Inspection on 21/09/07 for Aegel House

This inspection was carried out on 21st September 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

Aegel House 27/02/07

Aegel House 24/08/06

Aegel House 07/02/06

Aegel House 05/07/05

Aegel House 04/01/05

Aegel House 24/06/04

Aegel House 04/12/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Aegel House Burgh Road Aylsham Norfolk NR11 6AS Lead Inspector Jenny Rose Unannounced Inspection 21st September 2007 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 Aegel House DS0000035120.V351292.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. Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aegel House Address Burgh Road Aylsham Norfolk NR11 6AS 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) 01263 733171 01263 731456 aegelhouse@norfolk.gov.uk www.norfolk.gov.uk Norfolk County Council-Community Care vacant post Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 35 Service Users only Older People not falling in any other category Date of last inspection 27th February 2007 Brief Description of the Service: Aegel House is a purpose built, two-storey residential Care Home managed by Norfolk County Council. The Home is situated on the outskirts of the market town of Aylsham and provides care for up to 35 older people. Originally built in 1962 the Home was extensively modernised during 1996/7 and now provides attractive accommodation in mainly single rooms. Aided bathing and toilet facilities are strategically positioned around the building and the Home is well equipped with hoists and handrails, etc. A shaft lift provides assisted passage to the first floor. There are a variety of communal areas dotted around the Home including a small library room. There is a large dining room on the ground floor that leads to a small room used as a shop for the residents where they can make small purchases of toiletries and confectionary. The Home stands in its own extensive grounds, which include a large, secluded garden area to the rear of the premises. The patio area is furnished with very acceptable garden furniture that has been provided by the Friends of Aegel House, who are a very supportive group to the home. A day centre for older people is located within the Home and this is in active use on weekdays. The day centre, which can cater for up to twelve persons each day has its own exterior entrance, facilities and staffing compliment. This area of the building was not inspected, as it does not form part of the residential accommodation. The cost of a placement at Aegel House is £368.72 a week. Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care Services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out, by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgements for each outcome group. This was a key, unannounced inspection carried out over a period of 8 hours, during which time a partial tour of the premises was undertaken, care plans, staff files and records for regulation were examined. The newly appointed Manager was available throughout the Inspection. The majority of the thirty three people living in the Home on the day were seen and several spoken to in passing. Discussions took place in private with three residents, four members of staff on duty, two visitors and several people in passing. The Annual Quality Assurance Assessment (AQAA) as well as two comment cards from residents and eight from relatives/friends had been returned to the Commission prior to the Inspection providing useful information which has been reflected in this Report. What the service does well: • The Home stands in extensive grounds, including an accessible secluded area, with wildlife, including squirrels and birds which some residents enjoy watching. There is a variety of communal areas and the Home is light and airy providing a comfortable, clean and homely environment for people living there. A comprehensive needs assessment is undertaken prior to people being admitted to the Home and trial visits are offered before decisions are taken to live in the Home long term. Clear care plans, which are reviewed regularly guide staff in the care and support of individuals’ health and personal care needs, respecting their privacy and dignity. Residents, relatives and comment cards speak of the staff being helpful, caring and cheerful, although there is concern about staff shortages. • • • • Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 6 • • Relatives and friends are able to visit whenever they wish and are made welcome. There are good hygiene procedures in the administration of medication. What has improved since the last inspection? Two recommendations from the previous Inspection are being complied with, but remain: • • • More care staff are involved in completing NVQ qualifications. The time between staff commencing work and completing induction training has been shortened. Following a period of temporary management, the appointment of a permanent Manager has been made and staff morale has improved as a result. There has been redecoration of residents’ personal rooms and communal areas, as well as new carpets. A newsletter has been introduced and is appreciated, particularly by relatives. Automatic fire door closers have been fitted. Medication cabinets are in the process of being fitted in all residents’ rooms, in addition to lockable bedside cabinets. An activities area has been created off a downstairs lounge with large board games set out. • • • • • What they could do better: • There are several vacancies in the staff group and some anomalies in staffing hours, which need to be addressed to ensure that the dependency and changing needs of the people living in the home are met. There is room for improvement in building upon the details of personal life histories, with the resident’s permission, in conjunction with the activities programme in order to provide more person centred, holistic care. • Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 7 • The keyworker system should be reviewed to ensure that all people using the service can be sure that their needs, choices and rights are known, protected and promoted. 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. Aegel House DS0000035120.V351292.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 Aegel House DS0000035120.V351292.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the Home have their needs comprehensively assessed prior to admission to ensure the Home is suitable for them. The Home does not provide intermediate care. EVIDENCE: From the previous inspections there is evidence that prospective residents’ have their needs assessed prior to admission to ensure the Home is able to meet those needs. This assessment forms the basis of the care plans. The AQAA states that prospective residents are encouraged to visit the Home and that a folder of photographs showing facilities is under consideration, to be used in conjunction with the information in the brochure “All About Aegel”. Two care plans examined showed there was information available from the placing Social Care Worker and other Health and Social Care Professionals where appropriate, as well as evidence that the process had involved the resident and relatives where appropriate. One resident spoken to who had recently been admitted to the Home confirmed this process and felt that his needs were being met. Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the Home are satisfied with the way that staff deliver their care and respect their dignity, but reorganisation of the staffing rota would further ensure the quality of care. EVIDENCE: Four care plans examined all contained a photograph of the resident and comprehensive details necessary to enable staff to deliver the particular care needed. The care plans seen were person centred and focussed on the individual’s personal preferences in various aspects, including preferred time for daily routines, social contacts and interests. In one care plan seen there were details of the support the resident needed in order to maintain dignity and independence. Risk assessments are in place where necessary and these were discussed with the residents and relatives, as appropriate. These and the well-kept care plans seen were regularly reviewed with the resident and/or relatives. If a resident was unable to sign, a note was made of this. Information on weight and nutrition was included in care plans and the action to be taken regarding dietary supplements, particularly for one resident, who was observed not eating a full meal at lunch time. Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 11 Examination of care plans showed involvement of Health and Social Care Professionals. There was evidence of eye tests, dental care, chiropody and visits from the Continence Advisor. Observation of the medication round demonstrated that medication was appropriately stored in a first floor clinic room and the temperature of the room and the medicine refrigerator were monitored. The administration of medication was observed to be safely carried out by staff who had been trained and who were observed communicating appropriately with residents about their medication. Good hygiene practices were observed when staff were administering medication between residents; sterilising hands or wearing gloves each time. The MAR sheets appeared to be appropriately completed. There is a mini audit on each shift by a senior member of staff and a weekly audit, spot checked by the Manager and audited monthly. The record for the monthly audit of August showed no issues, other than two missing signatures and that appropriate action had been taken. There was one resident self-administering medication with a risk assessment in place and there are lockable medicine cabinets in each room. A requirement and a recommendation from the previous Pharmacy Inspection had been complied with and steps taken to ensure medicines are administered in line with prescribed instructions and that prescribed directions for tablets are indicated on the MAR chart as far forward as the date of the next scheduled blood test for one particular resident. It was observed, and residents spoken to confirmed, that they were treated with respect and that their privacy was protected. Two residents spoken to were satisfied with the way their dignity was promoted by staff during personal care tasks. There is a telephone room so that residents may receive calls in private or residents may have phones in their rooms. Relatives’ Comment Cards: “The staff are always helpful and cheerful.” “I haven’t had any serious concerns about her care, I’m sure if I had it would be dealt with appropriately.” “The Care Home, Aegel House, is perfect for my relative and all her needs.” What does the Home do well? “Care for all patients keeping them clean and most of all happy.” “My relative is very well cared for at Aegel House, she is very happy there.” “My relative is very happy living there.” “My friend has expressed a wish to be bathed twice a week. I appreciate that this request is dependent on staffing levels.” Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the Home have choice in their lifestyle, including well balanced meals. EVIDENCE: Recently an activities area has been established, with large versions of board games available. Photographs were seen of one resident playing draughts in this area the previous day. There was a record of activities on display in the hall. One senior member of staff has recently completed a Reminiscence Course and another member of staff on the day was beginning to organise an outing to a Christmas Show. There is an organ in the Dining Room, a large TV used for watching sport by many residents and a shop to enable residents to purchase small items of confectionery/toiletries. Although activities are recorded in the Daily Notes and there are good details in the care plans seen of life histories, there is a recommendation that Activities records should include details of individual resident’s life histories and interests, to further develop the activities programme according to individuals’ needs and wishes. To this end there is a further recommendation that the keyworkers’ role should be reviewed, which is dealt with elsewhere in this report. Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 13 Discussions with residents and relatives and from observation provided evidence that visitors are welcome in the Home and can see residents in private if they so wish and there is a designated room for this if required. Evidence from discussions with residents and staff and by observation also demonstrated that people living in the Home have autonomy and choice. There are regular residents’ meetings and residents’ rooms seen have a variety of personal possessions and pictures of family and friends. Staff were observed serving lunch according to residents’ choices between three items on the menu. For many, meal times appeared to be a social occasion, but there are some residents who prefer to eat their meals alone on their own table in the pleasant, light dining room while others prefer to eat meals in their own rooms. For one resident, there was a risk assessment regarding the eating of meals in his room relating to the risk of choking. Two residents were seen refusing to eat the main course; one resident said he would prefer a double helping of dessert, while another resident wished to be fed her dessert instead of the main course. Care plans showed that dietary supplements were available for those residents who had a poor appetite. Residents needing assistance with eating were seen to be given discreet help by staff members. Residents’ meetings and questionnaires provide the opportunity for the discussion of choices and quality of meals. Residents’ Comments: “Fish and chips today, that’s our favourite” Relatives’/Friends’ Comment Cards: “My mother is very happy there.” “Caring, friendly and open conditions make Aegel House a pleasant place for the residents.” “Home offers range of activities/entertainment.” “Very homely good atmosphere.” “My friend feels that the standard of food has deteriorated since he first entered Aegel House. I cannot comment as I do not eat the meals provided.” Aegel House DS0000035120.V351292.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 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the Home feel that complaints and concerns are listened to and acted upon, and that the Home’s policies and procedures ensure that residents are safeguarded. EVIDENCE: Since the last inspection two complaints had been received. One had been resolved and the other was inconclusive but appropriate action had been taken. The Home has a clear policy and procedure for dealing with complaints. A record is also kept of compliments. All residents and visitors spoken to, together with the comment cards demonstrated that the complaints procedure was well known and that the management were approachable. Examination of training records confirmed that staff have received training in recognising the signs and symptoms of abuse and staff spoken to gave a good account of their knowledge. All residents felt they were well treated by staff. Relative’s Comment Card: ”We do not have any complaints about anything.” Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 15 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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Since the last inspection there have been improvements to the Home which offers the people living there a comfortable, clean, airy and safe place in which to live. EVIDENCE: The Home is situated in extensive grounds which provide most residents’ rooms with pleasant views of the gardens and the wildlife to be seen. In the last twelve months several areas of the Home have been improved including refurbishment of the smoking room and redecoration of the Dining Room. Residents participated in the choice of colour scheme and redecoration of the laundry room. Two areas have been enclosed as store rooms for moving and handling equipment. There are plans to replace the upstairs corridor carpet and to enclose the raised patio area outside. Automatic door closers on all doors were in the process of being fitted, as well as lockable medication cabinets in residents’ rooms for topical medicines. All of the residents’ bedrooms seen were personalised. Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 16 The Home benefits from having various communal facilities, which are well kept, including a room where residents may receive visitors privately, a smoking room, hairdressing room and recently an activities area has been established. There is good lighting in corridors giving the Home a light and welcoming atmosphere. All the bathrooms and toilets seen were well appointed, clean and hygienic. There is a Maintenance Person who has worked in the Home for many years and staff are aware of infection control issues and work hard to keep a good standard of cleanliness and hygiene. Resident’s Comments: “I am looking forward to being able to have a walk in the garden” “I like my room” Relatives’/Friends’ Comment Cards: “The Home is very clean – no smell, which I think is very important.” “Facilities a bit dated….very homely, good atmosphere.” “Caring, friendly and open conditions make Aegel House a pleasant place for the residents.” Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the Home are satisfied with the delivery of care, but resolving staff shortages will improve the quality of the service and further ensure the safety of residents. EVIDENCE: All of the residents and relatives who were spoken to, together with the comment cards received, were complimentary about the staff team, many of whom have been employed in the Home for a number of years, which has helped provide the basis for stability. However, there were many comments from relatives and staff, as well as in comment cards that there are staff shortages, despite 30 hours guaranteed relief work hours being available. This was also identified on the day of the Inspection ‘peak’ times for activity, for example, just before meal times. The Manager said that she has identified some historical anomalies in staffing hours and would be reviewing the situation urgently. The AQAA also states that although staff absence records and follow-up procedures have been improved, there is the need to introduce a new staffing rota and There was recognition within the staff group that there were difficulties with staff shortages and the employment of agency staff. However, all staff spoken to were enthusiastic and enjoyed their work and said that their morale had improved with the appointment of a permanent manager, who was already taking a positive lead. Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 18 In view of the number of residents with high dependency needs, there is a requirement that the ratio of staff should be calculated according to the dependency needs of the residents, also taking into account the geography of the building. Staff files were examined and demonstrated that all of the documents and information needed prior to appointment were in place before a new member of staff started work. Staff have received training in Safeguarding Adults and all members of staff spoken to were aware of the issues involved. One member of staff spoken to said that she found her Induction Training effective and helpful and that she had completed it soon after commencing work. Staff files and staff spoken to provided evidence that further NVQ qualifications were being supported, together with computer and managerial training. However the recommendations from the previous inspection remain regarding NVQ and Induction training, when consideration is given to introducing the new staffing rotas. There is a keyworker system but one new resident did not appear to have been allocated a keyworker and there is therefore a recommendation that the keyworker system should be reviewed, in particular with regard to the development of a more structured activities programme taking into consideration each individuals’ needs and wishes. The evidence seen from staff files and from speaking to the staff that supervision takes place on a regular basis; there are sufficient handovers at the beginning and end of shifts together with staff meetings taking place on a regular basis to ensure that the on-duty staff are both enabled and competent to do their work. Relatives’/Friends’ Comments: “Staff very friendly and caring.” “In my opinion the staff are excellent and do provide a happy atmosphere, but must get frustrated that the system is asking them to provide more care than it is possible to give….more full time staffing.” “The staff work very hard and do their best, but they are very stretched”. “They need more staff, as sometimes they have a job to cope.” “More staff” was the answer to the question: How do you think the care home can improve? “There seems to be a problem at present with staffing levels; additionally I have noticed over the past 9-11 months that……there is an extra burden on carers….Carers cannot possibly provide all the support needed.” Staff Comments: “Good team…we get support.” Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although the Home has been well managed by temporary managers for some time, there is an improvement in morale for staff and people living in the Home with the appointment of a permanent manager, who is taking a positive lead. EVIDENCE: The new Manager, who had only been in post a few days at the time of the Inspection, has had several years experience in the care of older people, both in the public and private sectors. She will be undertaking her NVQ4 and has completed a course in the care of people with Dementia. It was evident from observation, talking to residents, staff and visitors that there was an improvement in morale in the Home and plans for moving forward. Since the last inspection there have been three Care Co-ordinators in place and staff are supervised regularly. Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 20 The quality of the service provided is monitored by the Local Authority which includes questionnaires to residents, their relatives and other interested parties. There are also staff questionnaires. A newsletter for the Home has recently been introduced and this is appreciated as a means of improving communications. Regular Regulation 26 visits take place and copies of these are sent to the Commission. A spot check was undertaken on the small amounts of monies kept by the Home for the residents. These were found to be in order and are also audited regularly by the Local Authority. Every resident has the facility for secure storage of valuables if required. Staff files contained evidence that all staff receive training relating to Moving and Handling, First Aid, Food Hygiene, Fire Safety and Infection Control; this was confirmed by members of staff spoken to. Accidents and Incidents were seen to be recorded and Regulation 37 forms are completed as appropriate. One of the Care Co-ordinators is taking on responsibility for Moving and Handling Training within the Home and, in conjunction with others, and has undertaken training in risk assessing the installation of bedrails. The Manager reported that a Fire Risk Assessment of the building was to be carried out in the next few days. Door closers were in the process of being fitted on all doors in the Home and other requirements from the Fire Officer’s inspection would be completed the following week. Fire Alarms are regularly tested. Staff Comments: “Nice to be settled with a permanent manager”. Relative’s Comment Card: “Aegel House now have a relations newsletter. I find this very helpful to keep me informed of up to date information.” Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 21 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 3 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 2 28 3 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 Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 22 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 OP27 Regulation 18(1)(a) Requirement Staffing ratios must be determined according to the assessed needs of residents and additional staff are on duty at peak times of activity during the day. This will ensure that the needs of the people living in the Home come first. Timescale for action 31/12/07 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 OP13 Good Practice Recommendations Consideration should be given to reviewing the role of the keyworker, particularly in relation to the activities programme, in order that individual needs, choices and rights of the people living in the Home are known, protected and promoted. Consideration should be given to developing the present activities programme in line with the needs, wishes and life histories of the people living in the Home. 2. OP14 Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 23 3. OP28 4. OP30 It would be good practice that care staff should continue to be encouraged to complete NVQ qualifications to further ensure that the staff group contains a larger percentage with this qualification. It would be good practice to continue to ensure that the time between commencing work and being offered induction training was as little time as possible. Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Aegel House DS0000035120.V351292.R01.S.doc Version 5.2 Page 25 - 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. 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