Inspection on 12/01/10 for Butlin House

This inspection was carried out on 12th January 2010.

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

Butlin House 04/10/07

Butlin House 22/06/06

Butlin House 18/11/05

Butlin House 06/12/04

Butlin House 28/07/04

Butlin House 27/01/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Butlin House Beaverbrook Court Bletchley Milton Keynes Buckinghamshire MK3 7JS Lead Inspector Joan Browne Key Unannounced Inspection 12th January 2010 09:00 DS0000042542.V378850.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Butlin House DS0000042542.V378850.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Butlin House DS0000042542.V378850.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Butlin House Address Beaverbrook Court Bletchley Milton Keynes Buckinghamshire MK3 7JS 01908 376049 01908 630534 carmelita@princescharitablecorporation.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) Printers` Charitable Corporation Manager post vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Butlin House DS0000042542.V378850.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 40. Date of last inspection 11th January 2008 Brief Description of the Service: Butlin House is a purpose built care home owned by the Printers Charitable Corporation. It is set in a residential area, close to local shops and other amenities, and is served by local bus services. Milton Keynes city centre is located a short distance away, where national rail and bus links are available. Butlin House can accommodate up to 40 elderly service users requiring personal care and nursing care. Accommodation is provided over two floors. All bedrooms are single occupancy with en-suite facilities. There are two communal bathrooms on the first floor and one on the ground floor with disabled bathing facilities. A large lounge and dining room are situated on the ground floor, and a quiet area is on the first floor. The home has a passenger lift and a stair lift. A team of qualified nurses, carers, catering, and housekeeping staff support the home’s manager. A qualified nurse is on duty 24 hours a day. Allied healthcare professionals are accessible through direct contact or by General Practitioner referral. Additional charges are made for hairdressing, chiropody, newspapers and toiletries. Butlin House DS0000042542.V378850.R01.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 that people who use this service experience adequate quality outcomes. This unannounced key inspection was conducted by Joan Browne on the 12 January 2010 and covered all of the key National Minimum Standards for older people. The last key inspection of the service took place on the 4 October 2007. Prior to the inspection, a detailed self assessment questionnaire was sent to the manager for completion and surveys were sent to a selection of people living at the home, staff and visiting professionals. Any replies that were received have helped to form judgements about the service. Information received by the Commission since the last inspection was also taken into account. The inspection consisted of discussions with people using the service, relatives, the manager and staff. Some of the homes required records were examined. Staffs practice was observed and a tour of the premises carried out. Feedback on the inspection findings and areas needing improvement was given to the manager at the end of the inspection. There were four requirements made on this visit. Please see health and personal care, staffing and management and administration outcome areas for full disclosure. Since the inspection the Care Quality Commission (CQC) has received an action plan from the organisations chief executive detailing how the areas requiring improvement will be addressed. We (the Commission) would like to thank all the people who use the service, relatives and staff who made the visit so productive and pleasant on the day. What the service does well: The needs of prospective service users are thoroughly assessed before they are offered a placement to ensure that all identified needs can be appropriately met. Consistent effort is made to understand the social history of each service user to enable them if possible to pursue previous interests outside of the home. Individuals are encouraged to exercise choice over how they spend their time. The standard of food is good and in the main meets service users nutritional needs. Butlin House DS0000042542.V378850.R01.S.doc Version 5.2 Page 6 There are complaints policies and procedures in place and information is available to service users about local advocacy services. Staff have received training in safeguarding older people. Service users and visitors who we spoke to were positive about the care offered at Butlin house. Comments included the home provides good care. They look after me well. My mothers needs are well met. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. Butlin House DS0000042542.V378850.R01.S.doc Version 5.2 Page 7 You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 Page 8 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 Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users needs are assessed before moving to the home to ensure their needs can be appropriately met. EVIDENCE: The AQAA informed that an assessment was undertaken on all individuals prior to admission to ensure that the home was able to meet individuals identified needs. We were told that either the manager or trained nurses undertake the assessments. The relative of one service user recently admitted to the home was spoken to. They confirmed that a pre-admission assessment had taken place which they were involved with and described it as thorough. This is important to enable staff to meet the needs of service users in a personalised manner. Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 Page 10 Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users health and personal care needs could be compromised by the homes inconsistent and inappropriate medication recording practice. EVIDENCE: The care of five service users was followed through. All had comprehensive care plans detailing how identified needs should be met by staff. Evidence seen indicated that the plans were being reviewed monthly. Scribbled over entries were noted in some care plans examined. The importance of maintaining records was reiterated to ensure that information recorded was clear. Two visitors spoken to on the day of the visit confirmed that they were regularly involved in their relatives care. The following comments were noted: I am involved in discussions and decision making about my mothers care. A second visitor said that staff looked after their relative well and know how she functions. Staff who returned surveys said that they were always or Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 Page 12 usually given up to date information about the needs of the service users they care for. Service users were registered with a local general practitioner (GP) and they were seen by the GP and other members of the primary healthcare team such as, the dietician, dentist, optician, chiropodist and tissue viability nurse on a regular basis. Service users at risk of developing pressure damage had been assessed and if at risk they had the appropriate care plans and support mattresses in place. Those at risk of falls or malnutrition had appropriate plans in place. A health care professional who returned a survey said that service users weights were regularly monitored and the homes staff would normally follow up dietetic advice. The homes medication storage facilities were satisfactory. Records are kept of medication delivered and disposed of by the home. Wherever possible the home encourages service users to maintain their independence and those assessed as capable to manage their own medication were encouraged to do so. We were told that one service user had been assessed as capable and the appropriate risk assessment was in place. The medication administration record (MAR) sheets were examined and inconsistencies in staffs recording and administration practice were noted. For example, there were gaps on six service users MAR sheets. The blister packs were checked and in some instances the tablets were not in the blister packs and appeared to have been administered but not signed for. It was not possible to verify that all service users had received their prescribed medication because some gaps seen related to liquids and creams. Handwritten entries on the MAR sheets were not always signed by two staff members to minimise the risk of error when transcribing. Entries on some MAR sheets had been written over or scribbled out. There was some inconsistency as to how medication which should be given when needed, but not regularly was recorded. For example, some staff recorded an entry when the medicine was not given. When variable dose medication was administered not all staff were recording if they had given one or two tablets. It was not possible to tell how much medication service users were receiving. Medication prescribed for a particular service user to be administered three times a day was being administered twice daily. The controlled drug record was checked and medication in stock corresponded with the record. Observation together with discussion with staff, relatives and service users all indicated that service users were treated respectfully and that their privacy and dignity were being maintained. Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A personalised and an appropriate range of activities are available for service users and visitors are welcome in the home, which enhances service users fulfilment and social stimulation. The provision of food to maintain service users health and well-being is good. EVIDENCE: The home employs an activity person and arrangements were being made to appoint a second activity person. The weekly activity programme was displayed on the notice board to remind service users and their relatives what was on offer. We were told that the activities provided were led by service users. For example, they are consulted on what should be provided. An outside entertainer is booked weekly to entertain service users. Each service user has one to one time with the activity person weekly. This time can be used to assist with letter writing, relaxation treatment, reading the newspapers or just having a chat. On the day of the inspection we observed the activity person supporting a particular service user with their mobility. A group relaxation activity had also taken place, which was followed by a residents meeting in Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 Page 14 the afternoon. The home has an activity fund and service users decide how it should be used. We were told that service users requested to have a party for the staff team to thank them for their support and this was arranged. A newsletter is produced monthly by one of the service users with some support from the activity person. Those service users who wish to promote their spiritual needs are able to do so. Church services are held regularly and some individuals receive Holy Communion on a weekly basis from a Eucharistic minister. Arrangements were being made for cultural theme days to be held. This means that service users would be able to experience different types of food from other countries. The staff team is multi-cultural and some have agreed to share their experience and culture with service users. We were told that service users integrate with people in the community. For example, some attend weekly coffee mornings at the sheltered housing complex nearby. All service users spoken to said that they decide on how to spend their day. The following comments were noted from a visitor: The home provides appropriate activities for the residents. Their preferences are granted and no one is forced to participate. The activity person is doing an excellent job. A number of family members were spoken to and all said that they could visit at any time and were made to feel welcome. They said that they were kept up to date with activities and special events such as trips to the garden centre or to the theatre. One relative said that she regularly volunteers to assist the activity person with escorting service users to the coffee mornings in the community. The lunch time meal was observed. The food was pleasantly prepared and presented. There were two choices on the main course and a range of deserts available. Mealtimes were a communal activity. Some people in the sheltered housing complex joined service users for lunch daily and were complimentary about the high standard of food. The vegetables were provided in tureens from which service users were seen to be helping themselves and serving each other. We observed a staff member assisting two service users with their meal at the same time. The manager explained that one of the service users does not normally require assistance. However, the practice should be reviewed to ensure that service users dignity is fully promoted. Service users and visitors told us that the food provided was good. One service user described themselves as not a big eater but since living in the home has put on weight. They said that the food was first class. They also told us that if they did not like what was on the menu the cook would provide an alternative. A visitor confirmed that they regularly visit and have a roast dinner with their relative especially on a Sunday. Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16&18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are protected from abuse or exploitation by the homes policies and are confident that any complaints they may have would be dealt with appropriately EVIDENCE: The homes complaints procedure was displayed on the notice board. The service users who returned a survey said that they knew who to speak to informally if they had a concern and that they knew how to make a formal complaint. Staff who returned a survey to us said that they knew what to do if anyone had any concerns about the home. The homes complaint record was seen and presented as being appropriately maintained. It demonstrated what the complaint was, how it had been investigated and the outcome. Visitors spoken to were confident that any complaint would be listened to and responded to appropriately. Service users who were asked told us that they felt safe living at the home. Staff confirmed that they had received training in the safeguarding of vulnerable adults. The AQAA stated that the home had made eleven safeguarding referrals and three of the referrals had been investigated by Social Services who take the lead in safeguarding investigations. The Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 Page 16 Commission has been made aware of the investigations. To date one of the investigations remains outstanding and is being investigated by the police. Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is comfortable, appropriately decorated and maintained to enable service users to live in a pleasant, safe and hygienic environment. EVIDENCE: The home is situated on two floors. All bedrooms have en-suite facilities comprising of toilet, wash hand basins and showers. Television and telephone points have been fitted in all bedrooms. All rooms seen were personalised and reflected the characters of individuals. A discussion was held with the manager regarding two vacant bedrooms that needed to be better presented. The home has a spacious dining room and adjoining lounge on the ground floor and a small lounge on the first floor. There is a landscaped garden that is wheelchair accessible. The layout of the home seemed suitable for its stated purpose and Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 Page 18 was maintained to a satisfactory standard. However, it was noted that some cupboard doors in the clinical room were beginning to show signs of tiredness and could benefit from a face lift. Visitors spoken to said that the management and staff encourage service users to see the home as their own. The premises were clean, hygienic and free from offensive odours on the day of the inspection. The laundry facilities were sited so that soiled articles of clothing and infected linen were not carried through areas where food was stored, prepared or eaten. The laundry room was fitted with washing machines with the specified programming ability to meet disinfection standards. The walls and floor in the laundry room were clean and impermeable. The sluice rooms were clean tidy and fitted with disinfectors to prevent the risk of infection. The AQAA informed that there was an action plan in place in connection with the prevention and control of infection and that fourteen staff had received training in the prevention and control of infection. Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users receive care from kind, well trained staff who can meet their diverse care needs. The homes recruitment procedures need to be reviewed to ensure that they are effectively and consistently applied to minimise the risk to service users of inappropriate staff being employed. EVIDENCE: The AQAA stated that the home uses a dependency tool to calculate staffing levels required. The manager told us that the home was currently using more than the staffing numbers required. On the day of the visit there were two registered nurses and five cares in the morning. This number was reduced to one trained nurse and four carers in the afternoon. One trained nurse and three carers cover the night shift. Staff who returned a survey to us told us that there were enough staff on duty either always (1), usually (2) and never (1). Staff were observed to be busy throughout the day. They were seen to be patient and to manage the work load. Interaction with service users was mostly when a care task had to be completed. One staff member commented that the home could do better by employing more carers to meet the needs of service users. Service users and relatives spoken to said that staff were kind, helpful and approachable. Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 Page 20 The manager said that more than 50 of the care staff had achieved the national vocation qualification (NVQ) at level 2. There is an ongoing training programme. Training records seen were in good order and showed that staff have had training in safe working practices with regular updates. Staff spoken to and those who returned a survey to us confirmed that they had good training opportunities. The recruitment files of two members of staff who had started at the home since the last inspection were checked. PoVA first checks and criminal record bureau clearances had been sought. It was noted that the prospective employees did not detail on their application forms dates of employment history. Gaps in employment history had not been explored. The manager must make sure that prospective staff members record employment dates on the application form to ensure that any gaps identified in employment history can be explored at the interview. Two references had been sought for each prospective staff member. There was no photograph on one of the files to confirm proof of identity. The manager must make sure that a photograph is on all staff members files to confirm proof of identity. There was evidence that the two staff members had undertaken an induction programme. Four members of staff returned the surveys. One said that they always had the support they needed to meet service users needs. Two said that they usually and one said that they never. Those staff spoken to during the inspection said that they were given the opportunity to attend training Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes record management, auditing and quality assurance system needs to be strengthened to ensure that service users interests, safety and welfare are promoted. The homes supervision framework is not consistent. This could mean that staff are not provided with the opportunity to discuss personal and development practice issues to improve outcomes for service users. EVIDENCE: The manager has worked at the home as a registered nurse for the past fifteen years. She was appointed as manager in September 2009 and has commenced the registration process with the Commission. She has completed the Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 Page 22 registered managers award certificate and updates her knowledge and skills by undertaking mandatory updated training and reading nursing journals. She is supported by a deputy manager, registered nurses, carers, housekeeping and kitchen staff to ensure the smooth running of the home. The AQAA stated that there was an annual quality assurance programme in place. It was noted that the quality assurance processes were not always consistently applied. For example, an action plan was developed following the outcome of the quality assurance questionnaire that was carried out in July 2009. The plan seen did not clearly identify that all issues had been fully addressed and were being monitored. There was no written information to indicate that the standard of the medication record sheets and care plans were being audited regularly to assess the standard of the records and identify areas for improvement and staff development. We were told that a representative from the organisation visits the home monthly to carry out regulation 26 visits. Service users, relatives and staff are interviewed and a written report is prepared. Copies of report visits were made available for the inspection purpose. A small amount of money is held in the home for service users to cover the cost of incidentals such as, hairdressing, newspapers and chiropody. The financial policy and procedure in the home ensure that service users money is protected. The manager said that the home aims to ensure that staff receive regular supervision. Staff spoken to said that they were not in receipt of regular supervision. The homes supervision matrix that was made available for the inspection process indicated that the homes supervision framework was not consistent. The manager must ensure that there is a consistent supervision framework in place to ensure that staff are given the opportunity to discuss practice issues to improve outcomes for service users. It was noted that the hoists used to transfer service users were stored in the corridors. There were no risk assessments in place to support how any identified or potential risks to service users and staff would be managed. A discussion was held with the manager regarding the importance of ensuring that safety records are maintained appropriately. Training records seen confirmed that staff had undertaken updated training in safe working practices. Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 2 2 Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 Page 24 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 13(2) Requirement There must be a system in place to ensure that medication is handled, recorded and administered appropriately. This is to ensure that service users health and welfare is not compromised. A photograph must be on all staff members files to confirm proof of identity. This is to ensure that the homes recruitment procedure is consistently applied to minimise the risk to service users of unsuitable staff being employed. There must be a system in place to ensure that all staff are supervised appropriately on a regular basis with written records of formal staff supervision maintained and kept up to date. This is to ensure that staff are provided with support and given the opportunity to discuss practice issues which is focused on delivering improved outcomes for service users. The storage of the hoists in the corridors must be assessed for DS0000042542.V378850.R01.S.doc Timescale for action 20/02/10 2 OP29 19 20/02/10 3 OP36 18(2) 20/02/10 4 OP38 13(4) 20/02/10 Butlin House Version 5.3 Page 25 the risk they present to service users and action taken to minimise any identified risk. This is to ensure that service users health and safety are protected and promoted. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Butlin House DS0000042542.V378850.R01.S.doc Version 5.3 Page 26 Care Quality Commission Care Quality Commission South East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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