Inspection on 25/09/08 for Bybuckle Court

This inspection was carried out on 25th September 2008.

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

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

Other inspections for this house

Bybuckle Court 03/07/07

Bybuckle Court 27/06/06

Bybuckle Court 13/09/05

Bybuckle Court 14/04/05

Bybuckle Court 02/09/04

Bybuckle Court 29/04/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 26/11/2008.

CARE HOMES FOR OLDER PEOPLE Bybuckle Court Marine Parade Seaford East Sussex BN25 2PZ Lead Inspector Melanie Freeman Unannounced Inspection 25th September 2008 09:50 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 Bybuckle Court DS0000021065.V372109.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. Bybuckle Court DS0000021065.V372109.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bybuckle Court Address Marine Parade Seaford East Sussex BN25 2PZ 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) 01323 898094 F/P 01323 898094 Mr James Lord Mrs Sylvia Lord Miss Samantha Bickerstaff Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Bybuckle Court DS0000021065.V372109.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 only – (PC) 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 17. Date of last inspection 31st July 2007 Brief Description of the Service: Bybuckle Court is an established home providing residential care for up to seventeen older people. It is a large detached property, overlooking the seafront in Seaford and within easy walking distance of the town centre shops, amenities and railway station. Resident’s accommodation comprises fifteen single rooms and one double room, situated on two floors. The majority of the rooms have en-suite facilities, including a toilet and washbasin and all are fitted with a call bell system. On the ground floor there is a large, light and spacious lounge and dining area. A shaft lift provides access to the first floor. In addition to Bybuckle Court, the proprietors own a second home in Seaford, Hillersdon Court, which also provides residential care for older people. Information about the service, including the Statement of Purpose, Service User’s Guide and CSCI reports is made available to prospective service users or their relatives, on request, as part of the admission process. The range of weekly fees from April 2008 is £365 - £420. Additional charges, not included in the fees, include hairdressing, chiropody, toiletries and newspapers. Bybuckle Court DS0000021065.V372109.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 2 star. This means the people who use this service experience good quality outcomes. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Bybuckle Court will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home on Wednesday 25 September 2008, and follow up contact with visiting health and social care professionals. The allocated inspector spent approximately five and a half hours in the home and was able to discuss matters with the registered manager who received the inspection feedback at the conclusion of the visit. A brief tour of the premises was undertaken and a range of documentation was reviewed including the homes statement of purpose and service users guide, pre-admission assessment procedures, the systems in place for handling complaints and protecting residents from harm, staff recruitment files, quality assurance systems and some health and safety records. The care documentation pertaining to two residents were reviewed in depth and the inspector ate a midday meal in the dining room. Comments shared by residents and their representatives during the inspection process included ‘I am very well looked after everything is tip top’ ‘the care could not be better’ ‘They look after me very well indeed I get on with all the carers’. At the time of compiling the report, in support of the visit, the Commission received survey forms about the service from eight residents and six staff members. An Annual Quality Assurance Assessment (AQAA) was not requested before this inspection and was therefore not available for the inspector. What the service does well: The home provides prospective residents and their families, with a good level of information about what services are provided at the home. Residents are Bybuckle Court DS0000021065.V372109.R01.S.doc Version 5.2 Page 6 fully assessed and individual plans of care are provided which sets out clearly each residents needs. The atmosphere of the home is comfortable, homely and relaxed and is seen very much as a ‘home’ for residents. The home has a core team of staff who have a good understanding of the needs of the people living at the home and they were observed to treat residents with care and respect. Staff spoke highly of the management arrangements and the team spirit in the home. The home is decorated in a style that suites the residents and is reflective of their needs and tastes. Resident meetings and the use of questionnaires enable all those living in the home to have a say in how it is run, including input into menus and activities. What has improved since the last inspection? What they could do better: The management of the home needs to ensure that all prospective residents are suitably assessed and that the home confirms in writing to the prospective resident or their representative that with regard to the needs assessment completed the home can meet the needs of the prospective resident. This ensures that decisions around admission to the home are informed and evidenced. Bybuckle Court DS0000021065.V372109.R01.S.doc Version 5.2 Page 7 There is a need to develop the homes risk assessments further to record the risk assessment process and to link these to individual care plans for specific care needs, both long and short term with clear guidance for staff to follow. The recruitment procedures must be improved to ensure all the required checks are completed and relevant documentation is held on file. This will ensure safe recruitment practice is followed at all times and in turn safeguard residents living in the home. The home needs to have a clear up to date Safeguarding Vulnerable Adults procedure based on local guidelines. This will provide appropriate guidelines to staff on how to recognise and deal with any suspicion or allegation of abuse. Clear up to date procedures reflecting best practice need to be implemented and followed with regard to the handling any valuables or money for residents. This will safeguard resident’s property and protect staff clearly identifying their responsibilities. 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. Bybuckle Court DS0000021065.V372109.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 Bybuckle Court DS0000021065.V372109.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): 1, 3 and 6 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and relatives, with a good level of information about the home, its facilities, services and the costs involved. The admission procedures ensure that all prospective residents are fully assessed before admission and are assured that their needs can be met by the home. This process ensures that the home admits only those residents whose needs can be met by the home. Intermediate care is not provided at Bybuckle Court. EVIDENCE: The home has a statement of purpose and a service users guide. That is displayed along with the last key inspection report in the front entrance area. Bybuckle Court DS0000021065.V372109.R01.S.doc Version 5.2 Page 10 In addition a copy of the service users guide and the last inspection is also left in each resident’s bedroom as a point of reference. These documents were found to be informative and the manager confirmed that she updates these regularly and will be including resident’s views within the service users guide. An assessment of the admission process followed included the review of the documentation relating to the last two admissions to the home. These confirmed that either the manager, or one of the senior carers assesses everyone prior to admission. This ensures that only those people who care needs can be met are offered a placement in the home. During the inspection visit relatives of a perspective resident were looking at the home and they were able to talk to staff and residents in order to get an overview of the home. The manager explained it was also normal practice for any prospective residents to visit the home themselves and to stay for a meal. Although prospective residents and their representatives are told verbally if the home is able to meet their needs following their assessment this is not currently confirmed in writing. This was discussed with the manager who confirmed that she would address this shortfall. Intermediate care is not provided at Bybuckle Court. Bybuckle Court DS0000021065.V372109.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 and 10 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. All aspects of the health, social and care of those living in the home are met and care is delivered in such a way that promotes and protects the residents’ privacy and dignity. With residents health care needs being supported by community resources as necessary. On the whole the homes practice ensure resident’s medicines are administered safely. EVIDENCE: Two individual plans of care were reviewed in depth as part of the inspection process these confirmed that residents are assessed following admission. Each resident has an individual plan of care that records specific care guidelines and were found to reflect peoples choices and preferences. There were clear Bybuckle Court DS0000021065.V372109.R01.S.doc Version 5.2 Page 12 records that indicated that the care was being reviewed regularly and in consultation with residents. The care plans promoted what residents could do for themselves and their preferred lifestyles. The promotion and maintenance of independence was very important to people living in the home who said ‘I like to do as much for my self as possible’. There was a record of how residents liked to be addressed and this was by their Christian or nickname. There is a key worker system in place with associate key workers identified to ensure those living in the home always have a named person to discuss care and personal needs. Although risk assessments are recorded the risk assessment process followed was not demonstrated or clear. An example of this is the risks associated with an individual who smokes and another who provides her own paracetamol to administer, as she needs them. There is no one in the home that is trained to complete risk assessments and this shortfall needs to be addressed to ensure all risks are fully assessed and responded to. Routine assessments are completed and include nutritional screening these however need to use regular weights to inform them. There was evidence that people living in the home have access to healthcare professionals including nurses, opticians, dentists and chiropodists. All residents spoken to were very satisfied with care provided at the home comments included ‘Fortunately found this place I think I was lucky’ ‘Nothing could be done better everything is fine and the staff are very good’ ‘I am very well looked after everything is tip top’ ‘the care could not be better’ The last key inspection raised some concerns in respect of the record keeping and this was followed up by the Commissions Pharmacist who completed a Random inspection the following month. This raised a number of shortfalls that the registered manager has worked in conjunction with the supplying pharmacist to address. Practice observed during the inspection confirmed that good medicine administration practice was being followed with medicines being administered directly to people from a drugs storage trolley. Medicine records were found to be on the whole well completed and accurate. Although as ‘required medicines’ were being recorded appropriately individual guidelines for still need to be provided and the manager said that this would be completed. New medicine policies and procedures have been implemented and systems were in place to record medicines coming into and going out of the home. The local pharmacist provides training on a six monthly basis. All staff that administer medicines are trained to do so and a record of their signatures are held on file for audit purposes. Although it was noted that the home does not currently have any controlled drugs the storage facilities available are not adequate. The home has a copy of the commission’s most recent guidance on the storage of controlled drugs and Bybuckle Court DS0000021065.V372109.R01.S.doc Version 5.2 Page 13 is aware that they need to implement these. The manager said that this would be progressed. All residents are well know to all the staff and are spoken to as individuals that happen to live in one place. The feeling and atmosphere was very much like a communal home. The rooms seen were very personalised and reflected the character and interests of the person living in them. Bybuckle Court DS0000021065.V372109.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 and 15 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are able to live their lives in accordance with their own expectations and preferences maintaining strong links with family and friends. Residents are able to make a range of choices about their lives. People in the home benefit from a choice of meals but the quality of the food throughout the day is variable. EVIDENCE: Residents living in the home are very able to direct there own days activity and their choices with regard to this are respected. There are no set routines in the home and this allows the care and services to be flexible. Residents spoken to were all positive about living in the home and the interaction between staff and other residents is important to their lifestyle. Bybuckle Court DS0000021065.V372109.R01.S.doc Version 5.2 Page 15 Visitors are also welcomed and are also seen as an important part of the ‘family’ at the home. Some entertainment is brought into the home usually on a monthly basis. Staff also spend time interacting with residents with conversation and also with board games, quizzes and some Bingo. A written programme of events is now provided. During the visit residents spoken to said that they liked trips out but these were rare and the further promotion of trips out of the home would be beneficial to residents and was raised with the manager. It was seen that residents were given choices on daily activity and staff indicated that residents could choose what they had to eat. However discussion with residents confirmed that they did not know what was for dinner and the use of menus that can be displayed was discussed with the manager. The meal eaten with residents was very good and included a soup and a roast dinner followed by a homemade dessert. All was well cooked and well presented and enjoyed by residents. Most feedback about the food was positive however the surveys and residents spoken to confirmed that the provision was variable. The homes own quality reviews have also raised some issues around the food. The manager agreed to investigate this matter further with more auditing and to progress an action plan that will respond to residents views. Residents have autonomy to go out of the home if they wish and do spend time with relatives, which they clearly enjoy. Bybuckle Court DS0000021065.V372109.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 and 18 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are confident that any complaint would be listened to and responded to. Although the Safeguarding Vulnerable Adults guidance in the home needs to be improved staff awareness ensures any adult protection issue would be responded to appropriately when identified. EVIDENCE: The homes complaint procedure has been updated since the last inspection; all residents have had access to this and had the opportunity to use it if they wanted to. A copy is held within the service users guide that is displayed in the front entrance area. The home has not received any complaint since the last inspection so it was not possible to review how the home responds to complaints or concerns. The manager however was able to demonstrate the new complaints procedure, which includes the use of forms that record the complaint and the action taken to investigate and resolve and also how these are held securely. Bybuckle Court DS0000021065.V372109.R01.S.doc Version 5.2 Page 17 Residents spoken to and the returned surveys indicated that residents are aware how to make a complaint and would know who to talk to. One resident said that ‘I am never un happy’ but recorded that they knew how to make a complaint. Although there is a Safeguarding Vulnerable Adults procedure this needs to be amended to clearly reflect the importance of reporting any allegation or suspicion of abuse to Social Services who are the lead authority at an early stage. In addition it was noted that the home did not have the most recent local policies and procedures on Safeguarding Vulnerable Adults. The registered manager acknowledged the need for a review of these documents in accordance with the local policies and procedures. The manager had a good understanding of Adult Protection issues and confirmed that training for staff has been arranged for the next month. Bybuckle Court DS0000021065.V372109.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 and 26 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The standard of decor within the home is satisfactory, providing a homely, safe and comfortable environment for those living in the home. EVIDENCE: A tour of the premises was carried out and most parts of the home are well maintained and attractively decorated. Individual bedrooms are personalised and homely and seen as the residents own space with many having their own possessions around them including pictures, ornaments and some furniture. Bybuckle is situated on the sea front and many of the rooms including the communal sitting room and dining room benefit from sea views. The home has limited outdoor space but there is some seating provided at the rear of the Bybuckle Court DS0000021065.V372109.R01.S.doc Version 5.2 Page 19 property next to the car park. The home has a passenger lift and all rooms are single apart from one double that is used for a married couple. The home was found to be clean and the laundry was found to be suitably equipped to ensure good infection control practice. During the tour of the home it was noted that some pots of cream were not labelled to ensure individual use and some tablets of soap and other toiletries were left in the communal bathrooms. This was raised with the manager who assured that she would address this matter and ensure all creams and toiletries are stored securely and used for individual use only. Bybuckle Court DS0000021065.V372109.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 and 30 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are sufficient staff with the skills and knowledge to provide consistent care to those living in the home. Although on the whole the recruitment practice followed safeguards those living in the home practice needs to be improved. EVIDENCE: At the time of this assessment visit there were 15 residents living in Bybuckle Court Care Home. Staff rotas indicated that there are two staff on duty for each shift in addition to the manager, cook and domestic staff throughout the weekdays with the weekends covered by two care and catering staff. One carer works during the night. The dependency of residents is fairly low with many wanting to be independent and the manager advised that the staffing arrangements are flexible. With extra staff being provided if the dependency of residents increases, an example of this was when a resident became very ill and wanted to stay in the Bybuckle Court DS0000021065.V372109.R01.S.doc Version 5.2 Page 21 home to die. She worked with the community services and the homeowner to ensure the needs of this resident could be met. All feedback received about staff working in the home was very positive and comments received included ‘The staff are absolutely wonderful very thoughtful and kind’ ‘I am quiet happy lovely staff and they are very kind, the carers are lovely people’ ‘Nothing could be done better everything is fine and the staff are very good’. There was evidence in the home to confirm that NVQ training is supported and five staff have completed training at level 2 or above, a further three are completing this training. Records examined during the inspection confirmed that staff training had lapsed over the past year, however there was evidence to confirm that this shortfall was being addressed. A variety of staff training had been arranged and addressed the mandatory training required. Staff surveys reflected a strong team spirit and that they felt well supported by the management of the home. ‘Bybuckle Court have a good rapport between staff and manager and senior staff any problems are addressed and discussed’ ‘If I feel that I cannot deal with something there is always other staff on shift to help. We all work as a good team’. Staff were also positive about the level of communication in the home and the training provided. Staff felt that the home was able to provide a good standard of care. ‘I think this is a great home we try to keep everyone happy and meet all needs’. The recruitment files pertaining to the three staff were reviewed as part of the inspection process and although these confirmed that all staff have and application form, two references, Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks are also completed however the following shortfalls were noted. • • • • • Health checks are not recorded Evidence of Identity are not retained within the recruitment files A photograph of each employee is not retained in each recruitment file There was no record of the interview completed There was no terms and conditions of employment or letter confirming status of employment These were discussed with the registered manager during the inspection visit. Bybuckle Court DS0000021065.V372109.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 and 38 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered manager is approachable and provides a leadership to the home. Quality monitoring processes are well developed and take into account resident’s views. Resident’s financial interests are safeguarded although records relating to valuables held on behalf of residents need to be improved. Systems are in place to protect the health, safety and welfare of residents and staff. EVIDENCE: Bybuckle Court DS0000021065.V372109.R01.S.doc Version 5.2 Page 23 The current manager has been in post for over a year and was registered with the commission in July 2008. She has worked in the home for eight years and has completed relevant training to support her career development in the care industry. She achieved the Registered Manager Award in January 2007. She has provided a clear leadership within the home, in an open and approachable manner. Throughout the visit to the home it was evident that both staff and those living in the home are happy to approach her with any concerns demonstrating there is a relaxed and welcoming atmosphere. The home uses questionnaires to gain residents views on the services in the home; these are reported on and responded to individually to improve the home wherever possible. The manager holds a small amount of money for a number of residents and this allows them to have their own money to purchase items as they wish. Each room has a lockable draw so money can be stored securely and the home has a visiting mobile shop. Three files relating to individual money held were examined along with the amount of money and were found to be accurate. Although receipts are held when money is exchanged for a service like hairdressing receipts are not used for money deposited for residents. A procedure in respect of holding and receiving money or valuables on behalf of residents is not available in the home for staff to follow. This needs to be provided and followed to safeguard residents and staff. The home normally has a maintenance person and systems are in place for them to respond to any maintenance issue raised by staff in the home. Regular safety checks and procedures are in place to ensure appropriate health and safety practice is followed in the home. Records indicated that the hot and cold water is checked and that the manager completes regular environmental risk assessments. Bybuckle Court DS0000021065.V372109.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 2 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 3 X 3 X 2 X X 3 Bybuckle Court DS0000021065.V372109.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 OP3 Regulation 14 (1) Requirement Prospective residents must be provided with written confirmation that the care home is suitable for the purpose of meeting their health and welfare needs. That the Registered Person ensures that appropriate risk assessments are in place to cover all areas of risk and responded to. Risk assessments must clearly record the process of risk assessment. These should cover those residents who handle any medicines and who smoke. That the home updates its safeguarding vulnerable adults (adult protection) policy and procedure in line with the local policies and procedures. That the registered person operates a thorough recruitment procedure that ensures the fitness of people who work in the DS0000021065.V372109.R01.S.doc Timescale for action 01/11/08 2. OP8 14 (1)(2) 01/11/08 3. OP18 13(4) 01/12/08 4. OP29 19 01/10/08 Bybuckle Court Version 5.2 Page 26 5. OP35 16(2) home. The registered person must ensure that the necessary checks and records are completed and held in respect of each employee. Suitable procedures need to be 01/12/08 implemented and followed to ensure residents money and valuables deposited for safekeeping, are dealt with appropriately, safely and with suitable records. 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 Bybuckle Court DS0000021065.V372109.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Bybuckle Court DS0000021065.V372109.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. 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