CARE HOMES FOR OLDER PEOPLE
Benoni Nursing Home Ltd Benoni 12 Carrallack Terrace St Just Cornwall TR19 7LW Lead Inspector
Stephen Baber Key Unannounced Inspection 18th April 2007 09:30 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 Benoni Nursing Home Ltd DS0000061997.V335468.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. Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Benoni Nursing Home Ltd Address Benoni 12 Carrallack Terrace St Just Cornwall TR19 7LW 01736 788433 F/P 01736 788433 kernowcare@aol.com 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) Benoni Nursing Home Ltd Mrs Susan Janice Mason Care Home 21 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (21), of places Physical disability over 65 years of age (2), Terminally ill over 65 years of age (2) Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Four service users may be accommodated who are aged between 55 to 64 years. 5th June 2006 Date of last inspection Brief Description of the Service: Benoni is a detached building situated in a residential area of St Just. The home is registered to provide accommodation and care, with nursing, for a maximum of 21 service users. This can include two service users with a dementia and 2 service users with a physical disability on admission The home is also registered to accommodate four service users from age 55 years of age to 64 years of age. Bedrooms are situated on the ground floor and first floor, and there are three bedrooms for service users receiving residential care on the second floor. There are three double rooms. The first and second floors are accessed by a shaft lift. The grounds are modest in size and there are areas for sitting outside. The slope from the road and car parking area to the main door is ramped, but is negotiable by a person in a wheelchair with assistance. There is a small step and a threshold at the main entrance; these are accessible with a wheelchair with assistance. The home has a strong link with the community and town of St Just. The registered provider is Benoni Nursing Home Ltd. The responsible individual is Mrs Helen Hutson. Fees range from £350 to £550 per week. Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place on 18th and 19th April 2007 and was a key inspection. The inspection over two days amounted to 12:5 hours. The purpose of the inspection was to ensure that service users’ needs are appropriately met in the home, with particular regard for ensuring good outcomes for them. This involved looking at the full range of documents, examination of the home’s written policies and procedures and records maintained to ensure the welfare and protection of service users living there. It involved an inspection of the home’s premises, interviews with service users and visiting relatives and observation of the daily life of the home. Time was spent discussing the management of the home with the manager and Responsible Individual and nursing staff. The principle method used was case tracking for service users and staff. This involves examining the care notes and documents for a select number of service users and following this through with interviews with them and staff working with them. This provided a valuable insight and enables me to gain a fuller picture on how service users needs are being met in the home. At this inspection, three service users were case tracked and three staff files were inspected. Overall the views and opinions of the service users staff and their representatives was that the manager and staff do all they can to provide a comfortable and cosy home that meets their needs. Service users made very positive comments about the caring staff and how they go out of their way to respect their privacy and dignity. What the service does well:
Since the last inspection in April 2006 the manager has made every effort to meet the requirements and recommendations set by the Commission for Social Care Inspection. The Registered Manager visits prospective service users prior to admission to undertake a needs assessment. The assessment forms the basis of the service users individual care plan. There are risk assessments in place for each service user and these are reviewed monthly along with the care plans. Informative daily records are kept for each service user. . The home has appointed an activities assistant who arranges various in-house activities, which are appropriate to the age and general infirmity of the service
Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 6 users. There is an open policy regarding visitors and it was noted that visitors were visiting regularly throughout the day at the home. Service users said to me that they enjoy being invited to partake in the activities if they wish to. I noted that visitors were made welcome and treated with care and respect. There is a complaints procedure and the home has received no complaints. The manager and staff have received lots of compliments from very satisfied service users and their representatives in the form of letters, thank you cards and small gifts. There is a warm welcoming atmosphere at the home and it was clean, comfortable and homely. The bedrooms are individualised with personal possessions. Hand-washing facilities for staff are good and alcohol-cleansing gel is provided. Protective clothing is also provided and staff were seen using it appropriately. Staffing levels are suitable and the Registered Manager said that more staff are brought in when the need arises. There is a qualified nurse on duty at all times. The manager of the home tries to ensure that working practices are safe. Staff receives regular training and equipment service checks are undertaken and up to date. The manager communicates effectively with the Commission and is very diligent in complying with regulation 37 notifications. Accidents are reported and they are audited by the Manager to try and prevent future occurrences. What has improved since the last inspection?
This was a very encouraging inspection with the manager, staff and the responsible individual for the company offering their full cooperation to complete the inspection. It is also noted the hard work that has been undertaken to improve the quality outcomes for service users which has gone up from adequate to good. The residents care plans have improved considerably since the last inspection both in format and content. More detailed assessments are used to guide, direct and inform staff. Care plans are discussed and signed by the service users or their representative if possible and reviewed every month along with the risk assessments. Another big improvement is in the area of individual staff training and in how professional staff files are maintained and updated. Although the home does not have specific facilities for rehabilitation, it is able to provide short-term or respite care.
Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 7 Service users have good access to a range of local healthcare providers. Their healthcare needs are considered in their individual assessments, prior to their admission to the home to ensure that their needs can be met there. Their ongoing healthcare needs are considered in their individual care plans and regularly reviewed. The service users said to me that they are well cared by the manager and staff and nothing is too much trouble for the. All of the service users I spoke with at the time of the inspection indicated that they are satisfied with the care and services provided to them. Ongoing training is provided for staff to update their skills and knowledge. The care assistants I spoke with said they receive good training, which helps improve their skills and knowledge. Some staff are appointed with no qualifications but within a short period they commence training to improve their skills. The manager has done a considerable amount of work since the last inspection to comply with the requirements detailed in the last report. Systems have now been set up with reference to staff supervision, better recruitment, more detailed care plans and assessments and policies and procedures that inform and direct staff. There have been ongoing improvements to the home’s physical environment to make it safer and more comfortable for service users. The company in the coming months are going to invest financially in the fabric of the home and new carpets are going to be purchased. New chairs and redecoration has already taken place. It was noted that throughout the inspection the manager ensures that her style of management approach creates an open, positive and inclusive atmosphere. What they could do better:
The manager must now continue to build on the good work she has completed and take the action necessary to prevent the service falling to the previous standards identified. Comprehensive feedback on the inspection was given to the manager and the following areas of improvements could be made to improve the service. • Training for all staff on the safe use of cot sides. • Fire updating training for some staff is now due • As part of the upgrading work consideration should be given to replacing some ceiling tiles, which are broken and stained, and carpets in some areas require replacement. This would improve the appearance of the home. • The Responsible Individual of the company must complete monthly regulation 26 reports on the conduct of the home.
Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 8 • Transcribing on the medication sheets and the witnessing of drugs regarded as controlled drugs should have two signatures. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Benoni Nursing Home Ltd DS0000061997.V335468.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 Benoni Nursing Home Ltd DS0000061997.V335468.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 3 and 6 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users are only admitted to the home following an assessment of their needs. This will ensure that their needs are met. Intermediate care is not offered. EVIDENCE: The manager said that prospective service users are visited in their homes and often in hospital, prior to deciding to admit them to the home. The assessment is comprehensive and covers all of the areas listed in standard 3.3. Three service users records were case tracked and their records evidenced that assessments were undertaken. Intermediate care where service users are helped to maximise their independence and return home is not provided at the home. Respite care for short periods is offered and the one lady receiving the care for several weeks
Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 11 said that it gives her sister a break. She said she enjoys the break and likened it to a holiday at the home. Benoni Nursing Home Ltd DS0000061997.V335468.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9,10 and 11 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans are generated for each service user and fully inform and direct staff in the care to be provided. Service users have access to health care services as necessary, policies are updated to ensure staff deliver care appropriately and ensure the assessed needs are met. The service users are protected by the homes policies and procedures for dealing with medicines but minor improvements should be made to protect service users. Systems are in place to ensure that residents are respected and their privacy is upheld. EVIDENCE: This is an area of the manager’s responsibility that has greatly improved. Care plans are held in individual folders along with care documentation and risk assessments. Three service users files were case tracked and all contained a care plan, which informed, directed and guided the staff. Staff confirmed they found the care plans very helpful and they could contribute to them by
Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 13 talking with the manager and nursing staff about any issues they had regarding the care to be given. The care plans refer to the risk assessments and other records to fully inform and direct the care staff. They evidence involvement of the service users or their representative and agreement is reached on the care to be given by all parties. There are specific risk assessments undertaken for all service users and these cover for example, Waterlow, nutritional, manual handling, environmental assessments. The actions required following the risk assessment direct staff. It was noted that several service users require cot sides/ bed rails. If a service user requires this, a written risk assessment is required with the documented permissions of the service users representative and relevant healthcare professionals. It is also recommended that training for staff in the proper use of cot sides would be helpful for the staff to ensure that they know how to use them correctly. All the service users I spoke with were satisfied with the care they received. I observed care practices generally as very caring and responsive to individual needs. The pharmacist inspected the safe storage and disposal of medication on the 3rd February 2007. he was satisfied with the way medication is stored, dispensed and disposed of. The home operates a direct dispensing system for medication. Medicines are only administered by registered nurses.The medicine administration records were complete but hand written details on the MAR charts/book on controlled drugs or medication that should be treated as controlled medication (Temezepam) i.e. book was not signed by two members of staff. Residents’ privacy was upheld during the inspection. Shared rooms are provided with appropriate screens. Privacy and dignity is included in the home’s statement of purpose. Sadly one service user passed away at the time of the inspection. It was noted how her privacy and dignity was respected by the staff before she left the home. Benoni Nursing Home Ltd DS0000061997.V335468.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of activities and aims to meet individual service users needs. Links with family and friends are good and allow service users the opportunity to socialise and maintain important family contact. Service Users are supported to maintain control over their lives and staff respects their individual preferences and choice. Dietary needs of service users are catered for with a varied menu that meets with individual’s approval. EVIDENCE: This is another area of improvement that has taken place. Activities take place in the home and service users can choose whether to join in. One care assistant is responsible for organising activities and at present Arts For Health visit every Wednesday to introduce new and varied activities like exercise to music, picture bingo and flags on a rope sessions which is enjoyed by the service users. One to one sessions also take place with individual service users, for example hand and head massage, chat, manicures or reading a book. Records are maintained for individuals in a file and there are photographs of service users around the home enjoying activities. It was
Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 15 noted the constant flow of visitors and staff said that service users could receive visitors at any time; the visitor’s book showed that several people visit the home each day. The routines of the home are essential to the security of the service users but the service users I spoke with said that they can have choice when they get up and when they go to bed. The whole atmosphere on the two-day visit was very relaxed with the staff talking with service users when they were going about their work. There is a set 4-week menu with choice offered at all mealtimes. The nursing staff completes nutritional assessments for individual service users. Fresh fruit and fresh vegetables were used at all mealtimes. Special diets are catered for and I noted that some service users were receiving one to one help at meal times, which were unhurried, and at a pace to suit individuals. I took a meal with the service users and manager and noted that the majority of service users had their meal in their armchair in one of the two sitting rooms. The manager said it had been agreed it would be difficult for many of the service users residents to leave their chairs and get up to the table, considering pain suffered and mobility difficulties. All service users that I spoke with said food was to a good standard and they enjoyed it very much. Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure that ensures complaints are listened to and acted upon. Arrangements are in place for the protection of service users and procedures for responding to suspicions or evidence of abuse ensure the safety and protection of service user. EVIDENCE: The home has a complaints policy and a method for recording complaints. No complaints have been received. Thank you cards and letters are kept. The manager has completed the adult protection training with Cornwall County Council. Eight staff are booked to attend the next round of training in the next few weeks. The manager has purchased television and video recorder for staff to watch the video on safeguarding adults and she undertakes training to all staff herself and arranges for staff to complete a written paper as a result of what they have been taught. Copies of the local multi-agency procedures have been obtained and made available to all staff so that they are aware of what action to take and which agencies to inform if they are concerned about the welfare and safety of a service user. Further opportunities exist for the manager and nursing staff to expand their experience by attending multi-agency training to familiarise themselves with the ways in which different local agencies work together to protect vulnerable people.
Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 17 Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is attractive, and comfortable so that service users enjoy a homely and well-maintained environment, although some improvements are needed in the fabric of the building to provide a good standard of accommodation. The home was clean and tidy at the time of the unannounced inspection and there was evidence of good hygiene practice throughout to protect from infection risks. EVIDENCE: The home has been updated since the last inspection with replacement of furniture, redecoration internally and externally. Internally the home looked brighter, well decorated, attractively furnished and comfortable for service users. There are continuous improvements being made to it to make it more attractive and safer for Service users and staff. Service users said that they were satisfied with the accommodation, including their private rooms, which
Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 19 were all personalised with treasure mementoes from home. It is recommended that that carpets and replacement of some ceiling tiles because they are stained and torn be included in the refurbishment programme. The home looked clean and tidy at the time of the unannounced inspection. Domestic staff are employed to keep it clean, so that care staff can focus on providing direct care to service users. It was observed throughout the inspection that excellent hygiene practices ensure the service users are free from infection risks. Staff receives training in infection control so that service users are better protected from cross-infection risks. Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels appear to be satisfactory so service users can be assured they will receive appropriate levels of support from staff. Service users are in safe hands and benefit from the 53 of care staff trained to at least NVQ level 2 and 3 in care. Recruitment procedures have been improved a nd are now robust to offer protection to the service users. Improved training provided for staff ensures that they possess the skills and competence to do their job well. EVIDENCE: The rota was inspected, and the inspector was provided with the names of staff on duty on the day of the inspection. There seemed suitable numbers of staff on duty, and service users needs appeared to be met promptly and efficiently. On the day • From • From • From • From • From of the inspection the following staff were on duty: 0730 until 17:00 and 20:00 Manager and one nurse. 0730 until 11:00 4 care staff. 11:00 until 1600 3 care staff and 4 two afternoons for activities. 16:00 until 20:00 2 care staff 18:00 until 07:30 1 nursing staff and 1 care staff. Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 21 Ancillary staff such as cooks, cleaners and maintenance staff are also provided. The provider and administrative also provide daily support for which the manager is appreciative. Throughout the inspection staff support was observed to be professional caring and competent. The service users I spoke with said that staff were very kind and helpful and responsive to their needs. The manager has improved all areas of her responsibilities in recruitment. Staff records were inspected, and information obtained for recruitment purposes was very much improved. Staff files were professionally presented making the retrieval of information easy. The manager has purchased a white board to record the training completed by the staff and the next updating sessions. 53 of the care staff holds a National Vocational Qualification in care at level two and three. The manager ensures that staff receive the training, required by regulation, which includes moving and handling, basic food hygiene, fire and infection control training. New staff receive the Skills For Care Induction training. The training certificates were kept under training in the individual staff file. I spoke with the staff who said that they appreciate the training they have completed and this will help them to progress in the social or nursing care field. Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 22 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35,36 and 38 were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager is a registered nurse and fit to manage the home. There is consultation between the registered provider, service users, their representatives and interested stakeholders so they have input to improving the service. Service users can fell assured that staff are appropriately supervised. Regulation 26 monthly reports should be up to date. There is a system in the home for dealing with service users money, which, safeguards and protects the service users financial interests. Health and safety measures are satisfactory but updating in fire training for staff is required. EVIDENCE: The manager is a qualified nurse with many experience in nursing care and management. Service users in the home have a good relationship with her and
Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 23 they can feel assured that the home is run and managed by a person who is fit to be in charge, of good character and able to discharge her responsibilities fully. Throughout the inspection the manager conducted herself with openness and respect, in which service users, family and staff feel valued and that their opinions matter. There is evidence of effective quality assurance and quality monitoring systems based on seeking the views of service users, representatives and interested stakeholders in place to measure success in meeting the aims, objectives and statement of purpose of the home. The results of the 2006 quality assurance exercise were professionally presented and produced a systematic cycle of planning action and review, reflecting outcomes for service users. The home has a policy for the management of service users money. Personal allowance money held for some service users is stored individually so that it is safe and can be checked during inspections. The records of all transactions were handwritten with service users encouraged to sign when money is withdrawn The manager has improved formal one to one supervision, which could be evidenced at the inspection. Staff said that they were appreciative of the supervision and it gives them the opportunity to contribute to care and their own development. Health and safety records were inspected. The fire officer inspected the home on the 5th February 2007 and they required that improvements to the fire risk plan be implemented. The staff member responsible has completed this. Staff have tested fire alarm call points and emergency lighting in accordance with guidance by the fire authority. External contractors are responsible for servicing the fire alarm and extinguishers. Staff receive relevant policies and procedure which are discussed at the one to one supervision sessions. Whilst the Responsible Individual has been writing her monthly report on the conduct of the organisation the reports were not up to date. The last one was completed in September 2006. These must be brought up to date and I would be grateful when you inform me when this has been completed. The organisational Health and Safety policies and procedures are professionally presented with corresponding national minimum standards preceding the policy and procedure. This makes for easy reference and staff find this useful particularly when they have to research information for their NVQ relating to the policies and procedures of the home. Benoni Nursing Home Ltd DS0000061997.V335468.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 x 2 Benoni Nursing Home Ltd DS0000061997.V335468.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 2 3 4 5 Refer to Standard OP7 OP9 OP19 OP38 OP38 Good Practice Recommendations The registered person should complete risk assessments with permission of service user or representatives and give all staff training in the safe use of cot sides. The registered person should ensure that transcribing onto the medication sheets should have the two signatures of staff. The registered person should as part of the improvement plan replace the stained and torn ceiling tiles and carpets in some areas. The registered person should arrange for all staff to be brought up to date with their fire training. The registered person should ensure that regulation 26 reports, which report on the conduct of the company, are kept up to date. Benoni Nursing Home Ltd DS0000061997.V335468.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Devon Office Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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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