Inspection on 02/07/08 for Biffins

This inspection was carried out on 2nd July 2008.

CSCI found this care home to be providing an Adequate service.

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

Biffins 07/08/07

Biffins 13/07/06

Biffins 06/12/05

Biffins 01/07/05

Biffins 15/12/04

Biffins 20/09/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Biffins 18 Thorpedene Gardens Shoeburyness Essex SS3 9JB Lead Inspector Sarah Hannington Unannounced Inspection 2nd July 2008 11:00 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 Biffins DS0000044339.V367654.R02.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. Biffins DS0000044339.V367654.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Biffins Address 18 Thorpedene Gardens Shoeburyness Essex SS3 9JB 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) 01702 292120 faizaljoomun@yahoo.co.uk Mrs Bibi Sehnaz Bano Joomun Mr Mohammed Faizal Joomun Mr Mohammed Faizal Joomun Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Biffins DS0000044339.V367654.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Total number of service users not to exceed 14. Service users to be older persons over the age of 65 years. Date of last inspection 7th August 2007 Brief Description of the Service: Biffins is a care home for older people over 65 years of age and can accommodate 14 people. It is situated in a residential area of Shoeburyness with easy access to shops and other amenities. There are good bus and train links to the area. The home has accommodation on two floors and there is a passenger lift to enable access to both floors. There are 10 single bedrooms and 2 twin bedrooms, although only 1 resident is occupying each of the twin bedrooms. The home has a large lounge/dining area and a large garden. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplies them with up to date information on the home. Fees range from £362.46 to £445.00 and there are additional charges for hairdressing, chiropodist, newspapers and private telephone and Sky TV. Biffins DS0000044339.V367654.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 Star. This means the people who use this service experience adequate quality outcomes. The site visit took six hours to complete and was carried out as part of the annual inspection programme for this home. This visit was conducted with assistance from the registered care manager/provider. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. The site visit also focused on any requirements and recommendations from the last key inspection. The Commission for Social Care Inspection looked at all of the information that we have received, or asked for since the last key inspection. We asked the manager to complete an Annual Quality Assurance Assessment (AQAA) form. This form is for the manager to look at and write down how well the service meets the needs of the people who live at Biffins care home. The new AQAA is not due back before the time of this report. Therefore the previous AQAA was used and discussion around improvements with the manger/provider was undertaken during the inspection. On this site inspection three relatives, seven residents, four staff and one professional was spoken with as part of this process. Surveys were also sent out and five were returned to us. Their comments will be included as part of this report. What the service does well: What has improved since the last inspection? Many inside and outside changes have taken place, which benefit the resident’s quality of life. Reviews of all Care plans are taking place. The manager has updated the Statement of Purpose and Service Users Guide. Staff cover on shifts when residents need more support has improved. Activities for all residents have been approved upon. Biffins DS0000044339.V367654.R02.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Biffins DS0000044339.V367654.R02.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 Biffins DS0000044339.V367654.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A robust assessment process reassures residents that their needs will be met before they move to the home. EVIDENCE: The manager reviewed the Service User Guide in May 2008 and contains up to date information on the services that the home provides. The care files of four new residents were looked at in terms of their preassessments prior to admission and information provided for people regarding the home. This showed us that prospective residents have enough information about the services offered and are given opportunities to visit the home. Good information on pre-assessments included personal preferences, general health care, and emotional, social and physical needs. The manager states on the AQAA that, ‘Prospective service users are given clear information, Service User Guide and Statement of Purpose. The weekly Biffins DS0000044339.V367654.R02.S.doc Version 5.2 Page 9 fee is well stated in both documents and the contract. The manager will assess all prospective service users at home, hospital or other setting to ensure their needs can be met before they are accepted to move in. All prospective service users are informed they will need to undertake a 4 week review before they become permanent.’ The residents commented that, ‘My family came in and looked around before I moved in’, ‘My relative received a brochure to look at before we had a look around the home’, ‘ my relative and me had a look around and chat with the staff before making a decision to move in’, ‘I had a meeting after four weeks to see if the home suited me.’ The home does not provide intermediate care. Biffins DS0000044339.V367654.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are successful in delivering appropriate care, although this may not always be documented appropriately yet for all residents. EVIDENCE: The manager states on the AQAA that, ‘Care plan are reviewed monthly Service Users and representatives are encouraged to participate in the annual care reviews.’ Four residents care plans (two of which were of the lastest residents admitted) and other related documentation was looked at such as, daily notes, risk assessments, any guidance for staff and indivdual assessments. All of the care plans looked at included health care needs such as, nutrtion,diet, mobilty, assessment of falls, weight monitoring, mental state, medication and social interests. In two of the care plans looked at there had been notes on a persons health history, these were in the files of the most Biffins DS0000044339.V367654.R02.S.doc Version 5.2 Page 11 recently admitted residents. This gave staff a background knowledge of indivduals support needs and the break down of the health care areas gave a basic outline for staff in what the issues are and how they should work with that individual. However care plans needed to evidence that residents input, views and requests form part of this process. In the files of residents that were looked at, lacked such detail. A resident’s care notes lacked information regarding the use of a turning chart being in place within their room. This person’s file made no reference to a risk assessment and there was no information given regarding how frequently this person should be turned. On the turning chart itself some days was recorded every two hours and on other days once for the whole day on other days it could be less than two hours or a more than a two hour period. When speaking with staff they were unsure of the procedure for this person and when speaking with the manager he informed me that this was a precautionary practice implemented by himself and not by the district nurse. A professional who came daily to the home did state that staff are good at maintaining any leg ulcers residents may have and that no further deteriotation had occurred and that the staff team had mananaged to prevent and heal any pressure sores that residents had accuired prior to moving into the home. Two of the care files looked at held very concise information such as, how to work with a person, their preferences, likes and dislikes, histories and the present situation and risk assessments reflected the current care plan. Two of the care files looked at had poor recording of general information and some information needed to be archived, this has been largely inherited from the previous owner. There was evidence that annual reviews are held including professionals with all residents and their representatives and regular reviews of documentation is held for all of the four residents care files looked at. Within daily notes held for indivduals it was clear to see that staff are developing recording styles by expanding on how the residents spent their day and what conversation or activities they had carried out. All residents have full access to specialised clinic, GP, district and community nurses, chiropody, dentist and eye care professionals. All appointments are recorded well. The residents commented that, ‘I have a regular appointments and the staff and manager always make sure I attend them and that I know what is going Biffins DS0000044339.V367654.R02.S.doc Version 5.2 Page 12 on’, ‘I have a regular nurse who comes into see me’, ‘if I am feeling unwell then the GP is called straight away’, ‘we are well looked after here and have appointments made if we want them’, ‘the staff always check if I am ok’. The manager states on the AQAA that, ‘we have developed MAR sheet that help staff to be safe with administration of medication. We have medication audit tool that is being used to identify and eliminate any problem or potential problem with medication.’ Policy and procedures are in place for the correct receipt, recording, storage and handling, administration and disposal of medications. We checked the records and noted that any medication changes had been recorded accurately. All MAR record sheets had been correctly recorded, signed for and there were no gaps in vital information needed. The administration records are maintained in accordance with agreed procedures and the royal pharmaceutical legislation. Evidence of documentation and the fact that no incidents around medication issues or practice would suggest that medication is kept to a strict protocol and is maintained consistently to a good standard. Signatures of staff who administer medication are present. Medication is stored in a locked cabinet and is kept in separate boxes and packets rather than an MDS (medication dosage system/ blister packs). Accredited certificates seen in staff files dated back to 2005 for medication training. Although well accounted for and correctly documented by the staff administering medication, the home does have controlled medication, which is not held within a controlled drugs cabinet, or have an official controlled drugs book held. Staff have out of their own good practice kept a book that records two signature and accounts for a count of tablets every time they have been administered. When speaking with staff they felt uncomfortable with the current situation around how the controlled medication is currently kept. The manager said that the cabinet was taken down off the wall as it was not held securely enough. This means that controlled drugs in the home are not stored in line with current legislation requirements as laid down by the Royal Pharmaceutical guidelines. Biffins DS0000044339.V367654.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities to participate in activities, education and leisure interests, which are suited to people’s lifestyle, are available for all of the residents. EVIDENCE: The residents commented that, ‘I get a daily paper and anything else I need from the local shops.’ ‘I get a national paper so that I can keep up with current affairs.’ ‘I keep a calendar which I mark down what I have done from day to day and this way it keeps my mind active.’ ‘I have my own phone in my room so I can make contact with my family as much as I like.’ ‘I receive my own mail here.’ ‘ I like the new activities they have bought in it keeps us from getting bored.’ ‘ I like watching the activities rather than joining in, but it is fun to watch’, ‘I have a minister who regularly comes in to visit me.’ The manager has arranged different hours for staff so that better 1-1 or group activities can go ahead. There are planned activities through out the week. Additionally entertainers visit the home from time to time. Staff were seen carrying out some of these activities such as bingo and skittles. Observation showed us that residents had their own daily papers of choice, puzzle books, library books and personal things that they liked to carry out during the day to Biffins DS0000044339.V367654.R02.S.doc Version 5.2 Page 14 occupy themselves. All residents had radios, television in their rooms. Residents had been following the tennis and lots of discussion regarding this was heard, after lunch people were watching this either in their private rooms or within the main lounge. The manager states on the AQAA that, ‘Family, friends and representatives are encouraged to visit service users.’ The relatives commented that, ‘ the staff always offer us refreshments when we arrive’, we always feel welcomed by the staff’, ‘We know all the staff there are never any agency or staff we do not know’, ‘If we ask questions about my relative we always get good information’, ‘ we can visit anytime and are always made to feel comfortable’. Observation during the inspection showed us that visitors came and went through out the day and that there was a good rapport with staff. Residents spoke freely and were happy to walk around chat, join in activities and seek the inspector out to have a chat. The residents commented that, ‘ The staff always make sure I that I stay in contact with my relatives’, ‘ The staff have supplied me with my own phone so I can regularly stay in contact with my family’, ‘the staff supported me in attending my relatives wedding’, ‘ my visitors are allowed to come anytime to see me’. The manager states on the AQAA that, ‘Staff interact well with service users and encourage them to participates in activities.’ Staff were seen to be supportive, caring and listened well to people. There was a natural banter and rapport with residents and one person who has dementia was seen to be well looked after, for example they would sometimes use body language as a means of communication and this was responded to promptly by staff and obviously well understood. The manager states on the AQAA that they, ‘Maintain a well balance diet and taking into consideration those that are diabetic.’ The residents commented that, ‘ The meals here are always nice and hot when they arrive’, ‘ If I am not keen on a meal then they cook me something else’, ‘we never wait long for meals’, ‘all the staff are good at cooking and I think the food is really tasty’, ‘The food is well cooked and of good quality’. The lunchtime period was observed on this inspection. The meal that was provided to residents was home cooked, appetising and nutritious. One person Biffins DS0000044339.V367654.R02.S.doc Version 5.2 Page 15 who was supported by staff to eat their meal, was handled with good interaction, sensitively, unrushed and handled with care and respect by that member of staff. Biffins DS0000044339.V367654.R02.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 and 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 ensure that peoples views are listened to, acted upon and support residents to be protected from abuse. EVIDENCE: The manager states on the AQAA that, ‘We have a complaint procedure in place and residents are reminded about the complaint procedure during their monthly meeting with the manager.’ There have been no complaints made to the home or reported to the CSCI office since the last inspection. There is a good complaints procedure in place. All complaints are recorded, maintained and outcomes recorded. The residents commented that, ‘ I would know who to complain to if I needed to.’ ‘ My relatives would take my concerns to the manager’. The relatives commented that, ‘ The staff always listen and resolve any issues that we have, although we have had no reason to make a complaint as such’, ‘ the manager is very approachable and if I had an issue I have no doubt it would be resolved to our satisfaction’. The manager had informed me that all staff have attended safe guarding (protection of vulnerable adults) training. Speaking with most of the staff they had good awareness around these issues and overall all staff knew where they Biffins DS0000044339.V367654.R02.S.doc Version 5.2 Page 17 could get advice from if they had concerns about safe guarding issues. Safe guarding training does not presently form part of the induction process for new staff. Biffins DS0000044339.V367654.R02.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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People live in a clean environment, however safety is not always maintained. EVIDENCE: Overall the home is comfortable and suitable for the needs of the present resident group. There is also a good cleaning programme in place. On the day of inspection the home was observed to be clean and all areas were odour free. People’s bedrooms were personalised and clean. There were an adequate number of bathrooms and toilets available. Some redecoration is needed to bathroom and toilet areas such as, repainting and updating of fixtures and fittings. However this is part of the overall maintenance plan of the home. Since the last inspection the manager has put in water valves to ensure that the hot water is within expected safe temperatures and staff regularly monitor these. The bath hoist has been changed and updated. New dining room chairs and garden furniture has been purchased. All the bedroom doors have been Biffins DS0000044339.V367654.R02.S.doc Version 5.2 Page 19 fitted with dorgards, this is a fire safety piece of equipment that is attached to the bottom of a door instead of using a door wedge to keep them open.(which is not allowed) This piece of equipment enables doors to be left open but will close automatically on the sound of a fire siren being triggered, therefore keeping the safety of the resident’s and staff secured. The residents commented that, ‘ The manager is really good with getting me bits of furniture that I need.’ ‘My clothes are always kept so nice by the staff’, ‘the manager always provides me with equipment that I ask for, he is really good like that’. The relatives commented that, ‘we visit on a regular basis and there are never any unpleasant smells’. ‘ The rooms are always kept clean’. ‘I never see anyone in this home look unhappy’, ‘they all look so well cared for and look nice.’ The home operates on the guidelines of the NHS universal Infection Control and staff spoken with were knowledgeable. The COSHH ( Chemicals or substances hazardous to Health) cupboard is located within the small laundry room. The laundry door itself has no lock but the COSHH cupboard does. In the laundry room a large tub of industrial washing powder was left unattended without a lid. The COSHH cupboard door was left unlocked. The COSHH cupboard contained three bottles of bleach. Bleach under the COSHH regulations is a product prohibited to use within care homes. Touring the premises it was noted that protective clothing, such as, boxes full of rubber gloves were left in resident’s bedrooms and in hallways. The manager needs to ensure that COSHH products are not left unattended. There were no current accredited certificates in staff files to evidence that recent health and safety, Infection control or health and safety training had recently taken place. Biffins DS0000044339.V367654.R02.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are protected by good staff recruitment, but the lack of training received could put residents at risk. EVIDENCE: The majority of the staff team have been in post for a long time and provide the residents with stability and consistency of care. Turn over is low and staff spoken with are happy in their roles and with the management. At present there are three vacancies and one staff member is on long term sickness. Speaking with the manager he is presently trying to recruit for the vacant posts. The staff team are covering the vacant hours and agency would only be used as an emergency. Additionally this has a knock on effect as the team find it hard to access and go on accredited training, although the manager has reassured us that he has done in house training in all expected areas, such as, manual handling, fire safety, food hygiene, health and safety and dementia. However certificates have not been issued by himself as his training in, ‘train the trainer’, is not yet fully completed. It is essential therefore that staff receive training in these areas whilst he is completing this. Biffins DS0000044339.V367654.R02.S.doc Version 5.2 Page 21 The manager has now been holding regular staff meetings and minutes of these are held. There are over half of the staff team that have qualified on the NVQ training and are being put forward to study the higher level. The home currently does meet its 50 recommendation. All staff spoken with commented that, ‘ we now have regular supervisions and staff meetings.’ The residents commented that, ‘ The staff here are really pleasant’, ‘ I think they deserve a medal for what they do and how hard they work.’ ‘ They always do little things for me that make a difference.’ ‘ As soon as I ring my buzzer they are up like a shot.’ ‘ Nothing is too much trouble for the staff here’. The relatives commented that, ‘The staff are always welcoming when we visit’, ‘the staff know my relative well and can always tell me what I need to know’. Biffins DS0000044339.V367654.R02.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): 31,32, 33, 35,36,37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the manager is keen to provide a good service, management systems are not fully in place in the home to enable this to happen. This is currently affecting outcomes for residents, which could be better in many areas. EVIDENCE: The manager is a qualified District Nurse and has achieved the NVQ4 and RMA (Registered Managers Award). Although there are a number of issues raised within this report, it is acknowledged that the manger has worked in a transparent way with CSCI during the inspection and was very open about issues that need improvement within the home. Additionally at all other times the manager keeps us well informed of any issues relating to the residents, staff and home. Through discussion, the manager evidenced that he has every intention to address the Biffins DS0000044339.V367654.R02.S.doc Version 5.2 Page 23 issues raised on the site inspection and put into place the things which needed improving upon. Finance systems evidenced that resident finances are protected. All health and safety checks that were inspected are up to date. Within the fire records looked at and staff practice around fire evacuation drills were found to be to a good standard. Quality Assurance is still being further developed and information needs to be collated and made available to CSCI and all other interested parties. The residents commented that, ‘the manager is very good and kind’, ‘ the manager always gets me to my appointments on time and I appreciate this’, ‘ I asked the manager if I could go out for a drive to the sea front one day and he is arranging this, he has arranged this and has showed me the car that we would be using.’ ‘ The manager is always helpful to us and finds solutions when we have problems.’ The staff commented, ‘since the new manager has taken over I feel that the care and paper work we use has been improved upon’, we are encouraged to achieve our NVQ training and at first although I wasn’t keen, now I have completed it, I feel I have achieved something and that it has benefited my work’. There were no current information relating to the code of conduct or that documentation around induction meets the ‘Skills for Care sector’ criteria. Biffins DS0000044339.V367654.R02.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 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 2 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 2 2 Biffins DS0000044339.V367654.R02.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. 1. Standard OP9 Regulation Requirement Timescale for action 31/07/08 2. OP26 3. OP30 Regulation Ensure that all controlled 13 (2) medication is kept within the guidelines and criteria of the ‘Royal Pharmaceutical standards and requirements.’ Regulation Ensure that all coshh supplies 16 (j) that are held is done so under (4)(a) (b) the health and safety (c ) requirements for care homes. Regulation Ensure that all training is 18 (1) (c) undertaken for all staff. This is in ) (i) relation to the manager having to complete train the trainer and staff records on training being out of date. 31/07/08 31/12/08 Biffins DS0000044339.V367654.R02.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP30 Good Practice Recommendations Ensure that as well as the homes induction package that the staff induction systems follow the ‘Skills for Care sector’ criteria for the induction process. Biffins DS0000044339.V367654.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Biffins DS0000044339.V367654.R02.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. 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