Inspection on 03/02/06 for Westcombe Park Nursing Home

This inspection was carried out on 3rd February 2006.

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

The inspector 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 26/07/05

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 Rd Blackheath London SE3 7RZ Lead Inspector Mrs Susan Hall Unannounced Inspection 3rd February 2006 10:00 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 Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 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. Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Westcombe Park Nursing Home Address 112 Westcombe Park Rd Blackheath London SE3 7RZ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8293 9093 020 8858 2026 www.bupa.co.uk 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 DS0000006775.V281739.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 10 beds for general nursing care of people aged 50 41 beds for the general nursing care of people aged 60 Date of last inspection 26th July 2005 Brief Description of the Service: Westcombe Park Nursing Home is situated at the rear of a privately owned apartment block, which is managed by Goldsborough estates. It is situated in a residential area, and is within walking distance of local shops, and public transport links. Access to the front entrance of the home is restricted to ambulances, or vehicles collecting or dropping off service users or visitors. Parking for visitors is available at the front of the private apartment block. Accommodation is provided on three floors – ground, first and second – with a passenger lift providing easy access to all floors. Most of the rooms are for single occupancy, and have en-suite toilet facilities. The home retains a number of shared rooms which can be offered to service users who prefer to share (e.g. married couples). Each floor has it’s own communal lounge, and a smaller quiet area. There are bathrooms and toilets on each floor. The ground floor includes a dining room, adjacent kitchen, and laundry facilities. An attractive rear garden provides outdoor space for service users when the weather is suitable. There is also a smaller sensory garden. Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place from 10.00 – 16.00. The Manager was available throughout the day, and assisted the Inspector with showing her around the home, and locating information. The Inspector was able to talk freely with staff and service users, viewed the premises, and examined care plans, medication, maintenance records and other documentation. She enjoyed chats with 4 service users, and met others briefly; and talked with 8 staff, including 3 nurses, chef and kitchen staff, and one of the maintenance men. Care staff were seen carrying out their duties calmly and efficiently. The home was clean throughout, and generally well maintained. There is an ongoing programme of redecoration, and where possible, service users are able to choose their preferred décor for their bedrooms. Service users were cheerful and talked positively about the home, the Manager, the staff, the food, and the activities. They were well groomed, and encouraged to sit where they wished, and to get up/ go to bed according to choice. What the service does well: Service users clearly enjoy living in the home, and are treated with respect and dignity by the staff. They are able to go out with assistance from staff, and a staff member will fetch any shopping they require. They are able to join in with activities if they wish, or stay in their own rooms, or sit in one of the quiet areas. Visitors are welcomed at any time. The home facilitates care staff in carrying out NVQ training, and 15 out of a total of 26 had completed NVQ level 2 or 3. This is above the projected percentage in the National Minimum Standards, and the home is commended for this. Maintenance records were clearly recorded and easy to follow, and the home employs 2 maintenance men to ensure that facilities are kept to a high standard. Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 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 DS0000006775.V281739.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 Good information is provided to assist service users and relatives in making a choice about where to live. Detailed contracts, and terms and conditions of residency, are provided. Pre-admission assessments are made to ensure that the home can meet the needs of the service users. EVIDENCE: The Statement of Purpose and Service User Guide are prepared in a format which is easy to follow and has the required information. The Manager stated that no changes had been made to these documents since the previous inspection. The Inspector viewed two pre-admission assessments, and noted that these were carried out using a pre-printed format, and were suitably detailed. These assessments are usually carried out by the Deputy Manager, who is a trained nurse, and the home’s Head of Care. She had recorded information which included service users’ personal data; medication; medical history; activities of Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 9 daily living (e.g. mobility, communication needs, continence, sleep pattern, personal hygiene needs); mental state, skin integrity and personal safety issues. Other information included a history of falls, and social and family interests. A placement is only offered if the home is able to meet the assessed needs of the service user. The home had been unable to offer a place to one of these two service users, as nurses did not have some specific training needed for that particular person. The home has places available for privately funded service users, and for those funded by local authority. Each service user is provided with a contract which specifies the terms and conditions of residency, and the Inspector noted that the contracts are signed by the Manager and the service user or a representative. Four of these were viewed by the Inspector. Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9,10 Care plans contain detailed information which enables staff to give effective care. Health needs are well met; and medication administration is generally satisfactory but requires some additional attention. Service users feel that they are treated with dignity and respect. EVIDENCE: The Inspector viewed 3 care plans from the ground floor and found these to be in good order, up to date, and well maintained. Assessments are carried out for skin integrity, dependency levels and nutritional needs, and these had been properly reviewed and updated each month. Care plans are developed according to each service user’s individual needs, and these had also been assessed monthly. They included all aspects of care, such as personal hygiene, eating and drinking, mobilisation, memory and orientation, wound care and social and spiritual needs. Health needs were appropriately documented, and included monthly weights, dependency levels, continence assessments, moving and handling assessments and risk assessments – e.g. for use of bedrails, or use of wheelchair. Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 11 Nursing staff ensure that monthly observations of temperature and blood pressure are recorded, and request a doctor’s visit as required. Wound care was well recorded, with a separate entry for the state of the wound and the dressing to be applied at each change of dressing. Visits from GPs and other health professionals were well recorded. The home is able to contact Greenwich Primary Care Trust (PCT) to arrange visits from “link” nurses for additional advice regarding diabetes, continence or tissue viability. The home is fortunate in having one GP who will oversee the care of all service users, unless they prefer to retain their previous GP. The format used for care planning does not allow much space to add additional information, and is not always easy to follow. The Inspector discussed this with the Manager, and was pleased to hear that the company are considering the use of a different system which would make information easier to access. The Inspector examined medication management on the first floor. Each floor has the same system in place. The medication trolley is locked in a cupboard adjacent to the nurses’ station, and storage cupboards are inside the same area. The home uses the nomad cassette system of administration. The trolley was in good order, and medication charts had been completed satisfactorily, except for handwritten entries. These had only been signed by one nurse, and the Inspector pointed out the importance of 2 staff to check any handwritten entries. Each medication administration record (MAR chart) included a photograph of the service user. A list of homely remedies had been signed by the GP. The Inspector noted that one service user had had medication “out of stock” for 5 days, and this is unsatisfactory. One of the homely remedies was dated for 2004, and needed replacing. The home also had a stock of medication (paracetamol) for staff, and this is also unsatisfactory, as the home is not responsible for administering any medication to staff. Any staff requiring medication must bring in their own, and keep it safely in their locker while on duty. Two requirements and a recommendation are given for this standard. The Inspector noted there were a number of opened eye drops and insulins in the drugs fridge, and discussed the importance of checking if they should be retained in the fridge or not after opening. This needs to be verified by checking the prescription leaflet for each of these medications, or checking with the Pharmacist. Service users spoke highly of the level of care they are given, and it was evident that they are treated with respect and consideration by all levels of staff. Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,15 Service users are provided with a range of activities, and are assisted in maintaining their preferred lifestyles. The home caters for differing nutritional needs, and supplies a good choice of menus, and home-cooked cakes and dishes. EVIDENCE: The Inspector had a long chat with 2 service users, who explained about the variety of activities available. There is a full time Activities Co-ordinator, who usually spends time with service users on a one to one basis in the mornings, and oversees group activities in the afternoons. One to one activities may just include spending time on a one to one conversation, but also includes taking service users out individually to the shops, or out for coffee/lunch. Group activities are available for anyone who wants to join in, and include things such as skittles, singing and indoor games. There is a weekly programme of activities, (which changes each week), and this is displayed on a notice board. There are also coffee afternoons and bazaars which relatives and visitors can attend, and birthday and garden parties. Several evening events with a buffet or cheese and wine had been organised during the previous year, and these had been much enjoyed by service users and their friends and relatives. The garden is used extensively in the summer months, and the home has a sensory garden area which is separate. An area on the first floor has Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 13 been decorated as a “pub” area, and this is open twice per month for drinks and singing round the piano. Care staff have commenced carrying out activities during weekend afternoons, and had arranged a film show for the next Saturday. Care plans include a “map of life” for each service user, showing details of their previous family life, occupation, interests and social activities. A record is retained of the activities in which they take part. The Manager has arranged for advocacy services to be available from Greenwich Advocacy Services for any service users who require this. The same advocate visits the home on a regular basis to assist residents in dealing with solicitors or other advisers. The Inspector discussed the food with service users, and they generally stated that this was good, with plenty of choice, and was well cooked. The kitchens were in good order, clean and tidy. There is a controlled daily and weekly cleaning schedule; and fridge, freezer and food temperatures are recorded daily. The kitchens have a separate servery area, another area for food preparation (e.g. sandwiches or vegetables); dry food storage rooms and an office. Fresh fruit and vegetables are delivered daily. The Inspector saw homemade soup, desserts and cakes all in the process of being cooked. Small plates of a variety of prepared fresh fruit are offered as a dessert at meal times or as an additional snack. Additional food can be requested at any time. There is a small kitchenette on each floor to enable staff to make fresh toast or drinks for service users, and for the use of relatives and visitors. Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The home has a straightforward complaints procedure, and service users and relatives know that their views will be taken into consideration. Staff are trained to recognise and prevent different types of abuse to older people. EVIDENCE: Complaints are audited into a complaints log every month, and this showed that one complaint had been made since the previous inspection. This had been properly investigated, and action had been taken to remedy the situation. The Manager speaks to most service users each day, so that she is quickly aware if they have any concerns; and she is nearly always available to speak with any relatives or visitors during the day. Staff are aware of the need to divulge any incidents of bad practice or suspicions of abuse, and are conversant with whistle-blowing procedures. The Manager stated that four staff were due to carry out an update in adult protection training the next week. These staff will then assist in updating other staff, with the aid of a training package. Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 - 26 The home provides a safe and comfortable environment for service users, and is pleasant and well maintained. There are sufficient toilets and bathrooms, and suitable specialist equipment. Heating, lighting and laundry facilities are all satisfactory. EVIDENCE: The Inspector viewed each floor, and saw that the premises were clean throughout and generally well maintained. Two maintenance employees keep the décor and equipment in good order, and also carry out gardening, repairs, and checks for fire and emergency lighting. There is a redecorating programme in place, and where possible, service users are able to choose the décor for their bedrooms. Bedrooms were of suitable sizes, and some have en-suite toilet facilities. The Inspector saw that some service users had been able to bring in personal items of furniture and other Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 16 possessions to help them feel at home. All bedrooms had been fitted with bedside lights (i.e. in addition to wall lights) since the last inspection. Maintenance records were well documented and easy to follow. The Inspector viewed servicing records for mobile hoists (7 in total); the passenger lift; fire logs, monthly fire extinguisher checks and emergency lighting; electrical items (PAT testing); and water temperatures. These are tested on a random basis each week. The home is well equipped, and has assisted baths, mobile hoists, handrails, pressure-relieving mattresses, and a sluice room on each floor. There is a call bell in each room. The laundry was tidy and well managed. Two laundry staff are employed to do the laundry, so that care staff can concentrate on caring. There are 3 washing machines and 2 dryers. The washing machines have an automated system to ensure the right mix of washing powder/liquids for each wash. A red alginate bag system is used for soiled items. Service users’ clothes are usually labelled prior to admission, but when labels need replacing the laundry staff or keyworkers ensure this is done. The home has a large comfortable lounge on the ground floor, a separate dining room, and quiet areas on each floor. These were well decorated, and had good quality furniture and furnishings. Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30 Suitable staffing levels are maintained to meet the dependency levels of service users. The company ensure that new staff have a detailed induction, and encourage all staff in completing ongoing training. EVIDENCE: Staffing levels have been set for each floor, according to the number of service users and their anticipated dependency levels. Additional staff would be brought on duty if dependency levels became higher – e.g. due to serious illness, where additional attention was required. The ratio of day care staff is usually 1 nurse and 2 care staff on the ground floor; 1 nurse and 3 care staff on the first floor; and 1 nurse and 3 care staff on the second floor. These are assisted by ancillary staff comprising a cook and 2 kitchen staff; a laundry assistant; a maintenance person; and 1 domestic assistant for each floor. Night staffing consists of 2 nurses and 3 care staff for the whole building. New staff carry out a 6-week induction programme, with the first 3 days as supernumerary. Untrained care staff work through foundational standards for 6 months, with the assistance of a senior staff member to mentor them. Care staff are encouraged to study for NVQ 2 and 3, and at the time of the inspection, 15 out of a total of 26 care staff had completed NVQ 2 or 3. This is a ratio of 57.6 and the home is commended for having above 50 trained to this level. Another 4 care staff were working towards level 3. Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 18 The home employs it’s own bank staff, and occasionally uses agency staff to cover for sickness or holidays. Where possible, the same agency staff cover shifts, as they already know the home and the service users. Nursing and care staff are enabled to carry out training to keep their professional standards up to date, and to develop their skills and competencies. Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,36,37,38 The Manager is suitably qualified and experienced to provide effective leadership in the home. One to one staff supervision ensures that staff are enabled to share their views and discuss their training needs. Records are well maintained and stored confidentially. The Manager ensures that the health and safety of service users and staff is maintained. EVIDENCE: The Manager is a trained nurse with many years of experience in nursing the elderly. She has also completed NVQ 4/RMA (Registered Managers’ Award) in management. She gives a lead to staff in carrying out their duties, and in ensuring that service users are well cared for. She is assisted by a Deputy Manager who is the training co-ordinator, and who works some hours directly “on the floor” alongside nursing and care staff, and some supernumerary hours to oversee training and documentation. Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 20 The Inspector viewed the format for one to one staff supervision sessions, and the Manager stated that this is now carried out for all staff 6 times per year. The Manager gives supervision to senior staff, and supervision of other staff is delegated to them. Staff also have a yearly appraisal. All staff had completed mandatory training in safe practices. Moving and handling training is carried out in house by 2 appropriately trained coordinators. Fire testing is carried out every week by the maintenance man, and includes checking that all doors close properly, and emergency lighting is working properly. He also carries out monthly visual checks on fire extinguishers, and checks water temperatures to ensure that thermostats are working correctly. Other duties include checking shower heads, cleaning tumble-dryers in the laundry, and checking hot trolleys for hot food storage. Records were excellently maintained. The Inspector viewed servicing records for all 7 mobile hoists, the passenger lift, assisted baths, and PAT testing for electrical items. These were all up to date. Accident records are completed according to HSE requirements. These were satisfactorily completed. The Manager carries out individual audits for Service Users to check if falls become more frequent. The Inspector recommended that a general audit of accident records is completed monthly, so that any pattern of accidents (e.g. time of day, person on duty) can easily be noted, and appropriate action taken. Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 3 3 Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 22 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 OP9 Regulation 13 (2) Requirement Ensure that homely remedies do not go out of date. Ensure that no prescribed medicines go out of stock. No medication should be stored or administered to staff. It is up to staff to provide any medication they require. Timescale for action 03/03/06 2 OP9 13 (2) 03/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP38 Good Practice Recommendations Ensure that handwritten entries on MAR charts are signed for by 2 staff. To carry out a monthly audit of all accidents in the home. Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Westcombe Park Nursing Home DS0000006775.V281739.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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