Inspection on 10/12/08 for Duchesne House

This is the latest available inspection report for this service, carried out on 10th December 2008.

CSCI found this care home to be providing an Excellent service.

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

Duchesne House 16/01/06

Duchesne House 08/08/05

Duchesne House 19/08/04

Duchesne House 06/04/04

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 27/02/2009.

CARE HOMES FOR OLDER PEOPLE Duchesne House Aubyn Square, Roehampton Lane London SW15 5ND Lead Inspector Sandy Patrick Key Unannounced Inspection 10:00 10th December 2008 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 Duchesne House DS0000010188.V364746.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. Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Duchesne House Address Aubyn Square, Roehampton Lane London SW15 5ND 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 8878 8282 020 8876 2758 juliemurrin@careduchesne.org.uk Society of the Sacred Heart Mrs Julie Murrin Care Home 22 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (22) of places Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th February 2007 Brief Description of the Service: Duchesne House is a single storey purpose built care home. It is situated on Roehampton Lane, near Queen Marys Hospital and within driving distance of Richmond Park. The home has its own grounds. All accommodation is provided in single rooms. Some bedrooms have en suite facilities. Everyone who lives at Duchesne House belongs to the Order of the Sacred Heart and are admitted by referral from the Province. The home does not accept any other people. Fees are not charged by this service as it is a registered charity. Duchesne House DS0000010188.V364746.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 3 stars. This means the people who use this service experience excellent quality outcomes. For this inspection we made an unannounced visit to the home. We met people who live there, visitors, the Manager and staff on duty. We were invited to join people who live at the home for a meal. We looked at the building, observed daily life at the home and looked at records. We also wrote to the Manager and asked her to complete a quality self assessment. We wrote to people who live at the home, important people in their lives and staff and asked them to complete surveys about their experiences. We looked at all the other information we had received about the home since the last inspection, including an annual service review which we undertook on 5th November 2007. Some of the things people said about Duchesne House were: ‘A good place to be’. ‘The home is good at everything’. ‘I am well cared for here by excellent staff who are very professional’. ‘It allows people to make decisions about their own lives – how to spend their time, what to do and where to go’. ‘I am very happy here’. ‘I am very grateful.’ ‘They provide care and support for every individual’. ‘The spirit and fellowship within our care home is outstanding.’ ‘People are happy there and the staff are very caring.’ ‘It is wonderful and could not be better.’ Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 6 What the service does well: 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. The summary of this inspection report can be made available in other formats on request. Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 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 Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who move to the home have the information they need to help them make the decision to do so. They are familiar with the service. Their needs are assessed to make sure these needs can be met at the home. EVIDENCE: People who live at the home are all sisters from the Order of the Scared Heart. The Sisters have all agreed and know about the aims and objectives of the home as it is part of their Order and is designed to provide a safe place for them when they need the support and care of others. There is a booklet about the home, services and facilities. This includes comments made by sisters who live there. This booklet is given to anyone who is thinking about moving there. One person told us, ‘they provided me Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 9 with an excellent booklet which gave us a clear summary of the main aspects regarding the care home’. The sisters all know the home and many of them have volunteered there in the past. They have opportunities to become familiar with the service before they move there. One sister told us, ‘I was a volunteer here before I came to stay so I already knew the people and the home’. Another person said, ‘we are a religious community and we already know each other and this means that friendships are already there before we came to live here.’ The sisters are able to stay at the home before they move there permanently. One person said, ‘I used to come and stay for weekends before I came here permanently’. The Manager makes an assessment of people’s needs and this is recorded. This is used to help create a plan of the care and support they need. We saw copies of completed assessments. When someone moves to the home, a key member of staff is identified to help them settle in and unpack if needed. Sisters who move to the home are also assigned a friend (another sister) who helps them work through any thoughts and feelings they have about their move. The Manager said that staff are trained to reinforce people’s strengths and freedoms to help them during their transition to living in the home. Sisters who contacted us said that the information and support they needed to help them when they moved to the home. Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home are given the support they need to stay healthy and well. They are well cared for by kind and attentive staff who respect their wishes and privacy. EVIDENCE: Each sister has her needs recorded in a plan which tells the staff what help and support she needs. The home is a caring community and sisters who live there as well as visiting sisters offer care and support to each other in addition to the work of the staff. Some of the sisters have signed records about them to indicate their agreement with the plan for their care. The Manager told us that some of the sisters had chosen not to do this. Records are reviewed and updated every month. Sisters who contacted us told us that they received the care and support they needed and wanted. They said that staff listened to them and acted upon what they said. We saw good examples of staff caring for people, listening to their concerns and helping them throughout our visit. Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 11 Where people may be at risk from a specific activity the staff make a recorded assessment of this. These record how people can be supported safely. Sisters are encouraged to sign these as a record of their agreement. The sisters are registered with local GPs and other health professionals as needed. One of the GPs offers a weekly surgery and visits the home as needed. Some of the health professionals contacted us and said that they felt the staff worked well with them and kept people healthy. People living at the home said that they had the support they needed with their health and wellbeing. The staff are all trained to help people move safely and in infection control. The home is part of a pilot project looking at practice and procedures around infection control and health care. The Manager, staff and sisters all give their views and ideas and share these with other projects to look at how health services for vulnerable people can be improved. The Manager said that some of the ideas raised by staff and sisters had been implemented at the home to help improve practice there. Some of the things people told us were, ‘the level of care, privacy and confidentiality is of an extremely high standard’, ‘they provide individual care for each of the people living there’ and ‘We stay in touch with our sisters who are hospitalised and news where appropriate is shared with other members of the province’. There is an appropriate medication procedure. Senior staff and night staff are responsible for managing and administering medication. They are trained and assessed as competent to do this. They have access to guidelines on good practice. Medication stock is recorded and audited monthly. We found that in most cases medication was managed safely. However, the amount of some medication held was not recorded on medication charts. In one instances someone had made a recording error and had covered this up with a sticker. There was no photographs of people attached to their medication records and should be. Some medication with a limited shelf life was not labelled with the date of opening. One person’s medication chart did not record information about their allergies. One professional who offers medical support to people living at the home said, ‘the home provides end of life care which is excellent and most people are able to stay living at the home supported by kind staff’. Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who live at the home are supported to continue their worship and live varied and fulfilling lives that they chose. EVIDENCE: The community’s daily routine and any activities are displayed in communal areas. Sisters are supported to understand that it is their choice to join in activities or not. Working sisters from the Order visit the home regularly to offer support and opportunities for different activities. The home has good links with the local university, schools and the hospital. Children and students visit, perform songs and offer other support to the sisters. Many of the sisters enjoy craftwork and do this individually and as part of a class. There is a sensory garden which people enjoy. The home is well resourced with a library containing a wide range of books and publications, games and computer equipment. Each day there is a religious service, opportunities for reflective prayers and an opportunity for the community to gather together and discuss the work of the Order and other sisters. Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 13 Feast days and religious festivals are celebrated. The staff have supported people to take short breaks and holidays and other members of the order and family members have supported the sisters to go on various holidays. The sisters who wish to use the local community. There is WIFI computer access throughout the building and many of the Sisters use computers and the internet to keep in touch with friends, family and other members of the Order who live abroad. There is a chapel within the home and sisters can use this for private worship as well as daily mass. A priest runs services from the chapel and joins the community for lunch each day. There is a speaker system to all rooms so that sisters who are unwell or unable to go to the chapel can still join in with the service. People told us that they felt there were enough organised activities for them to participate in if they wished. Many of the sisters organise their own activities as well in small groups. For example one sister told us that they had a regular ‘take away food’ night. Another sister told us she enjoyed playing board games and scrabble. Sisters are kept informed of changes and news from the Order by email and regular newsletters. A Pastoral Sister works full time at the home to offer support for those living there. Visitors are welcome at any time and there are rooms for guests to stay in if they wish. We met one visitor who told us, ‘It is very nice here – much nicer than other homes’. Some of the things people told us were, ‘there is a friendly and supportive atmosphere’, ‘sometimes I would like the carers to be more proactive in encouraging sisters who are confused to do an activity-like go for a walk or play a game, this does happen already, but it would be even better if this happened more often’, ‘the staff are fully supportive of the ethos of a religious community and their specific needs in a care home’, ‘I access the gym twice a week and this is a great help’ and ‘I enjoy board games, walking in the park, singing and hymns’. A volunteer who offers support at the home told us, ‘we help the sisters to keep in touch with family by welcoming visits, phone calls, sending emails and using skype to help sisters communicate with relatives abroad’. Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 14 Some of the things people who live at the home told us were, ‘we enjoy the visits-regular ones-of some of the more able sisters- we take an interest in and pray for the work they are doing’ and ‘as a member of the Religious Order to which all the residents belong, I am at home from home here.’ Many of the sisters have travelled internationally in their work for the order. They have held different jobs, many of them teaching and providing care. They have a natural interest in different cultures and some of them told us about this. One sister told us that they enjoyed finding out about the different backgrounds and believes of the staff. At Christmas time, the staff each provide a traditional dish from their country which they prepare for the Christmas party. The sisters told us that they enjoyed this event and some of the staff spoke enthusiastically about the food that they were hoping to bring to the party. One person told us, ‘the sisters benefit from contact with the staff who come from all over the world, as an international order this is a plus’. Sisters are encouraged to be as independent as they wish. There are small kitchenettes around the home where people can make themselves drinks and snacks. Some sisters manage their own laundry. Telephones are installed in bedrooms for people who wish and there are communal telephones located around the home for people to make private telephone calls. We saw that telephones had large buttons to assist people who needed these. We were invited to join the sisters for their midday meal. They said that they enjoyed entertaining and regularly had visitors. The food was flavoursome, well presented and people were able to help themselves to drinks, vegetables and condiments. People told us that they liked the food at the home. They said that it was well presented, tasty and varied. Some sisters told us that the usual cook was away on holiday but that her temporary replacement was good. One person said that the food was sometimes cold and that plates were not always warmed up. Some of the things that people told us about the food at Duchesne House were: ‘I have a restrictive diet but the carers give me every possible variation’, ‘we have a cook who gives us tasty meals’, ‘the food is usually excellent and prepared imaginatively’, ‘excellent food’, ‘good choice, good quantity and good food’, ‘you wont find better food than here’ and ‘we have a real variety’. Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are protected by clear procedures for making complaints and reporting abuse. EVIDENCE: There is a complaints procedure and sisters we spoke to said that they knew how to make a complaint and who to speak to if they were unhappy about anything. There have been no formal complaints since the last inspection. There is good informal support for people to raise concerns through Order members, each other and the staff team. There are procedures on abuse and whistle blowing and the staff are aware of the local authority procedures on safeguarding people. The staff told us that they had had training in this area and knew what to do if they suspected abuse. Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 16 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, 21, 22, 23, 24, 25 & 26 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. People live in a well maintained, safe and comfortable environment. EVIDENCE: The Manager told us that the sisters took a pride in their home and arranged where flowers, ornaments and pictures were displayed. The home is on one storey and is accessible for wheelchair users. The building benefits from a lot of natural light and is pleasantly designed and well maintained. In the past year, half of the bedrooms have been rebuilt and incorporate en suite facilities. Many of the bedrooms have doors opening onto the gardens. The sisters have personalised their bedrooms. There are a number of Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 17 communal rooms, including small lounges, kitchenettes and larger meeting rooms. There is also a chapel. These rooms are well equipped and resourced. The building is well maintained and there are attractive grounds, which include a sensory garden and a garden of remembrance. There are 5 bathrooms, some with special baths and a number of shower rooms. There is a continuous programme of work and repair. Recently older doors were replaced with new fire doors which can safely stay open, this has enabled people who find these doors heavy to operate to move safely around the home. Sisters can also chose to keep their bedrooms doors open and know that they will automatically close in the event of the fire alarm being activated. Some people manage their own laundry and staff are employed to offer this service for people who cannot or do not wish to. The home was clean and fresh throughout our visit. Some of the things people said about the home were: ‘perfect’, ‘we could do with having our windows cleaned more frequently’, ‘high standard of cleanliness – spills are dealt with very quickly by the staff’ and ‘clean facilities’. Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 18 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. People living at the home are cared for by well trained and supported staff. EVIDENCE: Some of the things people told us about the staff were: ‘the staff are always courteous – their attitude is invariably professional’, ‘the staff always have a professional attitude’, ‘the staff listen sympathetically to people’s concerns’, ‘we appreciate the internationality of our carers and have a good community relationship with all of them’, ‘the caring staff have created an atmosphere of friendliness and trust’, ‘the staff work hard to respond to the individuals in the community and are sensitive to the life style of the group’, ‘the staff cooperate with each other and together create work of a high standard’, ‘private and caring staff’, ‘there are good relationships between the sisters and carers’ and ‘the staff are well updated via courses and in house training’. The staff team is relatively stable and many of the staff have worked at the home for several years. We spoke to some of the staff on duty and they told us that they felt well supported and worked well as a team. They said that they had the information and training they needed to do their jobs. One member of staff said, ‘I am very happy here’. Another staff member told us, ‘the manager is really supportive and we are a good team’. Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 19 The staff are supported to undertake a range of training and NVQ qualifications. There are procedures to make sure suitable staff are recruited. These include reference checks, criminal record checks and a formal interview. Potential staff are shown around the home by some of the sisters but the Manager is considering involving the sisters more in the actual recruitment, possibly inviting some of them to sit on interview panels. We looked at a selection of staff files and saw that checks, application and ID were recorded. The staff undertake an induction into their role and complete a written work booklet. The staff on duty told us that they worked alongside exisiting staff and had the training and support they needed when they had started work at the home. There is a regular programme of training for staff including protection of vulnerable adults, manual handling and safety training. At the time of our inspection there was a high number of staff vacancies and this had an impact on the team. The Manager said that everyone had worked hard to make sure the staff vacancies did not have a negative impact on the service. The Manager told us that she had recently interviewed for new staff. There are regular team meetings and meetings with the staff team and sisters from the community to discuss changes in the house. The staff told us that the meetings were useful and informative. There are daily meetings between staff to handover information about everyone. Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People live in a well managed home where their opinions are sought and acted upon. There are recorded checks to make sure the service is delivered to a high standard and that people are kept safe. The Manager works towards continuous improvement. EVIDENCE: The Manager has worked at the home for over 13 years. She is appropriately qualified and experienced. She has the Registered Managers Award and is an NVQ Assessor. She is supported by a team of senior staff who all have special responsibilities to help with the running of the home. The Deputy Manager is undertaking her Registered Managers Award. The Manager told us that she Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 21 trained the senior staff to undertake all the different responsibilities for day to day management so that they could all do any job which was needed of them. The Manager told us about some of her plans for improvement. She showed a commitment to continuous improvement and setting new goals for the service. She showed a real dedication to the community and a very good knowledge of all the staff and people living in the home. She talked about her respect for the sisters and clearly values and cares for them very much. Some of the things people living at the home said about the way the service is managed were: ‘excellent care manager and a faithful team who work sensitively and give professional support’, ‘excellent leadership from the Manager and senior staff’ and ‘continues to build on the excellent care it provides to the sisters’. We met the Pastoral Sister who works with people who live at the home. She told us, ‘we are very lucky in the leadership of this home, the Manager is excellent’. One of the sisters living at the home said, ‘full marks to the Manager and Deputy Manager’. The Manager works closely with other local care homes and the local authority. She is part of a network group who look at examples of good practice and share training and ideas. She told us that this was very helpful in the continuous improvement of the service. Quality satisfaction surveys are issued to the sisters every two years. There are quarterly residents meetings and the Pastoral Sister speaks to those living at the home regularly to gain feedback on the service they receive. The local Province of the Order, members of the community and the homes management meet regularly to discuss the service and make sure the religious, pastoral and care needs of people living there are being met. The Manager and senior staff have regular individual meetings with all the staff to make sure they feel supported and are doing their jobs. These meetings are recorded. One of the sisters living in the home is responsible for managing the budgets for everyone else. The philosophy of the Order is that individual sisters do not possess money for themselves. However, everyone is allocated a budget which they believe will meet their needs each year. The sister who is in charge of looking after these budgets keeps accurate records of expenditure. A new fire risk assessment has been created which takes into account the changes in the environment. Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 22 There are recorded checks on health and safety, including fire safety, electrical checks, water temperatures and food storage temperatures. The Environmental Health Office visited the home in March 2008 and awarded them a 4 star (very good) rating. Duchesne House DS0000010188.V364746.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 3 X 3 4 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 3 3 4 4 3 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 4 4 3 X 3 3 X 3 Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Timescale for action The Registered Person must 31/01/09 make sure medication records are always accurate and: 1. 2. 3. 4. Record the amount of medication held. Record people’s allergies. Contain a photograph of the person they are about. Errors are not covered over by stickers. Requirement The Registered Person must make sure all medication with a limited shelf life is labelled with the date of opening. Duchesne House DS0000010188.V364746.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 OP12 OP15 OP26 Good Practice Recommendations The staff should make sure people who are confused get the support they need to access the garden and take part in other activities. The cook should make sure food and plates are warm so that people can always enjoy their meals. The Manager should make sure windows are cleaned regularly. Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 26 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 Duchesne House DS0000010188.V364746.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!