Inspection on 09/07/07 for Amberdene Lodge

This inspection was carried out on 9th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Amberdene Lodge 08/07/08

Amberdene Lodge 02/07/06

Amberdene Lodge 20/10/05

Amberdene Lodge 21/06/05

Amberdene Lodge 11/11/04

Amberdene Lodge 20/07/04

Amberdene Lodge 09/02/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Amberdene Lodge Amberdene Lodge 40-42 Boulevard Hull East Yorkshire HU3 2TA Lead Inspector Janet Lamb Key Unannounced Inspection 9th July 2007 09:00 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 DS0000000832.V345397.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. DS0000000832.V345397.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Amberdene Lodge Address Amberdene Lodge 40-42 Boulevard Hull East Yorkshire HU3 2TA 01482 587774 F/P 01482 587774 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) Mr Graham Abel Elaine Kathryn Grant Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (25) of places DS0000000832.V345397.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd July 2006 Brief Description of the Service: Amberdene is a large care home comprising of two Victorian houses on The Boulevard, off Anlaby Road in the west of Kingston-upon-Hull. Local services on Anlaby Road include a chemist, a GP surgery, taxi office, pubs and the Hull Royal Infirmary. Bus services to the city centre and out of the city are a short walk away. The home provides care and accommodation for a maximum of 25 older people, who may have dementia. The minimum and maximum charges for the home are £293.50 and £376.00. There are thirteen single rooms and six doubles on two floors, accessed via a passenger lift. None of the bedrooms have en-suite. There are three bathrooms and nine WCs. The home has two lounges and a dining room. There is a garden to the rear of the house, which is accessible via a concrete ramp. There is parking for two cars at the front of the building. DS0000000832.V345397.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 Amberdene has taken place over a period of time and involved sending a request for information to the home in May 2007 concerning service users and their family members, as well as staff and details of the home’s policies, procedures and practices. The Commission received the requested information in June 2007 and questionnaires were then issued to all service users and their relatives, their GP and any other health care professional with an interest in their care, to social service departments commissioning their care and to the staff working in the home. 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 9th July 2007 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. The communal areas of the home were viewed, along with two bedrooms A total of four service users and two staff were interviewed and the manager and one relative were asked to provide information or were spoken to during the site visit. All of the information collected was checked against the information obtained through questionnaires 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, having been given good information on what the home is like and what to expect, and they are provided with a good care plan for staff to follow. They are very 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 self medicate under safe practices or have their medication handled by the staff in the home, and the staff follow robust practices and procedures. The service handles medication extremely well and staff are well trained in medication administration. Service users experience good levels of privacy, have their dignity maintained, and their right to make decisions is respected. DS0000000832.V345397.R01.S.doc Version 5.2 Page 6 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 very good food, which matches their expectations and preferences, but also offers a satisfactory level of nutrition. Service users 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, as well as by the service’s policies, procedures and practice under the safeguarding adults’ systems. 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 service 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. DS0000000832.V345397.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 DS0000000832.V345397.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 only. Standard 6 is not applicable. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have their individual and diverse needs well assessed so they are confident needs will be met. They receive sufficient written information in the form of a statement of purpose and a service users guide so they can decide if the home is the right place for them. EVIDENCE: Service users, staff and the manager spoken to and files viewed with permission reveal the placing authorities undertake an assessment of service users’ needs before they take up residence in the home. These are used to aid the home manager in compiling a detailed plan of care. The assessment documents contain service users’ or their relatives’ signatures DS0000000832.V345397.R01.S.doc Version 5.2 Page 9 to show they have been involved in the process. Of the four service users interviewed two gave permission for their files to be viewed, but one was not very responsive to conversation. The fourth was not asked. One said, “I did have an assessment, I remember.” Another said, “If they let you look at my file it’s alright. I don’t mind.” Assessments include personal care, health issues, mobility, continence, medication taken, mental and social needs, safety and risk assessments and family member involvement. There is a statement of purpose and a service user guide in each service user’s room, one in the entrance hall and copies are also provided to relatives on admission of service users. Standard 6, intermediate care, is still not applicable. DS0000000832.V345397.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. People who use the service receive excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have their health and social care needs well documented in care plans, so they are confident all their needs will be met. They have good opportunities to self-medicate or their medication needs are well managed, and they enjoy good levels of privacy and their dignity is well maintained, so their overall quality of life is good. EVIDENCE: Discussion with service users, staff and the manager and viewing of files reveal all service users have a ‘community care’ care plan held on file and an Amberdene care plan that contains their picture, a signed letter that says they agree to the plan, and how to meet needs for such as personal care, health, mobility, nutrition, loss of senses, taking medication, social and mental health, religion, disability, ethnicity and culture. Where necessary care plans also contain risk assessment documents on falling, moving and handling etc. DS0000000832.V345397.R01.S.doc Version 5.2 Page 11 Service users are aware of care plans and know that daily diaries are maintained to show their progress, safety and wellbeing. Care plans are reviewed annually with the involvement of service users, their social services co-ordinator, and relatives etc. and annually with just relatives and staff in the home. These are recorded. Staff also review care plans monthly and make comments about continuity or changes that have been recognised. Service users with medical ailments or problems are referred to their GP, and the District Nursing services are accessed, along with outpatient services and treatment. All of these visits are recorded on file. The assistance of a social services’ dietician has been accessed since the last Commission visit to the home. Those service users with diabetes are receiving an improved service of health care because of it. One service user said, “I’m a tablet controlled diabetic, but I get offered certain foods as well. If I don’t like it I can have something else.” She was provided with low sugar biscuits for morning tea. Hearing, sight and dental appointments are carried out as necessary and such as physiotherapy is considered and tried. Chiropody services are also provided in the home. There is a policy, procedure and practice guidelines on medication administration for staff to follow. Handling and storage of medication is much improved and a robust medication administration trail is in place and followed. The home uses a pre-set controlled dosage system, and because there are some displaced service users due to the flooding, there is another system in place, which is also controlled but uses different containers. Service users spoken to are satisfied with the arrangements for their medication administration. One said, “I don’t want to look after my medicines, there are too many.” One service user having made comments on a questionnaire about not always having a sufficient supply in the home and having to go without for up to a week, was discussed with the manager. It is revealed that these comments were part of the complaint made in November 2006, and not new concerns. The manager assured the Commission that since the complaint and the random inspection no service user has run out of medicines because of the earlier requests for repeat prescriptions now being made. Discussion with the manager about requirements and recommendations set by the Pharmacy Inspector during the random inspection in March 2007 reveals that all of them are now being implemented or have been met. The local prescribing pharmacist has been very helpful and provided full assistance in reviewing the medication polices and procedures, in auditing the medication systems and in giving instruction to staff on administering medication. All senior staff have received training from Boots Chemist, the last ones having done this in May 2007, and they are also to do an accredited medication DS0000000832.V345397.R01.S.doc Version 5.2 Page 12 administration course starting in September 2007. Evidence of each requirement or recommendation met was seen. A medication administration round was observed and the carer made sure the medication she gave to each service user was correct, that they had water to take it with, that they took the drugs before she left them and that she then signed to say the drugs had been taken. She made sure the medication trolley was within her sights and was closed between administrations. Service users observed were treated with dignity during the site visit and those asked about their privacy said they have no concerns. Practice assisting with personal care was discreetly initiated. Some service users share rooms, but they are not unhappy about this. There are privacy screens in place. The manager explains that service users make telephone calls from the office if they do not have a phone of their own. Post is received unopened and family and friends can be seen in service users own rooms if they wish, but the tendency is to visit in the lounge and talk to several people. DS0000000832.V345397.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 and 15. People who use the service experience excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users enjoy flexible routines, good contact with relatives and friends, good opportunities to be selfdetermining, and highly satisfying food provision, so they are confident their daily lives and social activities meet their expectations. EVIDENCE: Discussion with service users, staff, the cook and the manager, viewing of files and menus and having sight of the mid-day meal, reveals service users daily lives and social activities are as they expect them to be. One service user, more active than the rest expresses the view that maybe there could be more to do in the home. This person often goes out with family, but said, “I do bingo sometimes, but there’s nothing else to do. I would like more, dominoes maybe, but the others are not able.” Another said, “The lasses are really good, you can have a laugh with them. I read a lot and like to go to the shops.” And a third said, “It’s okay here, though I’d rather be DS0000000832.V345397.R01.S.doc Version 5.2 Page 14 at home. Sometimes people cannot talk to you.” Service users say they have their nails painted, the hairdresser visits weekly, some watch too much television, and others like to knit. One is interested in gardening but only has a small plant in their room. The manager needs to look at other alternatives to keep service users occupied and entertained. There are some service users who are unable to make fully informed choices, but staff are sensitive to their needs and try to meet them respectfully. Service users wishes in relation to contact with family and friends are recorded in their plans of care. There are no restrictions on visiting unless imposed by the service users themselves. Bedrooms are used for receiving visitors or if preferred the lounges and dining room are available. Service users and the manager say they handle their own finances, wherever possible, or family members do. Some service users have a small amount of money held in safekeeping for which individual record books are kept, showing amount in/out, the balance and the signature of the service user. The hairdresser handed in a list of names of those she had seen and how much her service was for each. Service users say they are quite satisfied with these arrangements and are pleased they no longer have the responsibilities of budgeting and cooking etc. Service users spoken to were satisfied with the meals provided. Two said the food is not bad, another said, “Food is very nice here, you can have a choice and if you don’t like those you can have something else.” No adverse comments were made on questionnaires. The home is in good communication with a dietician and consults the visiting District Nurse about diets and controlling the sugar levels of those with diabetes. This is much improved since the random inspection. Discussion with the cook shows she enjoys her job very much and takes pride in what she produces. The mid-day meal was seen and looked appetising and nutritious. She is aware of the needs of those with diabetes and provides reduced and no sugar foods. At least three full meals a day are offered, one is always a hot cooked meal, and snacks are also available. Any religious or cultural diets would be and are catered for. One service user is from the Caribbean and sometimes prefers very spicy food, which is supplied where possible. Menus are produced after consultation with service users and take into consideration their likes and dislikes; menus are displayed, or explained to service users and these are changed according to requests or the seasons. Mealtimes are set, but in reality become flexible to accommodate service users individual needs. Service users have requested they have a ‘brunch’ each Saturday now and so this has been provided. There is a good choice of menu at teatime now also. DS0000000832.V345397.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 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users make use of informal complaint processes and systems and have all issues dealt with appropriately and they do not need to make many formal complaints, so service users are confident their concerns are dealt with effectively and efficiently. They also experience good promotion and protection of their welfare and so feel confident the systems in place to protect them are robust. EVIDENCE: Discussion with service users, staff and the manager and viewing of the complaint and protection systems documents reveal service users are generally listened to and well protected. Service users said they are often consulted about happenings in the home or changes that may be proposed, and they feel comfortable about making complaints. One said, “If I was unhappy I would tell them, I know the complaint procedure.” A relative visiting made comment that she had no worries about her mother living in the home, but would discuss them with the manager if she had. DS0000000832.V345397.R01.S.doc Version 5.2 Page 16 There has been one complaint received at the Commission since the last key inspection, concerning the management of medication and diabetes. This generated a random inspection including a visit from the Pharmacy Inspector in March 2007, and requirements and recommendations were made. These have all been looked at and discussed during this inspection and there is evidence to show they have now been met. Complaints are dealt with in the home usually without need to record them formally and service users say this works. Records show there have been four complaints made since the last key inspection. These were dealt with effectively and efficiently. Staff know the complaint procedure and that there are forms to complete if necessary. Staff have had training in safeguarding adults and know the procedures to follow should they have concerns or someone makes allegations. The safeguarding adults’ training should be updated to include the recent changes in the Safeguarding Adults’ Board protocols. Staff generally and overall from questionnaires and in discussion demonstrated a good understanding of protection and referral issues and procedures. Records show four there have been no referrals. DS0000000832.V345397.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have a well-maintained, clean and comfortable environment in which to live, so they are confident they have a good home. EVIDENCE: Discussion with service users and viewing of the communal areas of the home and three bedrooms with permission, reveals the living environment at Amberdene is suitable, well maintained and clean. The home is situated in a residential area along The Boulevard in Hull and is well maintained within a programme of routine maintenance. There is a rear garden for use by service users and this is accessed via a ramp, although few DS0000000832.V345397.R01.S.doc Version 5.2 Page 18 use it except on very hot days. The garden tends to be used little and the manager explains that the front of the house offers more activity in terms of ‘people watching’ and keeping an eye on what goes on. It is hoped a conservatory could be built to the front in the future with the aid of some government grant money that has been awarded. The building complies with the requirements of the local fire service and environmental health department. Service users commented on the cleanliness of the home in general and how their rooms are kept clean and tidy. The two communal lounges are opposite each other and lead easily to the dining room, all three acting as a focal point to the home. The home is clean and tidy in both communal and private areas and they are well maintained and welcoming. There is an infection control policy in place to protect service users from the risk of cross infection. Staff observed were using protective clothing, also to eliminate the risk of cross infection. The laundry is away from the kitchen and has separate access. It meets the Water Supply (Water Fittings) Regulations 1999 and provides sluicing and hand washing facilities. Some minor cosmetic repairs are needed to the tiling in several places and the space above the tiles now needs redecoration. The repairs will also improve the hygiene standards when cleaning down walls. The home accommodates needs of service users with diverse needs such as hearing impairment by providing a loop system on their telephone line, or physical disability by providing ramps to all areas of the house, and has such as grab rails, slide sheets, lifting belts and boards etc. DS0000000832.V345397.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users are cared for by well-recruited, well-trained, confident and skilled staff in satisfactory numbers to meet their needs, so they enjoy an excellent service of care. EVIDENCE: Discussion with staff and observation of some of their practice and interaction with service users shows they are a competent group of people that know their roles and responsibilities well. Staff are of mixed ages but work well as a team. They have a structure in place for senior carers and carers and have job descriptions and practice guidelines to follow. The rosters show who is working and when and according to the recommended Residential Staffing Forum figures, a minimum of 458.74 hours a week for 3 high, 17 medium and 4 low dependency service users, is needed. The home is meeting the needs of service users in respect of the number of care hours provided each week and because of the new service users in the home due to flooding there are now 490 care hours provided. DS0000000832.V345397.R01.S.doc Version 5.2 Page 20 There are 21 care staff employed, of whom 12 have completed or are soon to complete NVQ level 2, giving a figure of 57 with the award. This is satisfactory, but could be improved on. Staff confirm in interview their efforts to complete the award. Discussion with staff and viewing of files reveal recruitment is robust and protects service users. Identification information and details of security CRB checks undertaken are held on files in line with the requirements of schedule 2. Recruitment practices are satisfactory and standard 29 is being met. Information obtained from discussion and also from files shows staff undertake statutory training in fire safety, first aid, infection control, safeguarding adults, moving and handling, food hygiene, health and safety and medication administration if a senior, as well as in other relevant subjects such as incontinence, stroke awareness, etc. Staff are planning to do a course on diabetes and dementia awareness. The staff group are well trained and skilled in caring for older people. Standard 30 is met. DS0000000832.V345397.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users live in a home that is well run and in their best interests, where good systems are in place to determine the quality of the service, and where their financial interests are safeguarded and their health, safety and welfare are well promoted and protected, so they are confident they will be safe and well cared for. EVIDENCE: Discussion with the manager and staff, and viewing of documentation, safety records and certificates reveals, service users and staff benefit from a safe and well-run home. DS0000000832.V345397.R01.S.doc Version 5.2 Page 22 The manager has the Registered Manager’s Award, and has many years experience as manager of the home and constantly strives to improve her own knowledge and understanding of the care business for the benefit of improved services to service users. Standard 31 is well met. There have been no changes to the systems for quality assuring the service provided in the home since the last inspection except to improve on the surveying of stakeholders. Service users, relatives, health visitors and staff are all included in surveying for quality. An annual assessment has been carried out for the last 5 years or so and it looks at standards and key principles of care. There is an annual development plan devised each year and there is a residents’ bill of rights and a business plan to follow in respect of maintaining standards. The home intends to look at monthly assessments of different areas of care. Systems were not fully checked on this site visit, but the standard is considered met. Service users have control of their own finances, where possible, and if unable then their relatives do. Some have a small amount of money held in safekeeping for which the home maintains a record of money in and out, with signatures and running balance. These were not seen on the site visit, but service users spoken to explain how the system works and stated their satisfaction with it. The manager maintains a safe environment for service users and staff by ensuring all equipment is regularly serviced and certificated if necessary, by following all relevant legislation in respect of health and safety responsibilities, and by maintaining appropriate records of safety checks, etc. Areas sampled to determine whether or not standard 38 is met are, fire drills/safety equipment tests and systems, passenger and hoist lifting equipment, COSHH regulations and water temperature controls, have evidence to show the home is safe. There is a fire risk assessment in the home that is reviewed annually and that received approval by the visiting Humberside Fire & Rescue Service Officer in April 2007. This fire officer visit was the first for many years. Work recommended in the home, to upgrade all heat detectors to smoke detectors and to fit intumescent seals of fire safety exit doors, has been partly carried out. The home is yet to complete the fitting of the door seals, but this has been priced up and will be done once a carpenter is available to do the work – most are dealing with flood repairs around the city. There is a fire register kept by the front door and the home has notices to show where oxygen is stored and used. Weekly checks are carried out on the detecting equipment and recorded, and monthly drills are assimilated to test the knowledge and response of senior staff. A record of drills is also held. All DS0000000832.V345397.R01.S.doc Version 5.2 Page 23 staff undertook refresher fire safety training on 04/06/07, except the manager, one senior and two carers. The passenger and lifting hoist are maintained by H.S.B Horton and were last done on 11/05/07. There are cleaning material dilution instructions and risk assessments in place in a file in the laundry and staff are instructed to make sure all products are stored safely away. Water temperature checks are maintained and recorded appropriately. These are held in bathrooms so that staff can make the checks quickly and record them efficiently. Water temperatures are checked each time a bath is run for a service user and this is also recorded. A legionella check was not discussed, but the manager may wish to make sure such a test has been done and that a certificate or letter of clearance is available in the home. DS0000000832.V345397.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 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 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 4 DS0000000832.V345397.R01.S.doc Version 5.2 Page 25 No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 Refer to Standard OP13 Good Practice Recommendations The registered provider should try to offer a wider variety of activities in the home so that service users feel their lifestyle matches their expectations and satisfies their social and recreational needs. The registered provider should ensure the laundry is redecorated and that missing tiles are replaced, so that service user are confident they are living in a well maintained and hygienic home. 2 OP19 DS0000000832.V345397.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000000832.V345397.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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