Inspection on 17/05/07 for Bhajan Kaur Rai Hall

This inspection was carried out on 17th May 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

Bhajan Kaur Rai Hall 10/05/06

Bhajan Kaur Rai Hall 16/08/05

Bhajan Kaur Rai Hall 31/05/05

Bhajan Kaur Rai Hall 02/02/05

Bhajan Kaur Rai Hall 15/09/04

Bhajan Kaur Rai Hall 19/03/04

Similar services:

Applegarth

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Bhajan Kaur Rai Hall Epinal Way Care Centre Hospital Way Loughborough Leicestershire LE11 3GD Lead Inspector Anthea Richards Key Unannounced Inspection 17th May 2007 10:30 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 Bhajan Kaur Rai Hall DS0000001655.V337378.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. Bhajan Kaur Rai Hall DS0000001655.V337378.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bhajan Kaur Rai Hall Address Epinal Way Care Centre Hospital Way Loughborough Leicestershire LE11 3GD 01509 216616 01509 262710 surjit@rushcliffecare.co.uk 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) Rushcliffe Care Limited Mrs Karen Joy Wragg Care Home 33 Category(ies) of Dementia (12), Dementia - over 65 years of age registration, with number (22), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (12), Old age, not falling within any other category (21), Physical disability (21), Physical disability over 65 years of age (21), Sensory Impairment over 65 years of age (21) Bhajan Kaur Rai Hall DS0000001655.V337378.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. BKR Hall care home is registered to provide personal care to male and female service users who fall within the following categories:Physical disability over 65 years of age (PD(E)) 21. Physical disability over the age of 55 years (PD) 21. Old age, not falling within any other category (OP) 21. Sensory impairment over 65 years of age (SI(E)) 21. Mental disorder, excluding learning disability or dementia - over 65 years of age (MD(E)) 12. Dementia - over the age of 65 years (DE(E) 22, Dementia over the age of 55 years (DE) 12. Dementia, over the age of 65 DE(E) 12. Persons accommodated at BKR Hall under the categories of DE and DE(E) should be accommodated on the first floor only. The maximum number of persons to be accommodated on the first floor of BKR Hall under the DE and DE(E) categories is 12. Persons accommodated at BKR Hall under the categories of PD, PD(E), OP, MD(E) and SI(E) should be accommodated on the ground floor only. No one falling within the category MD(E) should be accommodated at BKR Hall lwhen there are 12 persons in total of this category already accommodated within the home. The maximum number of persons to be accommodated on the ground floor at BKR Hall is 21. The maximum number of persons to be accommodated at BKR Hall in total is 33. 10th May 2006 2. 3. 4. 5. 6. 7. Date of last inspection Brief Description of the Service: Bhajan Kaur Rai Hall Care Home is a care home providing personal care and accommodation for 33 people with physical and mental health needs. It provides separate accommodation for those people with mental health needs. Rushcliffe Care, who has a number of homes in the area, owns the home. It is located next to the Loughborough Hospital, and approximately one mile from the centre of Loughborough; it is accessible by public transport or car. There is plenty of parking for visitors. There are two other homes on the same site that are also owned by Rushcliffe Care. Bhajan Kaur Rai Hall DS0000001655.V337378.R01.S.doc Version 5.2 Page 5 The home is purpose built with all the adaptations needed to support the residents. The home has bedrooms and communal space on two floors, which can be accessed by stairs or a lift, which is suitable for wheelchair users. The first floor is divided into two areas, one of which gives a safe environment for the residents with mental health needs. There is a good standard of decoration throughout the home and all of the bedrooms have en-suite shower facilities. On both floors there are large dining rooms, and comfortable lounges with televisions, videos and books. There is an on site laundry and kitchen, which are clean and have good storage facilities. The home has a garden and patio area to the front and back of the building which is well maintained and which the residents can use in the better weather. The Statement of Purpose, Service Users’ Guide & Inspection Report are available on request. The Statement of Purpose, Service Users’ Guide are provided for all new residents. The registration certificate from the Commission for Social Care Inspection, showing which categories of care the home is registered for is displayed in the entrance area. The up to date insurance certificate is also there. The home can be contacted by telephone, fax or email. The fees range from £327.00 to £ 500.00 There are extra charges for hairdressing, chiropody, newspapers and personal items. Bhajan Kaur Rai Hall DS0000001655.V337378.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection of the care home, which ended with an unannounced visit to the service. Before the visit the inspector spent five hours reviewing information received by the Commission for Social Care Inspection (CSCI) since the last inspection on the tenth of May 2006. The home has had a thematic inspection on the 7th January 2007. This means that the inspector looks at particular areas of the service. On this visit we only looked at the Statement of Purpose, the service user guide and the complaints policy. This visit took place on the 17th May 2007 and lasted six hours. During the visit the inspector checked all the ‘key’ standards as identified in the National Minimum Standards. This was achieved through a method called ‘case tracking’. Case tracking means that the inspector looked at the care provided to three of the residents. To achieve this, the residents and, where possible, their families were spoken with. The inspector spoke with the staff supporting their care and looked at the records relating to their health and welfare. With their permission the residents’ bedrooms were looked at. The inspector also checked how the home was run and organised. This included looking at staff records, training and how the staff are organised. The inspector looked at health and safety records, menus, minutes of meetings and the quality audit. The policy for handling complaints and how the home dealt with them were looked at. The inspector looked at how prospective residents and their families are given information about the services the home can offer and whether they are suitable for them. During the visit the inspector spoke with the manager, the senior manager, staff, residents and the residents’ families. What the service does well: Bhajan Kaur Rai Hall provides a well -maintained homely place to live in. Bhajan Kaur Rai Hall DS0000001655.V337378.R01.S.doc Version 5.2 Page 7 All of the staff and the manager are trained to meet the needs of the residents. The staff, all show empathy and support when looking after them. Medication administration is well audited, which makes sure as far as possible that mistakes are avoided. The residents have a good choice of meals and individual wishes and needs are catered for. What has improved since the last inspection? What they could do better: The findings of the inspector during the visit were discussed with the manager at the end of the visit. A programme of activities should be put in place and records kept. This will give the residents added interest in their lives improving their quality of life. The complaints procedure could be written in a more easily read form. Fire drills and equipment checks should be completed and records kept. This will make sure that the staff are able to look after the residents in the event of a fire. The residents’ families could be encouraged to bring personal belongings into the home to give the resident familiar surroundings. Consideration could be given to using a different method of communicating between the three homes, other than using the tannoy system. This would give the residents a more pleasant environment to live in. The residents’ dignity could be improved if the staffing levels were high enough to allow the staff individual time with them. The staffing levels should be reviewed to provide adequate numbers of staff at times when there is the most need and the highest levels of dependency. Bhajan Kaur Rai Hall DS0000001655.V337378.R01.S.doc Version 5.2 Page 8 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. Bhajan Kaur Rai Hall DS0000001655.V337378.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 Bhajan Kaur Rai Hall DS0000001655.V337378.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): 1, 2, 3, 5. 6 is not applicable in this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are well assessed before moving into the home by the completion of a pre-admission assessment. They are offered a visit to the service by them and/or their family so that they know that they will receive the right care. EVIDENCE: All of the residents had received a Statement of Purpose and a Service Users guide. The Statement of Purpose and Service Users’ Guide give all of the information that is needed about the services offered and the Terms and Conditions for the home. Giving the prospective residents and their families a thorough Statement of Purpose & Service Users’ Guide makes sure that they have good information so that they can choose the most suitable care for them. Bhajan Kaur Rai Hall DS0000001655.V337378.R01.S.doc Version 5.2 Page 11 Two of the residents families spoken with told the inspector that they had a visit from the home manager before their relative was admitted. They confirmed that they were given the opportunity to visit the home before they came in. This makes sure that that the staff in the home have the the right information before the resident is admitted so that the resident gets the best care. It makes sure that the home can meet the residents needs and that the resident meets someone from the home who they can recognise. This makes the move into care easier to manage for them. Members of the staff spoken with said that they usually knew what the residents needs were before they moved in. The current registration certificate from the Commission for Social Care Inspection (CSCI) was displayed in the entrance of the home. An up to date insurance certificate was displayed in the entrance hall. This tells prospective residents that the home is registered to provide the care that they need. Bhajan Kaur Rai Hall DS0000001655.V337378.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): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff give the care to the residents as it is identified in the care plans, but it is not always with the dignity which they should expect. EVIDENCE: The care plans which were ‘case tracked were found to contain good individual evidence of the care being given to the residents. There are records showing the involvement of G.P.s, chiropodist, optician and dentist in the care of the residents. The residents and their families spoken with said that they could see the doctor and other health professionals when they needed to. The residents or their families had agreed with the care plans and had signed them. This was confirmed by the families spoken with. Bhajan Kaur Rai Hall DS0000001655.V337378.R01.S.doc Version 5.2 Page 13 The daily record of care is up to date which makes sure that the residents receive the right care and the staff know what has happened to them during the day or night. In the part of the home where the residents with dementia live the inspector saw a member of staff trying to manage to feed some of the residents. She was not able to give them individual care or dignity whilst doing this as she was on her own in the area. In the other dining room a resident was given her lunch and was left for a long time before a member of staff came to assist her. This meant that her lunch was cold and that she had to sit and watch everybody else eating their lunch before she was able to have hers. In other areas the staff were generally seen to be giving care in the right way, with privacy given where needed. They were seen to be speaking with the residents in a kind and private way. Staff spoken with were aware of the care needs of the residents and the residents and the families spoken with were happy that all care needs were being met. There are risk assessments in place to cover all the identified risks for the residents. This makes sure that the residents and the staff are protected from any risks that there may be, without restricting their activities. Medication records for the case tracked residents were in order. Medicines are given by the senior care staff, who have had training in giving them. Medicines were administered individually and the residents were seen to be taking them. The staff spoken with knew about the medicines and where to obtain information for any new ones. They were also aware of the requirements for the receipt, storage and disposal of medicines. The controlled (dangerous) drugs register was checked and found to be in order. There is a policy in place for the residents who are able to look after their own medicines. However, there were no residents looking after their own medicines at the time of the visit. Bhajan Kaur Rai Hall DS0000001655.V337378.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): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well supported in meeting their social, spiritual and nutritional needs, which gives them a good quality of life. EVIDENCE: The inspector was told that there was a new activities organiser and that activities were being arranged. There were no records in place to support any evidence of activities. One of the residents spoken with said that there were suitable activities, whilst the others said that there was little to do. There were no activities taking place on the day of the visit. Some of the residents were seen to be sleeping in front of the television. The residents have a choice of meals every day and the cook provides alternatives according to their needs. He provides home made cakes and puddings. Bhajan Kaur Rai Hall DS0000001655.V337378.R01.S.doc Version 5.2 Page 15 He has an understanding of the dietary needs of the residents such as diabetic, soft and liquidised diets. The inspector talked with the residents during lunchtime in the dining room. All the residents spoken with said that they were enjoying their meal and that they always had a choice of meals. Visitors are made very welcome in the home. This was confirmed by visitors and families spoken with who told the inspector that they were made very welcome at any time. The inspector observed the welcome given to visitors when coming into the home which was warm and friendly. They are spoken with regularly on a one to one basis by the manager. The manager sees each of the residents on a one to one basis every day. There are annual quality audits to get the views of the residents and their families. The manager holds regular residents meetings, which have minutes taken. These practices ensure that the residents maintain contact with the community and their families and that views for improvements can be considered. There is a regular church service within the home which the residents enjoy and communion can be arranged for them if they wish it. The local Roman Catholic church arranges visits for those residents of that faith. These practices make sure that the pastoral care needs of the residents are met and that all Faiths are provided for. Methods of communication such as translation and sign language can be provided if needed. A hairdresser visits once a week and the residents told the inspector that they really enjoyed her coming. Bhajan Kaur Rai Hall DS0000001655.V337378.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): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are systems in place to support and protect residents and staff are aware of the processes. EVIDENCE: There is a complaints policy in place which gives the details of how to complain and who to complain to if they needed to. The complaints book was looked at and there is a record of one complaint having been received since the last inspection on the 10th May 2006. This is still ongoing with social services. The Commission for Social Care Inspection have been told about this complaint. The residents spoken with were happy that they would speak to the manager or a member of staff, if they had a problem and that it would be dealt with. Families and visitors spoken with on the day of the visit said that they were aware of the procedure to complain and would have no concerns about doing so. The complaints procedure is difficult to read and at the thematic inspection in January 2007, it had beed recommended that it was produced in an easier to read form. This has not yet been done, although the manager said that she would get it done. Bhajan Kaur Rai Hall DS0000001655.V337378.R01.S.doc Version 5.2 Page 17 The staff spoken with knew how to deal with a complaint which was given to them and would be happy to do so. The staff spoken with were aware of ‘safeguarding adults’, the procedure to follow and would be prepared to ‘whistle blow’ if they thought that there was a need to. The staff that they had had training in safeguarding adults and this was confirmed by the training records held in the home. This makes sure that the residents are safe from any abuse and that any concerns are handled correctly. Accident forms were looked at, which were kept in a separate file, and were found to be in order. These could be kept in the individual residents file so that they were with the other information about the resident. Bhajan Kaur Rai Hall DS0000001655.V337378.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): 19, 20, 22, 23, 24, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents live in a home, which provides a pleasant physical area for them to live in, although the interruption of the tannoy system does not give them a good environment. The lack of fire records could put their safety at risk. EVIDENCE: The registration certificate from the Commission for Social Care Inspection was displayed with a current certificate of insurance. The inspection reports are available in the office. Bhajan Kaur Rai Hall is in Loughborough next to the hospital. There are two lounges and dining rooms. The home is very well maintained, clean and mostly free from any unpleasant odours giving the residents a pleasant place to live in. Bhajan Kaur Rai Hall DS0000001655.V337378.R01.S.doc Version 5.2 Page 19 There is a tannoy system in the home to tell staff about phone calls, which constantly interrupts the residents’ lives. Consideration could be given for a different way of communicating, as this does not give a very homely feel to the home. The residents and visitors spoken with seemed to be resigned to the fact that it was there and said that they would rather that it wasn’t. The gardens and patio areas are very well kept and easy for the residents to get to in the better weather. The bathrooms are clean, tidy and free of any hazards. With their permission, the case tracked residents bedrooms were looked at by the inspector. They provided good accommodation, some ofwhich had been personalised with the resident’s belongings. Families could be encouraged to bring personal items into their bedrooms, particularly for those with mental health needs. This will give the resident reassurance if they have familiar items around them which will help them to settle in the home. The bedrooms were clean and well maintained. Some of the bedrooms have en-suite facilities. There was evidence of a range of equipment such as hoists and mattresses having been provided to help in the care and comfort of the residents. The records for maintenance were looked at and found to be in order and up to date. The fire records were looked at and were found not to be up to date, for weekly checks, fire drills or for fire extinguisher checks. There were no outstanding safety or maintenance issues seen on the tour of the premises. Bhajan Kaur Rai Hall DS0000001655.V337378.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): 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents’ needs are not always met but their safety is protected by the recruitment policy and by the training that is in place. EVIDENCE: There is evidence of a good skill mix of staff to make sure that the residents have the right care. The duty rota reflected the number of staff on duty. The residents, staff and visitors spoken with felt that there were usually enough staff on duty to look after them properly. On the day of the visit the inspector saw evidence of a lack of staff at lunchtime, meaning that the residents were not being cared for adequately at that time. This is of particular concern in the area where the residents with mental health needs live. Two staff files were looked at by the inspector and the required information was complete in one of the files. This included evidence of identification, adequately completed application forms, two written references and Criminal Records Bureau checks. One of the application forms was not complete, which was shown to the manager who had it completed immediately. Bhajan Kaur Rai Hall DS0000001655.V337378.R01.S.doc Version 5.2 Page 21 There were records of staff training including induction and the staff spoken with confirmed that they received regular training in all the required areas. They said that they had training in first aid, food hygiene and moving and handling training. The staff receive training in dementia and challenging behaviour. There is a record of training held by the manager with the certificates in the staff files. The home has 50 of the staff with a National Vocational Qualifications(NVQ) in care at level two or above, which is the standard required. The Manager is completing the registered managers award through the National vocational award programme. The National Vocational Qualification is a qualification for care staff to make that they receive the right training in the needs of the resident group whom they are caring for. Bhajan Kaur Rai Hall DS0000001655.V337378.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): 31, 33, 35, 36, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is good communication between the manager, the staff and the residents. This generally makes sure that the residents are able to live in a home that gives them the care that they need and want, EVIDENCE: The manager was not available until the afternoon , however a senior carer and the senior manager were available for the rest of the visit. Bhajan Kaur Rai Hall DS0000001655.V337378.R01.S.doc Version 5.2 Page 23 The staff receive training to make sure that they can care for the residents safely whilst protecting them from any abuse. This was confirmed by available records, the manager and by staff spoken with. The manager holds regular meetings with the residents and their families as well as one to one discussions both to pass information on and to listen to their views and opinions. There are annual quality questionaires sent out to residents and their families to gain their views about the home. These practices allow the manager and the responsible person to respond to the residents and the staff’s needs. The home holds personal spending money on behalf of some of the residents. These records were found to be in order. Records for the maintenance of fire equipment, fire drills and training were not found to be up to date and could put the residents and the staff at risk. This was brought to the managers attention at the previous inspection on the 10th May 2006. Bhajan Kaur Rai Hall DS0000001655.V337378.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X 3 X 2 X 3 STAFFING Standard No Score 27 1 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 1 Bhajan Kaur Rai Hall DS0000001655.V337378.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? None 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 OP27 Regulation 27.4 Requirement Timescale for action 31/05/07 2 OP38 There must be adequate numbers of staff on duty to properly provide for the needs of the residents at all times. 23(4)(c)(d There must be arrangements 30/06/07 )(e) made for the maintenance of fire equipment, suitable fire training and drills for the staff to reduce the risk and protect the residents and the staff from fire. The arrangements must be recorded. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP10 OP12 OP19 Good Practice Recommendations There should be sufficient staff on duty to allow the residents to be treated with the dignity that they should expect. There should be appropriate and varied activities provided and recorded to give the residents a good quality of life. Consideration should be given to an alternative method of communication between the three homes. This will avoid DS0000001655.V337378.R01.S.doc Version 5.2 Page 26 Bhajan Kaur Rai Hall 4 OP24 the intrusion of the tannoy into the residents home. Consideration should be given to encouraging the residents’ families to provide personal belongings, to make their bedrooms familiar for them. Bhajan Kaur Rai Hall DS0000001655.V337378.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bhajan Kaur Rai Hall DS0000001655.V337378.R01.S.doc Version 5.2 Page 28 - 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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