Inspection on 29/10/07 for Batley Hall Nursing & Residential Home

This inspection was carried out on 29th October 2007.

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

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

CARE HOMES FOR OLDER PEOPLE Batley Hall Nursing & Residential Home Old Hall Road Batley West Yorkshire WF17 0AX Lead Inspector Elizabeth Hendry Key Unannounced Inspection 29th 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 DS0000071041.V353827.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. DS0000071041.V353827.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Batley Hall Nursing & Residential Home Address Old Hall Road Batley West Yorkshire WF17 0AX 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) 01924 472063 01924 420593 Maria Mallaband Ltd Mrs Patricia Starr Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51) of places DS0000071041.V353827.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only - Care home with nursing - Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP. The maximum number of service users who can be accommodated is: 51. The same owners have re-registered the home as a limited company. Previous report are not on our website, but obtainable from the office. 2. Date of last inspection Brief Description of the Service: Batley Hall is a privately owned home providing nursing and personal care to older people. It is a converted stone built hall with two extensions, which are well designed to blend in with the original building. It is situated in wellmaintained grounds with ample parking spaces and good views over the local countryside. The home is close to Batley town centre. Batley Hall has a service user guide which provides information about the range of services for existing and prospective residents. Weekly fees on the 29th of October 2007 ranged from £350 to £550 per week. Additional services such as hairdressing, newspapers, chiropody and personal items are not included in this fee. Information about the home and the services provided are available from the home in the statement of purpose and service user’s guide. People considering living in the home can obtain a copy of these and the last inspection report by contacting the home. DS0000071041.V353827.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of the Unannounced Inspection of Batley Hall Nursing Home a visit took place to the home. This took place between 08.45 am and 13.30 pm on the 29th October 2007. As part of the visit the Inspector chatted with people living at the home, had a tour of the building, spoke to the management of the home, members of the nursing and care teams, and the activities organiser. Their comments will be reflected within the report. A range of records and documentation relating to the running of the home were also examined and included some of the homes’ policies, procedures & guidelines, daily records, care plans, medication records and records pertaining to health and safety. In addition to the visit information has been collated from a number of sources including, an Annual Quality Assurance Audit that provides statistical information in relation to the running of the home, the outcome of the homes own customer satisfaction survey, and monthly reports detailing the outcome of unannounced visits to the home to assess the quality of the services provided. Further information was obtained through service user surveys, ten surveys were sent out to people living in the home, at the time of writing this report five had been returned. Information obtained from all these sources will be used in the writing of this report. Recently the owners have registered the home through a limited company. However the staff group is largely unchanged, although a new manager was employed in June 2007, and the commission has now approved her as the registered manager. This legal change means that previous reports will not be on the commissions website, but they can be obtained from offices. The inspector would like to thank those living at the home, the manager and staff for their hospitality and patient co-operation throughout the inspection. What the service does well: The atmosphere in the home is relaxed and informal. Staff and management are approachable and well liked by those living at the home. Those people spoken to during the visit said that “the staff are like my family, nothing is too much bother and I always feel like I can ask them anything”. Another person commented that ‘Everything is much better since the new manager took over, we get to go out far more often to places we want to go to”. People living in the home have a choice over what time they get up or go to bed and what time they have their breakfast. The quality of the food provided DS0000071041.V353827.R01.S.doc Version 5.2 Page 6 within the home is good and all the comments received in relation to the food were positive. Everyone spoken to within the home said that they have seen a vast improvement in the number of activities and trips out since the new manager and activities co-ordinator took over earlier in the summer. Daily activities are available within the home and those people who wish to continue with hobbies and activities undertaken prior to moving into the home are given full support and encouragement to do so. Care staff have a good knowledge of the needs, likes and dislikes of those in their care. Individual care plans and records seen are kept in good order with frequent reviews thus ensuring that any changing needs are always met. The medication administration policies and procedures adopted by the home are safe and staff are appropriately trained in medication administration prior to undertaking the task. What has improved since the last inspection? Requirements and Recommendations issued at the last key inspection have now been addressed. The administration and recording of medication is carried out appropriately, with staff recording the stock balances of the people’s medication, which is held within the home. The medication trolley is now locked to the wall within the treatment room when it is not in use. These practices ensure that the safety an dwell being of people living in the home is maintained. Care plans and risk assessments are kept up to date and reviewed monthly or earlier if required. A new manager took up their post in June 2007, since that time those people living at the home have said that there is more of a positive atmosphere the home become more focused on delivering the style of care preferred by each individual. The home continues to provide a high standard of care to all of the people using the service, in an informal, friendly and relaxed manner. Everyone spoken to within the home said that they have seen a vast improvement in the number of activities and trips out since the new manager and activities co-ordinator took over earlier in the summer. Daily activities are available within the home and those people who wish to continue with hobbies and activities undertaken prior to moving into the home are given full support and encouragement to do so. The registered manager confirmed that since the last inspection the carpets in some bedrooms and the lounge have been replaced, three bedrooms have had DS0000071041.V353827.R01.S.doc Version 5.2 Page 7 new furniture and replacement windows and French doors have been fitted to the main lounge. This has resulted in people living in a welcoming and well maintained environment. 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. DS0000071041.V353827.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 DS0000071041.V353827.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 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. People are properly assessed before moving into the home with the assurance that their needs will be met. EVIDENCE: The care records of four people living in the home were examined and all were found to have appropriate community care assessments, which are carried out by Social Services, prior to admission and provided the information the home needed about their needs. Within the Annual Quality Assurance Assessment returned to the Commission the Registered Manager confirmed that a pre admission assessment is undertaken to determine the lifestyle preferred by the individual and that this forms the basis of the homes care plan. Any one looking into moving into the home are invited to have a look around, spend time meeting and talking with those who already use the service, and to stay for a meal. The Registered Manager confirmed that all of the people living at the home have a contract of residence, which states what is and is not included within the weekly fee. Information regarding the trial period, notice of termination of DS0000071041.V353827.R01.S.doc Version 5.2 Page 10 contract and services available within the home is also included within this contract. Of the four service user surveys returned to CSCI all confirmed that they had received a contract of residence and that they received enough information about the home before deciding to move in. The home provides intermediate care for up to five people. GP’s, community nurses or hospital consultants are responsible for referring these people to the home and many are often admitted from the local hospital. The Registered Manager confirmed on the day of the visit and within the AQAA that their admission is on a short stay basis lasting two to six weeks. During this time staff rehabilitate the individual to enable them to go back into the community or a reassessment takes place if the individual requires nursing or residential care. The Primary Health Care Trust are responsible for paying the homes fees whilst the individual is at the home. DS0000071041.V353827.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 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. Care plans document the health, personal and social care needs of individuals living at the home, which ensures that peoples needs and aspirations can be fully met. Medication policies and procedures within the home are good which ensures that people living at the home are protected from poor practice. EVIDENCE: A sample of four care plans were viewed, all were found to contain details relating to the circumstances surrounding their admission into the home and personal, social, and healthcare needs and goals. The Manager spoke of holding regular reviews with G.P’s and social workers to ensure that the people living at the home are receiving the level of support needed. Staff were observed clearly displaying knowledge of each individual needs. DS0000071041.V353827.R01.S.doc Version 5.2 Page 12 Within each care plan there was a “Care Home” questionnaire that had been completed by either the individual or a relative. The questionnaire provided staff with a more detailed look at how the person chose to live their life prior to moving into the home. For example how they preferred to get washed and dressed, and what activities or hobbies they enjoyed before moving into the home. While this information was held within the care plan file it was not directly incorporated into a care plan. A discussion took place with the Registered Manager surrounding how valuable this questionnaire was in providing person centered care in particular for those people with little or no verbal communication, and how it could be better incorporated within the care plans. The Registered Manager confirmed that the homes care plans were currently being revised and that this questionnaire was a step in this process. The registered manager confirmed that staff were being supported to review all care plans to make them more specific to an individual. It was also noted that of the four care plans evidenced all contained the use of abbreviations, no information within these care plans as to what the abbreviations stood for could be found. This was raised with the Registered Manager who confirmed that staff would be asked to remove abbreviations and write all conditions in full. Of all the people spoken with on the day of the visit, all had awareness as to the contents of there care plan and confirmed that, should they wish to see the plan, staff would provide assistance. All of the service user surveys returned to CSCI indicated that they always or usually receive the care and support required, and that staff are usually available when they are needed. Daily records contain sufficient information and are consistently completed detailing the individual’s activities for the day and staff observations. All of the people spoken to at the visit complimented the dedication of the care staff, commenting that “they are always smiling” and “ if I need anything I just have to ask”. One person said that he has been made to feel at home. Individual care plans and medical notes viewed indicated that any problems identified were quickly addressed. A sample of medication administration records were viewed and found to have been completed correctly. During the visit two trained members of staff were observed checking that the quantities of controlled drugs tallied with the records kept. The nurse responsible for the ordering of medication within the home was knowledgeable about the homes medication policy and procedure and what to do in case of a medication error. The home has a dedicated treatment room where there is suitable storage for medication in cupboards, medication trolleys and a dedicated medicine refrigerator. DS0000071041.V353827.R01.S.doc Version 5.2 Page 13 The Registered Manager also explained that everyone involved in the management of people’s medication has completed a safe handling of medication training course. Throughout the visit, staff were observed treating people with respect and dignity whilst remaining positive and supportive. DS0000071041.V353827.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): 12,13,14 &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. The lifestyle at the home satisfies the needs of the people living there, and encourages the involvement of family and friends. EVIDENCE: An activities co-ordinator is employed at the home and has been in post since June 2007. From discussion with people who use the service that the activity co-ordinator knows the people living at the home well and what their likes, dislikes and abilities are regarding how they like to spend their time. After speaking with the people living at the home and their families and friends a record of previous hobbies and interests are documented within individual care plan files. Everyone spoken to within the home said that they have seen a vast improvement in the number of activities and trips out since the new manager and activities co-ordinator took over earlier in the summer. Activities provided include bingo, games, quizzes, outside entertainers, movement to music, films, arts and crafts. Trips out have also been arranged and have included a canal DS0000071041.V353827.R01.S.doc Version 5.2 Page 15 barge trip, a visit to the local donkey sanctuary and there is a forthcoming Christmas meal planned at a top hotel in Leeds. Everyone spoken to who had gone on these trips spoke enthusiastically and were looking forward to the next outing. The providers state in their Annual Quality Assurance that their plans for improvement over the next 12 months in this area include ‘Organising more trips, organising food sampling afternoons to give those people living at the home more choice in the food they like, giving people more choice in activities’. While the inspector did not observe a meal, feedback from people living at the home was favourable. One person said that the food is always nicely presented and home cooked. Another person said that mealtimes are relaxed and unhurried and that we can choose where we would like to eat; if we fancy it we can eat in our bedrooms. Within the large communal lounge there is a water cooler, since it has been the manager confirmed that people are drinking more fluids than they did before. A variety of hot and cold drinks are available at any time of the day or night. The food store cupboards were also examined and were all well stocked. There was a good variety of fresh and frozen vegetables and meat in addition to dairy products, tinned and dried foods. People living at the home spoke of the staff helping them to maintain contact with family and friends by encouraging trips home, inviting people for tea, organising telephone calls and posting any mail. Relatives were seen to visit the home during this visit and were made welcome by the staff. The Registered Manager spoke of involving relatives in home meetings, fundraising events and parties. People are encouraged to exercise control in their day-to-day lives wherever possible. Resident/relative meetings are held three monthly. Recently a resident’s forum was held where people who live at the home were given the opportunity to raise concerns, and make requests as to how the home should be run. From reading the minutes it was evident that the thoughts and ideas of those living in the home are not just listened to but also actioned. Recently two microphones have been purchased so that those people with poor hearing can hear what questions are being asked during meetings and what answers are being given. DS0000071041.V353827.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): 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. People can be confident that their complaint will be dealt with effectively. Staff have received suitable training and understand the adult protection safeguarding policies and procedures, which makes sure that the people they support are safe. EVIDENCE: The Commission is informed of all serious issues affecting people living in the home. The Providers undertake a monthly-unannounced visit to the home as part of their quality assurance and send a copy of the report to the Commission. A copy of the homes complaints policy is on display within the entrance hall and is also included within the service user guide provided to each person upon admission into the home. The policy is easy to read and provides clear guidelines for anyone wishing to complain. The Annual Quality Assurance Audit completed by the provider stated that the home has had five complaints in the last twelve months, all of which had been resolved within 28 days. One safeguarding referral had been made, investigated through the local authority procedures and was now closed. Two service user surveys returned to the commission stated that they were usually aware of whom to speak to if they were not happy; one said they always knew and one said they sometimes DS0000071041.V353827.R01.S.doc Version 5.2 Page 17 knew. During the visit to the home all of the people spoken with were aware of who to speak to with any problems or concerns. The manager confirmed that the home has an open door policy, which provides people living at the home and their families with the opportunity to discuss problems at any time with the Registered Manager, Nurse in Charge or a senior member of staff. At the time of the inspection there were no outstanding safeguarding referrals. Staff training records indicated that abuse awareness training is provided as part of the induction process. The registered manager confirmed that regular reference is made to the homes adult protection policy in staff meetings to ensure staff awareness is refreshed. DS0000071041.V353827.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): 19 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. The standard of the environment is good, creating an attractive and homely place to live. Infection control measures in place promote the wellbeing and health of both the people that live there and the staff. EVIDENCE: On the day of the visit, a tour of the home was undertaken. A good standard of decoration and furnishing was found throughout the home. The majority of fixtures and fittings were domestic in nature and of a good quality. The home sits in well maintained gardens, which are laid mainly to lawn; this provides additional seating and leisure space for people who live in the home during the summer months. Car parking is available to the front of the property. DS0000071041.V353827.R01.S.doc Version 5.2 Page 19 The home has an ongoing programme of maintenance and redecoration, the annual quality assurance audit completed by the provider confirmed that all old brown wardrobe furniture in bedrooms would be replaced in the coming months, and those ensuite bathrooms with small baths would also be replaced. All of the people spoken to said that their bedrooms were comfortable and that they had everything they needed. Of the bedrooms viewed all had been personalised to their individuals tastes with items of furniture, and pictures. Feedback from four service user surveys identified the home as being “always” or “usually” fresh and clean. On the day of the visit the home was found to be clean and tidy, with no offensive odours present. Staff training records sampled indicated that all staff receive infection control training as part of the induction programme, this was also confirmed within the annual quality assurance audit supplied by the provider. Throughout the course of the visit to the home all staff were seen to be adhering to infection control guidelines, gloves and aprons were available within communal bathrooms and medical treatment rooms and clinical waste bins were locked. DS0000071041.V353827.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): 27,28,29&30 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. People’s needs are met by trained and qualified staff who have undergone a thorough recruitment process before they are allowed to work in the home. People receive the care and support that they need from adequate numbers of staff that are appropriately trained, vetted and supervised. EVIDENCE: On the day of the visit to the home sufficient levels of staff were on duty to ensure all of the needs of the people living in the home could be met. Information provided within the Annual Quality Assurance Audit confirmed that on occasions when staffing levels were low due to sickness, and annual leave, agency staff are used to ensure good staffing levels are maintained. Training records viewed confirmed that the home provides comprehensive induction and mandatory training in movement and handling, health and safety, infection control and fire safety. The registered manager commented on how receptive the staff have been towards changes in work patterns and methods of recording It was added that these changes have had no adverse effect on the people living in the home as a result of the positive work ethic of the staff team. All of the people spoken with commented on the staff’s patience and DS0000071041.V353827.R01.S.doc Version 5.2 Page 21 understanding and were very complimentary of all members of the management team. All of the service user surveys returned to CSCI indicated that staff usually are available when they are needed. Staff were observed interacting well with people living in the home and were seen to take a proactive role with regards to meeting individual requests in both personal care and leisure activities. The registered manager explained the recruitment procedure in detail, confirming that no member of staff works within the home without a clear enhanced criminal records bureau or Protection of vulnerable adult check. Of the four staff files viewed, all were found to contain the required information including a criminal records bureau check, two written references and proof of identification. The home has a comprehensive staff induction programme which ensures that new staff do not work unsupervised until they are confident and sufficiently trained to do so; this involves the new starter shadowing an experienced member of staff. The registered manager said that only when they feel that the new starter is competent are they given separate duties. Of those staff files sampled, all contained evidence that regular supervision is undertaken. Details of identified training needs and personal development requirements are also formally discussed and recorded on a regular basis. A wide variety of training courses are accessed on a regular basis to ensure the changing needs of residents are fully met. Staff spoken to said that they just need to ask and additional support is given from both the management team and colleagues. DS0000071041.V353827.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): 31,33,35 and 38 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. People living at the home benefit from quality assurance procedures that ensure that the home runs in their best interests. The management of the home is good and it provides clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. The health, safety and welfare of individuals living at the home and staff are fully promoted. EVIDENCE: The home places a high priority on ensuring quality care for all residents. In addition to the inspection from CSCI, the home regular conducts internal quality audits, and monthly provider reports. A copy of the homes annual quality assurance assessment for 2006-2007 was viewed. To summarise it DS0000071041.V353827.R01.S.doc Version 5.2 Page 23 contained information as to what the service does well, areas that still require improvement and how the home would address any shortfalls. The manager has a clear understanding as to the goings on within the home. People that use the service spoke of the manager being a very friendly and approachable person who likes to get involved. The manager spoke of having an open door policy for staff and individuals to discuss personal issues and worries. Records seen are well maintained, accurate and regularly reviewed. No financial records relating to both the home and the people’ finances were inspected on this occasion, however no incidents surrounding the management of monies has been reported to CSCI. The homes annual quality assurance audit confirmed that monies are kept locked and secure at all times however they are always made accessible upon request at any time of the day or night. Health and safety certificates viewed identified a consistent and responsible outlook being placed upon individual’s wellbeing within the home by the management team. Records viewed, and information received prior to the visit, showed that regular fire safety checks are carried out and electrical appliances are tested annually. Training certificates viewed identified all staff undertake health and safety training as part of their induction process, with updates as required. Each of the care plans had risk assessments in place. The registered manager confirmed that all manual handling plans and risk assessments are reviewed to ensure that they contain clear and detailed instructions for staff to follow, to ensure the safety of both the individual and staff is maintained. The home has made adequate provision for the removal of clinical waste from the home. Tests of the fire alarm and emergency lighting system are recorded as being carried out weekly. Fire drills are also carried out periodically. Hot water temperatures are checked and recorded as required; any remedial action taken is also recorded. DS0000071041.V353827.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 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 X X 3 DS0000071041.V353827.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations Care plans are reviewed to contain only relevant information about the individuals’ current condition. With all other information held in a separate file to make it easier for staff to navigate their way through to the current care plan. Staff reduce the use of abbreviations within care plans to make sure all staff understand what they stand for. 2. 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