Inspection on 04/10/07 for Butlin House

This inspection was carried out on 4th October 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Butlin House 12/01/10

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Butlin House Beaverbrook Court Bletchley MILTON KEYNES Bucks MK3 7JS Lead Inspector Joan Browne Unannounced Inspection 4th October 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Butlin House Address Beaverbrook Court Bletchley MILTON KEYNES Bucks 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 vacant post Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 35 Service users Nursing Care 5 (five) beds dually registered That the home may provide care for 1 (one) service user under the age of 65. That this condition relates to a single, specific service user and that should this service user, for whatever reason, leave the home this condition will cease to apply and the home is required to notify CSCI immediately. 22nd June 2006 Date of last inspection 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 is located a short distance away, where national rail and bus links are available. Butlin House can accommodate up to 40 elderly residents requiring care and nursing needs. 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 - these contain 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. Fees range from £470.00 £707.00 per week. Additional charges are made for hairdressing, chiropody, newspapers and toiletries. Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was an unannounced ‘Key Inspection’ and was carried out on 4 October 2007. The inspector spent approximately seven hours in the service and looked at how well the service was doing. The inspection took into account detailed information provided by the service’s manager and a telephone discussion with her after the inspection because she was not available on the day of the inspection. Comment cards were sent to some service users, relatives and health and social care professionals. At the time of writing this report response to comment cards were received from eight service users. Their views and those of visitors and staff spoken to during the inspection have been reflected in this report. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Care plans were examined, which was followed by meeting with the individuals to see if the plan matched the assessed care needs. The medication system and accompanying records were examined along with staff rosters, staff recruitment files, training records and health and safety records. A tour of the premises was carried out and some time was spent meeting with service users, relatives who were visiting at the time of the inspection and staff. From the evidence seen it was considered that the home was providing a good service to meet the diverse needs of individuals of various religion, race and culture. The inspector would like to thank everyone who assisted in this inspection in any way. What the service does well: Prospective service users have their needs assessed prior to moving into the home to ensure that the home is able to meet the assessed needs. The lifestyle in the home suits people using the service including their preferences, cultural, religious and recreational needs. People using the service are encouraged to maintain contact with family and friends. Visitors are welcomed at the home. Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 6 People using the service are provided with wholesome and nutritious meals in pleasing surroundings. There is a complaints procedure to ensure that people using the service will be confident that their complaints would be listened to, taken seriously and acted upon. Staffing numbers and skill mix of qualified and unqualified staff are appropriate to meet the needs of people using the service. The home’s health and safety systems ensure that people using the service are protected from any potential risk of harm. What has improved since the last inspection? What they could do better: It is recommended in the interests of safety that the medication storage cupboard should not be used to store non-medication items. Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 7 To protect people using the service staff’s references from previous employers should have an official stamp to confirm their authenticity. In the interests of safety the armchair with the torn material should be replaced. A requirement has been made for the following: In the interests of safety for those people using the service threadbare carpets must be replaced. 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. Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 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.V352709.R01.S.doc Version 5.2 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. 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. Prospective people to use the service have his or her needs assessed by an experienced staff member before a service is provided, which should ensure that individuals’ diverse needs would be fully met. EVIDENCE: Case tracking confirmed good practice. Within the last year twelve residents had been admitted to the home. The deputy manager said that either the manager or herself would carry out assessments. Prospective residents are visited in hospital or in their own home. They are encouraged to look around the home and spend sometime before taking up occupancy. The preadmission record for a recently admitted resident was seen and it contained detailed information, which formed the basis of the care plan. Staff members Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 10 spoken to were able to describe the admissions procedure and the importance of making sure that new residents felt welcomed. Residents who responded to the Commission’s comment cards said that they had received enough information about the home to enable them to decide if the service provided would meet their diverse needs. The home does not provide intermediate care. Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use 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. There has been an improvement in the content of care plans seen, which should ensure that the health and personal care that people using the service receive is based on their diverse needs. Staff’s care practice ensures that people using the service privacy and dignity are upheld. EVIDENCE: It was pleasing to note that care plans seen showed signs of improvements and were generally complete. There was evidence that plans were reviewed monthly and contained detailed information relating to individuals’ medical diagnosis, preferred daily routine and risk assessments pertaining to moving and handling, falls, nutrition and tissue viability. Documents viewed were easy to read and informative providing staff with the essential information required to meeting individuals’ needs. It was noted in two of the care plans examined that forms relating to individuals’ wishes in the event of death and their agreement on what action should be taken in the event of them sustaining a cardiac arrest were in place Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 12 but had not been completed. It is acknowledged that some staff may not feel confident discussing such sensitive matters with individuals. However, it is a good practice and essential that residents’ wishes should be obtained and recorded to ensure that their requests are complied with. It was noted that the design of the care plan form did not provide a section for residents or their representatives to sign confirming their involvement in the development of the plan. Some residents spoken to during the inspection were not sure if they were consulted in the reviewing and development of their care plans. However, they were confident that staff were meeting their personal care needs appropriately and the care provided was of a high standard. Those residents who responded to the Commission’s comment cards said that they ‘always’ or ‘usually’ received the care and support needed. The service identified in its completed annual quality assurance assessment (AQAA) the need to ensure that residents and representatives were more involved with the development of the care plan. It is recommended that wherever possible residents are involved in the reviewing and development of their care plan. This would ensure that care provided is person centred and meets individuals’ diverse needs All residents were registered with a general practitioner of their choice and have access to health care facilities such as dental, chiropody and optical. Professional advice about the promotion of continence is sought and acted upon and aids and equipment needed are provided. It was noted that there were no residents living in the home on the day of the inspection that were suffering from pressure ulcers. Residents who responded to the Commission’s comment cards said that they ‘always’ or ‘usually’ receive the medical support needed. The medication administration record sheets were viewed and no unexplained gaps were noted. There were no residents self-administering their own medication. The controlled drug medication was checked and all medication was accounted for. It was noted that the cupboard where controlled medication and other stock medication was stored was being used to store valuables such as jewellery and other items belonging to residents. This practice is not acceptable and should cease. It is recommended that the security of the medication should not be compromised by the cupboard being used for non -clinical purposes. Staff were observed interacting appropriately with residents and were seen knocking at doors before entering. Their preferred term of address was recorded in care plans seen. Residents looked well groomed with attention to detail and were enabled to wear their jewellery and make up. There was a telephone facility in place for individuals to make and receive calls and some residents had their personal telephones installed in their bedrooms. All rooms were single occupancy to ensure that individuals’ privacy and dignity were not compromised. Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 13 A relative commented that the call bell in the main lounge was not accessible to residents. This was discussed with the deputy manager during the inspection who confirmed that arrangements were being made for the bell to be re-sited making it accessible to residents. Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. The home ensures that recreational activities provided meet people using the service expectations and diverse needs. Meals provided were varied and nutritious and served in pleasant surroundings. EVIDENCE: The home employs a dedicated activity organiser for thirty hours a week. Activities are organised to meet individuals’ choice and preference. Residents spoken to said that they have the choice of participating in activities if they wished to. On the day of the inspection a group of residents were participating in a game of bingo, which was followed by a piano recital by one of the residents. Some time was spent with the activity organiser who stated that she provides group activities such as games, bingo showing films, reminiscence and quizzes. One to one time is also spent reading and chatting to individuals who wish to remain in their rooms. Fund raising takes place and the money raised goes towards outings and monthly entertainment. Each month an outside entertainer is booked to perform to residents. The inspector was shown arts Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 15 and crafts material that were in the process of being made for the Christmas tombola. A record was maintained of individuals’ activity choices and preferences. A notice board in the main corridor listed current and planned activities for the coming months. Those residents who completed comment cards said that the home ‘always’ or ‘usually’ arranged activities. The following additional comments were noted: ‘Activities are much improved during the last 12 months.’ One particular resident possesses a computer and the individual is responsible for developing and producing the home’s monthly newsletter. This provides information on up and coming entertainment taking place. Residents said that they were able to entertain visitors in the privacy of their bedrooms if they wished to. Monthly communion services take place and those residents who wish to continue practicing their religion are able to participate and have communion. The staff support individuals to exercise choice and take control over their lives thus maximising and promoting independence. Wherever possible residents are supported to handle their own finances for as long as they wish to and are able to. It was evident that the home’s staff made residents aware of their entitlement to move in with personal possessions if they wished to. Some rooms seen were personalised with individuals’ personal belongings such as furniture, pictures and mementoes that reflected their personal characters. The home would support residents and their families to access the services of an advocate if they expressed a wish to have one. Residents are provided with three meals daily and hot and cold drinks and snacks were available at all times throughout the day and night. Meals are served in clean and pleasant surroundings in the dining room. Individuals spoken to said that lunchtime was a sociable occasion and the standard and quality of the food was good. There was a menu offering a choice of meals. Special diets such as diabetic and soft were catered for. Care staff monitor food and fluid intake and report any concerns to the nurse in charge so that action may be taken. Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use 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 has a complaints procedure to ensure that people using the service are able to express their concerns and listened to. The home is pro-active and reports incidents relating to the protection of vulnerable adults to the safeguarding vulnerable adult team. However, it needs to ensure that there is an audit trail of outcomes of investigations to ensure that those individuals subject to the investigations are satisfied with how the home has addressed them. EVIDENCE: A complaints procedure was available to all residents and this was included in the statement of purpose and displayed in the home. Individuals spoken to during the inspection said that they felt listened to and able to speak to the staff and manager if they were not happy about anything to do with their care. During the inspection a relative met with the deputy manager to discuss issues relating to care practices in the home and was satisfied with the outcome of the meeting. Information reflected in the home’s annual quality assurance assessment (AQAA) indicated that the home had received ten complaints within the last twelve months and 90 of the complaints were resolved within the twentyeight days timescale. No complainant had contacted the Commission with information concerning a complaint made to the service since the last Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 17 inspection. Residents who completed comment cards said that they knew how to make a complaint and who to speak to if they were not happy. The home has policies and procedures to protect residents from any potential harm or abuse. Staff undergo safeguarding vulnerable adult training at induction and training is regularly updated. The home has been pro-active by reporting incidents relating to the protection of vulnerable adults to the local safeguarding vulnerable team to be investigated and notifying the Commission of such incidents. However, in some reported incidents outcomes have not been recorded of the referrals made. The home is reminded that wherever possible outcomes to investigations should be obtained to ensure that there is an audit trail verifying that the incident has been investigated and those individuals subject to the investigations are satisfied with how home has dealt with the situation. Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Overall people using the service live in an environment that is clean pleasant and hygienic. However, threadbare carpets in certain areas of the building could pose a risk to people using the service and should be replaced to ensure individuals’ safety is protected. EVIDENCE: The inspector toured the home and a random selection of residents’ bedrooms was examined. All bedrooms have en-suite facilities comprising of toilet, wash hand basins and showers. Rooms were personalised and reflected the characters of individuals. The home has a spacious dining room and adjoining lounge on the ground floor and a small lounge on the first floor. The layout of the home seemed suitable for its stated purpose and was maintained to a satisfactory standard. The grounds and gardens looked attractive were well maintained and accessible to wheelchair users. Residents were able to sit outside and enjoy the view. Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 19 It was noted that the carpet in the dining area and the first floor corridor was threadbare and could pose a risk to residents. It is required that carpets are replaced to minimise any potential risk to people using the service. The carpet in a particular bedroom was heavily stained and needed shampooing. It is acknowledged that the day after the inspection. The manager informed the inspector that the carpet had been shampooed. A tear in the material of an armchair in a particular resident’s bedroom was noted and needed replacing. 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. Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use 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 ensures that there are sufficient numbers of staff who have been appropriately recruited, trained and skilled to meet the diverse needs of people using the service and to support the smooth running of the home. EVIDENCE: At the time of the inspection the home was appropriately staffed to meet residents’ needs. The staff team was multi-cultural consisting of qualified nurses, carers, administrative, catering and housekeeping staff. Members of staff were observed interacting and communicating appropriately with residents and each other. Residents who responded to the Commission’s comment cards said that staff were ‘always’ or ‘usually’ available when needed. Those spoken to during the inspection had high praise for staff saying ‘they are very kind and good at their jobs.’ The following additional comments were noted: ‘I visit the home frequently to see my mother and always find the staff willing and helpful. My mother is well cared for and happy.’ Staff spoken to during the inspection were knowledgeable about the residents’ needs. Some of them had worked at the home for a long time, which gives continuity of care. Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 21 It was noted that 69 of the care staff had achieved the national vocational qualification (NVQ) in direct care at level 2. Some staff were keen to progress to level 3 and the deputy manager was looking into how best this could be achieved. The recruitment files for six recently appointed staff members were examined. Files contained the required information and complied with the current legislations. On some references seen there were no official stamp to confirm their authenticity. It is recommended that in instances when references are obtained without an official stamp a note is recorded on the reference confirming that the authenticity of the reference had been verified. It is further recommended that staff’s files be better organised to ensure that information can be easily viewed. The training records were viewed. Mandatory training for all staff were up to date. In addition staff were accessing other relevant training with the local college, which focussed on improving outcomes for people using the service. All new staff undergo an induction programme in the home and in addition they attend a five-day induction training at the local college. Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use 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 new management arrangements ensure that the service is run in the best interests of people using the service. Safety records are appropriately maintained to ensure that individuals’ safety is promoted and protected. EVIDENCE: Within the last year the home has had three managers. The new manager and the deputy manager had been in their new positions for approximately two months. They were familiar with the day- to- day operation of the home, as both of them had previously worked at the home. The manager had worked in the home in the capacity of registered nurse and acting deputy manager. The Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 23 manager and the deputy manager were in the process of undertaking the registered managers award (RMA) training. Residents spoken to knew the management structure of the home and felt that the new manager had begun to make changes and improve the way the home was run. On the day of the inspection the deputy manager assisted with the inspection process because the manager was attending a care conference as part of her personal development training to update her knowledge, skills and competence in managing the home. Staff spoken to said that the home had become stable since the appointment of the new manager. They found the manager approachable and she made them feel valued and empowered them to make decisions. It was noted that staff meetings had taken place and a supervision framework was being introduced. The home has a quality assurance process in place and residents and their representatives’ views are sought on how the home was achieving its objectives for residents. It was noted that the organisation’s director visits the home monthly to carry out regulation 26 visits. Residents, relatives and staff are interviewed and a written report is prepared. The home keeps a small amount of money for some residents, which is used to cover payments for chiropody treatment, hairdresser fees and newspapers. This money is held in a separate bank account and each individual has a transaction sheet and written records of all transactions are maintained. Examination of a sample of health and safety records indicated that they were up to date and in good order. Information reflected in the home’s completed annual quality assurance assessment (AQAA) indicated that routine servicing and maintenance of equipment is undertaken at appropriate intervals to ensure that equipment used in the home is safe and free from any potential risks. Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 23(2)(b) Requirement In the interests of people using the service safety threadbare carpets must be replaced. Timescale for action 31/12/07 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 OP7 Good Practice Recommendations The forms in care plans relating to people using the service wishes in the event of their death and their agreement on what action is to be taken in the event of them sustaining a cardiac arrest should be completed to ensure that their wishes are complied with. The home should ensure that wherever possible people using the service or their representatives sign the care plan to confirm their involvement and agreement with the contents. In the interests of people using the service safety and best practice guidelines the medication cupboard should not be used to store non-medication items. To comply with best practice guidelines there should be an audit trail of outcomes of investigations to ensure that those individuals subject to the investigation are satisfied DS0000042542.V352709.R01.S.doc Version 5.2 Page 26 2. OP7 3 4 OP9 OP18 Butlin House 5 6 OP19 OP29 7 OP29 with how the home has addressed them. In the interests of safety the armchair with the torn material in the particular individual’s bedroom should be replaced. To comply with best practice guidelines and to protect people using the service, staff’s references from previous employers should have an official stamp to confirm their authenticity. Staff’s files should be better organised to ensure that the contents and information can be easily viewed. Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Butlin House DS0000042542.V352709.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!