Inspection on 02/08/07 for Bellsgrove

This inspection was carried out on 2nd August 2007.

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

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

Other inspections for this house

Bellsgrove 14/01/09

Bellsgrove 16/07/08

Bellsgrove 20/02/07

Bellsgrove 22/06/06

Bellsgrove 05/01/06

Bellsgrove 15/09/05

Bellsgrove 10/12/04

Bellsgrove 15/10/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Bellsgrove Bellsgrove 250 Cobham Road Fetcham Surrey KT22 9JF Lead Inspector Joseph Croft Unannounced Inspection 2nd August 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000013568.V347689.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. DS0000013568.V347689.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bellsgrove Address Bellsgrove 250 Cobham Road Fetcham Surrey KT22 9JF 01372 379596 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) bellsgrove@hotmail.com Mr Somasundaram Logathas Mrs Shyamala Logathas Mr James Iswurdut Sobun Care Home 14 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (5), Learning disability (1), Mental Disorder, of places excluding learning disability or dementia - over 65 years of age (5), Old age, not falling within any other category (14), Sensory impairment (1) DS0000013568.V347689.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Categories DE, LD and SI apply to a named service user only. 5 service users may fall within categories DE(E) or MD(E). For up to 5 additional places for day care within categories OP, DE(E) or MD(E). 20th February 2007 Date of last inspection Brief Description of the Service: Bellsgrove is a family run care home registered to accommodate up to fourteen older people. Up to five residents who may have dementia and up to five residents who may have mental disorder can be accommodated. The home is also registered to provide day care for up to five people. The home is a large detached property situated in the village of Fetcham, with a range of local shops nearby. The accommodation is set over two floors, with a passenger lift serving both floors. There are fourteen single bedrooms, a spacious lounge/dining room and a large conservatory. An enclosed garden is provided to the rear of the property and limited car parking is available to the front. The fees at this service range from £460.00 to £560.00. DS0000013568.V347689.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 2nd August 2007 using the ‘Inspecting for Better Lives’ (IBL) process. Regulation Inspector Mr Joe Croft undertook this visit and the registered provider, who also works at the home as the deputy manager, assisted him throughout. The registered manager arrived at the care home during the late afternoon. This site visit took place over a period of six hours, commencing at 10:00 and concluding at 16:30. The inspection process included a tour of the premises and sampling of residents’ care plans and risk assessments. Other documents sampled included the staff duty rota, menu, policies and procedures and records of medication. The Inspector had discussions with members of staff on duty, and with residents who were able to converse with him. Residents informed the Inspector that they were very happy living at the home, and were complimentary about the care they receive from staff, stating that the staff look after them well. Residents informed the Inspector that the food was good, and they are offered a choice of foods. During observations staff and residents were interacting in an appropriate manner, and residents were being addressed by their preferred names. The registered manager had not returned a completed Annual Quality Assurance Assessment (AQAA). A letter has been sent to the manager requesting this to be returned to the Commission For Social Care Inspection Oxford office no later than 10th August 2007. At the time of writing this report the Commission For Social Care Inspection had not received completed survey cards from residents, their relatives or other associated professionals. Feedback was provided to the registered person throughout and at the end of the site visit. What the service does well: The home has an admissions policy in place, which informs that pre-admission assessments would be undertaken at prospective residents’ homes or current placements prior to offering a place at the home. Residents are able to make choices about their life style, and to keep in contact with relatives and friends. DS0000013568.V347689.R01.S.doc Version 5.2 Page 6 The home provides a pleasant, accessible garden, which residents can use during the summer months, and a bright conservatory, which overlooks the garden. The home has a complaints system to enable residents and their families to raise concerns. People who use the service are protected by the home’s recruitment policy and procedures. Residents are able to bring their own furniture and possessions to keep in their bedrooms. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000013568.V347689.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000013568.V347689.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Assessment documentation is in place to ensure the individual needs of residents can be met. EVIDENCE: The registered provider informed the Inspector that there have been no admissions to the home since the last inspection. Pre- admission assessments were sampled during the previous inspection indicated that full needs assessments are completed prior to admission. The home has an admissions policy in place. This informs that pre-admission assessments would be undertaken at a prospective resident’s home or current placement, and assessments would be requested from funding authorities. The registered provider stated that prospective residents are invited to visit the home before accepting their place. A trail period of four weeks is offered to all new residents, after which there would be a review. DS0000013568.V347689.R01.S.doc Version 5.2 Page 9 Residents spoken to during the site visit were not able to recall the assessment process they went through before moving into the home. The home does not offer intermediate care. DS0000013568.V347689.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each resident is provided with an individual care plan, which details how the health, personal, emotional and social needs are to be met. Residents are treated with respect and dignity. Attention is required in regard to risk assessments and return of medication. EVIDENCE: Three care plans were sampled as part of the case tracking process. Care plans included information in regard to personal care needs, hygiene, mobility, medication, dietary needs, hearing and communication. Two of the files sampled had been fully reviewed in July 2007, and both these had been signed by the residents’ next of kin. The other care plan sampled had not been signed. The registered provider informed the Inspector that this relative has been contacted and asked to sign the care plan. Evidence of monthly review was noted for this particular care plan; however, the summary of these reviews was contained in one small paragraph. DS0000013568.V347689.R01.S.doc Version 5.2 Page 11 Discussions took place with the registered provider as to why this had not been expanded, as it was a recommendation from the last inspection report. The Inspector was informed that the home is to commence using the computer system care planning that would include more detail when reviewing care plans. It was noted in the care plans sampled that the religious and cultural needs of residents had not been recorded. A good practice recommendation has been made in regard to this. Risk assessments were included in the care plans sampled, and included risk in regard to mobility, personal hygiene, food and drink and medication. It was noted these were last reviewed in March 2006. It was noted that there are some residents who have had falls, however, the registered provider informed the inspector that risk assessments in regard to these had not been written. A requirement was made at the previous inspection that a risk assessment must be written in regard to the use of floor alarm pads for individuals, this also had not been attended to. The improvement plan received on the 25th April 2007 stated risk assessments were all now in writing and floor alarm risk assessments had been completed. Requirements in regard to risk assessments have been made, and the risk assessment in regard to the use of the floor alarm pads has been carried over in this report and must be complied with. During discussions staff were able to give an account of the care plans. Residents spoken to during the site visit were aware not fully of the care plans, although one could recall signing them. During discussion with residents and staff, and from viewing records, it was clear that health care professionals mainly support residents. Residents informed the Inspector that the GP visits them in the privacy of their bedrooms, they attend all National Health appointments as appropriate, and they receive their medication on time. The home uses the blister packs that are provided by the local pharmacy, and Medical Administration Record sheets (MARs) for the recording of medicines. The MAR sheets sampled were found to be in good order with no omissions in signatures. Medication was stored in secure a metal medicine cabinet. The registered provider informed the Inspector that only staff who have received the appropriate training administer the medication. This was confirmed during discussions with staff and the viewing of training records. Specimen signatures of staff who administer medication are held at the home. The registered provider stated that no resident is self-medicating, or taking a controlled drug. A requirement was made at the previous inspection that out of date medicines must be returned to the pharmacy. This was complied with in regard to the medication identified during that site visit; however, further out of date DS0000013568.V347689.R01.S.doc Version 5.2 Page 12 medication was noted during this site visit. The improvement plan received on the 25th April 2007 stated action had been taken to ensure this did not happen again. A further requirement has been made. Residents spoken to informed the Inspector that they are treated with dignity and respect. Staff informed the Inspector that they respect residents’ privacy through attending to personal care needs in private, knocking on bedroom doors and addressing residents by the names they prefer. The cultural background of the staff group is of Asian origin whilst the cultural background of the resident group is of British origin. Both the staff and resident groups are of mixed gender. DS0000013568.V347689.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices about their lifestyle, and are encouraged to keep in contact with relatives and friends. People who use the service are offered a balanced diet. EVIDENCE: The home employs an activity organiser who attends the home twice a week to organise activities for residents. During discussions, the activity organiser informed the Inspector that activities provided include puzzles, board games, playing cards, art and craft and planting flowers. Residents are encouraged to join in the activities, but it is their choice if they do not wish to participate. The activity organiser has been visiting the home for three and a half years, and stated she maintains records of activities residents partake in. These were viewed during the site visit, but the records were only up until February 2007. The Inspector was informed that up to date records had been written and would be put into the activity file. It was noted that the home has organised a coach trip and a summer BBQ for residents, their relatives and the local community to partake in. DS0000013568.V347689.R01.S.doc Version 5.2 Page 14 Staff and residents informed the Inspector that visitors are always made welcome at the home, there are no restrictions on visitors and residents can meet with their relatives in the privacy of their bedrooms. During the site visit a group of religious leaders from the local Church attended the home and delivered a religious service. All but two residents took part in this. During discussions, two Church leaders informed the Inspector that they provide a religious service once a month, and have been doing this for the last ten years. Residents have a choice in regard to taking part in the services. The church leaders were complimentary about the care home, stating that the residents are provided with good care, are always smartly dressed in their own clothes and are happy and content. Staffs, in their opinion, are kind and they always make them feel welcome at the home. There is always a minimum of three staff on duty each time they visit. Residents spoken to stated they have their own belongings in their bedrooms that include furniture, family photographs and televisions. Residents stated they make choices about the things they want to do, and the food they eat. Staff were observed to be interacting with residents in an appropriate manner, engaging in conversations and offering assistance as and when required. The home’s menus for the last four weeks were viewed. These provided evidence that residents are provided with three meals a day, and include fresh meat, fish, fresh vegetables and fruit. Staff informed the Inspector that residents are offered alternative meals when they do not like a particular meal, however, these are not recorded. A good practice recommendation in regard to this has been made. Staff undertake cooking duties at the home, and sampling of training records provided evidence that staff had received training in regard to food handling and hygiene. Lunch was observed during this site visit. Residents were eating in a relaxed atmosphere with appropriate numbers of staff available to offer assistance as and when required. A recommendation was made at the last inspection that the menu and dietary needs of residents be reviewed with the involvement of a dietician. The manager informed the Inspector that he is a qualified nutritionist and that he was satisfied with the menus. Residents informed the Inspector that the food is very good; one resident stated the food at the home is excellent. DS0000013568.V347689.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints system to enable residents and their families to raise concerns. Staff require training in Protection of Vulnerable Adults to ensure residents are protected from abuse. EVIDENCE: The home is currently subject to a Protection of Vulnerable Adults investigation. The Commission For Social Care Inspection Oxford office has not received any complaints in regard to the care home. The home has a Complaints Policy and Procedure that includes the timescales and Commission For Social Care Inspection contact details. The complaints book was viewed and provided evidence that one complaint had been dealt with by the home in December 2006. The registered provider informed the Inspector no other complaints had been received since then. During discussions, residents stated they make complaints to the manager should the need arise. The home has a copy of the recent Surrey Multi-Agency Protection of Vulnerable Adults Procedures. Discussions took place with the registered provider in regard to the content of the home’s Protection of Vulnerable Adults policy and procedure, as it does not provide sufficient detail in regard to what is abuse, or the appropriate guidance on the procedures that are to be DS0000013568.V347689.R01.S.doc Version 5.2 Page 16 followed. A requirement has been made that the Protection of Vulnerable Adults policy and procedure must be reviewed to ensure it is written in line with the Surrey Multi-Agency guidelines on the Protection of Vulnerable Adults. During the sampling of staff training files it was evidenced that staff had last received training in regard to the Protection of Vulnerable Adults in November 2005. It was noted that one member of staff had last attended training in 2000. A requirement has been made that all staff must receive annual refresher training in regard to the Protection of Vulnerable Adults to ensure residents are protected from abuse. During discussions staff informed the Inspector they would report all concerns to the manager. They stated they were aware of the Policies and Procedures in regard to the Protection of Vulnerable Adults. The registered provider informed the Inspector that the home does not have any dealings in regard to residents’ finances. DS0000013568.V347689.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service are provided with communal and individual living space. Improvement to identified areas is needed to ensure residents live in a homely comfortable and safe environment. EVIDENCE: A tour of the premises was undertaken. The accommodation is set over two floors, with a passenger lift serving both floors. There are fourteen single bedrooms, a spacious lounge/dining room and a large conservatory. There is a garden to the rear of the property that is appropriately maintained. Bedrooms and communal spaces were appropriately decorated, and residents had their own personal possessions that included photographs, televisions and radios. Residents informed the Inspector they liked their bedrooms, and having their own belongings with them. It was observed that two bedrooms had malodours, one of which was identified during the inspection of the 20th February 2007. The registered provider DS0000013568.V347689.R01.S.doc Version 5.2 Page 18 informed the Inspector that the carpet of the previous identified bedroom had been renewed, but he could not locate the receipt to evidence this, however, a copy of this would be forwarded to the Commission For Social Care Inspection Oxford office once located. A requirement in regard to the malodours has been made. New vanity units were noted in the bedrooms with the exception of one, which the registered provider stated is to be addressed. The hallway has wallpaper peeling away from the wall. The registered provider stated that there is an ongoing redecoration programme, however, this is not in written form. Liquid soap dispensers and paper towels are being put into the communal bathrooms and toilets. On the day of the site visit, there was one toilet left to complete. It was noted that the home were using free standing fans in communal areas, a requirement has been made that risk assessments in regard to these must be written. On the day of the site visit the home was clean and tidy. DS0000013568.V347689.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers to meet the needs of residents. People who use the service are protected by the home’s recruitment policy and procedures. EVIDENCE: The registered provider informed the Inspector that there are three members of staff on the early shift; two staff on the late shift, one waking night and one sleep in duty every evening. The home employs a member of staff who carries out cleaning from six to eight pm. The manager is supernumerary, however, the hours the manager works were not specified on the duty rota viewed. Training records viewed provided evidence that five staff hold the minimum of an NVQ level two and above, two of whom have completed the NVQ level 4 and the Registered managers Award (RMA). The home has a Recruitment Policy and Procedure. Two recruitment files were sampled. These included application forms, two written references, and Criminal Record Bureau and POVA checks. Proof of identification and photographs were included in the files sampled. Evidence of induction training was included in the staff files. The registered provider is currently attending ‘Induction Work in Social Care’ training, and DS0000013568.V347689.R01.S.doc Version 5.2 Page 20 stated this will be used to further develop the induction training for new staff at the home. During discussions staff stated they had received training appropriate to their role. Staff training files sampled on the day of the inspection evidenced the mandatory training attended. The registered provider informed the Inspector that the manager, who is a qualified trainer, is to provide in-house Dementia training for all staff. On the day of the site visit, only the registered provider had completed this training. DS0000013568.V347689.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36, 37 and 38 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There was evidence of areas of good management and practice within the home, however, identified issues in this report must be attended to. EVIDENCE: The registered manager has been in post for a number of years and is a qualified General and Mental Health nurse. The manager arrived at the home for the final part of this site visit. The manager must address the issues raised in this report in regard to risk assessments, medication, Protection of Vulnerable Adults, the environment, staff training and notifications. The manager had not returned the Annual Quality Assessment Assurance (AQAA) to the Commission For Social Care Inspection Oxford office. This must be attended to. DS0000013568.V347689.R01.S.doc Version 5.2 Page 22 The home had sent out questionnaires to residents’ relatives in January 2007, of which seven had been returned to the home. However, a survey to seek the views of residents had not been undertaken. The registered provider informed the inspector that meetings take place with the residents, but these are not recorded. A good practice recommendation has been made that formal meetings with residents should be recorded. The manager should produce a written summary of the findings of annual surveys undertaken by the home, and feed the findings back to residents and their relatives. The registered provider stated that the home does not handle any financial affairs or maintain monies on the behalf of residents. Any extra expenditure incurred such as chiropody is invoiced to residents’ representatives. Evidence that staff had receiving formal supervision was noted on the staff files sampled. During the viewing of accident records maintained at the home, it was noticed that certain events that affect the welfare of residents had not been notified to the Commission For Social Care Inspection through the Regulation 37 notifications. For example, there were two recorded falls that had resulted in minor cuts, and one unwitnessed fall. A requirement has been made in regard to this. The manager informed the Inspector that he wanted to change the registration certificate. The manager was advised this has to be done through the South East Regional Registration Team. The sampling of staff training files provided evidence that staff had received training in First Aid, Fire, Food Handling and Hygiene. Staff had received training in Manual Handling in May 2006, and this is now due for refresher training. It was noted that a number of staff had not received training in regard to Infection Control or Health and Safety. A requirement in regard to these has been made. During the site visit a sample of Health and Safety checks undertaken were viewed. These included the gas certificate, 27/07/06, electrical installation, 20/10/05, fire detection and fighting equipment, 15/03/07, Portable Appliance Testing, 27/09/06, Legionella testing, 15/02/07, and the Employers Liability Insurance that expires on the 26/08/07. Fire risk assessments had been written for the home. DS0000013568.V347689.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 X X 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 2 3 X X X X X X 2 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 2 X 3 X N/A 3 2 2 DS0000013568.V347689.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 OP7 Regulation 13 (4) (c) Requirement Timescale for action 02/09/07 2. OP9 13(2) Risk assessments in regards to the prevention of falls must be completed for residents. This will ensure that unnecessary risks to the health and safety of residents are identified and as far as possible eliminated. The registered person shall make 09/09/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medications in the home. This is the second time a requirement is made to ensure the home returns out of date medication in time. The policy and procedure for safeguarding adults must be reviewed to ensure it is in line with the recent Surrey Multi – Agency Procedures. This will ensure that residents are protected from abuse The Registered Person must ensure the offensive odour in the two identified bedrooms are eliminated ensuring that residents have clean and DS0000013568.V347689.R01.S.doc 3. OP18 13 (6) 02/09/07 4. OP26 16 (2) (k) 13 (4) (a) 09/08/07 Version 5.2 Page 25 pleasant bedrooms to live in. A risk assessment must be completed in respect of the use of freestanding fans in communal areas of the home. 24 The Annual Quality Assessment 10/08/07 Assurance (AQAA) must be completed and returned to the Commission For Social Care Inspection. 37 (1) (e) All appropriate accidents and 03/08/09 incidents must be sent to the Commission For Social Care Inspection. 18(1)(a-c) All staff must receive training in 02/10/07 regard to Infection Control and Health and Safety and up to date training in regard to Safeguarding Adults. This will ensure the health, safety and wellbeing of residents is promoted at all times. 5. OP31 6. OP37 7. OP38 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. 4. Refer to Standard OP7 OP7 OP15 OP33 Good Practice Recommendations The religious and cultural needs should be recorded in residents’ care plans. It is recommended that the care plan monthly reviews should be more detailed as opposed to one paragraph to reflect all care objectives. Alternative meals provided to residents should be recorded. Formal meetings with residents should be recorded. A written summary of the findings of annual surveys undertaken by the home should be produced and fed back to residents and their relatives. DS0000013568.V347689.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 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 DS0000013568.V347689.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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