Inspection on 04/06/08 for Auburn Mere

This inspection was carried out on 4th June 2008.

CSCI found this care home to be providing an Adequate service.

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

Auburn Mere 13/10/08

Auburn Mere 06/06/07

Auburn Mere 20/06/06

Auburn Mere 08/11/05

Auburn Mere 05/05/05

Auburn Mere 22/11/04

Auburn Mere 01/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Auburn Mere Woodlands Oxhey Lane Watford Hertfordshire WD19 5RE Lead Inspector Jeffrey Orange Unannounced Inspection 4th June 2008 08:00 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 Auburn Mere DS0000019276.V365767.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. Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Auburn Mere Address Woodlands Oxhey Lane Watford Hertfordshire WD19 5RE 01923 247310 01923 247311 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) Trafalgar Health Care Marlene Kelly Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: There are none Date of last inspection 6th June 2007 Brief Description of the Service: Auburn Mere is a residential care home providing accommodation and personal care for up to 34 older people. It is owned and operated by Trafalgar Healthcare Limited, which is a wholly owned subsidiary of J. Sai Country Homes Limited. Auburn Mere is located in Watford Heath, on the outskirts of Watford. The home is about ten minutes walk from Bushey railway station and 3-5 miles from either the M25 (J19) or M1(J5) there is also a local bus service that gives easy access to Watford’s amenities. Auburn Mere is situated in extensive grounds with accessible seating areas that benefit from outstanding rural views. Accommodation is offered on three floors in single occupancy rooms, with three bedrooms large enough for sharing on a positive choice basis. The majority of rooms have en-suite facilities and there are bathrooms and toilets on each floor. The communal areas are well situated throughout the home and are of varying sizes. All floors are served by a passenger lift. Weekly charges range from £550 to £880, additional charges apply for newspapers, hairdressing and chiropody. (These details were correct at 04/6/08) The home has a service user’s guide and statement of purpose that are provided to prospective service users. Copies of the latest report on the home from the Commission for Social Care Inspection (CSCI) are available in the home. Auburn Mere DS0000019276.V365767.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 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection took place over approximately 8 hours beginning early in the morning, which gave us an opportunity to see the experience of people living in the home as they were helped to get up, have their breakfasts and generally get ready for the day ahead. During the inspection it was possible to speak to people who live in the home about their experiences and also to speak to visiting relatives or healthcare professionals about the home. We spoke to members of the staff team and also to the home’s manager and proprietor. We also looked at some key records, including those for medication, staff recruitment and training and care plans for people living in Auburn Mere. This report also draws on information received from surveys completed by people living in the home or from relatives and carers. We have also made use of information provided by the home in their annual quality assurance assessment or AQAA. The AQAA is a self-assessment that focuses on how well care outcomes are being achieved for people living in Auburn Mere, it also includes some useful statistical information about the home. The above rating for Auburn Mere is arrived at using the Commission for Social Care Inspection’s “rule based approach”, which ensures that care services are assessed fairly and consistently using guidance that is readily available to care services and other interested parties, to make sure that the process of assessment is open and transparent. In this instance the rating reflects particular problems found in the medication records and practice of Auburn Mere. The home have provided an action plan to address these problems and provided this is carried out it is hoped that a future rating of the home will be able to reflect what in many instances were found to be good and in some cases excellent standards of care. What the service does well: “Best place I’ve lived in apart from my own home” was one comment made by a person living in Auburn Mere and this reflects what were overwhelmingly positive comments received in talking to people living in the home and also from surveys returned. Relatives were also very positive, “Brilliant caring staff” Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 6 and “The manager is most approachable and keen to make improvements that will benefit all parties” were only some of the comments received. The home benefits from a well-established, consistent and stable core staff team including significant contributions to the home by both maintenance and housekeeping staff. This helps make the home a pleasant place to live and work in and was reflected in survey returns, which overwhelmingly answered “always” to the question is the home fresh and clean? What has improved since the last inspection? What they could do better: Recognising the considerable improvements that have taken place in Auburn Mere over the past few months makes it all the more disappointing that weaknesses in the administration and recording of medication, which is a key and significant determinant of safety and well-being for people living in the home, has made it impossible to reflect the real progress made in other areas of the home’s activity in its overall rating. As indicated above this has been discussed with the manager and the proprietor and an action plan to address issues and bring about the required improvements has been submitted to the Commission. Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 7 The home have identified areas where they feel themselves that performance could be improved, including staff induction training, care planning and continued improvements in communication. It is a positive sign for people living in the home and those responsible for them that the manager and her staff team, supported by the proprietor, are so obviously committed to improving the standard of care and the built environment in Auburn Mere. 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. Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 3 5 (Standard 6 does not apply to Auburn Mere) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering Auburn Mere as a home for themselves or someone they are responsible for can be assured that they will have the basic information they need to make a reasonably well informed decision, although additional detail about how the diverse needs of prospective residents will be met and improved formats for the information would make this process more effective. People being assessed with a view to moving into Auburn Mere can be assured that they will only be admitted if their care needs can be met in a way that reflects their personal requirements and wishes following a thorough and robust process of assessment. Anyone considering Auburn Mere as a home for themselves or someone they are responsible for can be certain that they will be given every opportunity to visit the home in order to make sure that it is a place that they will feel comfortable living in. Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 10 EVIDENCE: 75 of the surveys received answered “YES” to the question did you receive enough information about this home before you moved in so you could decide if it was the right place for you? The home’s AQAA has identified the need to update the brochure about the home and the service user’s guide. It has been indicated that this process will include consultation with and the involvement of people living in the home to make sure it reflects their views and experiences. In conversation with relatives of people living in the home it was clear that they had been able to visit the home before any decision was made about admission. This is important as in many cases the individuals concerned leave the choice of home to other people, often family carers, and they need to be confident that they will be able to see what the home is like and whether they think the person for whom they are making the decision will be happy there and that their needs will be met. We looked at some pre-admission assessments for people who had recently moved into the home, these were very full and detailed and provide confidence that only those people whose needs can be appropriately are being admitted. Discussions with the home’s manager made it clear that reviews of people whose needs have changed and can perhaps no longer being fully met are being carried out and alternative placements sought to make sure they move to a care setting, typically one providing nursing care, which can now better meet their needs. This reflects very positively on Auburn Mere and should provide people living there with confidence that if their needs change significantly Auburn Mere will be proactive in ensuring that their needs are met within the best care setting for them. The overall level of satisfaction with the care provided in Auburn Mere was very high; “They look after all the residents in their care and look after their special needs” was one very typical comment made. Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in Auburn Mere can be confident that they will be able to access the healthcare services they need both in the home and the local community. People living in Auburn Mere can be assured that staff think in a person centred way when meeting their care needs and that their care will be provided in a way that respects their dignity and right to choose how their care is given. Although Auburn Mere has comprehensive medication policies and procedures, these have not always been completely followed and this could pose a risk to the health and well being of people living in the home if it is not addressed. EVIDENCE: The majority of people living in Auburn Mere have indicated in their survey returns that they either usually or always receive the medical care they need and that staff listen and act on what they say. Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 12 During this inspection we saw staff treating people living in the home appropriately, with respect and involving people living in home in decisions about their care and how it was to be given. When we looked at care plan documentation, we found evidence of people living in the home being able to access community health services such as hospitals and clinics and those that require a visit in the home have received them. We found that care plans contain the basic information required to help staff know what the current care needs of people living in the home are. The format is however not very “user friendly” which may be why the home’s AQAA has identified a need for staff to have more time to complete care plans and keep them fully up to date. We were informed in the home’s AQAA that a selection of care plans are routinely audited each month by the manager to ensure that the standard of completion is satisfactory. On person living in the home noted in their survey return that there had been occasions when their medication was not available at the time it should have been, which was obviously of concern to them. It was found on the day of this inspection that the temperature inside the home’s new medication storage area was too high which could adversely affect the medication stored there. It is understood that an air-conditioning unit has been ordered which will make sure that in future the temperature is within an acceptable range at all times. A number of medication recording errors were found and some practice, such as not dating medication on opening and failing to record the actual dose given when medication is prescribed in variable dosages was not satisfactory and did not meet the requirements of the home’s own medication policy and procedures. It is acknowledged that the manager has provided the CSCI with an action plan to address these concerns and has instituted enhanced monitoring and staff training. This should mean that in future the medication practice of the home offers better protection to those people living in the home who rely on staff to assist them with their medication. Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in Auburn Mere can be assured that they will have the opportunity to take part in meaningful daytime activities of their own choice in line with their individual interests and tastes. They can be certain that they will be encouraged and helped to develop and maintain important personal and family relationships and that they will be able to retain control over decisions that affect them. People who live in Auburn Mere can be satisfied that they will increasingly find the meals and mealtimes in the home pleasant and satisfying. EVIDENCE: “There is usually something arranged for every day. There are outings to garden centres, for meals cinema and the theatre”. This comment from one person living in the home typically reflects very positive comments received from nearly everyone either spoken to or who returned surveys about the activity programme. The home has a new activity organiser and in speaking to her, observing activities taking place during this inspection visit and looking at the activities programme, it became obvious why this particular part of the outcome area Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 14 attracted such positive comments from people living in the home and those responsible for them. “ Excellent activities available to stimulate residents” was one typical comment from a relative. Since the last inspection in June 2007 the home has acquired a mini bus which has already helped to increase the range of activities available outside of the home for people living in Auburn Mere and addressed one area that has previously been identified as unsatisfactory. A recent change in chef at the home means that this part of the home’s activity is in transition. In general the comments received from people living in the home were quite positive, with some individual requests such as for “more Yorkshire puddings” needing to be followed up in residents meetings or one to one with the chef. One survey from a relative noted the benefit to people living in the home of having “An attractive restaurant like dining room with small friendly tables and settings” Surveys from relatives of people living in Auburn Mere as well as conversations with them on the day made it clear how much they appreciate the positive impact of what they have identified as improved communication and consultation with the new manager and how beneficial this has been for people living in the home. “We are really happy with the home, especially the way they welcome new family members old and young to visit and communicate with other members of the household” is one comment recorded from a relative of a person living in Auburn Mere. Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in Auburn Mere and those who are responsible for them can be confident that the home provides a safe and understanding environment in which they can freely express their views and any concerns they may have, without repercussions for themselves or those they are responsible for. The home has a complaints policy and procedure that is clear and accessible and which should provide people who live in the home with confidence that any complaint they make will be listened to and taken seriously. Staff working in Auburn Mere are supported through training to be able to recognise actual or potential abuse and to know what action to take if it is seen or suspected and this should safeguard the well being of people living in the home. EVIDENCE: We found that staff training records include safeguarding (adult protection) training and the Hertfordshire County Council safeguarding procedure is available in the home for staff to follow in the event that a safeguarding referral has to be made. When we talked to staff during this inspection they had a good understanding of what constitutes abuse and also they recognised the term “whistle blowing” Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 16 which suggests that they would feel able to raise any concerns outside of the home if they felt they needed to. This level of awareness provides confidence that the people who live in the home are not at risk from staff not knowing how to recognise abuse or what to do if it is seen or suspected. The manager discussed the complaints records with the inspector and appears determined to make sure that complaints are collected and recorded in order that appropriate analysis can take place and appropriate action taken to address any common themes or trends identified. The manager and some senior staff have received training in the provisions of the new Mental Capacity Act which should enable them to ensure that those living in the home who are not able to make decisions on their own behalf are offered appropriate protection, whilst preserving the right of all those that are capable to take decisions about their own lives. 95 of all surveys returned from people living in the home or those responsible for them agreed that they knew how to make a complaint if they needed to. Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 25 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The provider and manager have ensured that the physical environment of the home provides well for the individual requirements of the people living there. People living in the home can be reassured that the homes built environment is homely, safe, clean and comfortable and is kept in a well maintained condition. People living in the home can be confident that they will benefit from a selection of communal areas throughout the home, which means that they and their visitors will have somewhere appropriate and convenient for them to sit and talk or relax and meet family and friends or to be more actively engaged with the activities organised by the home for them either with other people living in the home or individually. EVIDENCE: Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 18 We had discussions with the manager responsible for the maintenance of the home and also the senior housekeeper and this provided confirmation of the priority given to ensuring the safety and comfort of people living and working in Auburn Mere. Surveys returned from people living in the home and those responsible for them were again very positive about its cleanliness and lack of unpleasant smells, with 100 saying that the home was either always or usually fresh and clean. The home’s AQAA includes details of redecoration either already carried out or planned over the next year, which will ensure that the home remains a pleasant place for people to live and work. We noted that the staff responsible for keeping the home clean did not have a specialised trolley to use when moving around the home, this would help ensure the safety of people living in the home from coming into contact with harmful cleaning materials. It is also necessary in order to protect both staff and people living in the home for all cleaning products to be in containers that clearly show the nature of the contents, any potential hazards from their use and what to do if they are accidentally swallowed, spilt or if they come into contact with skin or eyes. This was discussed with the manager and it is understood that action has already been taken to address this. Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in Auburn Mere can be assured that any care they require will be provided by well trained and supported staff, in the numbers necessary to achieve good care outcomes for them and who have been subject to a robust recruitment process to ensure that they are fit to do so. EVIDENCE: Training records were seen and we were able to speak to members of the staff team who confirmed recent training they had received, including at level 2 and 3 NVQ in care. This demonstrates that staff have the skills they need to provide care to the people who currently live in Auburn Mere. Supervision has improved and now means that most staff receive the support through regular one to one supervision sessions that they need to be able to identify any training or development needs, to reinforce good practice and provide them with an opportunity to discuss those people living in the home for whom they are key workers. Recruitment records were seen to include evidence of the checks needed to protect people living in the home from receiving care from people who may not be suitable or safe to do so. Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 20 In general the responses from people who live in the home or who are responsible for them were very positive about the quality of staff and the care they provide. “I am very impressed with how well they attend the residents “, “brilliant caring staff” were some comments received and over 90 of returns agreed that care staff had the right skills and experience to look after people properly. During the inspection, between 8.45 and 9.00 am, there were no care staff in evidence for that fifteen minute period in the dining room or lounge where some people were either having breakfast or sitting. The maintenance and housekeeping staff were however talking to people and other care staff were in the home on different floors, getting people up and ready for breakfast. Consideration might be given to providing some additional care staff at key times when staff recognise they are stretched. One survey returned noted that “At times they are slow responding when they are very busy in the morning” and the majority of surveys answered “usually” to the question are the staff available when you need them? Another relative noted that “The staff are good in the way that they treat the residents” but also noted that “sometimes they seem a bit short of staff which adds to their pressure” Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 35 36 37 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in Auburn Mere can be confident that they live in a well managed home where their wellbeing and best interests are paramount in decisions made. Staff working in the home can be confident that they will be well supervised and supported to help them meet the care needs of people living in the home. EVIDENCE: “The manager is most approachable and keen to make improvements that will benefit all parties” was the assessment of one relative and this was repeated by several people who responded to surveys or in person on the day of the inspection. Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 22 When we spoke to staff, there was a consistent theme of recent improvement in the management of the home and a clear sense of progress and development; “Things are much better”, “she (the manager) has opened her arms”, “she (the manager) is easy to get on with” were individual comments from members of the staff team. When we talked to people living in the home, some of whom who have been resident for some years, as we spoke to staff who we had met on previous occasions and simply by observation and getting the feel of the home as it is currently operating, it was impossible not to recognise the very significant improvement that has taken place since the arrival of the current manager. The proprietor, manager and all members of the staff team can be proud of the progress that has been noticed and acknowledged both by people who live in the home and those responsible for them. Their efforts have improved the quality of life and the care experience of people living in Auburn Mere. It is understood that the home is not involved with the personal finances of people living in the home. The assessment of this outcome area reflects the very real improvements that have been found at the same time as having to reflect also the continued problems experienced over medication records principally, with some minor health and safety issues as well. The importance of medication to the overall health, safety and wellbeing of people living in the home is why it is a key standard to which the CSCI rightly attaches great importance. If the issues with medication and to a lesser extent health and safety are satisfactorily addressed it is hoped that the overall rating of this service will reflect what are in many cases excellent outcomes for people living in Auburn Mere. Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 3 3 2 2 Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 24 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 Standard OP9 Regulation 13(2) Requirement To make sure that the medication policies and procedure are safe for those people living in the home who rely upon them, the manager must make sure that the action plan dated the 6th June 2008, provided to the CSCI is fully implemented. Timescale for action 30/06/08 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 OP38 Good Practice Recommendations To make sure that people who live and work in the home are protected from accidental contact with materials hazardous to their health consideration should be given to providing the appropriate mobile storage of cleaning materials whilst they are in use in the home and all materials covered by the COSHH regulations 1988 should be in appropriate containers with the necessary DS0000019276.V365767.R01.S.doc Version 5.2 Page 25 Auburn Mere information readily available in the home for their safe use and what to do in the event of spillage or inappropriate use. Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Auburn Mere DS0000019276.V365767.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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