Inspection on 30/01/07 for Abbeyfield 10 Eastfield Park

This inspection was carried out on 30th January 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Abbeyfield 10 Eastfield Park 29/01/09

Abbeyfield 10 Eastfield Park 16/03/06

Abbeyfield 10 Eastfield Park 09/08/05

Abbeyfield 10 Eastfield Park 17/03/05

Abbeyfield 10 Eastfield Park 14/07/04

Abbeyfield 10 Eastfield Park 23/02/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE 10 Eastfield Park Weston Super Mare North Somerset BS23 2PE Lead Inspector Catherine Hill Unannounced Inspection 30th January 2007 09:35 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 10 Eastfield Park DS0000008110.V312589.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. 10 Eastfield Park DS0000008110.V312589.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 10 Eastfield Park Address Weston Super Mare North Somerset BS23 2PE 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) 01934 622144 01934 644532 s.furzeman@aol.com The Abbeyfield (WSM) Society Mrs Patricia Joan Boley Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places 10 Eastfield Park DS0000008110.V312589.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 20 persons aged 65 years and over requiring personal care only That Mrs Patricia Boley completes the Register Managers Award by December 2006 Date of last inspection Brief Description of the Service: 10 Eastfield Park is a care home owned by The Abbeyfield (Weston-superMare) Society and offers 24-hour personal care and accommodation for up to 20 elderly people. The home is at the end of a quiet cul-de-sac in Westonsuper-Mare, near a small private park. The home is on two floors and has a passenger lift. There are 17 single bedrooms, 13 of which have ensuite facilities. Residents may bring in small items of furniture if they wish, after discussion with the manager. There is an extensive front garden with seating. Regular transport is provided daily for residents wishing to go into town and the sea front. Current fee levels range from £343.20 to £416. 10 Eastfield Park DS0000008110.V312589.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out during the course of one day, between approximately 9.30 in the morning and 4.30 in the afternoon. The inspector spent some time at the beginning of the inspection with the new acting manager, who also showed the inspector around the premises. The inspector spent the remaining time before lunch talking individually and privately with six of the residents. The remaining time was spent looking at records and systems, talking with staff, and briefly meeting a few other residents. The records sampled included: • residents contracts • the Service Users Guide • records relating to residents care • medications, and medication systems and records • the complaints procedure and complaints record • staff recruitment and training records • staff meeting minutes • policies and procedures • Fire precautions records What the service does well: All the residents the inspector met were highly satisfied with the quality of service they receive. One person said the home is “a lovely place - you couldnt wish for anything better. Other comments included I like it here very much, and nice people. People felt that the home is well organized and several commented on how quickly and well their laundry is done. People felt that there is plenty to do, and one person said that staff go to great lengths to help them get out and about. Staff came in for particular praise. One resident said, They are all lovely every single one of them. They cant do enough for you. Ask for anything you want - if they havent got it, theyll try and get it. Another person told the inspector, The carers are just that - really caring. Residents felt that staff make time to have a chat with them, and are really approachable. Any small worries can be talked over and quickly resolved. Residents visitors are warmly welcomed and involved as much as residents wish in the life of the home. 10 Eastfield Park DS0000008110.V312589.R01.S.doc Version 5.2 Page 6 Residents also thought that the meals are very good. People described wellprepared, interesting and appetizing dishes, with plenty of choice. One person with special dietary needs said, They bend over backwards with my food. The home was spotlessly clean during this unannounced visit, and several of the residents commented to the inspector that it is always kept this way. A couple of people told the inspector in some detail about how thorough the domestic staff are in making sure that every nook and cranny is cleaned. The staff that the inspector met described a strong team spirit with high morale. Staff are evidently committed to providing an excellent, residentfocused service. Many of the staff have worked at the home for between 10 and 20 years: there is an extremely low staff turnover, which allows even stronger bonds to form amongst the staff and resident groups. What has improved since the last inspection? What they could do better: Residents contracts need to specify which element of the fee is for accommodation and which is for care. Several of the residents commented that they could only have one bath per week and that they would prefer more. The home has a newly built walk-in shower that some residents said they would be willing to try as an alternative to a bath. Window restrictors need to be fitted to an upstairs bathroom and any other upstairs rooms that do not have these. Volunteers identities need to be checked to the same standard as paid staff. Fire precautions checks need to be recorded, and staff need more frequent fire instruction. 10 Eastfield Park DS0000008110.V312589.R01.S.doc Version 5.2 Page 7 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. 10 Eastfield Park DS0000008110.V312589.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection 10 Eastfield Park DS0000008110.V312589.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, Quality in this outcome area is good. Prospective residents get good information on which to base their decision, although this should be updated in a few respects. The home gathers enough information to be reasonably sure it can offer the person a service. Residents interests are well protected by the contracts, although these also require some updating. EVIDENCE: The homes Statement of Purpose and its Service User Guide give clear information on the service and the sort of needs it is set up to meet. Some of the information in the Service User Guide needs to be updated: it lets residents know that they can plan to meet the CSCI inspector at announced inspections, but all inspections are now unannounced. This Guide also needs to be updated regarding management changes and the new savings limits before residents become liable to contribute to their own care. Very little information is given in the Guide about exactly how service users will be consulted, so the inspector recommended that this section is expanded to show what the home in fact does. 10 Eastfield Park DS0000008110.V312589.R01.S.doc Version 5.2 Page 10 Residents contracts include a good level of information about what the person can expect from the service. Contracts do not currently specify what element of the charge is in respect of accommodation and what is in respect of care. An effective pre-admission assessment is in use, which includes information on the prospective residents preferences and views. Following the pre-admission assessment, the manager writes to the person who requested the placement to confirm that the home will be able to offer a suitable service. This letter also notes the number of the room that is being offered, the current charge for that room, and that the level of dependency will also affect the fee level. The home does not provide intermediate care. The home has no vacancies. 10 Eastfield Park DS0000008110.V312589.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. Residents needs and preferences are well documented and well met. Medication practice is much safer than at the last inspection but still needs some minor improvements. EVIDENCE: Each persons notes are preceded by a front sheet summarizing all essential information, and a recent photograph. There is also a personal profile on each person that includes key information that might be of significance. Care plans give a good depth of information in a concise format, and reflect residents individual preferences. Care plans had been regularly reviewed and updated as required. Residents comments to the inspector revealed that staff are familiar with their needs and preferences, and are meeting these well. Conversation with staff indicated that care plans are living documents, regularly referred to in staffs daily work with residents. Very full notes are written up for staff promptly after a new resident has been admitted. This helps to ensure that staff know what the person requires from them. Daily notes included plenty of detail about what staff are doing to meet 10 Eastfield Park DS0000008110.V312589.R01.S.doc Version 5.2 Page 12 each persons needs, and what other external help they are seeking on the persons behalf. Any concerns that have been noted are followed up in subsequent notes. These notes also give an all-round picture of the person: how they are being supported to enjoy their social and leisure time, as well as how their physical care needs are being met. If a resident refuses care, this is recorded, but staff are also being creative about trying to offer support in a variety of ways that might suit individual preferences. At present, staff are recording in full in the daily notes all the care they give to frailer residents, which takes considerable time. The inspector suggested that a checklist is drawn up of all the care to be given, which staff could then simply initial and make a note of the time and date they have carried out each task. Separate records are kept of GPs visits, dental appointments, opticians checks and chiropody. These are clearly cross-referenced with daily notes so that staff attention is drawn to them promptly. These notes are also crossreferenced to accident records. Several of the residents commented to the inspector how pleased they are with the laundry service: clothes dont go missing, and are returned promptly in good condition. The CSCI Pharmacy Inspector visited following the last inspection. She gave advice on amending practices to meet legal requirements. The home has taken action to meet these. The medication records sampled were in good order and tallied with the balance of medications held. Practices described by staff were safe. Residents who self-medicate sign an agreement to this, and the continued success of this is regularly monitored. The inspector advised the manager to discuss lists of homely remedies that can be given to individual residents with their GPs to ensure that they are safe to administer, and suggested that GPs are asked if they will sign these lists. The new manager has taken photos of each resident to put with the Medication Administration Records as a further safeguard to reduce the risk of error. Interactions between staff and residents were warm and respectful. Conversations with residents and staff confirmed that residents are held in high regard. Many people have lived or worked at the home for a long time, and strong relationships have grown up over the years. 10 Eastfield Park DS0000008110.V312589.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. Residents enjoy plenty of opportunities to fill their social and leisure time with interesting pursuits, and are supported to have exceptionally good contact with the community. Routines are generally flexible but the current limit of one bath per person per week needs to be reviewed. EVIDENCE: Residents felt that their lives at the home are full and interesting. They described regular in-house activities and plenty of opportunities to go on local outings. Transport is provided twice a week for those people who want to go into town or to the seafront. One of the staff has particular responsibility for in-house activities. She lays on some sort of activity most days, including bingo, quizzes and games. She recently undertook a Flexercise training course and now provides these sessions for residents. Staff also have regular beauty sessions with the residents, which include nail-painting and aromatherapy. Residents visitors are made very welcome, are encouraged to maintain the sort of contact they had prior to the person moving into the home, and are invited to be involved in the homes life. 10 Eastfield Park DS0000008110.V312589.R01.S.doc Version 5.2 Page 14 Residents described flexible routines, but several people commented that they can only have one bath a week and would like more. Residents perception was that staff only have time to help them once a week. Residents were willing to consider having a shower as an alternative to a second bath. Bath arrangements need to be a lot more flexible, and those residents who would prefer a bath or shower more often must be offered this choice. The acting manager explained that there has been difficulty with the new shower - the shower hose will not reach the shower chair - and this may have put residents off using it. She has asked the contractor to come back and make adjustments to resolve this difficulty. The inspector suggested that each resident is consulted about how many baths or showers they would like each week. The days menus are on a blackboard outside the dining room. Residents comments about the food were very positive, and many people felt that the quality of meals and range of choice are excellent. Menus are varied, interesting and balanced, and likely to suit the needs and tastes of the resident group. The main meal is at lunchtime but a high tea is also on offer every afternoon. 10 Eastfield Park DS0000008110.V312589.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. Residents concerns are listened to, taken seriously, and acted upon. Residents well-being is actively promoted. EVIDENCE: There is a very welcoming complaint procedure. This includes CSCIs address but not their phone number. The inspector reminded the acting manager of this requirement. Any minor grumbles are treated as complaints, in that they are recorded in the complaints book, and a note kept of the action to address them and of outcomes. There have been no complaints more serious than a grumble for the past year or so. Residents described a friendly atmosphere and a willing staff team. Many people made comments to the inspector about how approachable and responsive they find the staff. Staff told the inspector that they feel encouraged to put the residents first in everything. The acting manager has started a thank-you file. The inspector suggested that cards and letters placed in this file are dated, so that staff can see when they came in. There is an abuse reporting policy, and really excellent guidelines on what staff should do if they suspect or are told about abuse. These guidelines are in line with North Somerset Social Services No Secrets policy. However, only the flow chart at the back of this guidance states that the duty officer should contact the police and Social Services: this guidance should be incorporated 10 Eastfield Park DS0000008110.V312589.R01.S.doc Version 5.2 Page 16 into the written policy as well, to ensure that staff in charge of the home take the right action. 10 Eastfield Park DS0000008110.V312589.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is good. Residents benefit from a pleasant and comfortable environment that is well suited to their needs. Ensuring that window restrictors are fitted where necessary will improve the overall standard of safety. EVIDENCE: The home is generally decorated and furnished to a good standard, looks comfortable and welcoming, and is well suited to residents needs. It has a pleasant lounge and separate dining room, with another small dining area leading off this. Communal bathrooms and toilets are within easy reach of all the bedrooms. A new walk-in shower has been fitted since the last inspection, and one of the unused communal bathrooms has been converted into an ensuite. Several of the residents bedrooms have also been fitted with new ensuite facilities. There are several garden areas at the back of the house, and large gardens at the front of the house. 10 Eastfield Park DS0000008110.V312589.R01.S.doc Version 5.2 Page 18 The first-floor landings look particularly lovely but the overall impression is slightly let down by the rather worn carpet on the first-floor landing area by Room 10. Some of the wooden furniture on this landing is also looking rather worn. All 17 bedrooms are now being used as singles, and 13 of them now have ensuite facilities. Since the last inspection, building work has been carried out to improve some of the bedrooms. Room -which leads on to a fire escape route - will not be used as a bedroom again after the present occupant moves out. Bedrooms were very individual, and most residents have brought in items of furniture and ornaments from their own homes. People evidently regard these rooms as their own, and staff were conscientious about knocking on bedroom doors and waiting for an invitation before entering. A passenger lift gives residents access to all areas except one first-floor wing of the home. This area is reached by a short flight of steps, fitted with a stair lift. There are grab rails fitted around corridors at key points, to help residents move around the home independently. And in/out board is used by residents. Some residents hold a front door key. Some of the bedroom doors are not lockable at present, despite the promise in the Service Users Guide that your room will have a lockable door. The inspector recommended that each resident is asked whether they would like a lock for their bedroom door. The inspector recommended that the Fire Officer is consulted about the inwards opening fire exit door in the corridor near the office, as it is unusual to have a fire exit opening inwards. She also suggested he is consulted about the glass panels in Rooms 3 and 4 as these may no longer be necessary, and as they detract from the privacy of the occupants. Window restrictors need to be fitted in the bathroom by Room 10 and to any other first-floor windows that are currently unrestricted. Radiators without low temperature surfaces have been risk assessed, and these assessments are regularly reviewed. All areas of the home were spotlessly clean and smelled fresh. Several residents told the inspector that the cleaning staff always maintain this standard. Although infection control practice is evidently good, communal nail files are being used. If anyone were to have a nail infection, this could be passed on to other residents this way. It is recommended that each resident should have their own nail file instead. 10 Eastfield Park DS0000008110.V312589.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. Residents safety is promoted by good staffing practices, but this needs to be improved by ensuring that volunteers are checked to the same standard. Staff training is satisfactory but few people have NVQs. EVIDENCE: There are at least 3 care staff on duty until 2.30 p.m., often 4. There are 2 care staff on duty in the afternoons. On most days, an extra person is rostered to work between 5 p.m. and 9 p.m. Two waking staff are on duty each night. The current level of residents needs is low to moderate. Residents said that they do not have to wait unduly for support with personal care, and that staff always come promptly if they ring their call bell. Several people also told the inspector have staff take time to stop and have a chat with residents. Staff went about their duties in a relaxed manner and felt that they do not have to rush. Staff recruitment practice is generally good but volunteers do not have the same checks in place. Checks need to be carried out on volunteers to the same standard as on paid staff. A copy of the General Social Care Council Code of Conduct is on the noticeboard near the kitchen, along with the minutes of the most recent staff meeting. 10 Eastfield Park DS0000008110.V312589.R01.S.doc Version 5.2 Page 20 Staff have recently had training in medications safe practice and in basic food hygiene. Earlier training includes health and safety, first aid, and manual handling. Two staff are currently doing NVQ 2 and two others are doing NVQ 3. 10 Eastfield Park DS0000008110.V312589.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37, 38 Quality in this outcome area is good. Residents and staff benefit from a wellrun home with a happy atmosphere. Residents have a lot of say in their dayto-day lives, and are at the heart of the homes decision-making. Staff are well supported. Health and safety checks need to be better documented. EVIDENCE: The registered manager has recently retired. An acting manager has been appointed and is applying for registration. She is currently undertaking the Registered Managers Award and hopes to complete this in the next six months. The new manager has drawn up a list of priorities and is working through these. She has been updating risk assessments on individual residents, has drawn up a nutritional assessment on one particular resident, started one-to10 Eastfield Park DS0000008110.V312589.R01.S.doc Version 5.2 Page 22 one supervision sessions with all staff, and held a general staff meeting, among other activities. Staff felt well supported, both by the manager and the team. Staff said that everyone in the team helps each other, and that there is a really pleasant working atmosphere. Any problems that arise are dealt with positively and openly. Individual staff supervision records are kept in one file to which only the manager has access. At the front of this file is a list of the most recent and the next supervision dates for each staff member. The manager also carries out regular staff appraisals. Senior staff supervise all other staff. The inspector spoke with some of the staff responsible for supervision, who described these sessions as covering training needs, staffing issues, resident issues, and the homes aims. Each staff member has formal supervision every couple of months, and occasional group sessions are held to discuss residents care. Residents and staff commented that communication in the home is effective. The acting manager has started reviewing policies and procedures. Policies on file had been signed and dated. This file also contains information such as lists of first aid kit contents. These need to be updated to reflect current guidelines on what should be kept in the first aid box, and the inspector suggested that it might be simpler to keep on file a copy of the list of contents that comes with the first aid kit itself. The inspector recommended that written policies on sexuality and smoking are drawn up. There is a wide range of health and safety risk assessments covering processes, equipment, and the environment. The Fire Risk Assessment was completed in May 2004, and provides clear and useful information. The new manager has started reviewing this, in the light of the new fire regulations that recently came into effect. Fire precautions are regularly checked by the contractor. The homes handyman carries out the routine checks of the fire alarms, emergency lights and fire extinguishers, but only records the fire alarm checks. All fire precautions equipment checks need to be recorded in the Fire Log Book. Staff receive regular fire instruction but this is not with the recommended frequency. Staff covering daytime duties need to have fire instruction at least every six months, and staff covering night-time duties need to have refresher training at least every three months. 10 Eastfield Park DS0000008110.V312589.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 2 3 3 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 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 2 10 Eastfield Park DS0000008110.V312589.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5 Timescale for action Residents contracts must specify 30/03/07 what element of the charge is in respect of accommodation and what is in respect of care. Bath arrangements need to be a 13/02/07 lot more flexible, and those residents who would prefer a bath or shower more often than once a week must be offered this choice. Window restrictors need to be 30/03/07 fitted in the bathroom by Room 10 and to any other first-floor windows that are currently unrestricted. Recruitment checks need to be 13/02/07 carried out on volunteers to the same standard as on paid staff. All fire precautions equipment 30/01/07 checks need to be recorded in the Fire Log Book. Staff covering daytime duties need to have fire instruction at least every six months, and staff covering night-time duties need to have refresher training at least every three months. Requirement 2. OP12 12 3. OP25 23 4. 5. OP29 OP38 19 13 10 Eastfield Park DS0000008110.V312589.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. 4. Refer to Standard OP1 OP9 OP18 OP19 Good Practice Recommendations The Service User Guide should be updated to reflect recent changes, and should indicate the means by which residents are consulted. Lists of homely remedies that can be given to individual residents should be discussed with their GPs to ensure that they are safe to administer. The abuse policy should be amended to make clear that staff must alert relevant agencies immediately if serious abuse is suspected. The Fire Officer should be consulted about the inwards opening fire exit door in the corridor near the office. Also about the glass panels in Rooms 3 and 4 as these may no longer be necessary, and they detract from the privacy of the occupants. Each resident should be asked whether they would like a lock for their bedroom door. Each resident should have their own nail file to prevent the possible spread of infection. Written policies on sexuality and smoking should be drawn up. 5. 6. 7. OP24 OP26 OP37 10 Eastfield Park DS0000008110.V312589.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 10 Eastfield Park DS0000008110.V312589.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!