assessments pages written and no care plans. She had put in blank care plan pages but had not yet written on them but plans to do an in depth review of all service users files. This was the case for this particular service user. There were records that showed that District Nurse and the GP’s were involved in the health care of the service users. However, there are omissions in the care plans, relating to the assessment of individuals health needs. There is no assessment tool for determining the service users skin integrity (risk of developing pressure sores). The daily records about each service user’s care and daily activity lacked detail, with general terms used “slept well” etc. There was no reference to the care prescribed in the care plans. This combined with the lack of care plans for some service users, demonstrates that these documents are not being actively used and referred to by care staff. The manager had identified this as an area for improvement and some staff have attended care plan writing training. She also plans to delegate the writing of the care plans to the senior carers. An audit of the home’s medication was conducted by the head of care and the manager. Unfortunately the multiple mezzanine levels prevent the medication trolleys being taken around the home. However, no errors were found during the audit. The records for controlled drugs did reveal that some had been signed out as returned to the chemist, but the chemist had failed to collect them for several days, resulting in incorrect records and totals of actual medication being held in the home. The book for recording CD’s does not meet the required specifications. Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is small range of social activity and stimulation provided. Relatives are welcomed to the home to provide the service users with the contact they need. Meals provided offer a varied diet for the service users. The home does not use different ways of communication to promote choice and personal control. EVIDENCE: Relatives are welcome to visit the home at any reasonable time and are encouraged to bring possessions in from the service users home to personalise their bedrooms. The activities are arranged by 2 volunteers and care staff. Three service users were seen to be encouraged to play a game after lunch but there was no activities provided for the other service users apart from watching television. However there are a small range of activities available, which include PAT (dog visiting) crafts and cake decorating. Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 14 Time was spent talking with the cook, who explained that although only one choice of meal is written on the menu, they do provide alternatives, these were recorded. There was no evidence to show how service users are supported to choose what they would prefer to eat that day, with some choice being based on the knowledge of what people like and dislike. The cook did state that service users are asked everyday what they would like. The menu is not produced in alternative formats such as pictorial. When speaking with service users, they were unaware of what the meals that day were. The cupboards were well stocked and this showed that special diets are catered for, Soya products are purchased for particular people. Meals are freshly prepared everyday, are homemade and predominately use fresh vegetables every day. One of chest freezer lids was completely broken away from it’s hinges. Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are different complaints procedure in use within the home which could lead to confusion. The staff have attended adult protection training but are not supported by a clear policy. EVIDENCE: The complaints procedure in the statement of purpose is different to the policy displayed within the home. These need to be the same and ensure that they comply with the regulations. The manager has developed new document for the recording of complaints, but needs to ensure that all staff are aware of it and how to complete them in her absence. The training matrix shows that staff have just completed adult protection training. The company policy & procedure is quite informative about the different types of abuse and the possible indicators. But then instructs people to conduct investigations. There is no mention of the need to refer to the Local Authority that carries the legal responsibility to investigate these matters. Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Regular and ongoing maintenance of the house and gardens provide a pleasant environment for service users. Some areas of the home had offensive odours and infection control practices do not comply with current policies. EVIDENCE: The Georgian Style Listed Building has been adapted to meet the needs of the service users. Being an older building maintenance is continuous and ongoing. During the visit it was evident that the hallway was in the process of being redecorated and new carpet was being laid. There are several mezzanine levels around the home that could restrict access for those with limited Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 17 mobility. The main stairway has a chair stair lift for access to the first floor. There is a summerhouse in the front secure garden for smokers and a gazebo in the back garden. There are three communal rooms, 2 lounges and a conservatory/dinning room. Radiators in the home are all guaranteed low surface temperature. Bedrooms are personalised with service users belongings and screens are provided in double rooms to ensure privacy. A husband & wife are supported to share a twin bed room and have this arranged with a seating area and a sleeping area. Some bed linen on the beds was found to be dirty. One area of the home was noted to have a very strong offensive odour, later in the day the fire exit door had been opened and the odour reduced. The manager stated that staff open all bedroom windows during the day to air them and then close them again at night. The overall cleanliness of the home was good. The laundry is situated in the basement. There was evidence of hand-washing laundry and the manager stated that soiled items are sluiced by hand. The home does not use alginate bags for washing soiled items. A full clinical waste bag was seen to be left in the secured front garden awaiting the handyman to take it to the main clinical waste bin. During the tour of the premises it was noted that toilet and bathroom doors are kept locked with staff holding the key to access them. In the toilets and bathrooms were shelves with piles of continence pads. This is a poor infection control practice and the manager confirmed the pads were individually prescribed by the PCT, and not for general use. In one service user bedroom it was observed that a used night time catheter bag was on a stand and it was confirmed by the manager that it would be reused that night and changed once a week. This practice does not comply with the Health Protection Agency infection control guidelines. The manager later showed that she did have a copy of these. In the office was a television screen that showed that there are four CCTV cameras in use around the home, covering the communal rooms and corridors. CCTV is only permitted on the main entrance to the home for security purposes. Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment procedures are adequate but need some improvement. Staff training has increased recently. EVIDENCE: At the time of the inspection visit there were 16 service users living at the home and 1 in hospital. The duty rota showing who is working, does not recorded the staffs designation, it written in pencil so it is difficult to track changes made to the shifts. It also does not clearly record the hours the manager is working. The rota shows that the care staff work 12-13 hour shifts a day, with 3-4 carers on duty during the day and at night two waking staff. Some of the service users were observed to require two carers to meet their needs. The care staff are supported by a team of ancillary staff that includes, cooks, domestics and a maintenance person. A member of staff has recently returned to work after a 6 month visit back home to Poland. Both the member of staff and the manager were unclear if Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 19 she had left her job or if she had been granted an absence. The file for this person held no record of a break in contract being agreed by the home. When they recently started to work again at the home, a new application and recruitment process was not followed. There was no evidence of copies of the Home Office papers required to permit a person from Poland to work in the UK. The manager then raised questions about two other carers rights to work. However, the staff file did contain all of the documentation when they were originally recruited. The manager showed that she has designed a new recruitment pack and is reviewing the procedure. The manager stated that she has held her first staff meeting and has started supervision with staff. The staff training matrix shows that a variety of course had been booked, these include dementia and adult protection. It is recommended that the content for the training course for dementia and medication is compared to the standards set in the “Skills for Care Module”. Five care staff have now completed the NVQ level 2 or above in care with a further seven due to start the course. The manager showed the induction pack the home uses and she stated she believed it was comparable to the Skills for Care common induction standards, but was not completely sure. Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 35 36 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A manager has been appointed but is yet to be assessed through the fit persons process, so is not registered with the Commission. Procedures for the safe handling of service users money are not adhered to. Some health & safety certificates are out of date or missing. EVIDENCE: The manager has been in post for just four weeks, no application has been made to become the registered manager but will need to be assessed through the fit persons process. The manager has been promoted from within the Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 21 company. She stated that she has enrolled on the registered managers award course. During the course of the inspection visit the manager and staff were very open and shared areas for improvement that she had already identified. The fact that she had in these first 4 weeks been assessing the status of various areas such as care plans, shows that she is adopting a proactive style of management. The records of service users monies had not been kept in a clear and easy to follow manner. Transactions had become muddled and there were times when only single signatures were used. The total sum of actual cash for two service users was less than the records indicated. The manager was unsure of what the insurance specified as an approved location for the storage of the service users monies, currently not held in a safe. The home uses a number of communal records, which are kept at the carers station, unsecured in a communal room. Those identified were breakfast/tea, residents out book (pages were torn out), homely remedies and others, these breech Data protection, by compromising service user confidentiality. Again the manager agreed to address this issue. A selection of the environmental certificates were checked, this showed that the fire records were up to date and the fire equipment had been serviced recently. Hoists and stair lifts had been serviced. The portable electrical appliances testing (PAT) was due January 2007. The electrical certificate could not be found in the home. The manager confirmed that they regularly survey service users and relatives, and conducts audits of medication and the building. However, this information needs to be collated into a final report for each year as part of it’s annual quality assurance programme. Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 X X 2 2 3 2 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 2 2 X 2 2 X 2 Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 23 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 sch 1 Requirement The statement of purpose must be reviewed and up date, ensuring it contains all of the required information. This is to ensure that the information provided in this legal document is accurate and does not mislead the public. Each service user (both private and local authority funded) must have a contract, these must be signed and a copy held in their file in the home. This is to ensure that each service user has a contract of terms and conditions with the home. Previous timescale:31/07/06. All service users must have care plans written. These must identify all of their needs and provide care staff with clear instructions on how to meet these needs. This is to ensure that service user are cared for appropriately and their individual needs met. All service users must have a DS0000023288.V341114.R01.S.doc Timescale for action 01/09/07 2. OP2 5 01/09/07 3. OP7 15 01/09/07 4. OP8 13 01/09/07 Page 24 Upton House Version 5.2 skin integrity assessment completed and regularly reviewed. This information must be included in the care plan and acted upon appropriately. This is to ensure that service users risk of developing pressure sores is monitored and the appropriate action to care for them is provided. 5. OP14 24 The home must be able to show how they enable service users to make choices and have a say in matters such as the menu and activities. This is to ensure that service users wishes and personal preferences are respected. The home must not use CCTV in areas other than the main entrance of the home and purely for security purposes. This is to maintain service users privacy and dignity within the home. The manager must ensure that all staff adheres to infection control procedures. Action must be taken to ensure soiled items are laundered in accordance with current guidelines, to include the use of alginate bags and to stop hand washing of items. Continence pads must be stored so as to prevent possible cross contamination. Catheter bags must not be reused once disconnected, in accordance with health protection agency guidelines. Action must be taken to prevent the offensive odours, to include Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 25 01/09/07 6. OP19 12 01/09/07 7. OP26 13 01/09/07 appropriate cleaning of areas and not just ventilation. This is to ensure that service users are protected as far as reasonable possible from infection. The manager must review the number of staff on duty during the day, taking into account the needs of the service user. This is to ensure enough staff are provided to meet the service users needs. The manager must contact the Home Office to seek clarification about the need for work permits for overseas staff. This is to ensure that the home only employs persons permitted to work within the UK. The manager must make an application to become the registered manager. The registered person is required to develop the quality assurance programme further and produce a written report. This is to ensure that there is regular monitoring of the homes performance. The records of service users monies must clear and accurate and the sums balance. The manager must check the homes insurance policy regarding where to keep the cash and how much they are insured to keep. This is to ensure that service users money is protected from possible abuse. The home must not use communal record books. This is to ensure that individuals confidential information is not inappropriately shared. DS0000023288.V341114.R01.S.doc 8. OP27 18 01/09/07 9. OP29 19 sch 2 01/09/07 10. OP31 CSA 11(1) 30/10/07 11. OP33 12 24 26 30/10/07 12. OP35 17 schedule 9 01/09/07 13. OP37 15 17 Data Protection act 01/09/07 Upton House Version 5.2 Page 26 14. OP38 EAW Reg 1989 Portable electrical equipment must be tested annually. The electrical certificate must be located and a copy sent to the CSCI local office. If this is not in date, a new certificate must be obtained. This is to ensure compliance with the Electricity at Work Regulations 2989 The manager must contact the fire officer regarding the key padded fire door to determine if this meets the current legislation and/or requires an override system. The manager is required to write to the CSCI local office to notify of the fire brigades response. This is to ensure that all persons within the home are able to leave the premises in the event of an fire. 01/09/07 23(4) 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 OP12 OP15 Good Practice Recommendations To obtain an approved Controlled drug register and ensure that the balance of tablets is not altered until the tablets have been returned to the chemist. To develop the programme of activities further to include more of the service users and their personal interest. To use a pictorial menu to enable service user to be aware of what food is on the menu and to support them making a choice. To consider reviewing the access to the garden areas for those with restricted mobility. DS0000023288.V341114.R01.S.doc Version 5.2 Page 27 4. OP20 Upton House 5. 6. OP30 OP37 To review the homes induction pack and ensure that it complies with the Skills for Care common induction standards. It would be appropriate to produce a mental capacity policy in light of the changes in legislation and the client group of the home. Upton House DS0000023288.V341114.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Upton House DS0000023288.V341114.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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