Inspection on 04/07/05 for Amerind Grove

This inspection was carried out on 4th July 2005.

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

Amerind Grove 07/01/09

Amerind Grove 17/06/08

Amerind Grove 28/08/07

Amerind Grove 06/12/06

Amerind Grove 01/08/06

Amerind Grove 26/01/06

Amerind Grove 25/01/05

Amerind Grove 09/08/04

Amerind Grove 23/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Amerind Grove 124-132 Raleigh Road Ashton Bristol BS3 1QN Lead Inspector Vanessa Carter Announced 4 - 8 July 2005 09:30 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 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. Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Amerind Grove Address 124-132 Raleigh Road Ashton Bristol BS3 1QN 0117 9533323 0117 9533406 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Bupa Care Homes Limited To be appointed Care home with nursing 150 Category(ies) of OP Old age (120) registration, with number MD(E) Mental Disorder -over 65 (1) of places MD Mental Disorder (30) DE Dementia (30) DE(E) Dementia - over 65 (30) Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate 120 Persons over 50 years of age receiving nursing care. Embassy House may accommodate up to 30 persons aged 65 years and over receiving residential care or nursing care. Embassy House may accommodate 1 named person with Mental Disorder aged 65 years and over, certificate will revert when this person leaves. Staffing Notice dated 13/8/1998 applies Picador House may accommodate up to 30 persons over 50 years of age with mental disorder excluding those detained under Section of the Mental Health Act 1983 or suffering psychotic illness. The Manager must be a Registered Nurse on Parts 1 or 12 of the NMC register The Registered Nurse in charge of Picador Unit is appropriately qualified to meet the mental health needs of service users who reside there. Picador House may accommodate up to 30 persons aged 50 years and over with Dementia (DE or DE(E)) Date of last inspection 25-January-2005 - Unannounced Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 5 Brief Description of the Service: Amerind Grove is a 150 bedded BUPA care home, situated in a residential area, approximately four miles from the city centre. The home is situated within walking distance from the local shops, and is on a local bus route. The home is a purpose built care home, designed specifically to meet the needs of elderly residents. There are five houses, each with 30 beds and its own character. Four are registered for nursing care and one for EMI nursing care. The home have currently made application to CSCI to increase the provision of EMI nursing places to 60, by changing one other house into a secure environment. All bedrooms are for single occupancy. The manager was appointed at the beginning of May, having previously been a home manager in another BUPA care home. She has made application to the CSCI for registration. Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over five days. Evidence was gathered from a tour of all five houses, a tour of the service area of the home, by talking to residents, their visitors, a number of the staff team and the house managers. The homes records were inspected and a sample of care planning documentation from each house. What the service does well: 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. Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 3 The home’s Statement of Purpose and Service User Guide are excellent, providing residents and prospective residents with clear details about the services available at the home. The home needs a more robust pre-admission assessment process, to ensure that placement is only offered to those residents whose needs they can meet. EVIDENCE: The Statement of Purpose has been updated to reflect the recent changes of Home Manager. Each of the residents, have an Information File placed in their room. In addition, the home has a brochure. This is provided to all prospective new residents, and copies are also displayed in the main reception area. The Home and House Managers each explained the homes processes in assessing and arranging admission of residents into the home. A pre-admission assessment is used. Some of those seen had only minimal information recorded, therefore it was difficult to determine how the assessor had made the decision that the home could meet the person’s needs. There is the Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 9 potential that placement could be offered in an inappropriate environment. All but one of the pre-admission assessments were unsigned and not dated. They were therefore invalid as they did not evidence they had been completed prior to admission. The home failed to meet this standard at the last inspection in January – further failure could result in enforcement action being taken against the home. Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The care planning system needs some amendment to ensure consistency throughout the home. Reviewing of the residents needs must be improved to ensure that residents are always provided with the care they need. Residents are in general well looked after in respect of their health and personal care, and are treated with respect and dignity. Medication is well managed. EVIDENCE: Three sets of care planning documentation were inspected in each of the five houses. The plans were recorded on a variety of different paperwork but the manager explained that the organisation is in the process of introducing improved documentation. In general the plans were well set out, and were supported with risk assessments in respect of pressure sore development, falls, nutrition and manual handling. A ‘Map of Life’ plan had been completed for each person that gave details of the residents past life and gave an insight into social activities they might enjoy. Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 11 The residents would benefit from a complete re-assessment of needs after a period of time (suggest 6 or 12 monthly), to ensure that documentation remains clear and concise, and any irrelevant information is removed from the residents file. The home complete a ‘Friends and Family’ care plan for each resident, and this was discussed with the management team. This is used to record family involvement and family contact. This document should be renamed accordingly, as it is not a plan that the care staff have to follow to ensure the residents needs are met. One person did not have a plan in respect of their mental health needs, and this was discussed during the inspection. Another person had a very dictatorial plan concerning ‘behaviour management’, and this needs to be rewritten in a more appropriate manner. Reviewing of these plans is generally undertaken on a monthly basis, but there were examples where changes to a persons needs had been detailed in the review but the plan had not been updated to reflect the changes. A number of care plans were written in ‘clinical terms’ and some care staff may not understand these. Care plans should be identifying those areas a resident needs assistance with, and the actions the care staff and the nurses need to undertake in order to meet those needs. Staff spoken with throughout the course of the inspection showed a very good understanding of the residents needs; this was particularly evident upon the dementia care unit. One part time staff member stated that she always ensured she was brought up to date regarding any changes to the residents, after a period of time off duty. The care planning documentation records all contacts with other healthcare professionals, including the GP dentist and optician. The care plan for one resident included the necessary items of equipment needed to maintain their comfort (for example - specialist air mattress). The wound care plans were detailed in respect of type of dressings used, but also need to state how often the dressings need to be renewed. Where appropriate the home have taken photographs of any wounds, having obtained consent to do so, for the purposes of monitoring progress. This had been required following the last inspection – the home has complied. The process for the ordering, receipt, storage, administration and disposal of medications was discussed with one of the Registered Nurses. A sample of medication administration charts was inspected, and appropriate recordings had been made where omissions to medications had been made. The Nurse explained the medication policy of the home. Each of the houses has a secure treatment room, where the drugs trolleys are kept when not in use. The home Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 12 must display hazard - warning signs at all times, where oxygen cylinders are stored or in use. A requirement was not issued in respect of this since the home made the necessary arrangements during the course of the inspection. One care assistant explained that in future, care staff will be expected to administer medications to those residents who are placed on a residential care basis (personal care only and not nursing care). The manager was reminded that only designated and appropriately trained staff could administer any medicines to these residents. This will be followed up at the next inspection, to ensure the regulation is being met. Residents spoken with during the course of the inspection gave a very mixed response about how they were treated and cared for by the care staff. One resident and their relative stated that on occasions staff have not been available to meet health needs promptly enough, and have had to wait to have call bells answered. Other residents were very complimentary about the staff, one stating ‘they can not do enough for me’. One resident said she was only ever dressed in her own clothes, and was called by the name she preferred. The nurses and care staff were seen going about their duties in a professional manner, knocking upon doors before entering, and being polite, kind and caring towards the residents. All residents stated that personal care was given in private. The bathrooms are all fitted with door locks and have a privacy curtain across the doorway, thereby shielding users from view if the door is opened. Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 Residents experience a stimulating and varied life at the home with visitors being able to visit the home as and when, and an improving standard of food being offered. EVIDENCE: There is plenty of evidence to suggest that residents are offered choice in how and where they spend their time, them being able to maintain contacts with outside interests, and in their choice of meals. One resident has an additional support worker to enable them to go out to the shops or other places of interest. Other residents were seen to be moving independently or with carers support, in between the different houses. One gentleman said he still goes out of the home on a weekly basis to the Stroke Club he attended prior to living in the home. The home has 3 full-time Activities Organisers, who provide a range of activities, in all five of the houses. A weekly activity plan is displayed in the reception area of each home. An exercise group was taking place on one of the inspection days and was an amusing event to watch. On another day a visiting harpist played for the residents. Those resident’s who lived in another of the houses, were assisted by the staff to attend these sessions. The activity plans for the preceding weeks also evidenced that this level of activity is normal. Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 14 Residents made many favourable comments about the activities arranged. One lady stated that some were ‘not her cup of tea’, and that she chose which ones she wanted to participate in. Some residents preferred to spend time in their own rooms, and were seen watching their own televisions, listening to music or the radio, or reading the daily newspaper. A newsletter is produced on a monthly basis by the activities team and is distributed to all residents. It details ‘dates for the diary’, recent events and changes to report, plus does a profile on a staff member and one resident. One person said they enjoyed reading it and were waiting for the next instalment. The residents are offered a choice of two main meals at the lunch time meal. The menu is varied and offers a range of nutritious and well balanced meals. One resident stated he gets a cooked breakfast of his choice every morning. There was a mixed response about the quality and standards of the meal, varying from good and bad, to satisfactory, to ‘just like you get at home’. One relative was concerned that on some occasions the sandwiches for the suppertime meal despite being covered, are not refrigerated when they are delivered over to the houses. Many residents stated that the standards of meals had improved recently, and they hoped that this continues. The home have recently employed a new Head Chef who has only been in post for a couple of weeks. Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The arrangements for protecting the residents are good however not all complaints are dealt with to a satisfactory conclusion, thereby meaning that residents and their representatives can feel they have not been listened too. EVIDENCE: The complaints procedure for the home is well displayed throughout the main reception area and all five of the houses. It is also included in the Service Users Guide supplied to all residents. Residents and relatives spoken with were aware of how to go about raising concerns. One resident said there was never any reason to complain however any grumbles she had, were always sorted out or an explanation given. One relative stated that they had had reason to raise concerns about the standards of care in the past and although improvements had been made they were short-lived. The relative stated that they had not received any correspondence following their complaint and this is contrary to the homes complaints procedure. An examination of the complaints log did not evidence that this complaint was recorded. For this reason, the standard is only partially met. The records of the most recently received complaint were examined and these showed that the manager has followed the complaints procedure of the home and brought about a satisfactory resolution for the complainant. This is the standard expected for each resident and their representatives. Staff spoken to during the course of the inspection demonstrated good awareness of adult abuse issues and talked of their responsibilities in protecting the residents from any form of abuse. Abuse awareness training Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 16 features during the induction and foundation training programmes and is also regularly discussed during training sessions. One staff member currently working on their induction programme made reference to the different types of abuse. Specific abuse training is arranged as part of the homes training plan. Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 22, 24 and 26 Residents are cared for in a comfortable and safe environment. It is well equipped however standards of hygiene are not acceptable in all parts of the homes EVIDENCE: Amerind Grove is a purpose built care home and is arranged as five separate single storey houses for 30 people each. The service facilities are all located in a sixth building. The grounds are surrounded by walled gardens, and the entrance has large steel gates that are locked over night. The houses are well maintained throughout and regular maintenance audits are undertaken. The records were inspected. The front doors to each of the homes are secured with a keypad door entry system, and all fire exits are linked into the call bell system. This creates a very secure environment for the residents. In addition, the dementia care unit Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 18 has wrought iron fencing surrounding the gardens thereby providing a safe place for those who like to wander. Each house has a large communal area consisting of lounge and dining area. The five houses, each have a different feel about them as they have been decorated in different styles. The manager stated that the company has corporate colours and wall coverings for all communal areas. Furnishings throughout the home, are homely and in good condition. The home is well equipped with a range of equipment to enable the care staff to undertake their duties and to move residents safely in line with good manual handling techniques. The manager explained that ‘disposable slings’ are available if residents have any infections, and this is good infection control management. The corridors in all five houses are wide and fitted with grab rails on both sides. Residents each have a single bedroom, with fitted wardrobes and a wash hand basin. Some of the bedrooms have recently been refurbished, whilst others need redecoration. The manager stated that the home is in the process of employing a decorator who will redecorate rooms in between residents. One resident stated they would like to have a locked drawer in their room to store valuables and this was reported to the manager. Not all parts of the home were in an acceptable state of cleanliness. The manager stated that they were soon to have a visit from the cleaning product supplier’s as there was concern over the effectiveness of the products. However, some of the cleaning practices seen in the home were inappropriate and do not comply with good infection control techniques. One room that had just been cleaned still had debris under the bed and this is not acceptable. Each house is supposed to have 10 hours housekeeping each day but care staff stated that on many occasions housekeeping staff are not available. The home manager is aware of these shortfalls and is currently looking to recruit a ‘temporary’ senior housekeeper, to cover sickness plus additional staff. For these reasons the home has only partially met this standard. Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 Residents are cared for by skilled and knowledgeable staff who are able to demonstrate a clear understanding of their roles. The arrangements for the induction of new staff are good. EVIDENCE: Registered Nurses and care staff from all five houses demonstrated their ability to do their jobs. The staff were enthusiastic about their work and spoke respectfully about the residents and their individuality. The care staffing levels appear to be appropriate from examining the duty rota but there was concern expressed by care staff and relatives about the numbers of housekeeping staff. Laundry and catering staff are provided in sufficient numbers. Staff turnover has been minimal for such a large home. Currently there are only 25 of care staff who have managed to achieve a NVQ Level 2 in Care, but further staff are working towards achieving this, and others are waiting to start. Some care staff have gone on and done NVQ Level 3. The home arranges for the staff to do ‘Personal Best’ training and this involves them adopting the role of the resident for a period of time, and experiencing Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 20 first hand what it is like to have to depend on another person. This is commendable. The home has robust recruitment procedures in place to ensure that the right person is employed by the home, ensuring the protection of the residents. They do this by asking prospective employees to complete an application form, provide two satisfactory written references, be successfully interviewed, and have a clear criminal record and POVAfirst check. Evidence was seen to confirm the home follows these procedures. All new staff have a three week induction period where they are supernumary and based in one of the houses, with a ‘mentor’. The house manager has taken the lead role to ensure that all new recruits are inducted properly, and this applies to both registered nurses and care staff. In the forth week the worker is allocated to the house in which they are assigned to work, and their induction programme is finalised. Two people who were currently in their induction period were complimentary about this system and stated they would be more confident once they finally started work. Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33 and 38 The manager is well supported by a senior staff team, but provides clear leadership. She needs to address the shortfalls in respects of health and safety as there is a potential for service users to be injured or become ill. EVIDENCE: The home manager has recently taken up her post and has made application to CSCI to become the registered manager. She is supported by one deputy manager, five house managers, plus a team of administrative staff. The manager is a level 1 registered nurse and has previously managed other care homes within the BUPA care group. The home manager gets a weekly report from each house and holds meetings with the managers on a monthly basis, enabling her to maintain an overview of how the whole home is performing. Audits are undertaken in a number of ways for example drug audits, care plan audits, staff sickness audits and Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 22 regular random ‘customer service audits’. The manager also stated that the new Head Chef will randomly select residents each month and ask them five ‘quality standards’ questions. A full Quality Assurance Audit was last completed in March and has resulted in a Development Plan being drawn. The manager and her team have already begun to address some of the issues raised. The home manager will be reintroducing Residents and Relatives Meeting now that she has settled into her post. The home were visited by the Environmental Health Department (EHO) in April, and a number of requirement notices were issued. Concern was raised about the standards of cleanliness in the kitchen and debris on the floor was noticed in between the food preparation areas and in the corners, on this inspection. The EHO also requested that the rear doorway into kitchen have an appropriate pest screen – this has yet to be actioned. The time span for both these issues was set at one month. The home has annual maintenance contracts in place for the servicing of the gas boiler, electrical wiring, electrical equipment, water supply, bathing and hoisting equipment. The records were seen. The home has a maintenance manager, newly appointed. He will undertaking all the portable appliance testing once he has received the appropriate training, but all equipment was currently up to date. He completes the random hot water testing and the records evidenced this is done on a regular basis. An inspection of the fire records evidences that all the weekly, monthly and quarterly checks are undertaken in respects of fire safety equipment. However there was no evidence to determine that staff had had the appropriate fire training. The manager must ensure that day staff receive instruction in fire safety on a six monthly basis and night staff on a three monthly basis. Discussions with staff supported that fire training has recently been overlooked. The manager must also ensure that storage of all cleaning products is compliant with relevant legislation – housekeepers must keep store cupboards locked at all times. Staff complete Health and Safety and Manual Handling training on an annual basis. Records evidenced this and discussions with the staff confirmed their awareness of relevant information. The home must ensure that consent is obtained where the use of bed rails is required to maintain a person’s safety – in general this had been obtained, but there were two examples where this had been omitted. Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 1 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x 3 x 3 x 2 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 Standard No 16 17 18 Score 2 x 3 3 x 3 x x x x 1 Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 24 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. 1. Standard OP3 Regulation 14 Requirement The home must ensure that detailed pre-admission assessments are completed for all residents and these should be signed and dated This requirement is being made for a second time Each resident must have a care plan for each identified need, and this should detail what actions the care staff need to take The homes complaints procedure must be used for all complaints made Good standards of cleanliness and hygiene must be maintained in all parts of the home, including the kitchen areas Day staff must receive fire training on a six monthly basis and night staff three monthly Risk assessments and consent must be obtained prior to the use of bed rails Timescale for action 08.08.05 2. OP7 15 08.10.05 3. 4. OP16 OP26 22 23(2)d 08.10.05 08.08.05 5. 6. 7. OP38 OP38 23(4)d 13(7) By 08.08.05 08.08.05 Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP7 Good Practice Recommendations The home should rename the friends and family care plan to reflect the purpose of the recordings. The home should keep detailed records of any person likely to leave the home, for identification purposes Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Amerind Grove D56_20371_AmerindGrove_229207_040705_Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!