Inspection on 24/08/06 for Boars Tye House

This inspection was carried out on 24th August 2006.

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

Boars Tye House 23/08/07

Boars Tye House 01/12/05

Boars Tye House 11/05/05

Boars Tye House 21/12/04

Boars Tye House 17/05/04

Boars Tye House 11/12/03

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Boars Tye House 20 Boars Tye Road Silver End Witham Essex CM8 3QA Lead Inspector A Thompson Unannounced Inspection 24th August 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Boars Tye House DS0000017775.V309716.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. Boars Tye House DS0000017775.V309716.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Boars Tye House Address 20 Boars Tye Road Silver End Witham Essex CM8 3QA 01376 584515 01376 585007 ourteam@boarstye.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) Mr Clive Weir Mrs Bernadette Weir Mr Clive Weir Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Boars Tye House DS0000017775.V309716.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 27 persons) 1st December 2005 Date of last inspection Brief Description of the Service: Boars Tye House is a fully detached property originally constructed approximately three hundred years ago as a farmhouse. The property has been converted and extended into a twenty-seven place residential home for elderly people (over the age 65). Accommodation is in twenty-three single rooms and two shared rooms. Sixteen of these benefit from fitted en-suite facilities. Accommodation is provided on both floors of the home, with communal lounge/dining rooms on the ground floor. Access between floors is provided by a shaft passenger lift. Boars Tye House is located in the village environment of Silver End and is approached via a private drive alongside a large, landscaped front garden. At the rear of the home there is a small rear garden and patio area, which is fully enclosed. Ample car parking is provided to the front for visitors, and bus services pass the front of the building along the main road. Local shopping facilities are a short walk away. Externally the home is very well maintained retaining an attractive period appearance. Internally much of the character of the original property has been retained. Information was not collected regarding the fees charged. Past inspection reports are available from the home, and from the CSCI internet website. Boars Tye House DS0000017775.V309716.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place on Thursday 24th August 2006. The home had prior knowledge of this visit as it included a registration variation site visit. The content of this report reflects the inspector’s findings on the day of the inspection along with information provided by the service and feedback by service users, relatives, staff and other parties. Practice and procedures occurring after this inspection will be reported on in future inspection reports. Discussions took place with seven service users, the registered provider/manager, deputy manager, administrator and five members of staff. Random samples of records, policies and procedures were inspected and a tour of parts of the premises and grounds took place. All residents spoken to were complimentary towards the care they received and with the quality of the food and accommodation offered. There were no visitors available to speak with during this inspection however results of the home’s own quality assurance surveys were seen. These had been extensively circulated to relatives, regular visitors to the home and other parties. CSCI questionnaires were also left at the home so that relatives not spoken with on the day had the opportunity to make their views on the service known directly to the Commission. Staff confirmed they received good support from the management team. They also confirmed that they had been provided wide ranging training opportunities, including NVQ training. Twenty-nine standards were inspected with three exceeded, twenty-four were met and two almost met. What the service does well: The home’s management team works well as a supporting and cohesive unit, offering clear lines of communication and guidance to the staff team. Much of the private accommodation available retains the original character of the property. The whole premises, including the grounds, were very well maintained. A wide range of training opportunities are offered to staff. Boars Tye House DS0000017775.V309716.R02.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Medication administration records must be correctly completed. -------------------------- 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. Boars Tye House DS0000017775.V309716.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 Boars Tye House DS0000017775.V309716.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home’s assessment format and process ensured that initial perceived needs were identified upon admission. Anyone considering moving into the home may visit to meet residents, staff and facilities, to enable them to assess the suitability of the service Boars Tye House DS0000017775.V309716.R02.S.doc Version 5.2 Page 9 EVIDENCE: One of the deputy managers visits prospective new residents to undertake an assessment of need. Evidence of this process was seen. Headings covered included: personal care, health, diet, weight, sight, hearing, communication, oral, foot care, mobility, dexterity, falls, continence, medication, social, interests & hobbies, safety & risk and mental health needs. A care plan is compiled after admission. Residents and their families are invited to visit before admission, to meet with existing residents and staff. Initial admission of all new residents is on a fourweek trial basis, after which a review of placement is undertaken involving the resident, their relatives and the responsible social worker. Boars Tye House DS0000017775.V309716.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The health, personal and social care needs of residents were adequately detailed in individual plans of care. Health care needs of residents were met, however medication administration records must be correctly completed. Residents felt they were treated with respect. EVIDENCE: Three care plans were inspected. Included was background information, personal details, next of kin contacts. The residents’ needs/action sheet covered areas of hygiene, mobility, continence, social, medical, diet, night care, acute care and also included was a risk assessment profile and a moving and handling profile. Needs instructions to staff covered the identified need with daily action required from them and the overall objectives. Care plans seen included records of residents’ weight, and had been regularly reviewed. Records of health needs visits, GP consultations and falls were also included in care plan files. Boars Tye House DS0000017775.V309716.R02.S.doc Version 5.2 Page 11 District Nursing services support the home in pressure sore assessment and will also supply appropriate aids and treatment. A dentist visits the home to provide treatment for residents. Continence advice is provided by the community Continence Nurse who also visits the home. Specialist dietary advice is available/provided by the Dietician based at a local hospital. Hearing tests are available at a local hospital and eyesight tests, and chiropody services are provided to residents either by visiting practitioners, or by visiting community based facilities. A choice of two GP surgeries is available to residents, although most use the local practice in Silver End. One resident was continuing to administer their own medication. This medication along with all general medication held in the home is kept locked at all times when not actually being administered. The written policy and procedures relating to self administering residents was available for inspection, as was the written agreement between the resident and the home. Records and medication stocks for self medicating residents are checked weekly by staff. Evidence was available to confirm that staff receive certificated training in medication procedures, update training was due to take place. This will be provided by the home’s Pharmacist. The homes medication policy and procedure was unchanged. This in cluded the Royal Pharmaceutical Society guidance manual for care homes. Areas covered included ordering, storage, administration and returns of unused stocks. A separate returns book/pad is maintained and was available for inspection. Medication administration records were inspected, not all had been fully completed. The manager undertook to ensure that this issue was immediately addressed. There is a requirement in this report regarding this. There is also a recommendation that before staff are permitted to take on the role of administering medication, they are subject to an in-house written competency assessment. Discussions with individual residents indicated that they were treated with respect by staff, as did observation of staff going about their duties and interactions with residents. Staff on duty were seen to be courteous, caring and professional in their dealings with residents, and residents spoken with said staff were helpful and considerate. Boars Tye House DS0000017775.V309716.R02.S.doc Version 5.2 Page 12 Treatments and consultations are provided in private, privacy screens were observed in shared rooms. Residents’ also confirmed that they wear their own clothes and that staff use their preferred term of address. Some residents had their own private telephone lines, for others a portable phone was available to receive private calls. Boars Tye House DS0000017775.V309716.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 at least once during a 12 month period. 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. The lifestyle experienced within the home matched the expectations of residents. They were able to maintain contact with family, friends and participate in the local community. Residents were offered a varied, appealing balanced diet and were supported to exercise choice in their daily lives. EVIDENCE: Residents meetings take place, relatives are welcome to attend these. Minutes of issues discussed and decisions made were inspected. Topics included: meals, routines and activities. Some residents attend a local church each week, with community support. There is also a monthly visit by local clergy to hold a communion service. Two part time staff work to provide daily activities in the home, records had been maintained of types of activities offered, these included: indoor games, quizzes, nail care, puzzles, bingo, visiting entertainers, board games, shopping Boars Tye House DS0000017775.V309716.R02.S.doc Version 5.2 Page 14 trips (using dial-a-ride), painting, sing-a-longs, outings, discussions, theatre and music. Residents spoken with confirmed they were fully satisfied with the choices and options made available to them regarding daily routines and leisure interests on offer. They were also complimentary about the care support provided by the staff team. Visitors are welcome at all times, the home’s statement of purpose confirms the visiting policy. Seating has been provided in a quiet area on the first floor for use by residents and their visitors who wish to meet away from the main lounge. Staff support residents in maintaining control of their finances, personal allowance monies are held for safekeeping and records of transactions and receipts are kept. Advocacy support is available and has been provided in the past to one resident at the request of the home. Notices were displayed regarding access to this service. Records seen and inspection of private rooms confirmed that residents had been permitted to bring their own personal items with them on admission. There was also confirmation of this direct from residents, who told the inspector of the furniture and personal items they had been permitted to bring in with them. Nutrition records had been maintained, these were seen and evidenced choice and variety. Menus were under review as there had been a recent change in Cook. Two weeks menus were available and were inspected and a further two weeks were being compiled. The registered manager advised that the new menus will be sent to the Community Dietician for advice on ensuring a balanced and nutritious diet is offered to residents. The main daily meal is lunch, with two choices. Residents decide their preference the afternoon before. All residents spoken with were complimentary about the food. Two said it was very good and that there was always a choice. Meals may be taken in private rooms if preferred. Boars Tye House DS0000017775.V309716.R02.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents knew how to complaint and the home’s complaints procedure allowed for residents and relatives to formally raise any concerns or areas of dissatisfaction with the service. The home’s adult protection policies, procedures and practices were aimed at ensuring residents welfare. EVIDENCE: The home’s complaints procedure contains guidance on how to make a complaint and who to complain to. Also included were timescales for responses from the home. Evidence was available to confirm that records are maintained in the home, of complaints received and of any investigation and resulting outcomes. Residents spoken with said they knew who to speak to in the home if they any concerns, and that in the past management had responded positively to any queries/issues they had raised. The registered provider and one deputy manager are POVA trainers (approved by Essex County Council & Essex Vulnerable Adults Protection Committee). Certificates of qualification entitled ‘Training for Trainers in the Protection of Vulnerable Adults’ were seen. Boars Tye House DS0000017775.V309716.R02.S.doc Version 5.2 Page 16 They have provided an in-house programme of training to staff on the subject of abuse and adult protection. Training certificates were seen, these were headed ‘Awareness in the Protection of Vulnerable Adults’. The homes own in-house policy on adult protection was inspected, this included guidance for staff on recognising and reporting abuse and action to be taken by staff and the person in charge if abuse is suspected. The home had a copy of the latest POVA guidelines and associated reporting forms. NVQ training also includes adult protection issues. The home also had a ‘whistle blowing’ policy which provided guidance to staff on their responsibilities to report any concerns to management. Boars Tye House DS0000017775.V309716.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Furnishings in the home looked comfortable and areas of the premises seen were very well maintained. Private accommodation was comfortable and suited to needs and preferences. The premises appeared safe, were accessible, and had sufficient (according to these standards) numbers of toilets and bathrooms. The home was clean and considered to be hygienic. EVIDENCE: Boars Tye House is a converted farmhouse set in the village of Silver End, nearest towns are Witham and Braintree. Boars Tye House DS0000017775.V309716.R02.S.doc Version 5.2 Page 18 The home is accessed via a private drive alongside the home’s large landscaped well maintained front garden, which is fully accessible to residents. There is also a smaller enclosed rear garden accessible from the conservatory and the back of the home. The home was fully accessible to residents’ currently accommodated and was very well maintained externally and internally. Individual private accommodation and facilities are all considered to be of a good standard with renewal of equipment and maintenance undertaken on an as and when required basis. The registered provider/manager had advised that since the last inspection twelve bedrooms had been decorated. Local shops are a short walk from the home and a bus service passes along the main road to the front of the property. There is one designated dining room in the home with one lounge/dining room and a further lounge and conservatory area, all on the ground floor. A small quiet area on the first floor has been set aside as a visitors area, should residents wish to meet their visitors away from the main lounge. Lighting in communal rooms was considered domestic in character and sufficiently bright. The furnishings of communal rooms were mainly domestic in character, of good quality and appropriate to the range of needs of residents. There are three communal bathrooms, two provided assisted bathing and one did not. All three bathrooms in the home have WC’s and in addition there are four separate communal WC’s (three on the ground floor and one on the first floor). Sixteen private bedrooms in the home benefit from fitted en-suite WC. A designated hair dressing room has been provided (this was previously an unused bathroom). Staff call systems were located in all private rooms and communal rooms seen. The home is equipped with a shaft passenger lift to provide access between floors. There were three portable hoists available for use by staff when resident’s require this level of support. Grab rails are located in corridor areas of assessed need. Ramps were seen to be fitted to appropriate areas to facilitate wheelchair access internally and externally. Boars Tye House DS0000017775.V309716.R02.S.doc Version 5.2 Page 19 Adaptations, aids and equipment in the home were considered by the inspector to be suitable and appropriate for the residents’ currently accommodated. The two deputy managers have been trained on environmental occupational therapy assessment. Rooms were well decorated, comfortable and evidenced individual taste. Preferences are encouraged/respected. During discussion with residents all said their rooms were comfortable. Door locks and keys are provided according to individual choice and risk assessment. All rooms inspected were naturally ventilated with windows and all were centrally heated. Hot water supplying the home is regularly tested by staff and records were available to confirm that baths are checked to ensure that temperature is 43 degrees celcuis before residents get into the water. However regulator valves were not been fitted to hot water supply to mechanically restrict hot water supply at or near to 43 degrees celcuis. There is an on-going recommendation regarding this item in this report. It is understood by the inspector that the local authority environmental health department has confirmed acceptance of the current arrangements and risk assessment in the home relating to hot water supply. All radiators in the home, seen, were guarded and lighting in residents’ rooms was considered domestic in character and fully appropriate for individuals requirements/needs. On the day of the inspection the premises were considered to be very clean and hygienic. Policies and procedures were available for inspection confirming that working practices are in place to control the spread of infection. A separate sluice is provided. The home’s laundry room was inspected and was equipped with appropriate industrial type washing machines and tumble driers. Washing machines were seen to be equipped with minimum 65 and 90°C wash cycles. The laundry flooring had an impermeable finish. Walls and work surfaces met the standard. Boars Tye House DS0000017775.V309716.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels met the needs of residents. Staff had been provided excellent training opportunities to equip them with the skills for their role. Staff recruitment procedures aimed at the protection of residents had been followed EVIDENCE: The home’s staffing rota was inspected and confirmed that staffing levels are being maintained at five care staff on duty on morning shifts, with four on duty afternoons. Night staffing is three on waking duties. Separate and additional rostered staff were employed to undertake cooking, kitchen assistant, administrative, activities, domestic and maintenance duties. Staff records evidenced that application forms had been completed, two written references obtained, contracts of terms & conditions issued and criminal records checks undertaken. Staff spoken with confirmed they had been police checked. Boars Tye House DS0000017775.V309716.R02.S.doc Version 5.2 Page 21 Training opportunities offered by the registered provider and management team to staff were impressive. Evidence of this included inspecting records and discussion with staff. The registered provider/manager has completed the Registered Managers Award (NVQ level 4). One deputy manager has commenced the NVQ level 4 and the other deputy will soon be commencing this award. One staff member was studying to be an NVQ Assessor. Nine Staff either had or were studying for the NVQ level 3 and seventeen staff either had or were studying for the NVQ level 2 award. This equates to over 90 of the staff team with or studying towards NVQ qualifications. The inspector was advised that a further nine staff were about to commence NVQ training in September 2006. New staff undergo the home’s own induction programme. This includes headings of: principles of care, personal care provision, routines, effects of the setting on service users, maintaining safety at work and code of conduct. Staff spoken with confirmed that they had undergone this training when commencing employment. One deputy manager is a Manual Handling Trainer, a POVA (protection of vulnerable adults) trainer and a Dementia Care trainer. This qualifies her to train staff in-house on these subjects. Staff training records had been maintained and evidenced that opportunities have been provided to staff in: Fire safety, first aid, health & safety, infection control, food hygiene, medication practices, moving & handling, bereavement, sensory awareness, managing aggression, risk management, tissue viability, introduction to dementia, bowel & catheter care, POVA, preventing falls and fractures in care, funerals, personal safety awareness, pressure care & continence promotion and environmental OT assessment. Most of these courses were provided by external trainers, in addition the home has an extensive package of in-house training resources which are presented to staff by one of the deputy managers. Subjects include: risk assessment, dementia care, supervision, health & safety, fire prevention, manual handling, concerns & whistleblowing, abuse, infection control, medication, role of the care worker and person centred care. Future planned training includes: aromatherapy, massage and hairdressing. Boars Tye House DS0000017775.V309716.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run and managed efficiently and effectively. Procedures for gaining the views of residents, relatives and visiting professionals were in place and had been thoroughly implemented. Records required by regulation were in place. Financial practices in the home appeared to have been competently managed. The health and safety of residents and staff appeared to have been assured. EVIDENCE: The registered provider is also the registered manager. He has completed the registered managers award and has undertaken other training relevant to the service provision. His experience fully meets the requirements for the manager’s role. Boars Tye House DS0000017775.V309716.R02.S.doc Version 5.2 Page 23 A comprehensive quality assurance survey exercise had just (August 2006) been undertaken. Questionnaires had been sent to and completed by: residents, relatives, district nurse, GP, social workers, dentist, opticians and chiropodists. Forty One responses had been returned and these were being collated and reviewed by the home. Once this exercise is completed an action plan summary will be completed for any actions identified. The quality assurance process includes asking for the views on the service, including staff attitudes & care provided, food, accommodation, activities and the information provided by the home. Some residents personal allowance monies were held for safe keeping by the home. Records of transactions, receipts and balances held were kept. A random sample of these checked were satisfactory. The standard relating to staff supervision was not inspected but evidence has been provided to the commission by the manager, to confirm that all staff have been offered formal supervision at least six times a year. Random samples of records required to be kept were inspected. These included: assessments, staff rotas, staff recruitment, accident records, visitors book, fire drills, regulation 37 notices, nutrition records, menus, furniture brought in by residents, medication, background info’ and next of kin details, cash held for safekeeping and fire procedures All seen were considered appropriately maintained except some medication records. See standard 9 for details. The control of substances hazardous to health (COSHH) regulations had been met by provision of a COSHH register, with data sheets for relevant substances used in the home. Comprehensive risk assessments were in place for safe working practices in and around the home. Discussions with staff, management and inspection of records confirmed that training is provided to staff in moving and handling, fire safety, food hygiene, first aid and basic training in infection control. Certificates and service records were available for inspection to confirm that the home’s fire alarms and equipment, passenger lift, hoists, call alarms, emergency lights, gas supply, portable electrical appliances and electrical installation supply had all been tested/serviced within recommended timescales. Boars Tye House DS0000017775.V309716.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 X 3 X 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 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X 3 3 Boars Tye House DS0000017775.V309716.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 17, schedule 3 Requirement The registered provider/manager must ensure that medication administration records are kept fully up to date. Timescale for action 31/08/06 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 OP9 Good Practice Recommendations The registered manager should consider including in the home’s medication training for staff, a recorded assessment of competency for undertaking the role of administering medication. The registered provider should ensure that hot water supply in the home is regulated to ensure delivery at or close 43 degrees celcuis. 2. OP25 Boars Tye House DS0000017775.V309716.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Boars Tye House DS0000017775.V309716.R02.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!