Inspection on 25/06/08 for Arran Manor

This inspection was carried out on 25th June 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Arran Manor 24/08/06

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Arran Manor 55 Westmoreland Avenue Hornchurch Essex RM11 2EJ Lead Inspector Mrs. Sandra Parnell-Hopkinson Unannounced/Announced Inspection 09:00 25 June and 15th August 2008 th 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 Arran Manor DS0000065865.V370346.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. Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Arran Manor Address 55 Westmoreland Avenue Hornchurch Essex RM11 2EJ 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) 01708 452 765 01708 452 804 Ms Beverley Holmes Vacant Care Home 22 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (22) of places Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th August 2006 Brief Description of the Service: Arran Manor is a large converted house set in an attractive residential area within the London Borough of Havering. The home has a small car park and it is within walking distance of local bus routes and is not too far from Gidea Park Station. The home has a good-sized private garden to the rear with a patio. The home primarily provides care for older people, with a variation to registration to allow 5 people with dementia to live at the home. The home does not provide nursing care and does not take people who are wheelchair dependant. There are two lounges, two dining rooms and a conservatory. Accommodation is mostly in single rooms with en suite facilities but there are two double rooms with en suite facilities for people wishing to share. The current scale of charges is from £560.00 to £600.00 per week. There are additional costs for items such as hairdressing, toiletries, chiropody and newspapers. Information is made available to prospective service users via a Service Users Guide, which is available prior to admission and throughout the home, with copies in every room. Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means that people who use the service experience excellent quality outcomes. This inspection took place over a period of two days. The first day of the inspection, 25th June 2008, was unannounced and undertaken by another inspector who, due to unforeseen circumstances, was unable to do a report. Therefore, a further announced visit was made to the home on the 15th August 2008 to verify previous evidence gathered, to speak to the proprietor, new manager and residents in order to finalise the inspection process. The inspection process included information contained in the annual quality assurance assessment (AQAA), previous regulation 37 notifications and regulation 26 reports and a tour of the home. We were also able to talk with some of the residents and staff members during the visits. We case tracked 5 people who use the service, together with viewing staff rotas, training schedules, activity programmes, maintenance records, accident records and menus. We did not look at staff recruitment, safeguarding and complaints on these visits as these areas were the focus of a previous inspection which had taken place on the 9th May 2008, and this specifically looked at safeguarding. A separate report has been published on safeguarding, but the findings of that visit have been incorporated in the overall quality rating of this inspection. What the service does well: The service provides accommodation to a very high standard and the home is clean, odour free and very well maintained. Prospective residents and their families are given the opportunity to visit the home prior to making a decision to move in, and all new residents are given a contract, a service user guide and any other relevant information regarding the home. Residents told us that they were happy at the home, and that the staff were very kind and caring. One resident told us “the food is very good and there is always a choice.” Another resident told us “I can always see my GP if I have any problems but the care here is excellent.” The findings of the inspection on safeguarding showed that the safeguarding systems in operation at the home work well to protect people. Detailed safeguarding information is provided to staff who are knowledgeable about safeguarding matters and have received relevant training. Recruitment Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 6 procedures are robust with the necessary checks and references being obtained prior to employment at the home. 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. Arran Manor DS0000065865.V370346.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 Arran Manor DS0000065865.V370346.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): 2 and 3 (standard 6 is not relevant to this service) People who use this service experience good quality outcomes. We have made this judgement using available evidence including a visit to the service. Prospective residents and their relatives are given information by the care home, together with an invitation to visit the home at any time to enable them to decide if they want to live at Arran Manor. A comprehensive assessment of their needs is undertaken before moving in and all current residents have a contract stating the terms and conditions of residency at the home. This should ensure that people moving into the home know that their needs will be met. EVIDENCE: We looked at the files for 5 residents and were satisfied that a comprehensive pre-admission assessment had been undertaken before they moved into the home, and that each resident had been given a copy of the terms and conditions of living at the home, together with a service user guide. The home also, where appropriate, uses assessment information from social services to supplement the information they have gained themselves to ensure Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 9 that the service can meet the needs of the individual resident. On the day of admission, a senior member of staff is assigned to admit and help the new resident/s to settle at Arran Manor. A copy of the Commission’s previous report was also available to residents and prospective residents. On the second day of the inspection we were able to talk with a resident who came to live at the home on that day, and she confirmed that she had been given the necessary information before making a firm decision to live at Arran Manor. The statement of purpose and service user guide are reviewed as necessary, and each resident has a copy of the service user guide in his/her bedroom. Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 People who use this service experience excellent quality outcomes in this area. We have made this judgement using available evidence including a visit to the service. People can be sure that the health and personal care received is based on their individual needs. They can also be sure that they will be treated with respect, and that their dignity and privacy will be preserved at all times. People are enabled to make decisions about their lives with the necessary assistance from staff, and are able to take risks within a positive framework which considers safety issues while aiming to improve outcomes for them. EVIDENCE: We looked at the files for 5 residents and found that each person had a comprehensive care plan which gave a sense of the person and his/her needs around both health and personal care. Each file also contained detailed risk assessments where appropriate. We saw evidence that care plans had been agreed with the individual, and also with his/her family where necessary. Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 11 Care plans indicated religious needs, cultural needs, same gender care and sexuality. In discussions with staff it was evident that religious and cultural needs were understood and that every effort is made to ensure that these are being met. Same gender care is met whenever possible, and it is only in exceptional circumstances due to staff sickness that this may not be met. However, staff were able to show a positive understanding of the importance of this and would deal appropriately with a situation if a resident objected to the provision of different gender care. We saw that care plans are being reviewed monthly and that daily recordings are being maintained. Some of the staff have received training in monitoring blood sugar levels of a resident who is diabetic. We saw evidence that fluid intake of all residents is monitored during hot weather, and at other times if the need is indicated. Residents told us that their personal care support is flexible and changes to meet their needs. In discussions with staff it was evident that they were fully aware of a resident’s individual personal needs, and were also aware of the need to ensure that all residents were treated with respect, and their dignity and privacy preserved. A comment made by a relative was “Generally I think Arran Man or, its management and staff do a wonderful job and mum couldn’t be happier.” Another comment was “my mother is excellently cared for. I would not hesitate to recommend Arran Manor.” We also observed that staff were very alert to changes in mood, behaviour and general wellbeing of the residents, and we saw staff interacting very sensitively to a resident, who had dementia, and who was showing signs of distress. Within a short time the resident appeared much calmer and cheerful. The service keeps a hospital admission log, and a form is completed which accompanies any resident who has to go to hospital as an emergency. The service also undertakes a needs assessment when a resident is re-admitted to the home following a hospital admission. This assessment looks at any changes and includes areas such as increased personal care needs, condition of skin, dietary needs, sleep pattern, medication, mobility and communication. One resident returned from hospital with a pressure sore and is seen by the district nurse. There is a care plan in place which includes periods of bed rest, and the resident is responding to the treatment. Residents have access to his/her GP, chiropodist, dentist and other health and social care professionals. Weights are closely monitored with monthly audits being undertaken and referrals are made to the GP, dietician and/or nutritionist. Some profile beds have been purchased for those residents where the need has been indicated, especially to avoid people falling out of bed as such beds can be lowered to be nearer the ground. The use of assistive technology in the form of sensor mats is also used for some residents who are at high risk of falling, especially when in their own bedroom out of the sight of a member of Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 12 staff. The home also undertakes a monthly audit of any accidents that may have happened and use this information to ensure that practices are changed in order to reduce the risk of similar accidents occurring in the future. We looked at medication records within the home and these were found to be in very good order. The service ensures that all residents have a regular review of their medications with their GP. We found that there was a good management system in place for the auditing of medication, and that medicine administration records (MAR) were completed and complied with the medication stock. Staff spoken to and training records confirmed recent training in the administration of medication. If a resident has an allergic reaction to either medication or food then this is highlighted in bold on both the care records and the medication sheets. Care plans showed evidence that end of life wishes are discussed with some of the residents. Some residents do not wish to discuss these issues at the present time, but the service ensures that this area is kept under review. Where a resident wishes to remain in the home towards the end of their life, they are enabled to do so provided the right level of care can be provided by the GP, district nurses or other agencies as necessary. Residents and their families can be sure that their religious or cultural needs will be met and respected by staff who are proactive and sensitive to these needs. Arran Manor DS0000065865.V370346.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 this service experience good quality outcomes. We have made this judgement using available evidence including a visit to the service. People using the service are able to take part in appropriate activities within the home, and are encouraged to maintain personal and family relationships, which enable them to enjoy a meaningful life with all the rights and responsibilities of citizenship. They can enjoy well balanced meals in pleasant surroundings, and this means that their nutritional needs can be met. EVIDENCE: As part of the comprehensive assessment all residents, wherever possible, are encouraged to develop a brief life history which includes hobbies and other interests. This enables the home to provide appropriate activities for those residents who wish to participate. Staff also ensure that they have time to sit and talk to residents. The service arranges activities such as clothes parties, quizzes, entertainment from external entertainers, arts and craft, jigsaw puzzles and card games. In the near future a quiz has been arranged with the sister home, and this will be followed by an ethnic meal prepared by some of the staff who are from the Philippines. There are also some residents who enjoy doing baking and others who help to dust or hang out washing. Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 14 Although some residents access community services, for example a new resident still attends a day centre, the service has identified in its AQAA (annual quality assurance assessment) the need to develop more community activities for residents. This might include accessing public transport for visits to a local pub, shops, restaurants and theatres. However, some residents do now visit the very local shops assisted by a carer. A comment made on a survey carried out by the home was “I find it easier and more enjoyable to talk to the staff. Stimulating conversation or talks would be greatly appreciated.” Another comment was “mum would like more trips/entertainment during the year – she likes the clothes parties that are organised.” The home is also registered to care for people living with dementia, and many of the staff have undertaken training in dementia care. We observed staff interacting well with all residents, and all residents appeared well dressed and groomed. All rooms are fitted with a telephone point so that residents can have their own private line if they wish, and there are also television points/aerials in each of the rooms. One resident has Sky television in his room and he really enjoys spending time in his room watching the many different programmes. Some residents have newspapers delivered to them. Both lounges have a flat screen television which is visible for all of the residents wherever they may be sitting. Care plans showed that residents choose when to get up and go to bed, and some residents confirmed this to us during conversations with them. Currently all of the residents are white British and although some of the staff are from other races we are satisfied that the residents’ cultural and religious needs are being met. Although there are no formal religious services held at the home, residents are free to visit local churches and would be enabled to do this. Also some residents have a visiting priest or lay person to visit them and administer Holy Communion. Although we did not observe mealtimes, residents told us that they enjoyed the food and that they were given choices. We saw a full menu cycle and both the proprietor and some of the residents told us that they had been involved in a review of the menus. We are satisfied that currently residents are receiving a balanced diet which is nutritional. One comment made by a resident was “I love dinner times.” A comment made to the home by a relative during a survey undertaken by the service was “the only suggestion I can think of at this time is maybe providing a biscuit with afternoon tea as the residents ask for one most days that I visit.” We did see tins of biscuits on the tea trolley during our visit on the 15th August, and this was also discussed with the manager and the proprietor who told us that biscuits were always on offer. Meals are taken in pleasant dining rooms with tables that have been appropriately laid with cloths, cruet, napkins and cutlery. Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 15 Residents meetings are held on a monthly basis and minutes are kept of such meetings. Arran Manor DS0000065865.V370346.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): 16 and 18 People who use this service experience good quality outcomes. We have made this judgement using available evidence including a visit to the service. People using the service can be assured that they will be protected from abuse, neglect and self-harm through staff awareness, knowledge and ongoing training. People will be enabled to complain, listened to and complaints acted upon. EVIDENCE: We did not look at these standards at this visit because they were the focus of an inspection around safeguarding which had been undertaken by the Commission on the 9th May, 2008. A separate report has been published around these standards, but a comment received from the inspector who did the focused inspection on safeguarding was “Overall the inspection showed that safeguarding systems in operation at this service work well to protect people. Detailed safeguarding information is provided to staff. Staff are knowledgeable about safeguarding matters, including whistleblowing, and have received relevant training.“ The focused inspection also included an expert by experience and again comments were very positive around these standards. The home does have a complaints procedure and complaints are dealt with in accordance with this procedure and there are currently no outstanding complaints. Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 17 There are not any safeguarding issues at this home at the present time, and no complaints had been received by the Commission. Arran Manor DS0000065865.V370346.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): 19 and 26 People who use this service experience excellent quality outcomes. We have made this judgement using available evidence including a visit to the service. The home is clean and hygienic and provides a homely, comfortable and safe environment for the people living there, and any equipment necessary for the promotion of their independence is provided. EVIDENCE: We did a tour of the home which was very clean, odour free and decorated and furnished to a high standard. Most of the bedrooms have now been redecorated and refurnished and all bedrooms have en suite facilities. There are 4 double bedrooms but 2 of these are now used for single occupancy. The lounges and dining rooms have also been redecorated and new flat screen televisions have been purchased for both lounges. There is a conservatory which leads into the garden which is well maintained with pathways for the ease of residents. Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 19 Although pictures and ornaments are in place around the home, residents are encouraged to bring in their own personal items so that their bedrooms are personal to them. The refurbishment work is ongoing and the home does have plans to build to additional single premier rooms which will lead directly onto the garden. These rooms will maintain the home’s numbers because of the reduction in the number of double rooms. Fire safety systems were checked and seen to be in good order, and all bedroom doors are fitted with magnetic door closures which are activated by the fire alarm. The home has an up to date fire safety risk assessment in place. At the time of this inspection the front elevation of the home was undergoing a facelift. The manager undertakes a health and safety audit every month and this includes a walk around the home. Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 20 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 this service experience good quality outcomes. We have made this judgement using available evidence including a visit to the service. Staff in the home are trained, skilled and employed in sufficient numbers to meet the needs of the residents. Residents are in safe hands at all times and are supported and protected by the home’s recruitment policy and practices. EVIDENCE: Staff files were not looked at during this inspection as these were inspected as part of the thematic inspection which took place in May, 2008. At that time recruitment procedures were found to be robust with the necessary references and checks being undertaken prior to a person being employed at the home. Staff numbers at the home are sufficient to meet the assessed needs of the current residents, and there is little use made of agency staff. When agency staff are used the home endeavours to ensure that there is consistent staff supplied by the agency. This is because agency staff undergo the home’s induction training which is signed of by the shift leader, prior to them working with residents. The home also ensures that the agency provides information confirming that the necessary checks and references have been undertaken prior to them being put forward to work at Arran Manor. The home has a training programme and all staff undertake mandatory training in safeguarding, health and safety, fire, moving and handling and risk assessment. Other training is available and use is made of both internal Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 21 resources and external resources such as the local authority or local colleges. Also district nurses will give training when necessary around areas such as blood sugar monitoring. Currently 85 of staff have been trained to NVQ level 2 or 3. Staff also demonstrated awareness of equality and diversity issues in discussions with us. Residents told us that “the staff are lovely and kind and they are really good, nothing is too much trouble.” Arran Manor DS0000065865.V370346.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): 31, 33, 35, 36 and 38 People who use this service experience good quality outcomes. We have made this judgement using available evidence including a visit to the service. The service operates an open, positive and inclusive management style which is to the benefit of the residents. Their rights and best interests are safeguarded by the home’s record keeping, policies and procedures and by the proactive approach taken by the manager. EVIDENCE: Since the previous key inspection undertaken in August 2006, the proprietor stepped down from being the registered manager and employed a manager to manage the home. This manager was registered with the Commission but has now resigned. Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 23 The deputy manager has now been appointed as the new manager of Arran Manor, and he has the required qualification (Registered Manager’s Award) and experience to run the home and meets its stated aims and objectives. On return from annual leave, the new manager will be applying for registration with the Commission. We were able to observe that the new manager operates an open, positive and inclusive management style, and residents and staff benefit from this which was noticeable from the relaxed and homely atmosphere within the home. We were satisfied that the new manager has a clear understanding of the principles and focus of the service and works continuously to improve life for the residents. There also appeared to be a good rapport between the new manager and the proprietor, which, hopefully, will be to the benefit of the service. Equal opportunities are promoted throughout the service and all staff spoken to have a good understanding of the importance of person centred care and positive and effective outcomes for residents. The organisation generally has sound policies and procedures and most of these are reviewed as necessary and in line with changes to legislation and good practice. Health and safety issues are a priority at the home, and a monthly audit is undertaken which includes a tour of the whole home by the manager using a risk assessment form. Risk assessments are undertaken for residents and these are reviewed on a regular basis, or more frequently if the need is indicated. There is also a monthly audit undertaken of medication and weights of residents. Accident records were inspected and seen to be in good order with the manager undertaking a review of accidents on a monthly basis looking for trends etc. that could be addressed. These are part of the home’s quality monitoring system which also includes residents’ meetings, regular surveys sent to residents and relatives and feedback from visiting health and social care professionals. A sample of surveys were seen and generally the comments were very positive about the care, the environment and the management, as was the feedback in discussions with residents and staff. Maintenance records such as those for insurance, fire safety, gas, electric, insurance and water were viewed and these were found to be in good order. Quality monitoring visits required under the Care Homes Regulations, Regulation 26, are undertaken by the responsible individual and copies of these reports were available at the home. Regulation 37 notifications of significant events affecting a resident, also required under the Care Homes Regulations, are also sent to the Commission. Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 24 The home does handle monies on behalf or residents. This is managed through an account at the home with families giving the home cheques and the home paying chiropodists, hairdressers as necessary. A petty cash float is held should any residents want access to cash amounts. Records are held and these showed evidence of transactions and running balances and receipts are available. Requirements identified at the previous key inspection have been complied with. Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 25 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP33 Regulation 24 Requirement The registered persons must ensure that the annual quality assurance assessment (AQAA), required by the Commission on an annual basis, is comprehensively completed in accordance with the guidance available to proprietors and managers. This will ensure that the service demonstrates areas of good practice and areas for improvement. Timescale for action 31/03/09 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 OP12 Good Practice Recommendations As identified by the proprietor in the AQAA (annual quality assurance assessment) the service should continue to look at ways of including more community-based activities for the benefit of residents at Arran Manor. Arran Manor DS0000065865.V370346.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Arran Manor DS0000065865.V370346.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. 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