Inspection on 14/01/08 for Antokol

This inspection was carried out on 14th January 2008.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Antokol 10/06/08

Antokol 18/09/07

Antokol 10/08/06

Antokol 18/10/05

Antokol 27/06/05

Antokol 15/03/05

Antokol 26/10/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

CARE HOMES FOR OLDER PEOPLE Antokol Antokol 45 Holbrook Lane Chislehurst Kent BR7 6PE Lead Inspector Unannounced Inspection 14th January 2008 10:00 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 Antokol DS0000006883.V358135.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. Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Antokol Address Antokol 45 Holbrook Lane Chislehurst Kent BR7 6PE 020 8467 8102 020 8468 7190 antokolhome@btconnect.com 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) Polish Citizens` Committee Housing Association Limited Ms Alina Gaskin Care Home 34 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 34 18th September 2007 Date of last inspection Brief Description of the Service: Antokol is a large detached house built in 1905. It was extended in 1986 and can now provide care to thirty-four elderly Polish people living in this country. The home maintains the Polish traditions, which the residents were accustomed to in their younger days. Stairs and a lift access all areas in the home. All the rooms have wash-hand basins. The bathrooms, shower room and toilets are located on both the ground floor and first floor. Some of these facilities have special adaptations and equipment to meet the needs of the residents. On the ground floor there is a large dining room, a sitting room with a library, and a separate lounge, which has Polish satellite TV. A newly designated quiet room is now operational. Residents may have telephones in their own rooms at their own expense. A pay phone is provided for both incoming and outgoing calls. There is parking to the front of the building and some off street parking available. In 2007 the home varied its registration categories to admit Dementia residents and frail elderly residents. Staff are provided throughout the day including waking night staff. Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 5 The fees in this home range between £ 500.00 to £570.00 Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted unannounced over a one day period by two inspectors. The lead inspector was assisted by a Polish speaking inspector Mr Robert Sobotka to assist with interviewing staff and reading those documents, which were in Polish. The inspection was facilitated by the Manager Alina Gaskin and her Deputy. The inspector toured the premises including communal areas and individual bedrooms. During the tour the inspector met with and spoke to residents who could speak English. At the time of the inspection there were only three staff that could speak English, the two Managers and a senior care worker all of whom the inspector had met with previously. To obtain information from staff that could not converse with the inspector, staff surveys were provided to them. These were handed out and staff asked to get assistance in completing them and return them to the CSCI. At the point of writing this report 04/02/08 no staff surveys had been returned. There were no relatives in visiting or health professionals attending the home. The inspector sampled two care plans and the supporting documentation including that obtained prior to admission for assessment purposes. The medication systems including storage and record keeping were inspected. A selection of health and safety, service certificates as well as quality assurance audits were also inspected. Overall the level of care residents receive is good and this is enhanced by the staff and ethos of the home being fully reflective of their origins. This was confirmed by the feedback during the site visit . However there are areas relating to recruitment and training of staff that compromise the safety of residents. In some areas there needs to be improvement which are further detailed in the body of this report. Three immediate requirements were left as a result of this inspection. What the service does well: The service provides a good level of care for the residents who reside there. Equipment is provided and the home engages with specialist services to promote resident care. Feedback from health professionals stated improvement in resident’s physical health whilst living in Antokol. The residents are encouraged to participate in the home and do so. They are often Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 7 involved in light domestic chores, which they enjoy. There is a large garden, which is used by several of the residents. The Polish ethos running throughout the home enables residents to settle well in the unfamiliar surrounding. It was evident that residents have choice in their day and exercise their preferences. The home enables residents to maintain a level of independence within a supportive environment without fostering dependency. The home although not purpose built is maintained in a clean tidy and hazard free manner. Bedrooms were personalised What has improved since the last inspection? What they could do better: The home needs to ensure that all staff are subject to robust recruitment procedures including POVA and CRB checks. Within one personnel file it was evident that no POVA check had not been conducted prior to employment. The employee had commenced work in the home 27/12/07 however the POVA application was dated 10/01/08.All staff need to be subject to robust recruitment procedures including checks made under POVA and CRB clearance. In order to satisfy the requirements of Regulation 19 the Registered Person must ensure that all items as detailed in Regulation 19, and paragraphs 1-7 of Schedule 2, Care Standards Act 2000 are addressed. An immediate requirement was left regarding this issue. The records for the weekly fire alarm testing had not been completed since 9/12/07. The fire alarm must be tested weekly and records to evidence this retained. An immediate requirement was left regarding this issue. The medication administration records were seen to be signed in the presence of the inspectors, by the Deputy Manager. She was seen to sign all of the medication charts, whilst in the office, sometime after the actual administration of the medications. She admitted that this is what she was doing. Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 8 In addition in one resident’s room there were a number of homely remedies, on an accessible table, and which had no supporting records. Regulation 13 (2) states: “The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home”. All medications must be signed immediately following the administration of the medication. All homely remedies need to be safely stored and have full instructions for administration, with supporting risk assessments. An immediate requirement was left regarding this issue. 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. Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 9 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 Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although potential residents have an assessment undertaken by senior staff, essential information obtained through the Community Care assessment procedures was absent Rresidents therefore cannot be confident that their care needs will be met. EVIDENCE: Since the last key inspection the home has varied it’s registration to take Dementia residents. It is essential that with this type of resident that all information is obtained from the multi disciplinary team as the residents themselves will be unlikely to provide the information. At the time of the site visit there were 27 residents on site. The admission information for those residents newly admitted was inspected. The records consisted of an admission assessment summary, which included the residents past medical history, medications, known allergies, social care and leisure Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 11 activities. There was some good information relating to residents needs recorded such as one person required the use of a magnifying glass. There was a hospital discharge letter an application form for Antokol and admission checklist. The inspector was unable to locate the Community Care Assessment information or contract. The Manager advised the inspectors that this information is not always provided or in some cases there is a long delay receiving this from the referring authority. The Manager advised the inspectors that there is a specific contract for those residents who are privately funded. One was viewed and it contained the weekly charges room to be occupied and contact details of the CSCI. It was signed by the resident and the Manager. It was also difficult to establish what trial visits or visits undertaken by relatives had been made. Residents must be provided with information on the service including an up to date Statement Of Purpose and Residents Guide as well as opportunities to sample the services provided. Please see requirement 1. Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments are in place although require more comprehensive information to fully reflect the resident’s needs, particularly as some have complex needs and multiple diagnoses. Care plans are the basis on which staff address care, hence they need to be comprehensive. The practice of signing all medication charts following administration is unsafe and introduce an element of risk to residents. EVIDENCE: The care plans were inspected by the two inspectors as the care plans are written in both English and Polish. The daily events are written in Polish only hence Mr Sobotka read these. He related that the content of these was general and limited on the actual specifics of the care that individual required. The care plans are set out using a standard format. Clear photographs were attached to the file. Those inspected were completed although limited on the actual content. Dates and staff signatures were in place. Six monthly reviews Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 13 were indicated however the standard states that care plans should be reviewed at least once a month. A staff member interviewed said that one of her roles would be to update resident’s care plans on a six-monthly basis however she did not mention that residents would be involved in this process. Risk assessments for manual handling and a falls screening form were in use. The care plan of one resident inspected by the Polish inspector noted that there were inconsistencies between her Polish and English care plans. Specialised equipment for residents needs was in use including hoists, pressure relieving beds and adaptations. One staff member confirmed that a District Nurse visited the home daily. In some bedroom incontinence pads were clearly visible and these should be stored in an accessible place although out of sight. The medications were seen to be safely stored in a locked trolley. The home had no Controlled Drugs in use at the time of the site visit. Eye drops in use were dated on opening. Medication charts had all information recorded, The medication administration records were seen to be signed in the presence of the inspectors, by the Deputy Manager. She was seen to sign all of the medication charts, whilst in the office, sometime after the actual administration of the medications at 10.40 am. She admitted that this is what she was doing and stated that she was signing it now, as it was a busy morning and she did not have time to do it then. In addition in one resident’s room there were a number of homely remedies, on an accessible table, and which had no supporting records. Regulation 13 (2) states: “The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home”. All medications must be signed immediately following the administration of the medication. All homely remedies need to be safely stored and have full instructions for administration, with supporting risk assessments. An immediate requirement was left regarding medications. Please see requirement 2. Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a limited selection of activities provided in the home and little in the way of individual activities on a one to one basis. EVIDENCE: The lead inspector spoke to one resident who was confined to her bed. She confirmed that she was very happy living in the home and felt that the residents were well cared for. She felt the food was good and that there was always enough of it. She added that the GP and the dentist were very pleasant. One area, which caused her concern, was the staff shortages, which occurred at times. Polish newspapers and satellite TV are provided in the home. Comments received on the day of the site visit indicated that social interaction including talking to resident and 1:1 activities was limited due to staff availability. It is essential that residents be provided with not only physical care but also social and psychological stmulation. This is particularly true of those residents Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 15 who suffer Dementia and may require close observations, distraction techniques or specialist approaches such as validation therapy. The lunch time was a relaxed affair with traditional Polish food on the menu. Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents, staff and visitors are provided with information on how to make a complaint, however they cannot always confident that their complaints will be investigated fully or in a timely manner. EVIDENCE: The complaints procedure was on display and available within the Statement of Purpose. The policy on display was in both the English and Polish language. There is a complaints policy, which specifies response times for complaints. In the complaints file there was the information in relation to one complaint received 5/1/08, which the Manager advised had been passed to the Polish Citizens Committee for investigation and response. The Manager was unable to say if this had been acknowledged or whether the complaint had been responded to. This needs to be addressed and a conclusion reached. The home needs to develop a complaints log that incorporates the elements of the complaint action taken the response includes whether the complaint is satisfied with the outcome. Mr Sobotka interviewed two care staff in Polish. They both were aware of adult protection although had a limited knowledge on whistle blowing procedures. It is essential that staff who have a limited command of the English language, Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 17 have a full knowledge of all procedures to protect the residents and themselves. The Manager stated that all staff had received training on whistle blowing and this is part of their induction. This needs to be revisited. The safety of residents is further compromised by inadequate recruitment procedures please see comments under the section headed “Staffing “. Please see requirement 3. Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is an adapted building maintained in a clean and tidy manner and provides a homely environment. EVIDENCE: A brief tour of the premises was undertaken. Areas were clean and tidy. Bedrooms were personalised. Communal space had improved with an additional quiet sitting areas provided for residents offering a choice from watching the TV. On the top floor there had been a new bathroom installed which was suitable for those with mobility impairment. In this bathroom the lock needed to be changed to ensure that sufficient privacy is provided to the resident whilst in an emergency staff can easily access the area. Antokol DS0000006883.V358135.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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are insufficient staff to address residents needs. Staff are not subject to robust recruitment procedures hence this introduces an element of risk to residents. Training is limited and mandatory topics are not addressed at the stated intervals and could put residents at risk. EVIDENCE: At the time of the inspection the Deputy Manager was in charge with two care staff and a religious sister, Alina Gaskin the Manager arrived shortly after the inspectors. The two Managers felt that they were under pressure to cope with limited staffing levels and without adequate support. The Manager related to the inspectors that they were short of staff, and that they had one staff vacancy. One of the sisters had returned to Krakoff and it is not certain whether a replacement person was coming to Antokol. When asked to identify areas where staffing levels had impacted on resident care she said that staff were not able to interact with the residents and that they were rushed. This was confirmed by residents in the home. Mr Sobotka inspected the personnel files. In the file of the employee who commenced employment 27/12/2007,the following information was available: a job description, a copy of her British birth certificate and passport, a completed application form. In addition there were notes of the interview Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 20 assessment completed by the Manager. The CRB application form completed and signed on 07/01/08. The member of staff had started working on 27/12/07.The “POVA First” slip was completed and signed on 10/01/08, however at the point of the inspection no CRB or POVA First had been received. A second staff file had the application form completed in Polish on 15/04/07, and two Polish references dated 10/04/07 and 30/03/07.The CRB disclosure was dated 21/05/07and the POVA check completed on the 16/05/07.In addition there was a copy of the Polish police check, which was satisfactory, two photos, her national insurance number confirmed by way of a letter, a copy of the Polish Insurance card, a copy of the Polish birth certificate and two references from Poland (translated by a sworn translator). The training file contained certificates in the following: Health and Safety 13/09/07 Introduction to Dementia 07/09/07 Food Safety in catering 03/07/07, which expires 03/07/2010. Manual Handling 19/06/07 Fire Safety 01/12/07 Health and Safety at work Adult protection and Whistle blowing 3/05/07 A third staff file contained the following: An application form in Polish dated 03/02/05 Two references from Poland A copy of the Polish CRB A Polish medical letter confirming that the person was physically fit for the job. Photograph. A copy of a Polish birth certificate. A copy of a Polish passport. This staff member had evidence of the following training: Manual Handling 22/03/07. Fire safety update 07/12/07. Manual Handling 22/03/05. Infection control 23/11/06. Fire safety 3/05/06. In addition she had received instruction on use of the lift and Dementia training. Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 21 The induction booklet was completed on 30/12/07. There was evidence of supervision sessions conducted on the following dates: 01/06/05, 01/10/05, 09/01/06, although there were none on file since. In addition there was evidence of grievance procedures started 22/08/07 and resolved on 31/08/07. The personnel file of one of the Polish Sister’s was selected for inspection. It included CRB clearance dated 12/03/04, although there was no POVA check prior to this. Her file contained a photo, a copy of a Polish passport, and a copy of the Polish birth certificate. The Sister had commenced work in the home on 07/07/8. Her training records indicated the following : Fire Safety at work 01/12/07 Moving and Handling 23/11/06 Fire Procedure update– 08/10/06. It is recommended that CRB’s be repeated every three years. Mr Sobotka interviewed staff and evidenced that overall they had a good knowledge of the assessed needs of the residents accommodated in the home. One staff member had started working in the kitchen for the first two months and then became a care assistant. Another staff member interviewed also had a good knowledge of the resident population. They were aware of the dietary needs of the residents and their assessed needs. He said that due to staff shortages activities have not been taking place. He identified that he was no longer able to take residents out for walks etc. He was aware of adult protection issues, but knew little of whistle blowing. The inspector also felt hat he would benefit from training around sexuality and sexual orientation, in general equality and diversity topics. In February 08 two staff are due to attend health and safety and manual handling instruction. Since the last site visit three staff have attended basic food hygiene. In February 08 two staff are due to attend health and safety training. Three staff attended Dementia training November 07. One staff had attended depression training November 07,and two staff had attended a working with relative’s session. Five staff are first aid trained and updates took place November 07. The home is a member of the Bromley training consortium. An immediate requirement was left regarding CRB and POVA clearance for employees. Please see requirements 4 and 5. Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced individual. Health and safety measures are not sufficiently robust to protect residents. Quality assurances measures are limited and provide little opportunity for residents, staff and visitors to input into the future development of the service. EVIDENCE: A discussion took place around recruitment of the new Manager. A Gaskin stated that she had verbally informed the Committee that she would be taking up a new position with the Probation Service and will no longer be working in the home. She said that her position has not been advertised, however the Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 23 Committee has advertised for the post of the Deputy Manager this could not be explained by Ms Gaskin. A record of accidents kept in the home was appropriately maintained. The inspector checked the resident’s financial records. It was evident that resident’s signatures were in place for transactions. Petty cash vouchers were used as receipts for chiropody. The money was correct as stated on the balance sheet and receipts available to support the transaction. The inspector was unable to access the financial accounts for the home. These need to be forwarded to the CSCI for inspection. There had been no further progress made in respect of quality assurance measures. Both the Registered Manager and the Deputy Manager stated that no Regulation 26 visits have been taking place for a long period of time. The Manger confirmed that since the last key inspection all staff had been up dated in fire training and certificates were issued. The records relating to fire procedures were inspected. The records for the weekly fire alarm testing had not been completed since 9/12/07. The fire alarm must be tested weekly and records to evidence this retained. An immediate requirement was left regarding this issue. Service certificates for lifts and lifting equipment were current ,as was the gas and PAT testing. Please see requirement 6. Antokol DS0000006883.V358135.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 2 X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 x 3 X x 2 Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 25 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 OP3 Standard Regulation 14 Requirement The Registered Manager must ensure that all assessment information is received prior to admission. Evidence that residents have been provided with information and opportunities to sample the service must be retained . The Registered Manager must ensure that care plans and risk assessments are fully reflective of the individuals needs. The Registered Manager must ensure that a complete record of complaints received, action taken and outcomes is retained and that all complaints are responded to in the time frames stated in the standards. The Registered Manager must ensure that staff are provided in sufficient numbers to address residents needs. The Registered Manager must ensure that staff receive mandatory training up dates at regular intervals. The Responsible Individual must ensure quality assurance DS0000006883.V358135.R01.S.doc Timescale for action 30/03/08 2 OP7 3 OP16 15 30/03/08 22 28/02/08 4. OP27 5 OP28 6 OP33 Antokol 18 30/03/08 18 30/03/08 26 30/03/08 Version 5.2 Page 26 measures are in place including Regulation 26 visits and an annual review of the service. 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 OP29 Refer to Standard OP12 Good Practice Recommendations The Registered Manager should review the activities provision within the home. The Registered Manager should ensue that CRB’s are repeated ever three years. Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Area Office River House 1 Maidstone Road Sidcup London DA14 5RH 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 Antokol DS0000006883.V358135.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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