Inspection on 18/09/08 for Daken House

This is the latest available inspection report for this service, carried out on 18th September 2008.

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

Other inspections for this house

Daken House 15/09/06

Daken House 13/12/05

Daken House 22/08/05

Daken House 28/01/05

Daken House 01/07/04

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 20/03/2009.

CARE HOMES FOR OLDER PEOPLE Daken House 240 Romford Road Forest Gate London E7 9HZ Lead Inspector Lea Alexander Unannounced Inspection 10:50 18 September 2008 th 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 Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Daken House Address 240 Romford Road Forest Gate London E7 9HZ 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 8221 2444 020 8221 2555 dkhumalo@lmkendon.co.uk LM Kendon Settlement Mrs Diana Khumalo Care Home 50 Category(ies) of Dementia (40), Old age, not falling within any registration, with number other category (10) of places Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered person may provide the following categories of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia - Code DE (maximum number of places: 40) Old Age, not falling within any other category - Code OP (maximum number of places: 10) The maximum number of service users who can be accommodated is: 50 6th September 2007 2. Date of last inspection Brief Description of the Service: Daken House is a 50 bedded, purpose built nursing home. It is owned by a charitable organisation, LM Kendon Settlement. The home primarily provides nursing care for people with dementia, living in the Borough of Newham. Permanent and respite (short term) accommodation is available. The home is divided into three separate units located on three floors. Strevens Unit on the ground floor has 13 bedrooms, The Reeves Suite situated on the first floor has 21 and The Glyde Suite on the second floor has 16 beds. Each unit has its own lounge, kitchen and dining area. Additional quiet lounges are available and there is a large activities/meeting room on the ground floor. Residents have access to their own hairdressing room within the building. A conservatory and range of patio areas with outdoor seating is also available. Daken House is situated on the Romford Road, in Forest Gate. Buses 25 and 86 run along this road to provide links to Stratford and Ilford. The nearest station is Forest Gate, British Rail Station. A small car park is available for visitors. A range of culturally diverse shops, services and amenities are situated on the Romford Road, Woodgrange Road and Upton Lane. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 5 The current statement of purpose and service user guide is available in the home and a copy can be obtained from the manager. At the time of this inspection the fees ranged from £591.00 to £629.00 per week and there are additional charges for services such as hairdressing, private chiropody, some outings and newspapers. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out this inspection over the course of the day. This was their first visit to the home. During the course of the inspection we spoke to the Manager, two care workers and the activities co-ordinator. We also spoke privately to several residents. We also looked at a range of documentation relating to the running of the home. The home completed and returned it Annual Quality Assurance Assessment within the timescales that we requested. We received completed feedback surveys from 9 people who use the service and 3 healthcare professionals. The majority of residents who completed surveys told us that they were satisfied with the service provided, three residents were extremely satisfied with the service provided. One resident commented that they would prefer to live in their own home. The majority of residents commented that they “always receive the care and support I need”. The three health care professionals who completed feedback forms were very satisfied with the service provided. They commented that the home provides a “caring, attentive and friendly service” and that “a good care service is provided”. One also commented that the home “responds well to feedback”. The quality rating for this service is ** stars. This means the people who use the service experience good quality outcomes. What the service does well: People who use the service told us that they “liked living in the home” and that they were “happy here”. Residents also commented that staffs were “friendly and helpful”. Potential residents are assessed prior to their moving in. The home encourages residents to participate in the day-to-day running and decisionmaking processes of the home. Residents are also supported and encouraged to make decisions about their own lives. Residents have individual plans and risk assessments that are person centred and regularly reviewed. People who use the service are supported to access a range of healthcare services. The home has demonstrated sound medication administration practises. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 7 Care workers promote resident’s dignity and respect, particularly whilst providing personal care. The home provides a range of varied, nutritious meals that reflect resident’s cultural backgrounds. People who use the service told us that they enjoyed the food provided. The home safeguards people who use the service from abuse. Residents are familiar with the complaints procedure. People who use the service benefit from a well maintained home with a range of shared spaces. Each resident has their own bedroom that they are able to personalise. People who use the service benefit from care workers who are suitably qualified and who receive regular training. The Manager is also suitably qualified and experienced. A range of health and safety tests and records are maintained in good order and available for inspection in line with current legislation. What has improved since the last inspection? What they could do better: Five requirements are made as a result of this inspection. The home must ensure that residents are appropriately supported to access local shops and other community facilities. A record must be maintained of all complaints including details of the investigation and action taken. The home must consider further environmental improvements to better meet the needs of people with dementia. This could include the use of colour and texture and introduction of visual objects such as an aquarium. The home must ensure that two satisfactory references are obtained for all care staff. Outcomes from the annual quality assurance survey should be collated and published. One requirement from a previous inspection is restated. The registered person must ensure that the home is free from offensive odours. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 9 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 Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions to the home are not made until a full needs assessment has been undertaken. EVIDENCE: We looked at the personnel files for three residents at the home, one from each unit. These evidenced that people who use the service were assessed by the home prior to their moving in. The Manager told us that the home does not provide intermediate care. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are involved in their care planning, and they are supported to make their own decisions and choices where possible. The care plan is a working document that is regularly reviewed. The home ensures that residents are consulted regularly about issues relating to the service provided. EVIDENCE: Each of the resident’s personal files that we examined contained an individual plan that included information on how the resident’s personal, social and healthcare needs were to be met. Some residents had signed their plan to evidence their involvement in the planning process. The plans that we saw had been reviewed every month. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 12 Each of the residents we case tracked had also been assessed for the risk of falls, and where appropriate a management strategy to minimise this risk had been developed. For each of the residents we case tracked a completed “getting to know you form” was available on their personal file. This was person centred and provided relevant life story information for the resident. Each of the residents we case tracked was evidenced as having comprehensive records of healthcare appointments they had attended. Recent medical appointments attended by residents included the GP, optician, dentist, nurse, podiatrist and psychiatrist. On one of the units we were advised of a resident with pressure sores. We examined the wound care notes. These evidenced that the resident was receiving specialist input from the tissue viability nurse and that there sores were being monitored and comprehensive records including photographs, were being maintained. One family member we spoke to told us that their family member had received “excellent” wound care from the home previously. We were told that at the time of this inspection none of the residents were self-medicating or receiving any controlled medications. The homes medication policy had been inspected at a previous inspection and was evidenced as complying with National Minimum Standards. We examined the available medication for one resident on each of the homes units. We found that the available medication corresponded with the Medication Administration Record (MAR) sheet. We also found the MAR sheets to be correctly completed and in good order. On each unit medication was securely stored within locked cabinets. The individual plans we saw evidenced that resident’s preferences for assistance with personal care are reflected in their plans. The residents we spoke to confirmed that they are able to choose their own clothes and appearance. Residents also told us that they felt respected and well cared for by staff. We spoke with two care workers at the home. Each was able to describe to us the practical steps they would take to promote dignity and respect whilst providing personal care. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to maintain family relationships. Residents are involved in meaningful daytime activities of their own choice according to their interests and abilities. A range of varied, nutritious and culturally appropriate meals are provided. Care staffs are sensitive to the needs of residents who find it difficult to eat, and provide sensitive assistance with feeding. EVIDENCE: The home employs an activities co-ordinator who works within the home for five hours each day for five days per week. They have developed a structured activities programme and the Manager told us that outside of this care staffs on individual units engage in activities with residents. We looked at the activities programme and found that it consisted mainly of sing-alongs and games activities on the units. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 14 During the course of our visit we observed residents engaging in a gardening group with the activities co-ordinator and in later on in the day in individual one to one sessions with the activities co-ordinator reading the papers and having hand massages. Whilst on individual units we observed care workers engaging residents in conversation and sing along activities. We also spoke to the activities co-ordinator who told us that some residents gather in the main lounge to play the organ and that a singer also attends regularly to lead music sessions that residents can participate in. The Manager told us that one resident attends a day service for several days each week. The home also organises events within the community and recently residents had been shopping on the nearby Green Street and on a separate occasion had a day trip to Epping with lunch. The residents that we spoke to told us that they were generally happy with the activities provided, however one resident told us that they would like more staff support to enable to visit local shops. The homes residents are of a predominantly White British background. There are a very small number of Asian residents. The Manager told us that the home has regular Church of England and Roman Catholic services within the home, but at present they do not mark or celebrate other religious festivals. Discussion with people who use the service, with the Manager and care workers evidenced that the majority of residents have frequent contact with their family and that the home encourages and supports this. The Manager told us that the home supports people using the service to make their own decisions by including them in decision making processes about their every day lives wherever possible. We were also told that were residents were no longer able to make decisions for themselves their family members were encouraged to participate in the decision making process. The home has developed a “getting to know you form” that is completed by residents or their families on admission. This includes information on likes and dislikes, personal history, relationships, significant life events, occupational and hobbies and interests information. Residents meetings are held bi-monthly. We looked at the minutes of these meetings and noted that residents were able to use the forum to participate in the day-to-day decision making processes of the home and to feedback on the service provided. The individual plans of the residents we case tracked included information on their right and ability to make decisions about their everyday lives. The residents we spoke to also told us that they are able to make decisions about their every day lives within the home. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 15 We spoke with the kitchen staff on duty; they told us that they develop the weekly menu based on feedback from people who use the service on what meals they have enjoyed. During our visit we found a copy of today’s menu displayed on each unit. We were present on Reeves Unit whilst lunch was served to residents. We noted that five carers and one nurse were on duty during this period. Meals arrived at the unit already plated, and staffs were observed to take a plate containing each meal choice to residents, to explain what the meals were and to ask them to choose which meal they would like to eat. Some residents were observed to require assistance with eating, and this was provided in a discreet manner. Were possible staff were observed to provide assistance, such as cutting up food, before encouraging residents to feed themselves. One resident declined to eat lunch, and we observed that the nurse in charge came to speak to them. They were given a choice of where to eat the meal, and eventually the meal was saved for the resident as they decided to take rest in their room and eat lunch later. Throughout the mealtime period staff were observed communicating freely with residents and offering reassurance and support appropriately. We looked at the record meals provided by the home and found this evidenced that a range of varied and nutritious meals are provided. The home is also able to provide meals that reflect the cultural backgrounds of people who use the service. Residents that we spoke to told us that they enjoyed the food provided, and that the meals were of a good standard. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and others involved in the service have told us that they are happy with the service provided. The home has developed and introduced a complaints policy and procedure, and regularly arranges safeguarding training for staff. However, the home must ensure that the investigation undertaken and its outcome are recorded for all complaints. EVIDENCE: The home has developed and implemented a complaints policy and procedure. We looked at this and found that it complied with National Minimum Standards. We asked to see the homes complaints log. This evidenced that the home had a made a record of the date and nature of a number of complaints that had been received since the last inspection. We also noted that the home had received several letters and cards complimenting the care that had been provided. We looked at detail at four complaints records. These evidenced that in three cases the home had recorded details of the investigation undertaken, the Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 17 outcome and actions taken. However for a fourth complaint we were under able to find these details. Residents we spoke to told us that they knew how to make a complaint and felt happy to do this if there was anything about the service they were not satisfied with. One resident we spoke to told us that they had made a complaint in the past, and that they were satisfied with how the home had dealt with this. The Manager told us that there had been no safeguarding matters since the previous inspection. Both of the care workers we spoke to demonstrated an awareness of safeguarding issues and their responsibilities should they have any safeguarding concerns. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service benefit from a comfortable, well-maintained environment. Residents have their own bedroom that can be personalised. A range of communal spaces is available. Bathrooms and toilets are fitted with appropriate aids. However, the home must ensure that the home is free from offensive odours and consider further environmental improvements to better meet the needs of residents with dementia. EVIDENCE: The home is situated just off the busy Romford Road near Stratford. There is a small car park to the front. Access to the home is by an intercom system. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 19 From an entrance hallway the general office, staff offices, lift to all floors, WC and large communal lounge can be accessed. A payphone is situated in this area and it is decorated with photographs of activities that residents have participated in. In the large communal lounge there is a range of seating, a TV, stereo and organ. Some activities materials such as games are also located in this area. This lounge also has tea-making facilities. The Strevens Unit is located on this ground floor level. It can be accessed from the main entrance hall or via a conservatory leading from the main communal lounge. There is a lounge for residents of this unit, which again has a range of comfortable seating and a TV. A sluice room, staff changing rooms and a hairdressing room for residents are all located on this ground floor level. On the first floor, either stairs or a lift can access the Reeves suite. Since the last inspection the home has completed building works adding an additional 7bed capacity to this unit. On the third floor stairs or a lift can be used to access the Glyde Suite. On both units there is a nurses station located in the main corridor. Both suites have a large lounge and dining area and separate smaller lounges. All lounges have a range of comfortable seating, a TV and stereo. On all units residents have their own bedrooms. The residents name and a picture are displayed on the door. Some residents have chosen to personalise their rooms with items of furniture, pictures or other memento’s. On each unit there are two bathrooms, one with a WC and walk in shower and one with a WC and parker bath. A separate sluice is also provided on each unit. We carried out a site inspection and found the home to be suitable, safe and well maintained. During our site inspection we noted that the home had introduced pictures to residents bedroom doors in addition to the their names, to support residents with dementia to recognise their rooms. The previous inspection had suggested the introduction of colour and texture into the environment and the use of containers with touch and feel objects. We spoke the Manager who told us that containers had been introduced, but that these had not been successful and that they had in fact caused potential obstructions so had been removed. During the course of our inspection we noted that the home was clean and tidy. However, we did note a strong smell of urine on the Reeves Unit at some times of the day. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff members undertake external qualifications. Sufficient staffs are rostered on duty to meet the needs of people who use the service. The home regularly provides training on core areas to care workers. However, the home must ensure that suitable references are available for inspection for all staff members. EVIDENCE: We spoke with the Manager and examined the homes staffing roster. This evidenced that since the last inspection staffing levels have been reviewed and increased. Each unit has a nurse on duty for the day and night shifts. In addition twelve care workers are deployed within the three units during the day shift and five carers are employed over the units during a waking night shift. The home also employs domestic and laundry staff and kitchen staff. We compared the staffing rota with the staffing situation found in the home on the day of our visit and found that the two corresponded. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 21 The Manager told us that all of the homes permanent care staff has obtained NVQ level 2, and that dementia care and safeguarding courses are regularly run for all care staff. We looked at the personnel records available for two care staff. These evidenced that the home obtained a Criminal Records Bureau (CRB) check for each prior to their starting employment. For one care worker we also found evidence of the home having obtained two satisfactory references, however for the other care staff only one reference was available on file. We spoke with the Manager and looked at the available training records. These evidenced that since the last inspection a range of training had been provided to care staff including: first aid, health and safety, moving and transferring, fire safety, assisting with medication, safeguarding and dementia care. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager has the required qualifications and experience. The service has sound policies and procedures. Regular health and safety checks are carried out and recorded. EVIDENCE: The home Manager has successfully obtained NVQ level 4, and the Deputy Manager is currently studying for this qualification. We asked the Manager about the homes quality assurance processes and were told that the home sends out feedback surveys to residents, their families, Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 23 staff and other stakeholders on a yearly basis. We were told that survey forms for 2008 had recently been sent out, and that upon receipt the home would collate the information and publish outcomes. The Manager told us that people who are able to manage their finances independently are supported to have their own bank accounts. The majority of residents who require support in managing their finances receive this assistance from their families. The Manager also told us that a small number of residents have an appointee to manage their finances on their behalf. We looked at the homes weekly fire alarm test records. These evidenced that tests occur on a weekly basis and that fire alarm equipment is maintained in good working order. We also looked at the homes records of accidents and incidents. This identified a range of incidents as having occurred since the last inspection, including occurrences of challenging behaviour from some residents. Other residents were evidenced as having had a number of falls. We case tracked one of the residents who was identified as having had several falls and noted that their care plan and risk assessment identified concerns in this area and included a management plan to minimise potential risks. We looked at the homes records of fridge and freezer temperatures. These evidenced that daily temperature checks are taken and recorded and that the homes fridges and freezers are maintained within acceptable limits. During our inspection of the premises we noted that the contents of the fridge were all appropriately date labelled. The home also maintains a record of water temperatures. We looked at this log and evidenced that regular temperature tests are carried out, and that the homes water tanks are cleaned on a yearly basis. Two of the residents we case tracked were evidenced as using specialist equipment such as hoists. We also saw records that evidenced that this equipment is regularly maintained and staffs receive training on how to use it. Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 24 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X 2 X X X 2 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 3 X 2 X 3 X X 3 Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP12 Regulation 16 Requirement The home must ensure that residents are appropriately supported to access local shops and other community facilities. A record must be maintained of all complaints including details of the investigation and action taken. The home must consider further environmental improvements to the home to better meet the needs of people with dementia. This could include the use of colour and texture and introduction of visual objects such as an aquarium. The registered person must ensure that the home must is free from offensive odours. This is a restated requirement. The previous target of the 30/11/07 was not met. 5. OP29 17 The home must ensure that two DS0000007355.V364741.R01.S.doc Timescale for action 17/09/09 2. OP16 22 17/03/09 3. OP22 23 17/09/09 4. OP26 16 17/03/09 17/03/09 Page 26 Daken House Version 5.2 satisfactory references are obtained for all care staff. 6. OP33 24 Outcomes from the annual quality assurance survey should be collated and published. 17/04/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Daken House DS0000007355.V364741.R01.S.doc Version 5.2 Page 28 - 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. 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