Inspection on 26/07/05 for Westcombe Park Nursing Home

This inspection was carried out on 26th July 2005.

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 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

Westcombe Park Nursing Home 02/03/07

Westcombe Park Nursing Home 03/02/06

Westcombe Park Nursing Home 20/04/05

Westcombe Park Nursing Home 19/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Westcombe Park Nursing Home 112 Westcombe Park Road Blackheath London SE3 7RZ Lead Inspector Keith Izzard Announced 26 July 2005 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 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. Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Westcombe Park Nursing Home Address 112 Westcombe Park Road, Black heath, London SE3 7RZ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020-8293 9093 020-8858 2026 HILLSN@BUPA.com BUPA Care Homes (Partnerships) Limited Nicola Hills Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51) of places Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 10 beds for general nursing care of people aged 50 - Imposed 1 April 2002, 41 beds for the general nursing care of people aged 60 - Imposed 1 April 2002. Date of last inspection 20 March 2005 Brief Description of the Service: Westcombe Park Nursing Home is located to the rear of a privately owned apartment block, which is managed by Goldsborough Estates. The home is sited on a residential road within walking distance of local shops and public transport links. Access to the front entrance of the Care Home is restricted to ambulances or vehicles collecting or dropping off visitors or service users. Parking is provided for visitors in front of the private apartments. Westcombe Park Nursing Home is registered to provide nursing care for 51 male or female service users, ten of whom can be aged 50 years and over and 41 of whom must be at least 60 years of age. Accommodation is provided on three floors. Each of the floors has a variety of bedrooms, forty-three of the rooms are single occupancy and three rooms are shared. Forty of the bedrooms have ensuite facilities. Each of the floors has a communal lounge, bathrooms and toilets. On the ground floor there is a dining room and a large lounge, which is used for activities. Kitchen and laundry facilities are provided on site. At the rear of the property service users have access to a shared garden. Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was undertaken as part of the routine inspection programme and was completed in 7.75 hours by two Inspectors. The last inspection was unannounced on 20th March 2005. The inspection included a complete tour of the premises, inspecting records, talking to six residents, the manager and ten members of the staff team. Only One relative was seen but ten comment cards had been received from residents and relatives and one from the GP for the home. The comments made were generally positive and no concerns were expressed about the home. Overall, the home was clean, tidy and safe for residents who were cared for by staff members who were caring and professional in their relationship with residents. What the service does well: Staff and management communicated with relatives and worked with them and residents to meet individual needs and provide residents with a lifestyle suited to them. Staff received training to enable them to fulfil their role. Records were well maintained and care plans were up to date and reflected resident needs. Staff spoke respectfully about the residents and showed insight and knowledge into their needs. Residents interviewed were complimentary about staff members and expressed no concerns about the service provided by the home. The manager and staff members were positive about the inspection process and assisted the Inspectors in a constructive way. Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 Page 6 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. Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 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 standard(s) 1-6 Adequate information was provided about the service in the statement of purpose and service user guide to enable prospective residents to make a decision to the suitability of the service. Admission procedures were in place to comply with these standards including contracts for residents, however the manager must sign these. EVIDENCE: The manager or her deputy undertakes a formal assessment of residents needs prior to admission. The assessment included assessing residents health and welfare needs and judging whether there were any particular safety issues such as a history of falls. These were comprehensive but must include more social history and information regarding hobbies and interests. Requirement 1 Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 Page 9 The home confirms the arrangements for admission in writing and provides information about the care and facilities provided prior to admission. The letter sent to prospective residents confirmed that the home was able to meet the individual’s needs in respect of health and welfare. Contracts for residents had been provided that met this Standard, except the manager must sign them, as well as residents or their relatives / advocates. Requirement 2 Standard 6 was not assessed as the home does not provide and intermediate care service. Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7-11 Resident’s needs were being met based on assessment of need and with the involvement of the resident. Medicines were generally safely managed, however, NMC guidance on medication must be available. Pharmacy labels must have full administration instructions including topical preparations. The actual dose administered when a variable dose is prescribed must be recorded. Some topical preparations had been dispensed with ‘as directed’ on the label. EVIDENCE: Four care plans were viewed from each of the three floors, all included preadmission assessments but as mentioned in a previous Standard. None of them had much information regarding the resident’s hobbies, interests or social history. Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 Page 11 Assessment of need and risk assessments had been completed well. Care plans were prepared for identified needs and provided details as to how care was to be delivered. Care plans were reviewed monthly. In two care plans it was evident that the resident and or a relative were involved with preparing the plans. Daily evaluation records reflected the implementation of care plans. There were no residents with pressure sores in the home but sadly during the inspection a resident was readmitted to the home from hospital and whilst there had developed high grade pressures sores. This matter was appropriately the subject of a complaint made to the hospital by staff of the home. Care assistants said they were not formally involved with preparing or reviewing care plans but said that they fed back issues in relation to key residents to the named nurse. Residents and relatives seen said they were happy with the way care was provided. Medications were assessed on the first floor. Staff said that policies and procedures were provided in relation to medication management. However neither these nor the NMC guidance on medication were available. Requirement 3 Records were kept for receipt, administration and disposal of medicines brought into the home. Staff members were aware of the changes to pharmacy contracts and the disposal of medicines. Medicines were supplied using the NOMAD system. Medication administration records were kept and included resident’s photos, date of birth and room number as identification. These records were well maintained. None of the residents administered their own medicines. Medicine and dressing storage areas were very small and one medicine ridge was available between the three floors Medication records for three residents were checked. Inaccuracies were noted on one in relation to the amount administered when a variable dose was prescribed. Some topical preparations had been dispensed with ‘as directed’ on the label. Requirement 4 Hand written entries on medication charts were signed by the GP. A homely remedies list was provided and agreed with the GP. This included Oxygen, which was stored outside the home and yellow paraffin, which is a topical application. Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 Page 12 Staff had access to up to date information on medicines and said if they had any queries on medicines they would get advice from the supplying chemist, the GP, the medicine information leaflet or a colleague. Residents said that staff treated them with respect. Comments were made such as ‘staff talk to me and always tell what they are doing’, ‘I can’t complain, they look after me very well’, ‘I don’t wish for anything, they look after me’ and ‘staff are very friendly’. Residents can stay in the home in the final days of life provided their needs can be met. The decision to provide this type of care to a resident had been made with relatives and the GP. Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12-15 Residents interviewed stated their satisfaction with their lifestyle within the home in relation to this group of Standards. Attention was given to meeting the leisure and social needs of the residents but recording of their social histories would inform this. Meals provided were varied and planned to meet the resident’s choice and preferences but their requirements should be recorded in their social care plans following consultation with them. EVIDENCE: Residents were seen in different areas of the home. Some stayed in their rooms, some sat in the main or quiet areas of the home. Some were reading the daily papers and said they liked to keep up with the news. Residents who spoke to the inspector said they could spend their day as they wished and said they did not get bored. More effort should be made to obtain the residents social history prior to or at the time of admission. The pre-admission assessment format had a section in relation to social background and interest but this was scantily completed on the two of the care plans viewed. Individual social activity care plans must be improved in consultation with residents. Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 Page 14 Requirement 1. Lunch was observed on the second and ground floors. Some residents went to the dining room on the ground floor but quite a number stayed on their own floor to heave their meal. Residents could choose where to have their meal and several stayed in their room. Residents who spoke to the inspectors said they were satisfied with the meals provided and the choice available. During lunch it was evident a meal choice was available and staff offered appropriate assistance where needed. Foods were pureed separately to make them look appetising. One resident said they liked only fish and said they were given a variety of fish cooked in a variety of ways. There was a difference of opinion between the staff and the manager as to how the dietary needs of an ethnic minority resident were being met. On the day of the inspection the resident had egg for breakfast and for lunch. Staff said the resident ‘had eggs all the time’. It would therefore be advisable to prepare an individual menu in consultation with the resident and relatives. Recommendation 1 In the kitchenette on the second floor foods with a shelf like were stored in the fridge but were not dated when opened. Requirement 5 Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16-18 Adequate systems were in place to ensure residents were protected from abuse and to manage complaints about the service. EVIDENCE: The Inspector examined the complaints and compliments file and noted that all the five complaints logged since the previous examination of complaints had been dealt with within timescales required and that records maintained were of a good standard. All complaints had been dealt with to the satisfaction of the complainants except one. This complaint was also made directly to the CSCI following a detailed investigation by BUPA that was unacceptable to the complainant, who was a friend of the resident. The complaint was additionally investigated by CSCI and was found to have been thoroughly and appropriately responded to by the home, both to the satisfaction of the resident concerned and her immediate next of kin. The Inspectors interviewed the resident concerned and received confirmation in writing from the relatives that they were fully satisfied with the outcome and with the service provided by the home. Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 Page 16 The home has a policy and procedure relating to the protection of vulnerable adults and copy of Greenwich Councils Adult Protection Procedure was also available in the home. Staff can use the homes whistle blowing procedure to report any concerns that they may have about practices that occur in the home. The home had one investigation to do with alleged rough handling by a member of care staff. This was appropriately referred to the Adult Protection team for investigation, the worker was suspended from duty pending the outcome of the investigation and reinstated when the outcome was found to be unintentional rough handling, retraining was appropriately provided. It was noted that the welfare of service users had been maintained and procedures implemented in accordance with requirements. The manager agreed with the Inspector’s suggestion that more staff receive updated training in Adult Protection issues following comments made by some staff members of uncertainty regarding this area and in respect of whistle blowing. Requirement 6 The system for dealing with resident’s finances was examined and found to be accountable, well managed, and with a clear audit trail. Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19-26 Overall, residents live in a safe, well maintained environment with equipment provided for their needs and within comfortable surroundings. Some minor repairs and modifications were needed. The home was clean pleasant and hygienic. EVIDENCE: The manager said that the first floor was currently being refurbished. New carpets and curtains were on order and bedrooms 11 and 40 were due to be redecorated. She said that last year the refurbishment programme focussed on the bedrooms and this year the communal areas would be addressed. Therefore, requirements have not been made in relation to the state of the carpet on the first floor and the manager will advise the Commission when the carpet has been replaced. In the meantime the carpet must be kept clean especially round the kitchenette doorway. The home was generally clean and tidy and residents who spoke to the inspector said they were satisfied with their bedrooms and the communal space. Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 Page 18 Quiet areas were provided at one end of the corridors on the first and second floors and the middle of the ground floor. Residents said they like to sit in these areas for a chat with each other or to receive visitors. On the first floor this area had been made to look like and old inn and was called the ‘Reminiscence Inn’. Staff members said that this facility was used in the afternoons, for residents to enjoy a drink, to chat and to have time for reflection, if they wished. This is commendable. Six bedrooms were assessed against the standards. Bedrooms were clean and tidy. Residents said they were satisfied with their rooms and they way they were laid out. They said they could and had brought in some personal items to make the room ‘feel homely’. None of the bedrooms had bedside or over bed lights. This should be reviewed as it could pose a risk to residents at night or be disturbing when care was required at night. Recommendation 2 The Inspector could not turn off the cold water tap in room 40, which was dripping and had stained the washbasin. Bathrooms were generally clean and tidy. In the bathroom near room 32 on the second floor there was no call bell or grab rail by the toilet. In the shower room on the second floor the grab rail looked very rusty at the hinge and should be checked to ensure it is safe to use. The bathroom on the first floor near room 22 the bath tap was dripping and had stained the bath and there was no grab rail or call bell by the toilet. Requirement 7 Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27-30 The needs of residents were met by trained staff who were competent and provided a good skill mix, however, the reasons for the divergence of opinion between two staff teams and the other staff team in relation to night time care must be examined by management. Good recruitment practices were evident. EVIDENCE: The staff on duty on all floors complied with the home’s staffing notice. There was a marked difference in the attitude of staff towards the management of the home between the first and second floor staff teams. This issue was discussed with the manager as it seemed to be an ‘in house issue’. The need to ensure this does not affect resident care must be monitored by the manager, as the indication from the second floor was that it did. For example, staff on the second floor, were of the opinion that the night staff were not meeting the needs of the residents and when issues were reported to the manager they felt appropriate action had not been taken. Recommendation 3 Staff on the first floor confirmed they did not have any similar concerns and said the day and night staff worked ‘as a team’. Staff spoken to on the ground floor reported a good relationship with management and between themselves. It was evident from interviews with staff members that they had an awareness of resident needs and how to meet these. Staff said they received supervision in practice but did not receive one to one formal supervision. Recommendation 4 Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 Page 20 Staff said they received the training needed to fulfil their role and evidence was provided for this, as training records were examined. Staff had a good understanding of infection control but some were not aware of the homes whistle blowing policy and were unclear as to how they would handle a suspicion or allegation of abuse. Requirement 6 Three staff personal files were inspected. These were well maintained and contained most of the information required by regulation. The information missing included recent photos for two of the employees. There was no evidence to show that hand written references for two employees had been verified as genuine. These areas should be attended to. Recommendation 5 Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35,38 Records required by Regulation were kept and well maintained. Health and Safety records examined showed that attention was given to ensuring a safe environment was provided for residents and others. The evident divergent views expressed by care staff on one unit in respect of the night- time and day staff members’ roles should be addressed by the manager. EVIDENCE: The home had policies and procedures as required by regulation. A sample of safety records checked showed safety systems and maintenance were routinely addressed. Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 Page 22 Regular monthly visits under Regulation26 have been conducted and those reports provided to CSCI examined. The manager and deputy do regular three monthly spot checks, unannounced and at night. The home has an annual audit and the manager has a rolling programme of audits and is required to regularly submit these to the head office of the provider. Service user and relative surveys have been introduced and these are staggered over the year. Ten service user / relative comment cards were received by CSCI. Nine of these were complimentary about the home the other commented on the lack of someone available in the reception area at weekends and the absence of a facility for leaving messages for staff. The manager agreed to set up a system for messages in the reception area in the absence of a receptionist. Additionally, a comment card was received from the GP for the home and this was complimentary. The system for dealing with resident’s finances was examined and found to be accountable, well managed, and with a clear audit trail. The Inspector was not aware of any financial irregularities in relation to the running of the home and has no reason to doubt the financial viability of the organisation. Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x 3 3 3 2 3 3 Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 Page 24 no Are there any outstanding requirements from the last inspection? 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 3 &12 Regulation 14 &16 Requirement Pre admission assessments must include a social history identifying the interests and hobbies of residents. Indivdual social care plansmust be prepared in consultation with residents. Contracts provided for residents must be signed by both the manager and the resident, or their representative. The NMC and other policies /procedures for medication must be readily available for staff. Pharmacy labels must have full administration instructions including topical preparations. The homely remedy policy must not include topical preparations. Accurate records of administration of medicines must be kept including the dose administered when a variable dose is prescribed. Food with a predetermined shelf life must be dated when it was opened. Further numbers of staff must receive updated training in adult protection matters and the whistle blowing policy. Timescale for action 1/10/05 2. 2 5 1/10/05 3. 9 13 1/10/05 4. 9 13 1/10/05 5. 6. 15 18 13 13 1/10/05 1/10/05 Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 Page 25 7. 19 23 Two dripping taps must be repaired and two bathrooms without call bells or grab rails must be provided with these facilities. 1/12/05 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 15 23 28 Good Practice Recommendations The diet of one resident should receive an individual menu in consultation with that resident and their family. The lack of bedside or over bed lights should be reviewed to ensure that this does not constitute a risk for some residents or disturbance when care might be required. The issues behind the divergent views of staff members regarding night time and day time staff members should be identified and improved, possibly requiring some team building by management. Staff personal files should include recent photographs of the employee and any hand written references are verified as genuine. 4. 5. 29 Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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 Westcombe Park Nursing Home G51-G01 S6775 Westcombe Park V233072 26-0705 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!