Inspection on 01/05/08 for Hames Hall

This is the latest available inspection report for this service, carried out on 1st May 2008.

CSCI found this care home to be providing an Good 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

Hames Hall 20/02/06

Hames Hall 09/06/05

Hames Hall 11/10/04

Hames Hall 21/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Hames Hall Gote Brow Cockermouth Cumbria CA13 0NN Lead Inspector Diane Jinks Unannounced Inspection 10:30 1st May 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 Hames Hall DS0000022654.V361902.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. Hames Hall DS0000022654.V361902.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hames Hall Address Gote Brow Cockermouth Cumbria CA13 0NN 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) 01900 827601 F/P 01900 827601 Lakeland Care (Hames Hall) Ltd Vacant Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Hames Hall DS0000022654.V361902.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th April 2007 Brief Description of the Service: Hames Hall is a large Victorian country mansion situated in extensive grounds on the outskirts of Cockermouth. The house has been extended and adapted to provide accommodation for up to 25 older people. The home is decorated and furnished to a high standard providing comfortable and pleasant accommodation. There are two bathrooms that have been adapted to provide assisted bathing and 17 of the bedrooms have en-suite facilities. A passenger lift provides easy access between the two floors. There are gardens, which are accessible from the house and there is a car parking area. The weekly fees for this home are from £500 per week, dependent on the type of room required. There are extra charges for hairdressing, magazines, chiropodists and other personal items that residents may wish to have. Hames Hall DS0000022654.V361902.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 2 star. This means the people who use this service experience good quality outcomes. The assessment of this service took place over several weeks and included a visit to the home. People using this service, staff, visitors and relatives were asked for their views and opinions about the home, either during the visit or by completing questionnaires. The provider completed an Annual Quality Assurance Assessment, which helped verify information throughout the inspection process. What the service does well: What has improved since the last inspection? The staff recruitment procedures have improved to ensure that all staff have been properly checked before commencing work at the home. Nutritional assessments are now carried out as part of the care assessment. This helps ensure that people using this service receive suitable nutrition and support when needed. Hames Hall DS0000022654.V361902.R01.S.doc Version 5.2 Page 6 Some areas of the home have been redecorated and new carpets have been fitted. The new owner is also in the process of replacing some of the soft furnishings at the home. 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. Hames Hall DS0000022654.V361902.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 Hames Hall DS0000022654.V361902.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): Standards 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People using this service have their health and social care needs assessed prior to moving into the home. This helps to ensure that their care needs and expectations are met appropriately. EVIDENCE: The home produces a brochure and a service users guide, which are given to people who may be considering moving into Hames Hall. People participating in the assessment of this service indicate that they received sufficient information to help them make a decision about moving into the home. People living at the home are also provided with a contract regarding their terms and conditions of occupancy. Hames Hall DS0000022654.V361902.R01.S.doc Version 5.2 Page 9 There is a process at the home to help people make a decision about moving in a planned way. The process includes a four week trial period, which helps to ensure that the home is suitable, that the move will go smoothly and any anxieties that the person may have are reduced. For example, there is a person is currently in the process of moving into the home. They have started to furnish the room they have chosen to occupy with some of their own possessions, pictures and photographs and have started day visits to the home. This process also helps the home to make an accurate assessment of the person’s needs and develop a suitable care plan. A sample of three care files was looked at during our visit to this service. Evidence shows that people have their needs assessed prior to admission and in some cases reviews have taken place shortly after admission to help ensure that the person’s needs and requirements are being met appropriately. They all contain pre-admission assessments undertaken by the home or social worker. Where people have been transferred from hospital, the hospital transfer notes are obtained and included in the care file. Hames Hall DS0000022654.V361902.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): Standards 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. People using this service generally have a care plan that reflects their needs and support requirements. There are gaps in some of the plans, which may mean that people do not always have their care needs met in the most appropriate way. EVIDENCE: Surveys indicate that people generally receive care and support as expected and receive medical attention when necessary. Some of the people spoken to during our visit to the home say that they are able to make choices about their lifestyle. They also say that staff treat them with respect and are mindful of privacy. Hames Hall DS0000022654.V361902.R01.S.doc Version 5.2 Page 11 The sample of care files we looked at show that care plans are developed from the initial assessment of a person’s needs. They also show that people are involved with the development of their care plans. Care plans include an element of risk assessment and more recently, have started to include nutritional assessments. Care plans and risk assessments are reviewed each month and generally accurately reflect the care and support required. This helps to ensure that people receive the right level of support and care to meet their requirements and expectations. There are some areas that need to be monitored and recorded more carefully. Where concerns are been identified, appropriate action is not always taken and this potentially leaves people’s wellbeing at risk. Although there are some gaps in the care planning process, the staff spoken to during our visit were able to give verbal updates about the need of the people living at the home. Some staff did comment that they are not always updated with changes in care needs. They felt that improvements could be made to the ways in which information is passed on to them. Records show that people using this service have access to health care professionals such as their doctor, physiotherapists, opticians and dentists. People participating in the inspection generally feel that their needs are usually met properly. They did indicate that the owners of the home changed very quickly and without much notice in December 2007. This caused some concerns. However, people say that the standard and level of care has not been affected by these changes. Comments received from people include: ‘I feel that my relative is very well cared for and supported. For example, an optician was contacted when staff noticed a deterioration in her eyesight.’ Another person said ‘residents are very well cared for and treated as individuals and with respect. It feels like a home and not an institute.’ The home has policies and procedures in place to help ensure that medication is handled and administered safely. A sample of medication records was looked at, they were up to date, signed and appear to be kept accurately. The medication storage area was also looked at. It is maintained in a clean, tidy and well organised manner. There are some arrangements in place to help ensure the safe storage of medicines that are liable to mis-use. These do not currently comply with the changes in legislation and this has been discussed with the deputy manager. There are designated care workers with the responsibility of administering medication. They have undertaken training in this subject to help ensure that medication is administered and managed safely. Hames Hall DS0000022654.V361902.R01.S.doc Version 5.2 Page 12 Some people living at the home retain responsibility for their own medication. They are provided with a safe place to store their medicines in their own rooms. This is subject to an assessment to help ensure that individuals can manage their own medicines safely. Hames Hall DS0000022654.V361902.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): Standards 12 – 15. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home encourages people to maintain contact with their families, friends and local community. This helps to ensure that people using this service have opportunities to make positive choices and decisions about their lifestyle. EVIDENCE: The deputy manager states that an activities programme has been developed, although this has always been on a low key basis. Local special interest groups, entertainers and schools visit the home on occasions. Some of the people that live at Hames Hall say that there are sometimes activities for them to participate in if they wish. Examples given included games, exercise classes and entertainers, such as singers coming into the home. Other people do not wish to join in such things and are happy to ‘entertain themselves’. Hames Hall DS0000022654.V361902.R01.S.doc Version 5.2 Page 14 Regular religious services are held at the home and quite a number of people like to attend these. Some people indicated in the surveys that improvements to the available activities could be made, particularly for people who may have some degree of dementia. During our visit to the home, staff were seen to be very busy supporting people with their general care needs and there appeared to be very little time available for staff to provide social stimulation. Visitors are made welcome at the home and tea and biscuits are served, either in the person’s own rooms or one of the communal areas. People living at Hames Hall are able to have their own choice of newspapers and magazines delivered and hairdressers visit the home. Some people have personalised their own rooms. They have their own televisions, DVD players and radio’s. Some people have also chosen to have their own telephone installed in their room. This helps them to maintain contact with their families and friends. Staff were observed working with people at the home. They treat people with respect and dignity – staff refer to residents as Mr or Mrs unless residents tell them of other preferences. Staff knock on doors to private areas and wait for a response before entering. Where people require assistance with personal tasks such as bathing, this is provided with minimal intervention to help ensure that privacy, dignity and independence is maintained and encouraged as much as possible. The service of the lunchtime meal was observed. Lunch was a very pleasant and sociable experience. The dining room provides a very pleasant environment overlooking the garden – tables are laid with flowers, glasses and linen tablecloths and napkins. Where people may need assistance with their meals or drinks, staff provided this with care and sensitivity. We sat in the dining room with some of the people who live at the home. They told us that the meals are very good and that there is always a choice and plenty of food. Meals tend to be at set times. Breakfast is generally served in people’s own room, but they may use the dining room if they prefer. Lunch consists of three courses and ‘high tea’ is served at 5pm with a hot choice of meal also available. Tea/coffee and biscuits are served mid morning and afternoon. People living at the home say that they can have anything they want at any time – they ‘just need to ring the bell’. Hames Hall DS0000022654.V361902.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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home takes concerns and complaints seriously. People living at the home are confident that any concerns they may have will be responded to quickly and appropriately. EVIDENCE: There is a complaints process in place at the home. This information is included in the brochure and service user guide, which are given to people at the commencement of their stay in the home. The complaint process is also on display in the main reception area at the home. There have not been any complaints or safeguarding issues raised since the last inspection of this service. The home receives many letters of thanks and compliments from people who use this service and their families. Some people who returned surveys say that there is some confusion at the moment regarding to whom complaints should be addressed. This appears to be due to the change of ownership at the home and the lack of a registered manager. However, most people added that they would discuss any concerns initially with the familiar figure of the deputy manager at the home and they are confident that staff will listen, take them seriously and act upon anything that they might bring to their attention. Hames Hall DS0000022654.V361902.R01.S.doc Version 5.2 Page 16 During our visit to this service it became very evident that people living at Hames Hall find the deputy manager very approachable and speak to her freely throughout the day. Although there have been no major complaints at the home, there are issues raised and dealt with on a day to day basis. The deputy manager plans to start recording these matters to try to identify areas where improvements could be made. Most staff have received training in adult abuse and the protection of vulnerable adults. Further training on this subject is planned and the home hopes to provide further training about the Mental Capacity Act. Some of the staff were spoken to during the visit and indications are that they know about adult abuse and protection, they also mentioned the whistle blowing process. It is evident that they are clear about reporting matters of concern or poor practice to the manager, social worker or the Commission for Social Care Inspection. Hames Hall DS0000022654.V361902.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Hames Hall is furnished and maintained to a very high standard. It provides a homely, clean, safe and comfortable environment for the people that live there. EVIDENCE: The home is clean, warm, fresh and maintained to an exceptionally high standard. There are three housekeepers employed at the home. They are responsible for maintaining the high standards of general cleanliness. There are communal areas including a comfortable lounge, dining room and conservatory, which over look the extensive gardens and grounds at the home. Hames Hall DS0000022654.V361902.R01.S.doc Version 5.2 Page 18 Some of the carpets have recently been replaced and another has been re-laid to ensure it is secure and safe. There are handrails throughout the home to assist people with limited mobility and there is a passenger lift to the first floor. During our visit to the home we also looked at the laundry and the kitchen. Both areas are kept in a clean, tidy and well organised manner. Most of the bedrooms at the home have en-suite facilities. There are two rooms that are large enough to accommodate two people; for example, a married couple are happily living in one of them. Bedrooms are generally redecorated when they become empty, with carpets cleaned or replaced. The owners of the home are in the process of replacing many of the soft furnishings. The people we spoke to during our visit are very happy with their rooms and the accommodation. They have been able to personalise them with items of their own furniture and with smaller personal belongings such as pictures, ornaments, and photographs. Many people have their own televisions and telephones installed in their private rooms. There are also communal bathrooms and toilets throughout the home. These are kept warm, pleasantly decorated and equipped with aids and adaptations to help people access these facilities safely. One of the communal baths has quite badly damaged enamelling which needs repairing or the bath replacing, to help reduce any risks of cross infection. In various places throughout the home, protective clothing is available for use by staff. Toilets and bathrooms are also equipped with hand wash and paper towels. These measures help to promote good hygiene practices. There is a maintenance plan at the home to help ensure that the home continues to provide a high standard of accommodation and pleasant surroundings to the people that live there. Hames Hall DS0000022654.V361902.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The staffing levels do not consistently meet the expectations of people living at Hames Hall. This means that people using this service may not always have their needs met in a timely manner. EVIDENCE: The people who completed the home’s self-assessment said that the ‘level of staff reflects not only the dependency needs of our clients but also provided for hotel levels of individual attention’. The staffing rota is said to have been reorganised to try to make improvements to this problem and the home is in the process of recruiting more care staff. Comments we received from some of people we spoke to during our visit and comments made on surveys indicate that there are still some concerns regarding staffing levels. One person said; ‘my only concern up to date is that on the first shift, morning shift, there is reduced help for the staff and I trust this will be remedied by the addition of another care worker. The staff, under the circumstances, have done an excellent job.’ Another person said that ‘staff are very caring and conscientious but dont always have time to deal with unscheduled situations promptly.’ Hames Hall DS0000022654.V361902.R01.S.doc Version 5.2 Page 20 Similar concerns have been raised by some of the staff and visitors to the home and although generally people think that the ‘staff are wonderful and caring,’ they also feel that ‘more staff would help as the present staff are run off their feet.’ Most people living at the home know the staff team well. A visitor to the home suggested that information about staff and their roles could be on view somewhere in the home. This would help new residents and visitors familiarise themselves with staff. We observed staff working with some of the people that live at Hames Hall. They were very busy all day with very little time to spend with residents other than for care or support tasks. One person commented that ‘Staff don’t have time to spend on a one to one basis and above a care level.’ The self assessment also states ‘Our residents receive a ‘room service’ level of attention which has to be balanced with the overall dependency needs of the Home, to ensure that we avoid disproportionate levels of care to some service users to the detriment of others.’ At the moment the home does not appear to be getting this quite right and further consideration should be given to the changing needs and dependency of some of the people living at the home when devising staffing rotas. We looked at a sample of staff personnel records, including recruitment and training records. There is a recruitment process in place at the home. References are obtained and prospective staff undergo Criminal Record Bureau (CRB) checks and Protection of Vulnerable Adults (POVA) checks, prior to their employment. This helps to make sure that only suitable staff are employed. The training records show that staff are provided with some training to help them work safely and raise their understanding of the needs of people using this service. Training includes subjects such as health and safety, fire safety, manual handling, first aid and adult protection. Some staff have also undertaken some specialised training in dementia awareness and some of the staff we spoke to indicated that they would like to receive further training in this subject, to help them manage the changing needs of some of the people that live at the home. Although staff do receive training, there are some gaps in the training records and this may mean that staff are not kept up to date with current thinking and good practices. One of the recently employed members of staff had not completed induction training or adult protection training. The person responsible for carrying out risk assessments had not undertaken refresher training for some time. Hames Hall DS0000022654.V361902.R01.S.doc Version 5.2 Page 21 Most of the staff at the home have already obtained or are working towards a National Vocational Qualification (NVQ) in care. This training helps to ensure that people living at the home are supported and cared for appropriately and safely. Hames Hall DS0000022654.V361902.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): Standards 31, 33, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home continues to be run and managed in the best interests of the people that use this service. EVIDENCE: Hames Hall was sold recently to new owners. The new owners have extensive experience and knowledge of owning and operating residential care homes. Comments received from people who live and work at Hames Hall, indicate that there were initial concerns following the sale of the home. They said that the takeover has not affected the standard of care or the general standards at the home. They added, ‘staff have still given their best under difficult circumstances.’ Some people also indicate that they are concerned about the Hames Hall DS0000022654.V361902.R01.S.doc Version 5.2 Page 23 long term effects of the home not having a manager. However, the new owners have recently appointed a manager, who is due to take up her post in May 2008. The acting manager has extensive knowledge and experience of working at Hames Hall. She has helped to implement the improvements and recommendations we made after the last inspection of this service. The self-assessment that we ask the manager/owner to complete was returned to us on time. It contains clear, relevant information and identifies where improvements have been made over the last 12 months and where further improvement still needs to be made. The acting manager has worked hard to support staff and residents and this is reflected throughout the home and through the comments received from staff, residents and visitors. The records looked at were generally up to date, although there are a few gaps that require attention to ensure the continued safety and well-being of both the staff and people who use this service. The new owner was at the home for a short time during this inspection. He visits regularly and is in daily contact with the acting manager. Although he visits he does not presently keep a record of these visits as required. There is evidence to demonstrate that staff receive supervision of their care practices and are able to speak to the acting manager on a daily basis. The owner makes sure that all servicing of boilers, appliances and equipment is at least annually or more frequently if necessary and all the policies and procedures in place at the home have been reviewed since the takeover. Risk assessments are in place in the care files and generally meet the requirements of the people for which they are intended. Some staff have first aid training and health and safety training is provided. Accident records are completed as necessary and the home keeps us informed of any events that affect the well-being of the people that live at Hames Hall. Hames Hall DS0000022654.V361902.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 4 X 2 X X X X 3 STAFFING Standard No Score 27 2 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X 3 Hames Hall DS0000022654.V361902.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement People living at the home must have an up to date plan of their care. Where changes to their treatment or needs have been identified, this must be recorded to ensure they receive the right type of support and care. Consideration must be given to the aims and purpose of the home, the dependency of the people living at the home and their changing needs, when devising staffing rotas. The home must have a suitably qualified and competent manager who is registered with the Commission for Social Care Inspection. Timescale for action 30/06/08 2 OP27 18 30/06/08 3 OP31 9 31/08/08 Hames Hall DS0000022654.V361902.R01.S.doc Version 5.2 Page 26 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 Refer to Standard OP1 Good Practice Recommendations It is recommended that the information provided to people thinking about using this service be reviewed and updated to reflect the changes in management and ownership at the home. It is recommended that staff are allocated time to support people with stimulating, social and leisure activities, on a one to one basis if necessary. It is recommended that where baths are damaged, they be replaced or re-enamelled as appropriate. This will help reduce any risk of cross infection to people who use this service. 2 3 OP12 OP21 Hames Hall DS0000022654.V361902.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Hames Hall DS0000022654.V361902.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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