Inspection on 31/01/07 for Walton Manor

This inspection was carried out on 31st January 2007.

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

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

Other inspections for this house

Walton Manor 04/07/07

Walton Manor 28/02/06

Walton Manor 26/09/05

Walton Manor 21/03/05

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Walton Manor 187 Shay Lane Walton Wakefield WF2 6NW Lead Inspector Susan Vardaxi 31 January 2007, 2 st nd Key Unannounced Inspection and 23rd February 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Walton Manor DS0000062365.V313268.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. Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Walton Manor Address 187 Shay Lane Walton Wakefield WF2 6NW 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) 01924 249777 01924 249777 neilgreenhalgh@hotmail.co.uk Walton Manor Ltd Ms Linda Armitage Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can provide care and accommodation for three named service users with physical disabilities, category PD (E) 28th February 2006 Date of last inspection Brief Description of the Service: Walton Manor is a privately owned care home for older people situated in Walton village on the outskirts of Wakefield. It is set back from the road in large well-maintained grounds, having gardens to the front and the rear. Car parking space is available. The home offers accommodation for 36 people in single and double bedrooms over two floors accessible by shaft lift. Most rooms have en-suite facilities. There are communal areas of different sizes that are furnished to provide comfortable area for the service users. Service users are registered with several local GP practices and district nurses support the care team at Walton Manor in the care of the people who live there. The provider makes information about the service available to enquirers when initial enquiries are made via the service users guide. A copy of the inspection report is available on the reception desk. The fees charged in February 2007 were from £405 to £555; hairdressing chiropody and personal newspapers are charged in addition to the fees. Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Three unannounced visits to the home occurred on the 31st January, 2nd February 2007, and 23 February 2007 and extended over a period of 23 hours. Due to medication issues identified at earlier visits the third visit included a CSCI Pharmacist Inspector. The visits included talks with some service users’, two visitors; some care staff on duty, the cook and the registered person, the manager and assistant manager. Some records were checked, practice was observed and a walk round the premises completed. Some comment cards were sent to some service users, relatives social and health providers seeking their views of the service. At the time of the visits eight-comment cards were received from service users, eight from relatives and one from a GP who were generally satisfied with the care provided. Since the last full regulation inspection in February 2006 three CSCI Pharmacist visits have occurred. The first of these, in March 2006, followed a medication incident, and the home was required to make the medication system safer for service users. The second pharmacist visit, in July 2006 was to establish that the action required had been taken and found that regulations were now met. As part of this inspection the inspector completed an audit of medication and found that service users needs were not being fully protected by medication practices. This resulted in the CSCI pharmacist inspector completing a further audit of medications on 23rd February 2007 and this found some regulations had not been fully met. An extension is currently being built onto the home to increase the number of accommodation available. What the service does well: All service users spoken with said they are well cared for, treated with respect & the care staff are very good. Generally positive comments regarding the staff were also made on survey forms completed by the service users, relatives and a GP prior to these visits. Everyone who participated showed that they are satisfied with the overall care provided. Service users spoken with said they would be confident to make a complaint if needed and they have choice in pursuing their personal interests and daily activities. Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 6 Care plans examined have been developed and risk assessments seen had been competed and reviewed appropriately which means service users needs can be identified & met. The meal served for lunch was sampled and found to be cooked and presented to a good standard. All service users spoken with said they are very satisfied with the meals. The home is cleaned, decorated and furnished to a high standard. Some re decoration and replacement of ceilings and cornices was being completed. The manager and staff are to be commended for ensuring the standard of cleanliness has been upheld with minimal disruption during the building work. Health and safety was well managed during this period of rebuild. What has improved since the last inspection? What they could do better: Following a medication incident in February 2006 a CSCI Pharmacist Inspector made two requirements for improvements in medication procedures in March 2006 and the improvements made were found at the Pharmacist Inspectors visit in July 2006, when medication processes were considered to be “excellent”. However, some shortfalls were observed in respect of medication recording at the regulatory visits on January 31st and 2nd February 2007 and the Pharmacist Inspector and Regulation Inspector therefore made an unannounced visit on 23rd February 2007 in respect of this and found that there were again problems with medication practices which could place service users at risk. Whilst accidents had been appropriately recorded the related notifications to the commission on two occasions had not occurred, which meant the Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 7 commission was not receiving the information about the issues concerning the care of service users that we should. Whilst the lighting, on the days of the visits, appeared satisfactory a comment card received from a service user considered the lighting in some communal areas to be poor. 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 summary of this inspection report can be made available in other formats on request. Walton Manor DS0000062365.V313268.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 Walton Manor DS0000062365.V313268.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): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission arrangements are satisfactory. EVIDENCE: Service users’ records seen showed that pre admission assessments had been completed, however it has been brought to the managers attention that they had not always been dated. Good admission records were seen that included copies of letters sent to service users confirming that the home can meet their needs and copies of assessments completed one month after admission. Intermediate care is not provided at the home. Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is Poor This judgement has been made using available evidence including visits to this service. Whilst the standard of care planning, risk assessment and upholding service users dignity and privacy is satisfactory improvement is needed in some areas of medications procedures and practice to ensure service users are not at risk. EVIDENCE: Care plans sampled included assessed needs and changes in needs had been recorded, and the assistant manager said further development is to occur to ensure changes are not lost in the reviewing process. To identify and meet the health needs of service users risk assessments had been completed on the records checked these included, self-medication, prevention of falls and manual handling, nutrition, and special dietary needs. To improve the monitoring of service users health new weighing scales had been provided, as required at the last inspection, and service users’ weight was recorded on the records checked. Appropriate contact with health Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 11 professionals occurs and records of GP, and other health care providers visits had also been recorded. Positive interaction between staff and service users was observed and service users spoke highly of the staff. Throughout lunch staff were seen assisting service users appropriately & interaction throughout the day promoted SU privacy and dignity. There continue to be problems with the safe administration of medication within the home. Following an incident in March 2006 a CSCI Pharmacist visit took place on 29 March 2006 and requirements and recommendations were made to improve the way medication was dealt with. A Pharmacy Inspector visited again on 19 July 2006 to inspect this and found that the previous requirements had been met. The overall finding of that specialist inspection was that there were excellent medication policies and procedures in place for staff to follow in order to protect service users health and wellbeing and practice was found to be good. During this unannounced inspection, at visits on the 31 January and 2 February 2006 some further problems relating to medicines were found. Those identified included some omissions in signing to confirm medicine had been given to service users, some inaccuracies in medication checked including a discrepancy of some 18 tablets relating to one service users medicine. Multi pack recording systems also meant that there was no clear audit trail being maintained. Some drugs administered were not named, which could lead to error and short life eye drops medication were not in their dated carton which meant they could have been used when no longer effective and of no benefit to the service user. Because of this and given previous concerns a Pharmacist Inspector was asked to visit again and check systems within the home. This inspection took place on 23 February 2007. At this visit the Pharmacy Inspector found that some improvements had been made in the problems identified on the 31 January and 2 February 2007. MAR sheets were in good order and there were no discrepancies in stock balances. The Pharmacy Inspector found that policies and procedures were easy to read and reflected current practice to enable staff to act safely when dealing with medicines. The morning medication round was also observed and safe practices were followed and encouragement, support and advice offered. Staff were aware of the medical conditions of service users. The individual needs of the service users were recognised and the administration of medication reflected this. Staff responsible for medication identified the worries some service users had about their medication and offered support and encouragement when needed. Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 12 However, some changes were found to MAR charts, which did not include details of who had authorised the change, the date of the change and a signature of the person concerned. During the medication round, some staff were seen to ask questions of the person in charge of medication administration, and such disturbances could lead to error. Some medication within the fridge did not have a date of opening, which could lead to use beyond use by date. The review date for medication policy was overdue and some service users’ self administering risk assessments were out of date. While the health and personal care needs are generally well met the repeated problems with regard to medication and the risks that those pose to service users mean that this area of care provision is poor. The registered person must take steps to ensure that the policies and practice with regard to medication within the home are maintained safely. Walton Manor DS0000062365.V313268.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 good. This judgement has been made using available evidence including a visit to this service. Service users individual social needs are respected and encouraged and activities are provided in accordance with this. There is a good choice of meals that most services users like. EVIDENCE: Service users preferences in respect of social activities had been recorded in the care plans checked and discussion with service users found varied individual or communal activities occur. Service users views recorded on the comment cards received prior to the inspection showed that activities are “provided sometimes”. Some service users said they prefer to spend their days in their bedrooms pursuing individual interests. One service user spoken with said they still completed three crosswords a month, they go out, write and receives letters. One service user said they enjoy reading and watching television. The activities records checked showed, some card and board games, bingo and craft sessions had occurred and some entertainment had been provided Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 14 occasionally. The manager said not all service users want to join in for activities when entertainers visit, and on one occasion only four service users attended the concert. Some service users were observed in the lounges and in bedrooms reading the daily newspapers Comment cards were received from service users’ relatives and friends, comments included “ staff mostly welcome you”; they are “kept informed of important matters” and were generally satisfied with the care provided. One service user’s relative felt they were not kept informed or consulted about the care, however were satisfied with the care provided. Two visitors spoken with said they had been visiting a service user in the home for eight years and staff had always made them welcome. Information provided on the pre inspection questionnaire and a comment card showed Power of Attorney arrangements have been made for some service users. Two service users were joined in one of the homes dining rooms for lunch. The meal sampled was chicken stew and dumplings, which had been cooked and was served to a very good standard. The two service users had made other choices from the menu. The decor and furnishings provided a pleasant environment for service users to eat in. Comments made on the comment cards completed by service users included “ excellent varied diet” and a service user spoken with said the “chef is marvellous”. One relative felt that some food lines were poor quality. However it was established from the menus seen and from discussions with service users that a choice of three meals is provided at lunch and suppertime and that generally service users are very satisfied with the provision of meals. Walton Manor DS0000062365.V313268.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): Quality in this outcome area is good. 16, 17, 18 This judgement has been made using available evidence including a visit to this service. Complaints are recorded appropriately and some safeguarding training is currently being provided to enable staff to better identify the various forms of abuse. EVIDENCE: Service users spoken with said they would be confident to make a complaint if necessary. Some comment cards showed that relatives did not know how to make a complaint. Two visitors said a named service user would not hesitate to complain if needed. The manager said a copy of the homes complaints procedure is displayed on the notice board and in the service user’s guide, however she would look into this. The homes complaint records were seen; one complaint had been made regarding the heating in a service user’s bedroom which had been dealt with immediately. A senior carer said some service users are able to vote at general and local elections and those who choose to vote generally vote by post. Some staff spoken with said they are aware of their duty under the Whistleblowing policy. Information provided on the pre inspection questionnaire showed some safeguarding training had been provided and Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 16 further training was planned. The assistant manager said she had delivered some of the training to staff. Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 17 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): 19,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is decorated and cleaned to a high standard and provides a pleasant comfortable environment for service users to live in. EVIDENCE: The home is set in its own ground; the grounds are easily accessible for service users. Building work is currently being carried out to provide additional accommodation at the home, some internal work, re decoration and replacement of fabrics and furnishings is also being completed. It was observed that the work inside the home was being well managed. The manager said the fire officer had informed them that his proposed inspection would be postponed until all work had been completed. The provider said they Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 18 were in constant contact with the fire officer to ensure that they are complying with fire requirements as work is progressing. The standard of cleanliness had been upheld as at the last visit even though some areas had benefited from the replacement of cornices ceilings and re decor. The domestic staff are to be commended for upholding a very high standard of cleanliness during the improvements. An anonymous comment card received showed that a service user considered the lighting in some communal areas to be poor. Their care plan could not be checked in relation to their needs due to anonymity. The communal rooms seen appeared to be generally well lit by natural and electrical lighting and a service user was seen reading in a small lounge. The lighting in a dining room was low however service users raised no complaints at the visit. The laundry facilities were not checked at this visit; no indicators of cross infection were observed. Information provided on the pre inspection questionnaire showed that some Infection control training had been provided. Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The current staffing levels and training arrangements are satisfactory. Service users are protected by the homes recruitment procedures. EVIDENCE: Comment cards received from relatives showed three felt there were not always enough staff on duty. The manager felt this was probably due to the layout of the rooms in the home and staff assisting service users at the times that relatives visited. The staff rosters showed a senior carer and two carers are rostered from 7:30am to 3:30pm and one of the carers starts work at 7am to help night staff at a time when some service users may need assistance getting up. One senior carer and 2 carers are rostered from 3.30pm to 9:30pm and one carer from 5pm to 10pm. Two carers are rostered on duty at night. Staff spoken with said the manager; assistant manager and the provider always assist staff whenever needed and staffing levels seemed sufficient to meet the needs of current service users. Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 20 The staff rosters showed a senior carer and two carers are rostered from 7:30am to 3:30pm and one of the carers starts work at 7am to help night staff at a time when some service users may need assistance getting up. One senior carer and 2 carers are rostered from 3.30pm to 9:30pm and one carer from 5pm to 10pm. Two carers are rostered on duty at night. Staff spoken with said the manager; assistant manager and the provider always assist staff whenever needed and staffing levels seemed sufficient to meet the needs of current service users. Staff spoken with and information provided on the pre inspection questionnaire showed that NVQ training is provided. Dementia, palliative care, medication and safeguarding training and some mandatory training had also been provided. Safe recruitment and induction processes were found. Records held for three staff recruited since the last full inspection were checked and showed job application forms had been completed, CRB and POVA first checks had been completed and satisfactory references obtained prior to staff starting work at the home. Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Audits of records and monitoring of practice need to be completed to ensure that staff are working to the homes policies and procedures whilst maintaining accurate records as required by regulation to ensure the home is managed effectively. EVIDENCE: Some records seen showed audits of records are not always completed. Some Management issues in relation to Health and Safety and Medication were discussed with the manager at the time. Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 22 The manager said this would be dealt with by way of delegation of responsibilities within the senior staff team in future. Records checked identified some service user and staff meetings had been held since the last inspection. The provider sends copies of reports following of her unannounced visits the home to the Commission. However, some of the homes questionnaires to establish service users’ view of the home had been completed. A service user had commented that the push button on the lift gave a little shock. The manager said she had dealt with this at the time. The assistant manager said she had felt little tingles on some occasions when she had pressed the lift button. The manager arranged for the lift to be put out of action and contacted the lift engineers immediately. The provider has since contacted the Commission and confirmed that this had occurred, and the provider said that manager is pursuing this further and was said to be safe. Some service users records of transactions made by the home for hairdressing chiropody etc were checked and no discrepancies were observed. Staff spoken with confirmed that formal supervision occurs. The Commission had not received notification that some falls that occurred and had involved a service user going to hospital and of a service user’s demise in hospital as required by regulation. Health and Safety arrangements observed at both visits in respect of the work being completed in the home were well managed. The kitchen door, which is a fire door, was seen to be wedged open on the first visit; staff were seen working in the kitchen at the time. At the second visit an automatic doorclosing device had been fitted onto the door. A senior carer spoken with said that during the building of the extension. A carer is designated the responsibility for ensuring a fire exit door was open should the fire alarms be activated. The pre inspection questionnaire showed that some fire training had been held and further training was planned, fire drills are held when the fire alarms are activated on a weekly basis. These records were not checked at this visit, however the provider has confirmed since the inspection that fire training for staff including night staff occurs regularly. Some records of running hot water temperature checks seen were satisfactory and shaft lift and bath and mobile hoist services completed. Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X 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 3 18 3 3 3 X X 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 1 1 Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9OP37 Regulation 13(2) 17(3) Timescale for action The registered person shall make 23/03/07 arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. • Medication prescribed to be taken in variable doses (e.g.) analgesics must be accurately recorded to ensure a clear audit trail is maintained. • The date of opening must be recorded on medication with a limited number of days of use once opened. • Medication must be administered as prescribed. If a change is made to the medication or a new medication is started this must be accurately recorded on the MAR chart. The registered person must 23/03/07 notify the Commission without delay of any incidences that occur that directly affect the service users including: • On a service user’s death DS0000062365.V313268.R01.S.doc Version 5.2 Page 25 Requirement 2 OP38 37(a)(e) Walton Manor which must include the circumstances of his/her death. • Serious injury. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations A second member of staff should witness all hand written annotations on Medication Administration Record (MAR) charts. • A record of temperature should be maintained for all areas where medicines are kept (fridge should be monitored daily). • Both eye drop dispensers and cartons should both be dated at time of opening, and the dispenser stored in the correct carton to reduce the possibility of errors occurring • An updated risk assessment should be done for all residents self administering their medication • The MAR folder needs to be improved. New dividers should be used. The recording of the timing of administration should be on the same sheet as the record of administration. A check of current medication should be made and any medicines not in use should be removed from the MAR. The Registered person should liaise with the pharmacy to provide new MAR charts if required. • A review of the medication policy is needed as the review date has expired. • A copy of prescriptions requested should be kept. The registered person should discuss with SU and monitor the lighting in the home, and take action if required, to ensure lighting is adequate for service users at all times. • 2 OP25 Walton Manor DS0000062365.V313268.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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. 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