Care Home: Danson House Residential Care Home

What has improved since the last inspection? All of those requirements that were issued at the last inspection have been addressed. Medication records have improved although we still raised some issues about these. Recruitment procedures have improved and were able to see that, in order to protect those who use the service, all of the appropriate clearance is gained prior to any new member of staff being employed. We are told that the service has organised more social events for residents, including trips out of the home and they have amended the menus in response to requests from some people.Danson HouseDS0000006792.V375583.R01.S.doc Version 5.2 Page 7A sluice facility for commode pots has been installed and the redecoration and refurbishment plan has continued despite the plans for redevelopment of the home. What the care home could do better: At this visit we raised some other issues regarding medication practices in the home. We have acknowledged the improvements that have been made however, have asked them to carry out a regular audit to ensure that any errors are identified promptly and addressed. We have also said that, where medication is given as a variable dose, there must be a care plan in place to indicate how staff should decide how much medication should be administered. When we visited we noted that several residents like to have their bedroom doors left open. This could be a risk in the event of a fire. These doors should all be kept shut however, if residents wish to keep them open they must be fitted with automatic closers which operate in the event of a fire and help keep them safe. Key inspection report CARE HOMES FOR OLDER PEOPLE Danson House Glynde Road Bexleyheath Kent DA7 4EU Lead Inspector Alison Ford Unannounced Inspection 10:15 15th June 2009 DS0000006792.V375583.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Danson House DS0000006792.V375583.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Danson House DS0000006792.V375583.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Danson House Address Glynde Road Bexleyheath Kent DA7 4EU 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 8304 3762 020 8301 2646 nicole.shilling@kcht.org.uk www.kcht.org Kent Community Housing Trust Mrs Nicole Sandra Shilling Care Home 46 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (45) of places Danson House DS0000006792.V375583.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 46 20th June 2008 Date of last inspection Brief Description of the Service: Danson House is owned and managed by Kent Community Housing Trust (KCHT) which is a charitable not for profit trust. The home was purpose built and provides accommodation on two floors. It is located in a residential road within walking distance of shops, a mainline railway station and bus routes. The home is registered to provide personal care and accommodation for 46 older people. The building is divided into five separate units, Silver (10 beds), Katie (9 beds), Family (10 beds), Royal Blue (9 beds). Each unit has a lounge/dining area, kitchenette, toilet/bathroom facilities and bedrooms. Respite care is also provided. There is parking to the side of the property with garden and patio areas at the rear. The home also provides day care for a maximum of four older people. This part of the service is not regulated. Residents pay privately for items such as hairdressing, chiropody, newspapers and social outings. A copy of their Statement of Purpose and Service user Guide can be obtained from them and their latest inspection report can be downloaded from thee website of The Care Quality Commission at www.cqc.org.uk . Danson House DS0000006792.V375583.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star. This means that people using the service receive a good service. This report follows a key inspection visit to the service which was unannounced. When writing the report we have also taken into consideration other information that we have received since our last visit. This includes complaints, notifications and comments that people have made about the service. The homes manager also sent us their Annual Quality Assurance Assessment (AQAA). This is a self assessment that they complete every year. It gives us some statistical information about the service and also tells us about how well they consider that they are meeting their aims and objectives and about their plans for the future. The AQAA was sent to us when we asked for it, it was completed well and it gave us a lot of useful information about the service. During the inspection visit we walked around the home and spoke with some of the residents who live there and also to some of their relatives to try and find out what it is like to live in the home. We also spoke to several staff members and to the manager of the home. We looked at a sample of care plans and also to some of the documentation that the home is required to keep as evidence of its commitment to the health and safety of residents and staff. Currently fees are £421.85 per week. Extra charges would be payable for services such as hairdressing and chiropody and these would be discussed prior to any placement being agreed. There are plans for Danson House to be redeveloped in eighteen months to two years time. Prospective residents are told about this and the majority of new placements are now for respite. The relatives that we spoke with during our visit said that they had all received letters about the proposals and were being kept informed. Danson House DS0000006792.V375583.R01.S.doc Version 5.2 Page 6 What the service does well: This home provides clean comfortable and well maintained accommodation for the people who live there. However, KCHT have identified that the building would not comply with the standards expected of a newer build and have decided to redevelop this site and offer residents the opportunity to move to another of their homes, one of which, Dovedale, will be a brand new purpose built facility. Meanwhile the home continues to provide good care for its residents, many of whom have lived there for some time. There is a stable workforce, staff turnover is low and we could see that for those people who have been employed all of the necessary checks have been completed before they start and they have a comprehensive induction programme. We saw that residents all have individual care plans which show how they like to be supported and ensures that their health care needs will be met. They say that they are free to choose how they spend their days. They tell us that the staff that care for them are kind and caring. One lady said “they are so lovely, very patient when it takes me long time to do something and very caring”. Another said “I couldn’t manage without them, they are wonderful”. Staff training is kept up to date to ensure that staff have the skills that they need. People told us that the meals that are served are “really good” and that the cook “is superb, a real cook”. Alternative meal options are always available and special diets can be catered for. Medication in the home is generally well managed and some people are able to self medicate, within a risk management framework. Any money kept on behalf of residents is kept safely and there are appropriate records maintained. There is a complaints procedure in place in the home however, complaints are few. People said that they would tell the staff if they had any concerns and everything would be sorted out. The Commission has not received any concerns about the service since the last inspection. What has improved since the last inspection? All of those requirements that were issued at the last inspection have been addressed. Medication records have improved although we still raised some issues about these. Recruitment procedures have improved and were able to see that, in order to protect those who use the service, all of the appropriate clearance is gained prior to any new member of staff being employed. We are told that the service has organised more social events for residents, including trips out of the home and they have amended the menus in response to requests from some people. Danson House DS0000006792.V375583.R01.S.doc Version 5.2 Page 7 A sluice facility for commode pots has been installed and the redecoration and refurbishment plan has continued despite the plans for redevelopment of the home. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Danson House DS0000006792.V375583.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 Danson House DS0000006792.V375583.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3, 6. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. No-one is admitted in to the home without a full and comprehensive assessment being undertaken to ensure that the home will be able to meet their needs and that they will be happy living there. This home does not offer intermediate care, this standard does not apply. EVIDENCE: There is an assessments officer who responds to requests for admission to the home and undertakes a full assessment of potential residents needs to assess their suitability to come and live in the home. In the event of the assessment officer not being available, a senior member of staff from the home would do this. Danson House DS0000006792.V375583.R01.S.doc Version 5.2 Page 10 We were able to see copies of the assessment that had been undertaken and these form the basis of future care planning. Potential residents would be encouraged to visit the home if they were able to see if they felt that they would like to live there. We met some people who had originally come to the home for respite and either decided to stay or returned when they became frailer. This home does not offer intermediate care. Danson House DS0000006792.V375583.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Resident’s healthcare needs are being met in a way which suits their needs and preferences and they are treated with respect and dignity. Medication practices within the home are well organised and generally we can be sure that people are getting their medication as it has been prescribed for them. EVIDENCE: We looked at a sample of care plans. We found that they contained good information about how people wanted to be supported. We liked the way that they were written in the first person e.g. I like to have tea to drink during the day and like two spoonfuls of sugar. This made them much more personal, giving a good picture of the problems that residents were experiencing, and they were easier to read. While we looked at some of the care plans we spoke with staff members about the residents. They had a good knowledge of the people that they were supporting Danson House DS0000006792.V375583.R01.S.doc Version 5.2 Page 12 and their needs. One resident had poor hearing and the carer was able to explain how she should be approached and the best ways to communicate with her. We saw that risk assessments were in place for moving and handling, for self medication and also what would happen if medication was refused. For the resident who was deaf this included steps to be taken in the event of the fire alarm going off. Care plans are reviewed regularly so that any changes can be identified and addressed. There was evidence that other healthcare professionals are involved in residents care such as the doctor, nurse practitioner and district nurse. We were told that the nurse practitioner visits weekly and that the doctor will come if anyone is unwell. The manager told us that there is work going on in the home which based on the Eden Project, an initiative concerned with working in partnership with people to achieve their potential and making care very person focussed. We looked at medication procedures in the home. A monitored dosage scheme is in place whereby the majority of medication is supplied in blister packs and receipt and administration are recorded on an individual record sheet. Staff who administer medication have all been trained. Everything was generally in good order with few omissions. Previous requirements have all been addressed. We did recommend that where medication dosages were variable there should be a care plan to indicate when each dose should be given. Also, the record sheet must indicate how much was administered at each dose to enable an accurate audit to be undertaken. Some people in the home are able to look after their own medication. Risk assessments have been done and lockable facilities’ are supplied. We have asked the home to ensure that a regular medication audit is undertaken which will include checking that residents who are self medicating have taken all of their tablets as they were prescribed. People that we spoke with told us that staff were respectful towards them and we noted that they interacted well and were kind and caring. Personal care is delivered in residents own rooms and they told us that things were done as they liked them. Danson House DS0000006792.V375583.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14,15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to choose how they spend their days. There are activities arranged for them to join in with if they wish and they enjoy the meals that are served to them. EVIDENCE: The AQAA tells us that daily routines at this home are flexible and people that we spoke with agreed that they were able to choose how they spent their days. One lady told us “if I don’t feel like It I don’t get up, I stay in bed” while others said that they were able to get up when they wanted and go to bed when they were ready. There is timetable of activities on the wall and various sessions are arranged, by the two activities organisers, for those who want to join in. People told us that they like the music and dancing although one said that they would like more quizzes as they were not arranged often. Some people tell us that they are able to go out of the home and visitors told us that they are always made welcome. One resident said “I have been on my own so long that it’s really nice to have some company”. Danson House DS0000006792.V375583.R01.S.doc Version 5.2 Page 14 Residents’ told us that the food that is served is very good. One lady said “I really like the afters”. The day’s menus are given to them the afternoon before, for them to choose what they would like. However, there are always alternatives if they change their mind on the day. Food is cooked in the central kitchen and brought to each unit in heated trolleys and served by staff. Special diets can always be catered for. The cook told us that she goes out to talk with residents to see if they are happy with the food and can change things accordingly. She makes celebratory cakes for birthdays and leaving do’s which are always appreciated and one resident told us about the lovely cake that they had enjoyed. Danson House DS0000006792.V375583.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16,18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are confident that action will be taken to address any concerns they raise and there is a complaints procedure in place. Policies and procedures help to ensure that they are protected from abuse. EVIDENCE: Information regarding KCHTs complaints procedure is available in the Service User Guide and also displayed in the front hall. However, the residents that we spoke with told us that if they had any complaints or concerns they would tell the staff and it would be sorted out. Records are e kept of any complaints brought to the managers attention and action taken by KCHT to address these. No complaints have been made to the Commission regarding the home since the last inspection. Training in relation to safeguarding adults is included in the organisation’s induction and mandatory training programme. Safeguarding adults is also included in scenarios used as part of the homes interview process, which enables the manager to assess prospective staff members understanding and identify any potential training needs. Danson House DS0000006792.V375583.R01.S.doc Version 5.2 Page 16 The staff that we spoke with during our visit had a good understanding of what they should do if they suspected residents were being abused and they told us that they had received recent training. The manager is aware of the Deprivation of Liberty Safeguarding guidance and currently has one resident who is being considered for referral. Danson House DS0000006792.V375583.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19.26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home which, although it would not comply with standards expected from a newer facility, provides clean and comfortable accommodation suitable for their needs. EVIDENCE: The home provides clean and comfortable accommodation for the people who live there. Although it would not meet new regulations and it is heading towards eventual closure, it continues to be maintained and residents told us that they are happy and comfortable. Adaptations throughout the home help those with limited mobility; there are handrails in the corridors and assisted bathroom facilities. Danson House DS0000006792.V375583.R01.S.doc Version 5.2 Page 18 Residents have been able to personalise their rooms, with pictures, ornaments and small pieces of furniture and we saw that some of them are quite homely. One lady told us that she had even brought some of her own bedding in. We did note that several of the residents like to have their bedroom doors open. This could be a risk in the event of a fire and residents’ must be encouraged to shut them. If they do not want to, an automatic closer must be fitted which operates in the event of a fire, when the alarm is activated. Each unit has a lounge and there is also a large communal area on the ground floor, which is used for group activities and entertainments. The garden to the rear of the property is very unkempt however we are told that this is rarely used. There is another courtyard type area which has seating and lots of pots and tubs of flowers. People tend to sit out here and when we visited several were enjoying the sunshine. Laundry facilities are well managed, and sited away from areas frequented by residents. All staff are trained in infection control and there are protective gloves and aprons available for them. Residents told us that the home is always clean and the day we visited it was free from any malodour. Danson House DS0000006792.V375583.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are cared for and supported by sufficient suitably trained staff. Robust recruitment procedures are in place to help safeguard them. EVIDENCE: On the day that we visited there were enough staff on duty to provide care for residents and the rotas showed that this was generally the case. Although some agency staff are used this is minimal, there had been 5 the week prior to our visit. Care staff are supported by ancillary staff including cleaners and cooks. Residents that we spoke with were complimentary about staff, one told us that they were”very nice” another that “they are really caring and kind” and “very patient with me”. We saw that they had a pleasant way with them, were cheerful and chatty and interacted well with people. KCHT gives staff training a high priority and those carers we spoke with were able to tell us about recent training they had attended. This has included moving and handling, first aid, care planning, The Mental Capacity Act, dementia and managing challenging behaviour. Danson House DS0000006792.V375583.R01.S.doc Version 5.2 Page 20 Individual certificate were in staff files however, a training matrix was not available and this would have made it easier to check which staff have undertaken sessions. All staff have regular supervision and appraisal in order to monitor their performance and identify any training needs. We have been told that the majority of care staff have attained an NVQ qualification to at least level 2. Robust recruitment procedures are in place to safeguard residents. We looked at files of two new staff members and all of the necessary documentation was in place. This includes checks against the Criminal Records Bureau and Protection of Vulnerable Adults list to ensure that those who have been judged as being unsuitable to work with vulnerable adults are prevented from doing so. Danson House DS0000006792.V375583.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a home which is well managed, in their best interests. EVIDENCE: The home is managed by a Mr Terence Heslington. He is currently waiting to be registered with The Care Quality Commission but has many years experience working with this client group and displayed a good understanding of their needs. In order to satisfy themselves that the home is running well, KCHT undertake monthly inspections of the care and service provided in the home and copies of Danson House DS0000006792.V375583.R01.S.doc Version 5.2 Page 22 these reports are available in the home. In addition there are satisfaction surveys sent out to residents and their relatives and regular relatives meetings. Some relatives that we spoke with told us that they have attended these and that they always know what is happening in the home. They have all had letters about the proposed new plans for the home. The home does not take financial responsibility for any of the residents however, some money is held for them for personal use. This would mainly be for services such as hairdressing or chiropody. We looked at a sample of the records and they were easy to understand and accurate. The AQAA gave us information about when services and equipment were serviced and this was all up to date. The home complies with health and safety regulations and there had been a recent environmental health officer’s visit to the kitchen which was satisfactory. The temperature of the hot water in the home is checked regularly however, we did note that it is recorded as pass or fail. We have recommended that it should actually state the temperature so that we can be sure that residents are not at risk. We looked at accident records. We have recommended that these should be completed in more detail in order to provide an accurate record of the occurrence and for ease of audit. This should include a full explanation of the incident, any action or treatment that was required, and the names of any witnesses. Danson House DS0000006792.V375583.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 3 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 X 18 3 2 X X X X X X 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 X 3 X 3 X X 3 Danson House DS0000006792.V375583.R01.S.doc Version 5.2 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 OP8 Regulation 13(2) Requirement Where medication is prescribed to be give as a variable dose there must be a care plan in place indicating how this should be decided. A regular medication audit must be undertaken to ensure that records are accurate and errors are identified and addressed promptly. This must include checking the medication of those people who administer their own medicines. Where resident’s request that their doors are left open they must be fitted with an automatic closer which operates in the event of a fire, to ensure their safety. Timescale for action 30/08/09 2 OP9 13(2) 30/08/09 3 OP19 13(4)(c ) 30/09/09 Danson House DS0000006792.V375583.R01.S.doc Version 5.2 Page 25 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 OP30 OP38 OP38 Good Practice Recommendations It is recommended that a training matrix should be devised to make it easier to see which staff member have attended training. It is recommended that the records of hot water temperature should state the actual temperature of the water rather than pass or fail. It is recommended that accident records should be more detailed to allow an accurate audit to be undertaken. Danson House DS0000006792.V375583.R01.S.doc Version 5.2 Page 26 Care Quality Commission London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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