Inspection on 23/11/06 for 99 -105 Durham Care Homes

This inspection was carried out on 23rd November 2006.

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

99 -105 Durham Care Homes 03/01/08

99 -105 Durham Care Homes 28/02/06

99 -105 Durham Care Homes 03/11/05

99 -105 Durham Care Homes 16/02/05

99 -105 Durham Care Homes 21/10/04

Similar services:

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

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

CARE HOMES FOR OLDER PEOPLE 99 -105 Durham Care Homes 99-105 Durham Street Holderness Road Hull East Yorkshire HU8 8RF Lead Inspector Janet Lamb Unannounced Inspection 23rd November 2006 09:30 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 DS0000000845.V320454.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. DS0000000845.V320454.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 99 -105 Durham Care Homes Address 99-105 Durham Street Holderness Road Hull East Yorkshire HU8 8RF 01482 229766 F/P 01482 229766 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) Durham Care Homes Mrs Joan Langfield Care Home 20 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (20) of places DS0000000845.V320454.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2006 Brief Description of the Service: Durham Care Homes is situated to the east of the city of Hull, on Durham street, which runs off a main road. The home is registered to provide care and accommodation for twenty older people who may also be suffering from dementia. Charges range from £287.50 to £327.50. There are fourteen single rooms and three shared rooms. A large lounge and a dining room are available on the ground floor of the home, and a small lounge is available on the first floor. A small car park and patio/garden area is available to the rear of the premises for residents use. Shops, churches and local health facilities are all accessible within a small distance, public transport is also available close to the home on the main road. DS0000000845.V320454.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection of 99-105 Durham Care Homes has taken place over a period of time and involved sending a pre-inspection questionnaire to the home in August 2006 requesting information about service users and their family members. The Commission received the requested information on 25th August 2006 and questionnaires and survey comment cards were then issued to all service users and their relatives, their GP and any other health care professional with an interest in their care. This information obtained from surveys and information already known from having had contact with the home over the last few months, was used to suggest what it must be like living there. A site visit was made to the home on 23rd November 2006 to test these suggestions, and to interview service users, staff, visitors and the home Manager. Some documents were viewed with permission from those people they concerned, and some records were also looked at. A total of six service users, three staff, one relative and the Manager, were spoken to or interviewed during the site visit and all of the information collected was checked against the information obtained through comment cards and details already known because of previous information gathering and contact with the home. What the service does well: Service users are well assessed on entry to the home and are provided with a good care plan for staff to follow. They are well supported with health care that meets their needs and their expectations. They are protected from possible harm due to taking the wrong medication, because they have their medication handled by the staff in the home, and the staff follow robust practices and procedures. Service users experience good levels of privacy, have their dignity maintained, and their right to make decisions respected. They are encouraged to maintain contact with family members and friends and enjoy visits from these people any time of the day, and they are encouraged to exercise choice and control over their lives. Service users enjoy good food, which matches their expectations and preferences, but also offers a satisfactory level of nutrition. DS0000000845.V320454.R01.S.doc Version 5.2 Page 6 They are confident their complaints will be listened to and acted upon. Service users are protected from abuse by robust recruitment and selection procedures and practices. Service users experience a safe, clean and well-maintained environment. A sufficient number of care staff work in the home on each shift to meet the needs of service users. The Manager runs the home in the best interests of the service users, safeguards their financial interests, and maintains their health, safety and welfare. 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. DS0000000845.V320454.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 DS0000000845.V320454.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): 3 and 6, but 6 is not applicable. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. EVIDENCE: Four service users were interviewed informally and asked if they would give permission for their files to be viewed. All four service users only had a vague understanding of what assessments and care plans are, but explained they had nothing to hide and they could be viewed. One service user said, “I don’t remember having a meeting or review or seeing a care plan, but I always get to know what happens.” DS0000000845.V320454.R01.S.doc Version 5.2 Page 9 Files seen contained copies of assessments done by local authorities as well as copies of assessments done by the home: an assessment of prospective service users on initial contact, and a DMA (David Mason Associates) skills assessment document. All of these showed evidence of service user and family member involvement and contained signatures where possible. All were dated, contained relevant information and showed where differences in particular needs require special attention or action to meet them. The Manager confirmed the assessment process and explained that a care plan is produced from all of the information obtained on service users. Care plans are comprehensive in the information they hold. Service users also have contracts on files and where possible they or their relative signs them. There is information available in the form of statement of purpose and service user guide, for service users to make a decision about the home before they consider moving in. These documents are held in service users’ rooms and are labelled for easy recognition. Standard 6 is not applicable, as the home does not take service users for intermediate care. DS0000000845.V320454.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 and 10. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users receive good health and personal care and support, so their needs are well met. They benefit from good medication administration and from good levels of privacy and dignity within the home, so their health care needs are also well met. EVIDENCE: All service users have a care plan from which staff take their instruction on how to meet assessed needs. Service users showed little interest in these, but gave permission for them to be viewed. Care plans held in files are compiled by the local authority and by the home and all are comprehensive and relevant at the time of compilation. Details held include issues under the equality and diversity umbrella, for those service users with particular and different needs, whether they be physical, religious, or sexual etc. DS0000000845.V320454.R01.S.doc Version 5.2 Page 11 Care plans are reviewed monthly within the home to maintain relevance and annually with the local authority to ensure continuity of service is being provided. Service users’ differing needs are well met. Service users spoken to agree they usually have meetings with the Manager, key worker and their relative once in a while, but could not attribute the meetings to reviewing of care plans. They were satisfied that any care needs they have are usually well met, one saying, “The girls help automatically, they know who needs what, you wouldn’t be stranded, they help you. I don’t know if the help we need is on a care plan. Some of us need more help than others.” Another said, “I have my medical problems attended to every eight weeks.” All service users spoken to were satisfied with the arrangements for contacting a GP or visiting the hospital etc. One said, “If we’re poorly there is a doctor on Holderness Road, with three or four of them in the practice. You can change doctors if you want to.” Observation of interaction between staff and service users shows there are some caring relationships, and between service users that there are some tolerant ones. Staff are very understanding of service users needs and emotional states, while some service users forget what problems others have, but reminders are polite and considerate. The home presented a caring, homely atmosphere in which to live. There are no service users in the home that self-medicate. All receive it from staff that are trained to administer it, usually only senior staff. Staff confirmed these arrangements in interviews and service users spoken to are satisfied the responsibility to look after their medicine lies with the home. One said, “I won’t look after it myself, I’d get mixed up.” Another said, “We get our medicines when we need them, they are locked in the office. I am happy that the home keeps them.” There are medication administration policies and procedures for staff to follow, and practices are robust and safe. Systems inspected were satisfactory. The home uses a monitored dosage system, for which medication administration sheets are maintained and completed upon giving medicines to service users. These records are accurately maintained. Storage is adequate, and disposal of any unused medicines is according to safe procedures. There are no controlled medicines held in the home at the moment, and the visiting District Nurse takes away any sharps s/he uses, after each visit. Service users spoken to are satisfied with the levels of respect that staff show them concerning their privacy and dignity. Visits from their GP and assistance with personal care are carried out in the privacy of bedrooms. Observation of staff revealed that they are sensitive and discreet when dealing with personal issues. DS0000000845.V320454.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 and 15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Outcomes for service users regarding daily life and social activities are good so they enjoy doing the things on offer, see visitors regularly, make their own decisions as much as possible and are positive about the food provision. EVIDENCE: Service users and staff spoken to indicate there are some set routines within the day, which service users generally accept as being necessary for consistency and management of the volume of tasks to be carried out. Some flexibility exists though, as some service users make their own decisions about bathing, rising or going to bed, about what they will and will not engage in etc. Preferences are recorded in care plans whenever possible and choices are respected, especially in respect of equality and diversity needs. One service user said “I’m up early but only by choice, I go to bed when I like and get help to take a bath twice a week.” DS0000000845.V320454.R01.S.doc Version 5.2 Page 13 Service users spoken to are satisfied with the arrangements and freedom exercised around receiving visitors to the home and to their rooms if they wish. One visitor observed on the day of the site visit and spoken to also expressed satisfaction with the home. Comments on service user questionnaires and relatives’ comment cards are all positive, with no adverse statements made. One relative said, “I cannot praise staff highly enough. They are all most kind to me and my aunt. Durham House is always beautifully clean and welcoming. Thank you to everyone.” Individuals’ diary notes and the visitor’s book contain evidence of visitors to the home. There is evidence of service users acting independently and according to their personal choice in diary notes as well, and those spoken to confirm they can make their own decisions on most things. One or two explained they are all dependent people and therefore their choices may be limited, but generally they enjoy freedom of thought, word and deed. There are few service users that handle their own finances, most preferring their son or daughter to deal with such affairs. These arrangements are satisfactory, according to the service users spoken to. Management explain that some service users have small amounts held in safekeeping for which receipts are given and records are maintained. These were not seen. There is no computer within the home so financial and other business matters are not electronically monitored. Service users spoken to about the meal provision are complimentary of the food they receive. One said, “The food’s good enough, if we don’t like it we can have something else.” Another said on a questionnaire, “The meals are excellent. I have only been here six days and I am very happy.” Menus are compiled by the home Manager and the cook after consulting service users, and although meals are set each day with no named alternative, service users do not see this to be a problem. Lunch always consists of a soup starter, main meal and a dessert. Observation of the lunchtime meal revealed an appetising and nourishing meal of ‘cockieleekie’ soup, sausage and Yorkshire pudding, potatoes and peas and cherry pie and cream. The dining room is very pleasantly decorated and tables are properly set with cloths, placemats, cutlery, condiments and a floral centrepiece. There were no complaints about any aspect of the food provided. DS0000000845.V320454.R01.S.doc Version 5.2 Page 14 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 and 18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Complaint management and protection of service users are good, so service users are listened to and they are confident they will be protected. EVIDENCE: The home has clear and detailed policies and procedures in place for making complaints and maintaining protection of service users. There is a complaint record held, which shows five complaints made in the home over the last twelve months, four were not serious and easily resolved, while one was a little more serious, but was also resolved. The Manager has implemented new complaint recording forms in place of the complaint book, which are now data protection compliant, as recommended at the last inspection. There has been no occasion to implement the home’s systems for reporting or recording vulnerable adult issues over the last twelve months. Service users spoken to about making complaints are very confident about approaching the Manager or any of the staff. One service user said, “If I had a complaint I would go to the head here. They call her ____.” DS0000000845.V320454.R01.S.doc Version 5.2 Page 15 All service user questionnaires received showed service users are clear about their course of action. One stated, “I would tell a member of staff and they would go to ____ or ______.” Two relatives stated they were not aware of the complaint procedure. Three staff spoken to are also confident about handling complaint information and confirmed the Manager deals with issues quickly and sensitively. All staff submitting information on questionnaires stated they had confidence in approaching the Manager for any reason. Adult protection issues are not fully understood by service users, but those spoken to state they would go straight to the Manager or Deputy if they were unhappy about anything. Staff are aware of their responsibilities and have done abuse awareness training with Hull and East Riding Adult Protection Committee, as well as seen a video and completed a questionnaire on the subject. The Manager confirmed training undertaken by the staff. DS0000000845.V320454.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 and 26. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is suitable for its stated purpose, and both cleanliness and maintenance are good, so service users enjoy a safe, homely environment. EVIDENCE: A tour of the premises revealed all rooms are clean, comfortable and very personalised. The property is well maintained and suitable for its stated purpose. Individual and collective needs are satisfactorily met by the property with the exception of the dining room having limited floor space. This would not be a problem if all service users were fully ambulant without the aid of frames and wheelchairs, but because almost all of them now require such equipment the dining space cannot cope. DS0000000845.V320454.R01.S.doc Version 5.2 Page 17 Staff make very clear comments on their questionnaires about the space being inadequate and observation of service users entering the dining room for lunch confirmed there are some difficulties manoeuvring everyone into their place. Those service users that are hearing impaired have fire safety lights in their rooms to alert them to the fire alarms going off. One service user has had her emergency call bell cord removed from her room following a risk assessment of her safety and night staff undertake half-hourly checks on her throughout the night. There is a pleasant garden to the front of the home overlooking the car park. The home complies with the requirements of the local fire service and environmental health departments, from which visits to the home were last made in April 2005 and July 2006 respectively. The home meets requirements of standard 26 in respect of laundry equipment and hygiene facilities. Service users spoken to are satisfied with the cleanliness of the house and their personal space. Comments on questionnaires include, “I think it’s a lovely home,” and “I was shown around the home without having to make an appointment, which I thought was very good.” DS0000000845.V320454.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 and 30. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing complement of the home is sufficient to meet service users’ needs, but there are not enough staff with the recommended qualifications, so service users’ needs are being met, although staff group competence could improve. Recruitment and selection practices and training opportunities are good and so service users are well protected. EVIDENCE: Discussion with the Manager and staff and inspection of the contract hours list and the duty rosters reveal there are 437.5 contracted care hours per week: excluding the Manager’s hours, but including the Deputy’s hours. The preinspection questionnaire shows there to be 570 hours provided. The Residential Staffing Forum requires there to be 393.05 care hours per week for 4 medium dependency and 14 low dependency service users currently in the home, as stated by the Manager on the day of the site visit. Four staff questionnaires suggested there are not enough staff on duty and this impacts on staff being able to spend sufficient time with service users. Discussion with staff on the site visit reveals they would like to have some DS0000000845.V320454.R01.S.doc Version 5.2 Page 19 more help at the very beginning of the day when service users want to be up, and in the afternoons during the summer months when service users want to be in and out of the garden. Other times, in their opinion, when three staff on duty does not seem sufficient is when service users need escorting to hospital. However, the home is providing sufficient care staffing hours per week to meet the recommendations of the Residential Staffing Forum, and observation of care staff on the day of the site visit shows there are sufficient staff on duty. Service users made no adverse comments about being cared for or receiving assistance and support in a timely manner. Standard 27 is being met. Of the 21 care staff in the home (including the Deputy and a bank staff) nine have achieved NVQ level 2 or 3, giving a figure of 43 . Efforts need to continue to achieve 50 . Staff spoken to confirmed they had done the course and information in their training files was viewed. The Manager explained that the ‘Skills For Care’ course is being looked at for everyone and booklets have been ordered. Other mandatory training was also discussed and evidence of courses completed was seen in training files and on the homes staffing list. There is a recruitment and selection policy and procedure in place, and practice is good in respect of ensuring the requirements of schedule 2 are being followed. Staff discussed the recruitment process they followed and files confirmed the information obtained to determine their identity and acquire a Criminal Records Bureau check. The Manager also confirmed how the home recruits new staff, although many of the current staff are long standing employees. DS0000000845.V320454.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, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The management of the home is effective and the health, safety and welfare of service users and staff is satisfactorily maintained, so that service users know the home is safely run in their best interests. EVIDENCE: Discussion with the Manager reveals she has already completed NVQ Level 4 in Management, and supplemented this with 4 care units from NVQ Level 4 Registered Manager’s Award. Therefore she is qualified, competent and experienced to carry out the role of Registered Manager. DS0000000845.V320454.R01.S.doc Version 5.2 Page 21 Discussion with staff and service users and information obtained from questionnaires shows the Manager is considered to be a very approachable person that effectively and efficiently resolves problems for them and quickly deals with issues for action. The home has a system in place for monitoring the quality of the service it provides to service users. This includes some daily, weekly or monthly audits on all areas of the home from the premises to the care given to service users and reviewing of care plans etc. Service user and relatives meetings are held on an informal basis, and regulation 26 visits are made and reported on, daily verbal consultations are carried out and written surveys are done on various issues, all to determine the performance of the service. An annual report is also published. The only requirement yet to be met, is to send a copy of any report issued under schedule 24 to the Commission, if and when the quality assurance systems are reviewed. Staff are aware of the quality audits within the home, but service users are not particularly informed. They are confident they can talk to any of the staff or management and feel sure they will be listened to. The home is run in their best interest whenever possible. There is a policy and a procedure for handling service users’ finances within the home, and staff understand their responsibilities regarding protection of service users. There are very few service uses that handle their own finances, most have family members that do so. Two service users receive personal allowance from the home and this is receipted where possible and recorded at the company headquarters. There are more service users that have small amounts of money held in safekeeping, which is satisfactorily recorded and receipted in or out. Four areas of health and safety were looked at during the site visit: fire drills/safety equipment tests and systems, passenger and hoist lifting equipment, Control Of Substances Hazardous to Health (COSHH) regulations and water temperature controls. The home has fire safety policies and procedures and a fire risk assessment, carries out weekly checks on the system and periodic training drills to ensure all staff receive three or four a year. Staff are aware of their responsibilities and confirmed they receive appropriate training and instruction in fire safety. Training files hold certificates etc. There is no passenger lift in the home, but a stair lift, a bath hoist and a mobile hoist. All are serviced by a contractor and were last checked on 24/10/06, 09/06/06 and 09/11/06 respectively. Staff have policies and procedures to follow in respect of moving and lifting people, and are trained in moving and handling and the use of hoists. Evidence is available in training files and on the staff list. DS0000000845.V320454.R01.S.doc Version 5.2 Page 22 There is a risk assessment document held for each product in the home. All cleaning products used in the home are stored in a locked cupboard and have accompanying information for safe use under the COSHH regulations. One cleaner spoken to is aware of her responsibilities for safe use of products and ensures they are kept under supervision at all times, when in use. Practice observed was satisfactory. The handyman undertakes temperature checks on the hot water outlets on a regular basis and records the findings. A full legionella water test was carried out on 14/06/06. Overall there is good evidence to show that the home is well managed and service user and staff have their health, safety and welfare well protected. DS0000000845.V320454.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000000845.V320454.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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP28 OP35 Good Practice Recommendations The registered Provider should ensure there are 50 of care staff with the NVQ Level 2 in Care or equivalent by 30/06/07. Information about the non-interest bearing account should be put into the service user guide so resident’s can decide if they wish to place their money elsewhere. (This was not checked on this inspection.) 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