Inspection on 03/04/07 for Aliwal Manor

This inspection was carried out on 3rd April 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Aliwal Manor 01/04/08

Aliwal Manor 02/08/06

Aliwal Manor 20/12/05

Aliwal Manor 20/09/05

Aliwal Manor 23/09/04

Aliwal Manor 20/04/04

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 Aliwal Manor Turners Lane Whittlesey Cambridgeshire PE7 1EH Lead Inspector Nicky Hone Key Unannounced Inspection 3rd April 2007 1:10 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 Aliwal Manor DS0000015291.V335295.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. Aliwal Manor DS0000015291.V335295.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Aliwal Manor Address Turners Lane Whittlesey Cambridgeshire PE7 1EH 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) 01733 203347 01733 203566 Aliwal Healthcare Ltd ***Post Vacant*** Care Home 30 Category(ies) of Dementia - over 65 years of age (9), Old age, registration, with number not falling within any other category (30) of places Aliwal Manor DS0000015291.V335295.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2006 Brief Description of the Service: Aliwal Manor is a care home providing accommodation for up to thirty older people. The home is situated in the town of Whittlesey, Cambridgeshire with good access to local facilities, such as shops, churches and pubs. The city of Peterborough, with its wide range of leisure facilities, is within a 10-minute drive. The home is divided into four separate units: Wordsworth, Shelley, Byron, and Tennyson, one of which is for nine people with dementia. One unit is upstairs, accessed by a lift or stairs, and is for people who are more independent and need less staff support. Each unit has its own lounge, dining area and kitchen where snacks and drinks are prepared, and a number of bedrooms. The main meals are prepared in the central kitchen and there is a main laundry room. There are an adequate number of toilets and the home has five large bathrooms, with assisted bathing equipment. There is a separate shower room. The home employs an activities coordinator who works at the home for four hours a day. There is a large lounge in the centre of the home which is used as a day centre by people in the local community on two days a week and can be used by people living in the home. The fees for accommodation and care at Aliwal Manor are £350 for residential care and £415 for dementia care. Twenty four of the places are block-booked by Cambridgeshire County Council, with the other six available to people who fund their own care. Private fees are £400 to £475. In addition, residents pat for items of a personal nature, such as toiletries, newspapers, hairdressing, chiropody and so on. The Commission for Social Care Inspection (CSCI) produces a published report following each key inspection. These reports are available in the foyer of the home. Aliwal Manor DS0000015291.V335295.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. We carried out an inspection of Aliwal Manor using the Commission for Social Care Inspection’s methodology. This report makes judgements about the service based on the evidence we have gathered. Before the inspection we sent a questionnaire to the manager for her to give us some factual information about the service. We also sent some survey forms to the manager for her to give to residents and their relatives. We received eight responses from residents, and seven from relatives. Our evidence also includes an inspection of the home which we carried out on 03/04/07. During our visit we spoke with service users, staff and the manager, had a look round the building and checked some of the records kept by the home. There were 28 service users in residence, all over 65 years of age. Since the last inspection, Mrs Margaret Charles has been appointed as the manager of Aliwal Manor. Although she is not yet registered with the CSCI, she is referred to as ‘the manager’ throughout this report. What the service does well: The responses to the survey we sent out showed that generally residents and their relatives are satisfied with the service they receive. One person wrote “The welcome I received helped me so much. The staff and carers are so kind and helpful. In fact it seems more like home from home or a very good hotel”; and another “I am very happy here”. Residents are able to make a number of choices about the way they lead their lives and people we spoke with and saw on the day we visited the home seemed content. The atmosphere in the home was relaxed and relationships between residents and staff appeared to be caring, warm and respectful. Full assessments are carried out before people move into the home, to make sure their needs can be met. Visitors are made welcome at Aliwal Manor and their views are asked for and acted on whenever possible. The company carries out a survey of the views of residents and their relatives and publishes the responses in a report. Aliwal Manor DS0000015291.V335295.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Five of the six requirements from the last inspection which had not been met related to the environment, most of which was not within the manager’s control. We felt she had tried to get the issues resolved but had not been supported by the company to do so. This inspection has resulted in twelve requirements being made (including the six carried forward). The home’s Statement of Purpose and registration state that there are nine places at Aliwal Manor for people with dementia. On the day we inspected there were nineteen people with dementia which means the home was not operating within its Statement of Purpose. Several areas of carpets were very dirty and stained; some areas of hard flooring were badly damaged; one of the unit kitchens was dirty; some minor maintenance issues were identified; and the shower did not work. The outside of the home was not clean and tidy, and there was an unacceptable smell in several areas of the home. Due to the additional number of people with dementia who live at the home, there are not sufficient staff on duty. Some prescribed creams were not stored securely as they were on a shelf in the fridge in one of the unit kitchens. Chemicals were stored in an unlocked cupboard under one of the unit kitchen sinks. The fire alarms had not been Aliwal Manor DS0000015291.V335295.R01.S.doc Version 5.2 Page 7 tested weekly as required. The last fire drill had identified that staff were not sure of the procedure to follow, yet no further drills had taken place. 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. Aliwal Manor DS0000015291.V335295.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 Aliwal Manor DS0000015291.V335295.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): 1, 2, 3, 6 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Full assessments of each new resident’s needs are taken into consideration before the person is admitted so that the person knows the home will be suitable for them. The statement of purpose did not contain accurate information. EVIDENCE: The home has a statement of purpose and service user guide, both of which had been recently updated and were on display in the entrance hall. We became aware during our inspection, however, that several residents with a diagnosis of dementia had been admitted to units other than the one designated for dementia care. The manager said there were probably an Aliwal Manor DS0000015291.V335295.R01.S.doc Version 5.2 Page 10 additional ten residents. This means that the home was not operating within its registration, or within its statement of purpose. The manager told us that a new copy of the home’s Terms and Conditions had recently been drawn up for each resident and sent to the person’s relatives to be signed. Not all had been returned. Each new resident has their needs assessed both by their care manager (social worker) and by one of the senior staff from the home. The assessments are detailed and give a good base to develop the person’s care plan. Standard 6 refers to Intermediate care which is a service offered by some homes, giving short-term, intensive rehabilitation for people leaving hospital before returning to their own homes. This service is not offered at Aliwal Manor, therefore standard 6 is not applicable. Aliwal Manor DS0000015291.V335295.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The information in care plans has improved so that staff know how to meet everyone’s personal and health care needs. Medication practices are of a good standard so that medicines are dealt with safely. EVIDENCE: The manager and staff team have worked hard to make sure that each person has a detailed, meaningful and up to date care plan, which is regularly reviewed. The manager felt they have almost achieved this, although there is still more work to do, and the quality of the plans has to be maintained by regular reviews. We looked at the care plans for two residents. Each one consisted of an “Assessment and Carer’s Guide” which gave a brief summary of the person’s needs, and a detailed care plan. The brief summary gives an ‘at-a-glance’ Aliwal Manor DS0000015291.V335295.R01.S.doc Version 5.2 Page 12 view of the person: each section is then repeated in the care plan, with detailed guidance for staff. We also looked at the care plan for a person having a respite stay at Aliwal Manor, which consisted only of the “Assessment and Carer’s Guide”. This was completed fully and we considered that it gave staff adequate information to be able to care for the person in the way they wanted. One person’s care plan showed that staff are paying a lot of attention to controlling the pain s/he is in. This included a new observational tool for the staff to use, as the person is unable to say when s/he is in pain. A chiropodist visits the home regularly and people go to the dentist when they need to. People are assisted if needed to see an optician. The manager said she is considering using the services of a mobile optician which would visit the home each year. One person commented on the survey that they have to pay for an escort for hospital visits. The home uses the Boots Monitored Dosage System to administer medication. Staff are trained to administer the medication from trolleys which are securely attached to the wall in each dining/kitchen area. We checked Medication Administration Record (MAR) charts in two units. Recording was done well, with no gaps, and clear reasons were recorded if a medication had not been given. One person told us he did not want to take control of his medicines but was happy for staff to give them to him. The Controlled Drug record was correct. Three tubes of prescribed cream were on a shelf in the door of the fridge in one of the unit kitchens. Creams do not always need to be stored in a fridge, but if they do, they must be in a locked container. Our observation, and responses to the survey, showed that staff treat service users with respect. Aliwal Manor DS0000015291.V335295.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have a wide range of choices available to them so that they have some control over their lives. EVIDENCE: The manager told us that the amount and range of activities for the residents has improved, and the activities coordinator has been working on building up an activities programme. Outside entertainment is brought into the home once a month, and a fund-raising event is held every other month. The activities coordinator leads some group activities and also spends one-to-one time with each resident each month. One person told us there is often something going on but s/he chooses not to join in, preferring to read a newspaper or watch TV. A day centre for people from the community runs in the central lounge on two days a week: residents are encouraged to join in with whatever activities are taking place. Aliwal Manor DS0000015291.V335295.R01.S.doc Version 5.2 Page 14 There is a trolley shop which goes to each unit, offering residents the chance to buy personal items such as toiletries, crisps, sweets, birthday cards, fruit and so on. The week before our inspection there was a big party in the day centre for one of the resident’s 80th birthday, and we were told that all the residents eat together in the day centre on special occasions such as Christmas Day, Easter Sunday and Bank Holidays. Four of the eight residents who responded to our survey ticked ‘always’ in response to the question about whether the home provides suitable activities, and four ticked ‘usually’. All of the people who responded to the home’s own questionnaire said there is a range of activities available. Visitors are made welcome at the home and included in residents’ lives if the resident wants them to be. Visitors know that they can make themselves a drink if they would like one, in the unit kitchens. All eight residents who responded to the CSCI survey, said that they always like the meals at the home. One person wrote “We have a very good cook here”; and another “Meals are of good quality and a choice of 2”. One person we spoke to said “The cook is very good and the food’s very good. There’s a choice of two things everyday, and a roast twice a week. We decide what we want the day before and there’s other things (such as jacket potatoes, salad or omelette) if you don’t like the two choices”. This person also told us that residents could have a cooked breakfast every day if they wanted to. S/he chooses not to, preferring to have grapefruit, cereal (or porridge) and toast. The cook also told us that very few people ask for a cooked breakfast, preferring to have a “fry-up” occasionally for lunch. The menus we saw showed that a wide variety of nutritious meals is offered. The meal on the day we visited the home was quiche or fish-cakes. A choice of light meals, such as beans on toast, egg and chips, bacon sandwiches and tea-cakes is available for the meal at 5.30 in the evening. The home uses local fruit and vegetables, and homemade cakes are always available for tea. The kitchen was very clean and all the store cupboards, fridges and so on were well organised. Good records are kept, including daily temperatures of hot and cold food, fridges, freezers and so on, and a detailed record of the meal provided for each person. Aliwal Manor DS0000015291.V335295.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are confident that their concerns will be listened to and acted on, and that staff have received training to make sure that residents are protected from harm. EVIDENCE: The manager has set up a folder to store all information about complaints and compliments received. There have been two complaints since she started and both have been responded to appropriately. Several compliments have been received. Residents said that they are happy to approach the staff, the team leaders or the manager. One person remembered being given a copy of the complaints procedure. The manager told us that one of the team leaders is undertaking training so that she can train the other staff in Protection of Vulnerable Adults. Eight staff were booked onto a POVA course at the end of April: once they have done this, all staff will have had POVA training. Aliwal Manor DS0000015291.V335295.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, 21, 24, 26 People who use this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some areas of the building are not maintained or cleaned well enough to make sure residents have a clean, comfortable, well-decorated home, which smells pleasant. EVIDENCE: It was very disappointing to find that the physical environment had not improved since the inspection in August. For example, some of the carpets were stained badly and had patches of ground-in dirt; some areas of hard flooring had patches of the flooring missing; one of the unit kitchens was very Aliwal Manor DS0000015291.V335295.R01.S.doc Version 5.2 Page 17 dirty (sink, walls, radiator); and one of the raised toilet seats seen was old and stained. We considered that some of the issues to do with the environment were out of the manager’s control and that she had not been given the support she needed by the company to rectify the defects. The grounds outside the home had been slightly improved but will need more work to make them pleasant for the residents to use in the summer. The porch at the entrance to the home looked unclean, shabby and not welcoming. The manager had completed a maintenance plan when she started work at the home, and had updated it in March 2007. She has asked the company to replace all the corridor carpets, and to replace carpets with hard flooring in some of the bedrooms. She feels that this is the only way the smell in the house will be eliminated. Residents are encouraged to bring personal possessions into their rooms and some of the rooms we saw had various items of the person’s furniture, pictures, ornaments and other possessions. One person told us s/he gets two baths a week, which is enough, but would have a shower every day if the shower were working properly. On the day we inspected there was a strong smell of urine in several areas, including in the entrance hall. One of the complaints received by the home was about the smell in the home and one person who responded to our survey wrote “A strong smell sometimes emanates from dirty washing in linen trolleys in the corridor”. Aliwal Manor DS0000015291.V335295.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are recruited well and receive good training opportunities so they can do their jobs well. There are not always enough staff to meet residents’ needs. EVIDENCE: Staff rotas show that there are usually two staff in the dementia care unit and one in each of the other two units on the ground floor. The team leader is the fifth member of staff and checks on the people in the upstairs unit who are more independent, as well as running the shift. This level of staff is the same each day. An activities coordinator works four hours a day, plus a longer day on Tuesdays to run the day centre. On the day we inspected the home one of the staff covering the two units downstairs was from an agency and this was the first time she had worked at the home. She had to ask questions of the staff member in the next unit as she did not know where things were kept, nor did she know each individual resident’s needs. Aliwal Manor DS0000015291.V335295.R01.S.doc Version 5.2 Page 19 We are concerned, especially as there is now a high number of people with dementia in these two units, that this level of staff is not sufficient to make sure people’s needs are met and they are kept safe. Six out of seven of the relatives who replied to our survey said there are enough staff on duty, and one person said there are not. Additional staff have been employed to assist in the kitchen: the cook told us this is a great improvement. Since the manager took up her post in August 2006 she has worked hard to make sure that all staff have received all the necessary training, and to set up records to show that this has happened. Each staff member now has their own training folder and the manager keeps a matrix which shows at a glance who has done which training and when. All staff are completing (or have completed) an induction workbook, to make sure everyone has done the same induction. As well as this, since August most of the staff have done training in safe moving; food hygiene; health and safety; infection control; POVA; dementia; and fire safety. Of the 22 care staff who work at Aliwal Manor, 12 have been awarded a National Vocational Qualification (NVQ) level 2 or 3 in care, and 2 staff are registered to start. Two of the staff completed the NVQ 2 in six weeks. The personnel file of a member of staff who started working at the home in February 2007 was checked. The file was in excellent order, with all documents filed neatly and easily accessible. All the required information had been obtained before the person started work, except for the Criminal Record Bureau check. The manager said the person will continue to be supervised until the CRB disclosure arrives. Aliwal Manor DS0000015291.V335295.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, 36, 37, 38 People who use this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management of this home has improved but more work is still needed to make sure residents are kept safe. EVIDENCE: The current manager, Margaret Charles, started work at the home in August 2006. Since then she and the staff team have made great strides in improving the service offered by the home. She has had to overhaul and update many of the systems that were in place, for example care plans, and has had to start from scratch in some areas such as staff training as no records were found. She is aware that there is still some way to go in some areas, but feels she has a strong staff team to support her. Aliwal Manor DS0000015291.V335295.R01.S.doc Version 5.2 Page 21 The manager is registered to start NVQ 4 and the Registered Manager Award. She is not yet registered with the CSCI. One person we spoke with told us that residents’ meetings are held regularly. This person said “They are very useful meetings – things get sorted”. The home sent out fifty two questionnaires to residents and relatives in January 2007: thirteen were returned. The results were collated into a report, using pie charts to show the responses to each question. All comments made were also recorded. There were two positive comments and sixteen comments for improvements. The manager contacted some of the people who had raised a concern so that the matter could be discussed with them; some issues were discussed at a relatives’ meeting; and she drew up an action plan to address all the issues. The report was bound and was available in the foyer of the home, and a copy was sent to the CSCI. The home does not hold cash for any residents, and the only involvement in any aspect of residents’ financial affairs is that personal allowance for a few residents is banked weekly. The manager told us that all staff are having regular supervision: they now sign a record each time they have a supervision session. Some chemicals were found in an unlocked cupboard under the sink in one of the unit kitchens. The chemicals were not in their original containers and we were not able to identify what they were. The manager was asked to immediately make sure all chemicals are stored securely. We saw some items of portable electrical equipment with recent stickers on them, showing that testing had been carried out in January 2007. We also saw certificates showing that hoists, the lift and all fire extinguishers had been serviced and/or checked as required. Hot water temperatures at all taps are recorded monthly: the record showed that the temperatures have been within acceptable limits. We checked records of tests of the fire alarm and emergency lighting systems. The fire alarms had not been tested weekly as required; only three tests had been done since 05/02/07 (9 weeks). An immediate requirement was left at the home. A fire drill had been carried out on 05/02/07 and a note made that more drills are needed as some staff were unsure what to do. No further drills had been done. The Environmental Health Officer had visited the home in February 2007 and was pleased with all aspects of the kitchen. Data sheets for all the chemicals used in the home (COSHH data) were available for staff. Aliwal Manor DS0000015291.V335295.R01.S.doc Version 5.2 Page 22 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X 2 X X 3 X 1 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 2 X 3 X 3 3 2 2 Aliwal Manor DS0000015291.V335295.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 2 Standard OP1 OP9 Regulation 4 13(2) Requirement The home must work within its Statement of Purpose. All prescribed medicines (including creams) must be stored safely. The registered person must ensure that the home is kept well-maintained. Defects must be rectified. This was a requirement following the previous inspection. The timescale of 30/09/06 was not met. Carpets identified as stained must be cleaned or replaced. This was a requirement following the previous inspection. The timescale of 31/12/06 was not met. External grounds must be appropriately maintained. This was a requirement following the previous inspection. The timescale of DS0000015291.V335295.R01.S.doc Timescale for action 31/05/07 03/04/07 3 OP19 23(2)(b) 31/05/07 4 OP19 16(2)(c) 30/04/07 5 OP19 23(2)(o) 31/05/07 Aliwal Manor Version 5.2 Page 24 31/08/06 was not fully met. 6 7 OP21 OP26 23(2)(j) 23(2)(d) The shower must be repaired All parts of the home must be kept clean. This was a requirement following the previous inspection. The timescale of 30/08/06 was not met. The premises must be kept free from offensive odours. This was a requirement following the previous inspection. The timescale of 30/08/06 was not met. There must always be enough staff working in the home to meet the needs of service users. This was a requirement following the previous inspection. The timescale of 30/08/06 was not met. Tests of the fire alarm system must be carried out as required. An immediate requirement was left at the home. Fire drills must be carried out regularly so that all staff know how to respond in case of fire. Chemicals must be stored safely. An immediate requirement was left at the home. 31/05/07 31/05/07 8 OP26 16(2)(k) 30/04/07 9 OP27 18(1)(a) 31/05/07 10 OP38 23(4)(c) (v) 04/04/07 11 OP38 23 (4)(e) 31/05/07 12 OP38 13(4) 03/04/07 Aliwal Manor DS0000015291.V335295.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. Refer to Standard Good Practice Recommendations Aliwal Manor DS0000015291.V335295.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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. 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