CARE HOMES FOR OLDER PEOPLE
Balmoral Nursing Home 6 Beighton Road Woodhouse Sheffield South Yorkshire S13 7PR Lead Inspector
Sue Turner Key Unannounced Inspection 8th October 2007 08:45 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 DS0000021767.V349747.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. DS0000021767.V349747.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Balmoral Nursing Home Address 6 Beighton Road Woodhouse Sheffield South Yorkshire S13 7PR 0114 254 0635 0114 254 8159 balmoral@fshc.co.uk None Four Seasons Healthcare (England) Limited (Wholly owned subsidiary of Four Seasons Health Care Ltd) Mrs Catherine Matthews Care Home 85 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) Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (60) of places DS0000021767.V349747.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Old Age not falling within any other category - 5 places to be for people over 60 years old within the total of 60 places. Dementia, over the age of 60 years - 5 places within the total of 25 places. 17th April 2007 Date of last inspection Brief Description of the Service: Balmoral is a purpose built home, which provides nursing and personal care to older people. It is situated in the village of Woodhouse, within easy reach of shops, churches, public transport and small parks. Balmoral is a large home and accommodation is provided over three floors. There are stairs and lifts to each floor. There are TV lounges, sitting rooms and separate dining rooms were people are able to have meals with others and their relatives. Chiropodist, hairdressers and various complementary therapists attend the home. Whist the majority of people are permanent, the home also provides short term and respite care. A copy of the previous inspection report was on display and available for anyone visiting or using the home. Information about how to raise any issues of concern or make a complaint was on display in the entrance hall. The manager confirmed that the range of monthly fees from 1st April 2007 were £318.00 - £550.00 per week. Additional charges included newspapers, hairdressing and private chiropody. DS0000021767.V349747.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out by Sue Turner and Mike O Neil regulation inspectors. The site visit took place between the hours of 8:45 am and 4:45 pm. Catherine Matthews is the registered manager and was present during the visit and the regional manager; Denise Mc Dougal was also present when feedback was given. Prior to the visit the registered manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Questionnaires, regarding the quality of the care and support provided, were sent to people living in the home, their relatives and any professionals involved in peoples care. The Commission for Social Care Inspection (CSCI) received four questionnaires from people using the service, one from a relative and two from professionals. Comments and feedback from these have been included in this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to ten staff, two relatives and five people living in the home. The inspector checked all key standards and the standards relating to the requirements outstanding from the homes last inspection in April 2007. The progress made has been reported on under the relevant standard in this report. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. What the service does well:
DS0000021767.V349747.R01.S.doc Version 5.2 Page 6 People living in the home said that the care they were receiving was good. They made comments such as: “Staff are very good to me” and “I feel safe and happy living here”. The information received from questionnaires and from talking to relatives and people was in the main positive. Health professionals made comments such as: “On the whole I find that the staff do consider people as individuals”, “I generally find that the nurses work in a safe and cautious manner” and “Staff know the residents well and are kind and considerate”. Relatives said that: “Dad always looks well cared for when we visit him” and “Staff always make me feel welcome and I think Dad has put some weight on whilst he’s been here, which is what he needed”. The inspector observed that people were well dressed in clean clothes and had received a very good standard of personal care. People’s health care was monitored and access to health specialists was available. In the main people said that staff were always respectful towards them. People said that they had a choice of food and that the quality of food served was “good”, “alright” and “sometimes not hot enough”. There was a complaints procedure and adult protection procedure in place, to promote peoples safety. People said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. People said that they felt safe living at the home. The home was clean and tidy. No unpleasant odours were noticeable in the home. People living in the home and their relatives said that the home was always kept “clean and tidy”. Agreed levels of staff were being maintained. A recruitment procedure was in operation to ensure the safety of people living in the home. DS0000021767.V349747.R01.S.doc Version 5.2 Page 7 In the main health and safety procedures were identified and carried out, and systems were checked and serviced to maintain a safe environment. What has improved since the last inspection?
Staff said that they had many opportunities to be involved in training, which was appropriate to their work role. Examples of recent training undertaken by the staff were managing aggressive behaviour, infection control, adult safeguarding, dementia and moving and handling. Where necessary peoples behaviour was being monitored and reviewed so that others living in the home felt more comfortable and relaxed. An activities worker had been recently recruited and was spending time getting to know people. Two people said they had enjoyed a trip out of the home to Crystal Peaks Shopping Centre and Rother Valley Country Park. The catering staff were providing a good selection of desserts for people who were on a diabetic diet. Staff spoken to had attended training in adult protection and had a clear understanding of adult abuse and their own roles and responsibilities in ensuring that people were kept safe. Bathing facilities were available and in use on each unit. Central heating levels were being monitored and further work to ensure that the temperature in the home was maintained at an acceptable level was planned to be completed over the next few months. Since the last inspection the registered manager and regional manager had worked hard to improve many aspects of the service provision. Staff said that the managers’ presence around the home had been more visible and they felt able to go to them and discuss any concerns, issues or ideas for good practice and improvements. Staff said that they were receiving formal supervision from their line managers, every two months. The health, safety and welfare of people was promoted and protected by fire doors being kept locked/shut where appropriate and wheelchairs having footplates in situ at all times. Records seen were organised in a way, which allowed information to be easily retrieved. DS0000021767.V349747.R01.S.doc Version 5.2 Page 8 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. DS0000021767.V349747.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 DS0000021767.V349747.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 and 3. Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provided sufficient updated and relevant information to inform people about their rights and choices. Pre admission information ensured the home was able to meet peoples health, social and care needs. EVIDENCE: The homes Statement of Purpose and Service User Guide were available, both in the entrance hall, for anyone visiting the home and a copy was also in each persons room. These included useful information about the home and the services offered. Both the Statement of Purpose and Service User Guide had been updated accordingly. DS0000021767.V349747.R01.S.doc Version 5.2 Page 11 Each person also had a written contract/statement of terms and conditions with the home. This provided important information that helped people to understand what they could expect from the service. Prior to admission taking place professionals and staff assessed people. This either took place at Balmoral or at peoples own homes if they preferred. The manager said that assessments in hospitals were also possible if needed. The home had introduced the new Dependency Assessment Rating Tool (DART) aimed at ensuring a comprehensive pre assessment prior to anyone being admitted into the home. This tool applied to all categories of people including those choosing a respite or short-term stay. DS0000021767.V349747.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some medication procedures and one persons health care records did not fully protect people’s health and welfare. In the main people and their relatives were complimentary about the way staff promoted their privacy and dignity. EVIDENCE: The AQAA stated that from the DART assessment a comprehensive care plan was generated which was delivered in a person centred approach. Care plans seen (3) had improved since the last inspection and the staff had clearly made an effort to meet the requirements made at the last inspection. The care plans however still lacked enough information about peoples emotional and social care needs and did not give a real picture of the person for whom the care was planned.
DS0000021767.V349747.R01.S.doc Version 5.2 Page 13 One care plan seen identified that the person was displaying aggressive behaviour, however their care plans didn’t include enough detailed information on how to manage the aggression they were showing. Documenting keep calm does not provide staff with enough information on how to meet a persons needs if the person is distressed or aggressive. The care plans identified that a range of health professionals visited the home to assist in maintaining peoples health care needs. People said that GP’s, dentist, opticians and chiropodists also visited the home as requested. People and their relatives said that staff did talk to them about their preferences and needs, but they had not been fully involved in reviewing their care plans. Reviews were recorded monthly but did not identify that the person or their relative had been involved in this review. Generic and individual risk assessments were seen in the care plans, these were in the main up to date. For one person who self-administered their medication, a review of their ability to self medicate had not taken place for over a year. The inspector spoke to the person and they said they were happy to carry on self-administering, however the inspector believes that a review of this should take place. Relatives said: “Staff have been very efficient, keep me well informed and are prompt to summon a GP when needed”. “When dad fell down, staff were quick to let me know what was happening”. “More resources are needed at the home for consistency and quality of care” Medicines were securely stored around the home in locked trolleys within locked cupboards. People spoken to said that staff administered their medication at appropriate times. There was evidence that managers and trained staff were auditing medication administration procedures, however there were some gaps in the medication administration records (MAR). Controlled drugs (CD) were kept in a clinical room and within a double locking cabinet. In the main, people and relatives spoken with, and via their questionnaires, confirmed that the carers treated them with respect and provided personal care and support in a way that maintained their dignity and privacy and was sensitive to their individual needs and wishes. One person spoken to raised some concerns about the way one member of staff behaved and spoke to her. This is further reported upon in Standard 18. DS0000021767.V349747.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The routines of daily living were flexible and allowed for people preferences and choices to be provided for. The recruitment of the activities worker will provide a much-needed programme of social contact and enhance people’s lifestyle. EVIDENCE: The home had recently recruited a full time activities worker who was initially spending time getting to know people and finding out about the things they enjoyed doing. People said: “I’m looking forward to the activities programme taking off as we’ve missed out recently”. “Activities are only sometimes available due to lack of resources”. DS0000021767.V349747.R01.S.doc Version 5.2 Page 15 “The only thing that would make living here any better would be if I could get out more”. The AQAA stated that there were plans for developing a more structured activity programme, incorporating one to one sessions, group activity, and in house entertainment and planned outings. Relatives spoken to said they were able to visit at any time and were made to feel very welcome. The inspector saw that everyone coming to the home was made to feel comfortable whilst visiting their loved one. One person said they sometimes felt quite lonely. They didn’t have anyone that visited them in the home and were not always able to talk to staff about how they felt. The inspector asked if they would like the home to arrange for them to be visited by an independent person or advocate to which he/she said yes. The manager was asked to look into this and said that she had a contact person who would arrange this. Staff were seen and heard offering people choices about many things. People were asked their meal preferences, where they wanted to sit and how they wanted to spend their day. Staff working on the Elderly Mentally Infirm (EMI) unit were helping people to exercise choice and manage their lives in a supportive and considerate way. People were able to bring personal items with them into the home. All of the bedrooms seen were individually personalised, spacious and homely. People said that the meals at the home were “ alright”, “good”, “fine” and “could do with being hotter”. One person said, “Sometimes meals are just warm and staff don’t always wait until the soup and sandwiches are finished, before a warm pudding is put on the table” The main meal of the day was served in the evening, which suited people living in the home. At lunchtime a light meal was served and alternatives were always available. The cook said that there were a number of people who required a diabetic diet. People on diets were offered equivalent choices and a variety of specially made desserts. The inspector observed lunch being served in two dining rooms. Meals were served in a pleasant relaxed manner and people were sat at tables, which had been nicely set. Staff were seen assisting people to eat in a supportive way. In the EMI unit a board clearly showed what meals were being served for that day, alongside other useful information. This information would also be valuable for people and visitors in the other units. DS0000021767.V349747.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place and people and their relatives felt confident that any concerns they voiced would be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were kept safe. EVIDENCE: People and their families had been provided with a copy of the homes complaints procedure, which was also on display in the entrance hall. This contained details of who to speak to at the home and informed the reader of who to contact outside of the home to make a complaint should they wish to do so. People and relatives said that they felt comfortable in going to any member of the staff or management team, knowing that any concerns they may have would be addressed. The home kept a record of complaints, which detailed the action taken and outcomes. The home had received five complaints in the last twelve months; each had been investigated by the registered manager and/or provider and any appropriate action taken as necessary. We had not received any complaints about the home since the last inspection.
DS0000021767.V349747.R01.S.doc Version 5.2 Page 17 The AQAA stated that since the last inspection staff had undertaken training in adult protection and via staff discussions, cultural differences, whistle blowing and reporting procedures had been addressed. Staff spoken to confirmed this and showed an understanding of their roles and responsibilities. On the day of the inspection one person raised concerns about the way one member of staff spoke and cared for her/him. The person had discussed their concerns with their family who subsequently reported this to the adult safeguarding board. A meeting was held with the senior managers of the organisation and an agreement was made that the organisation would carry out a full investigation. Immediate action was taken by the providers to ensure the well being of everyone living in the home. DS0000021767.V349747.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was clean and generally well maintained, providing a pleasant environment for people and their visitors. EVIDENCE: Many areas within the home had been refurbished and the AQAA stated that over the next three years this would continue with the money obtained via the capital grant. The home was clean and tidy. Lounge and dining areas were domestically furnished and a tour of the building identified that some areas of the home were in need of minor repair. A handy person was employed to help maintain
DS0000021767.V349747.R01.S.doc Version 5.2 Page 19 the environment. Some homely touches were provided, however some bathrooms and toilets looked quite bare. The air temperature in the home was cosy, however this was due to the outside temperature being much cooler, as the thermostat is located outside. The manager said that the organisation had made a commitment to re site the thermostat to ensure that a comfortable temperature is maintained at all times. Staff working in the EMI unit should be commended for their hard work and effort in providing an environment that enhanced the well being of people living with dementia. Corridors displayed items of interest that initiated conversation and brought back happy memories. The ambience within this unit was very responsive, relaxed and homely. Bedrooms checked were homely and people said their beds were comfortable, bed linen was clean and in a good condition. The manager said that a housekeeper was now in post who had the responsibility of checking all areas of the home daily and reviewing the cleaning schedules. Controls of infection procedures were in place. Staff were observed using protective aprons and gloves. People were seen wearing nicely laundered clothes and had received a high standards of personal care. DS0000021767.V349747.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Minimum staffing levels were being maintained, however staff numbers in one unit need to be monitored and reviewed to ensure that people’s individual needs are being consistently met. Recruitment procedures promoted the protection of people and staff had completed training. EVIDENCE: Staff said that recently staffing levels at the home had “settled down” and less agency hours were being used. People’s views about how quickly staff responded to them differed. One person said the staff responded quickly if she called them, one said staff sometimes took along time to come and another person said that she always had to wait along time for staff to respond when she called them. The inspector believes that this is because dependency levels on one particular unit are higher and therefore a reconsideration of the staffing hours for that unit should be undertaken. Staff were able to talk about the various training courses that they had attended, which included all of the mandatory training, for example, Moving
DS0000021767.V349747.R01.S.doc Version 5.2 Page 21 and Handling, Food Hygiene, Adult Protection, First Aid and Fire. Qualified staff had undertaken training in medication procedures and some other specialised topics for example diabetes and dementia. Due to their being people living in the home that have Parkinson’s Disease, training and awareness around this topic should be provided to all staff. Of the 40 care staff, 4 staff had achieved NVQ level 2 in care. This falls well below the recommended 50 of the care staff trained to NVQ level 2 in care by 2005 to ensure the staff team were qualified and competent to carry out their duties. Three records of employment were checked. These included all of the required information including interview assessment, verification of identity, references, certificates of training, health checks and evidence of Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) check. Application forms fully recorded previous employment. DS0000021767.V349747.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager’s approach benefited people and staff. The quality assurance systems ensured that the home was run in the best interests of everyone. People’s monies were safely handled, which ensured that finances were accurate and safeguarded. People’s health and safety had been put at risk, in some areas. DS0000021767.V349747.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager is experienced in the care of older people, is a registered nurse and had completed her Registered Managers Award (RMA). Since the last inspection the registered manager, with the support of the regional manager, had worked hard to action the requirements made and this was evidenced by the many developments made within the service. Staff said that the manager had made herself “more visible” around the home. Everyone spoken to and information from questionnaires confirmed that people, staff and relatives were all happy to approach the manager at any time for advice, guidance or to look at any issues. They all said that they were confident that she would respond to them appropriately and swiftly. The AQAA stated many ways in which the home monitored the quality of the service offered. Annual customer surveys were sent out and the results were published and acted upon. The regional manager carried out monthly visits to the home and provided a report to the manager and us. Staff, resident and relative meetings were held and the manager had an open door policy so that people were able to express their opinions to her personally. The home handles money on behalf of some people. This was checked for three people. Account sheets were kept, receipts were seen for all transactions and monies kept balanced with what was recorded on the account sheet. Formal staff supervision, to develop, inform and support staff took place at regular intervals and staff said that they found this useful and beneficial. Equipment at the home was serviced and maintained. Fire records evidenced that weekly fire alarm checks took place. Staff said fire drill training took place on a regular basis, however these were always at the same time and on the same day. The record of fire drills did not state the duration of the fire drill. People’s wheelchairs had footplates in situ. During the site visit two hazards were seen that could affect the safety and well being of people in the home: • The surface temperature of one radiator in the EMI unit was above 50 degrees. The regional manager said that a radiator cover would be put in place to avoid any risk to anyone living in, working at or visiting the home. A refrigerator in the ground floor dining room contained food and liquids that were out of date and the refrigerator temperature was not being monitored. • DS0000021767.V349747.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 3 3 3 X X 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 3 X X X X 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 DS0000021767.V349747.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. Standard OP7 Regulation 15 Requirement Care plans must contain sufficient detail to ensure that people receive a consistent high standard of care. Including emotional, personal and social care needs. Previous timescale 01/07/07 partly met. Timescale for action 01/12/07 2. OP9 13 3. OP27 18 4. OP30 18 To ensure peoples health and 08/10/07 welfare, MAR sheets must be fully completed and signed at the time of medication administration. For the unit identified, staffing 22/10/07 numbers/levels must be reassessed to ensure that people’s individual needs are being met. Staff must receive training, 01/12/07 which is appropriate to their work role. This must include training in Parkinson’s Disease Awareness. So that people’s health and safety is not put at risk radiators must be guarded or have
DS0000021767.V349747.R01.S.doc 5. OP38 13 (4) (c) 22/10/07 Version 5.2 Page 26 6. OP38 16 (2) (j) guaranteed low surface temperature. Satisfactory standards of 08/10/07 hygiene must be maintained therefore: Regular checks of the food, fluids and temperature of all refrigerators must be taken. 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. 3. Refer to Standard OP7 OP9 OP12 Good Practice Recommendations People and/or their representative should be involved in the care planning and reviewing process. A review of the risk assessment to self-administer their medication should take place for the person identified. People should be consulted regarding the variety of activities offered. Further activities and trips out of the home should be provided, to ensure that peoples social and recreational needs are met. An independent visitor/advocate should be acquired to visit and support the person identified. All food should be served at an appropriate temperature and staff should make sure that people have finished one course before another is served. There should be a menu board on display in all units so that people living in and visiting the home are aware of the meals on offer. Toilets and bathrooms should be made to look more homely and appealing. 50 of care staff should be trained to NVQ level 2 in care. So that fire drills are a valuable learning process they should take place at different times and on different days. The duration of the fire drill should also be recorded. 4. 5. 6. 7. 8. 9. OP14 OP15 OP15 OP19 OP28 OP38 DS0000021767.V349747.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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
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