Inspection on 08/07/08 for Cambrian House

This inspection was carried out on 8th July 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

Cambrian House 03/11/09

Cambrian House 18/06/07

Cambrian House 17/10/06

Cambrian House 13/03/06

Cambrian House 01/07/05

Cambrian House 17/11/04

Cambrian House 02/05/04

Cambrian House 02/04/04

Cambrian House 16/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Cambrian House 294 Chester Road North Kidderminster Worcestershire DY10 2RR Lead Inspector Emily White Key Unannounced Inspection 8th July 2008 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 DS0000018498.V367961.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. DS0000018498.V367961.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cambrian House Address 294 Chester Road North Kidderminster Worcestershire DY10 2RR 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) 01562 825537 01562 825537 None Kidderminster Care Ltd Manager post vacant Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (25), of places Physical disability over 65 years of age (25) DS0000018498.V367961.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th June 2007 Brief Description of the Service: Cambrian House is a care home providing personal care and accommodation for up to twenty-five older people of either sex, who may have a physical disability or a mental health need associated with old age. It is located in a residential area on a main road about a mile and a half from Kidderminster town centre. The home is a large three-storey house, which has been adapted and extended for its current purpose. Accommodation for the residents is provided on the ground and first floor. On the first floor there are seven single bedrooms, six of which are en-suite and there are eighteen single bedrooms on the ground floor, seventeen of which are en-suite. There are communal bathrooms fitted with Parker baths and one conventional bathroom, and there are separate communal toilets provided in addition to those ensuite. Communal lounges, a coffee shop and dining areas are also provided. Access to both floors is provided by a shaft lift and handrails are appropriately placed through the home. There is parking at the front and side of the house and at the rear there is a good-sized level enclosed garden with seating and tables. On 08/07/2008 the scale of charges for the home as quoted from their guide is £400 per week. The CSCI inspection report is also available within the guide. DS0000018498.V367961.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. This is a key inspection report which looks at the National Minimum Standards for care homes for older people and whether people are receiving a good service. To plan for the inspection we looked at the Annual Quality Assurance Assessment which is a form completed by the manager. This tells us about what the home does well, what it could do better and plans for improvement. We also looked at surveys sent to us from people who use the service, staff and health professionals. During the inspection we looked in detail at the experience of four people who use the service, including all aspects of the care there. This involved speaking to them, looking at records, observing life in the home and speaking to staff and the manager. We also met some other people who use the service and spoke to them about their experiences. What the service does well: People who use the service tell us that they feel well cared for and they are happy they moved there. They tell us that they like the staff and the manager and feel safe. Daily life and social activities for groups are well managed and there is a lot of opportunity for visitors to be involved. There is a new role of activities coordinator who will be looking at activities for people who prefer not to join a group. Staff are well recruited and have received training to give them specialist skills to care for people. Staff have a good understanding of how to keep vulnerable people safe. Communication is good with outside health professionals such as doctors and district nurses. People’s health needs are met and any changes are acted on quickly. DS0000018498.V367961.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The service is developing the way that it offers care for people with a diagnosis of dementia and end of life care. This means catering for people’s physical and mental health needs as they increase, and at the same time making sure people with lower needs receive a good quality service. For example: • • One-to-one support should be offered to those at risk from isolation. Care plans should be updated in detail for people requiring end of life care or for people with regularly changing needs. Please contact the provider for advice of actions taken in response to this DS0000018498.V367961.R01.S.doc Version 5.2 Page 7 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. DS0000018498.V367961.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 DS0000018498.V367961.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, 2, 3, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can decide whether the service will meet their needs because they can visit and get accurate, up to date information. People can also be confident that the service will meet their needs because they have a full face to face assessment of their needs before they move. EVIDENCE: The Annual Quality Assurance Assessment tells us that the needs of everyone are assessed before they move to make sure their needs can be met. We looked at the needs assessments of people who have recently moved to Cambrian House. The manager carries out the assessment by meeting people and looking at needs such as sleeping, personal hygiene, breathing, mobilisation, eating and drinking, vision and hearing, communication and social contacts. Local authority assessments are also available where DS0000018498.V367961.R01.S.doc Version 5.2 Page 10 appropriate. One family member confirmed his mother has been assessed and one resident could remember the manager coming to see her. Three surveys returned to us said that they all had enough information before they moved. People are invited to spend a day if they wish to before they move, and the majority of people we spoke to said that their families had visited and helped them make a decision. People and their families are given an information pack when they express interest, including a detailed guide with information about complaints, example menus, results from resident surveys. One family member said he had lots of information about the service before his mother moved in. Everyone has a more detailed care plan based on this initial assessment which means that their needs are met as soon as they move in. There is a key worker system in place, with staff names in people’s rooms. Key workers assist when a new person moves in. One person told us: “I wasn’t sure about moving here but when I came I was made very welcome and now I wouldn’t live anywhere else. I have made friends” DS0000018498.V367961.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, 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have a detailed plan of care that they or their families have been consulted about. The plan is updated and ensures people’s needs are met. People are treated with dignity, their privacy is respected, and they are assisted with their medications in a safe way. The service needs to fully consider its resources as people’s needs increase, so that they receive the same quality of care throughout their stay. EVIDENCE: We looked at four people’s care plans. A standard system for care planning is used which means all areas of people’s care are detailed and easy to follow. People’s care needs are written in plans in a person centred way which focuses on things people are able to do for themselves, for example: “… needs assistance of one carer to help with washing, she is able to wash her face and upper part of her body with support”. All plans are signed by the person or DS0000018498.V367961.R01.S.doc Version 5.2 Page 12 their family. The plan is discussed with the person and family present when they first move in. All areas are reviewed monthly and updated according to a change in needs, and are signed and dated by senior staff member. The care plans include standard risk assessments, for example falls and moving and handling, however we did not see additional individualised risk assessments for people outside of the standard format. Outside health professionals are well used for advice and care planning, and most changes are documented, for example in people’s weight or mental well being. For the majority of care plans all areas of people’s health care needs are completed in detail and notes are kept twice daily. However these vary in detail according to the staff member, from “slept well, had lunch” to a more comprehensive account of the person’s mood, the help they needed and what they did that day. The Annual Quality Assurance Assessment tells us that the key worker system makes sure people have someone who knows them very well and that their needs are met. In addition to the daily notes is a monthly comment by the person’s key worker which usually focuses on well being. These comments, the daily notes and our observations of staff show that staff refer to residents with respect. Care plans state people’s wishes such as “will choose her own clothes for the day”. One person tells us that: “everyone is always very polite and friendly, they will always do as I ask”. On the advice of the pharmacy and the previous inspection, the medication policy has been reviewed and changed from three policies into one. This has made medications easier to manage. A new larger medication trolley is being used, and there is a checklist for orders, receipt and disposal of medications, and a list of approved signatures for staff who are medication trained. The manager does a weekly check of the medication administration record. We observed medications being given to people appropriately. The service now uses an end of life care plan using the gold standard framework from the primary care trust. Families are being asked to complete this with people, and some are available for us to see in care plans. The service has a small number of people who wish to remain there for the end of their life, and the service is balancing these wishes with the ability to offer good end of life care. We looked at one care plan where someone has become very unwell and whose needs are increasing. The daily notes show a great deal of support from district nurses and the doctor, however, the long term needs plan, medication and personal care areas of the care plan had not been updated straight away following a change in needs or visit from the doctor. The daily notes did not have enough detail for a person requiring end of life care, for example little reference to continence or pressure care. A risk assessment for pressure area care had not been completed despite increased lengths of time in bed. DS0000018498.V367961.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to keep in touch with family and friends and the service is flexible and offers choice in people’s daily life and social activities. The service is developing ideas to support activity on a one to one level. EVIDENCE: Care plans, surveys and people who use the service tell us that there is plenty of opportunity for social contact and activities in groups. Staff have time built into their shifts for activities rather than just on care work. We observed people playing bingo and playing catch with a ball in the lounge. An activity timetable is displayed around the house and posters advertising an international day, a ragtime band, and physiotherapy to music are up. In people’s care plans a record is kept of what activities people are involved in every day. For those who do not join in the group, activities tend to be based around television, reading and visitors. We spoke to two people who chose to stay in their rooms for much of the day. Both people said there was a lot on DS0000018498.V367961.R01.S.doc Version 5.2 Page 14 but they chose not to join in. Their choices are respected but there is little on offer for one to one time with staff. Both people said they would like it if the staff came to see them more for a chat. They told us: “I’m left to myself and I do what I like” and “There are activities arranged but I don’t take part as I like to stay in my room and do my knitting, word search books and watch my TV.” We also spoke to a family member who said that he felt those who chose to stay in their room are left alone in terms of social contact and activities. While people’s autonomy and choice not to participate in group activities is respected, the manager and staff recognise that some people are at risk from isolation if they choose to remain in their room. There are plans to develop a more personalised approach to activities, for example, care plans outline people’s likes and dislikes, and there are plans for everyone to have a “life story” with help from families, which will help social contact and planning activities. A member of staff has been designated Activities coordinator, and there are plans for a booklet to be developed from the life story, using photos and other information, so that staff can spend one-to-one time with residents who prefer not to participate in groups. Visitors are welcome at all times to Cambrian House – a new coffee shop has been made from a redundant lounge where people can meet visitors, and several staff and people who use the service tell us that it is well used. Families and representatives are also invited to meetings at people’s request. One person told us she is able to go to church every Sunday and to her church meeting every Friday, as her friends pick her up. There is opportunity for spiritual needs to be met through visiting services. The service does not have its own transport and therefore relies on visitors, relatives and friends to provide most community contact for people. The Annual Quality Assurance Assessment tells us that there is a 28 day menu which is rotated which provides a lot of choice. People who use the service tell us that the food is always good. We looked at some menus which are varied and healthy. Meals are taken in rooms or in one of two different dining rooms according to choice. Choices are offered and if someone doesn’t like something an alternative is offered. We observed staff being respectful at all times, for example asking if people has finished before taking plates away, offering more of servings, drinks etc. During lunch time we observed everyone in the dining room finishing their meal and saying they liked it. People who take lunch in their rooms tell us they do not have to wait for their meals. DS0000018498.V367961.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. If people have any concerns they know how to complain, and they are confident that any complaints will be listened to and put right promptly. The service safeguards people from abuse and neglect and people feel safe where they live. EVIDENCE: Everyone we spoke to during the day told us they know how to complain but have never needed to. Most people know who they could speak to when they are not happy. The complaints process is provided in the service user guide and a log is kept of all complaints - there have been no formal complaints in a year. The management understands that minor complaints need to be taken seriously and there are plenty of opportunities for people to communicate to staff, for example, a communication book in all rooms so that families can write comments to staff and staff to families; resident meetings are held every three months where comments are encouraged and minutes are taken; the manager does a “round” of the service once a week, speaks to everyone who uses the service and takes notes on their comments. The management understands the importance of people’s legal rights and while no one has required an assessment of their mental capacity so far, the manager intends to train staff on the Mental Capacity Act. DS0000018498.V367961.R01.S.doc Version 5.2 Page 16 The Annual Quality Assurance Assessment tells us that there is a thorough recruitment process and abuse awareness training as part of staff induction. We spoke to staff who all understand what it means to safeguard vulnerable adults and what to do if they need to complain or make an allegation. All staff understand what is meant by the term “whistle blowing”. We looked at two staff files which confirmed that correct recruitment procedures are followed and that staff have had training on adult protection, some recently and others to be renewed. All of the service’s policies and procedures are up to date. DS0000018498.V367961.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s rooms are personalised and homely. The rest of the house and garden is pleasant, homely, clean and hygienic. The service provides areas for communal activity, quiet time, and spaces for meeting visitors, but could develop areas that are little used. EVIDENCE: People’s rooms are well decorated with homely furniture and personalised with their own belongings. The communal rooms and hallways have photographs of activities and residents, and posters advertising upcoming events within the house. The communal areas downstairs include two lounges and a coffee bar which is used by people when they have visitors. People we spoke to and a family member tell us that the coffee bar was a recent change and that it is DS0000018498.V367961.R01.S.doc Version 5.2 Page 18 well used by everyone. In the main lounge the TV was only briefly on during our visit, and at other times appropriate music was playing or activities are taking place. The house has a homely atmosphere, however there is little evidence of creative ways to reorient people around the house, and the garden and upstairs lounge are not used very much although they are both attractive areas. There are sufficient toilets, bathrooms and laundry which are all clean and hygienic with gloves and aprons for staff. Soiled laundry is sealed and kept separately from other items, and there is an appropriate infection control policy in which all staff have been trained. Following the previous inspection, the office space has been changed to maximise the use of space with new shelving and new storage space. An old bathroom has also been converted to use as storage space. The Annual Quality Assurance Assessment tells us that there is a regular redecorating and maintenance programme in place. DS0000018498.V367961.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are met and they are cared for by staff who get good training and support from managers. People have confidence in the staff but the service may need to fully consider its resources as people’s needs increase, so that they receive the same quality of care throughout their stay. EVIDENCE: We spoke to people who use the service who tells us that they like the staff for example: “we like the staff they look after us” and “when people are interested in their jobs it makes you feel comfortable”. Surveys also tell us that staff listen and act on what is said to them, and that staff are usually available when needed. The Annual Quality Assurance Assessment tells us that the majority of the staff are NVQ qualified. We looked at two staff files of a key worker and a new member of staff. Both are well qualified with relevant experience, the new staff member having NVQ2. Staff files show training is up to date. The manager keeps a training matrix and staff tell us that training is available for them. For example many staff have been on a dementia course which they said was challenging but has heightened their awareness of person centred care, and DS0000018498.V367961.R01.S.doc Version 5.2 Page 20 communication with people with dementia. The manager intends to book remaining staff on this course. Staff files tell us that all recruitment processes are adhered to with full CRB checks, references, interviews, and a probationary period. A new staff member told us that her induction lasted two weeks, in which she did a lot of shadowing, and training in health and safety, moving and handling and first aid. Staff files show a full Skills for Care induction checklist. The Annual Quality Assurance Assessment tells us that there is much lower staff turnover and that a majority of staff have been retained this year. Changes to the staff rotas to two longer shifts have meant that there is less of a daily change of staff for residents, and that lunchtimes are less hectic. Staff tell us there is more time for activities and things feel calmer during the day. The manager recognises that there are some concerns and that these have been raised through surveys and in our discussions with staff. Staff tell us that that they would like more help so that they can provide better one-to-one support in activities. They also report concerns about people whose needs are increasing. Staff say they feel able to manage high needs but are concerned that it affects other residents by taking their time away. Staff report that some people, particularly those with dementia, have difficulty understanding staff for whom English is a second language. We found that some more able people who choose not to join in group activities experience less staff contact than others. In addition, one person with high care needs has not has their care plan fully updated. The manager is aware of these concerns and is addressing them through training and reorganising of shifts. However as people’s physical and mental health needs increase there may be a need to consider resources in the service. DS0000018498.V367961.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People get the right support from the service because it is managed well with an open approach that considers their opinions. People can have confidence in the service because it is safe and safeguards their money and physical health. EVIDENCE: The manager had been deputy at Cambrian House for several years and has been acting manager for 9 months. She has applied to CSCI for registration. Staff and residents express a lot of confidence in the manager. People who use the service tell us: “the manager is lovely” and “I look forward to seeing her”. The manager has developed an open and inclusive atmosphere where staff and DS0000018498.V367961.R01.S.doc Version 5.2 Page 22 residents are encouraged to contribute through supervision, meetings, one-toone discussions with manager, surveys and feedback from visitors through a communications book. There is a quality assurance system based on people’s feedback from annual surveys and a three monthly residents meeting. Relatives are invited to these meetings with people’s permission and everyone is encouraged to speak out. Minutes are taken and people’s views are acted upon. The area manager visits weekly and completes monthly audits based on the National Minimum Standards. An action plan is developed and the results are put into the service guide for people to read. Policies and procedures are updated regularly. The majority of residents either control their own money or have families to help them. Small amounts for hairdressing may be left with the service. These are kept separately locked in a cabinet in the managers office and have a signing in and out record for each person. Staff tell us they have regular supervision and feel well supported. Staff files confirm supervision every three months and recording shows staff concerns are taken seriously, and opportunities for personal development are taken up. Staff files also show that staff have been trained in moving and handling, fire safety, first aid, food hygiene and infection control. We observed staff during the day who were all adhering to safe and hygienic working practices. The Annual Quality Assurance Assessment was completed and gave some detail particularly in reference to the quality assurance system. More details around plans for developing the service would improve the information in the AQAA. Daily notes, accident logs and other records are maintained and secure, however some daily notes vary in detail according to the staff member, from “slept well, has lunch” to a more comprehensive account of the person’s mood, the help they needed and what they did that day. We also noted one minor error in medication recording. The manager has adopted a very “hands on” approach for example a weekly medication audit, and a weekly “round” of the service to speak to all people using the service. The manager is aware of some of the concerns about resources and has put methods in place to address these, but as the service develops particularly in the area of dementia care it may be beneficial to consider appointment of a deputy manager or care coordinator. DS0000018498.V367961.R01.S.doc Version 5.2 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 18 3 3 3 3 3 3 3 3 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 3 3 3 x 3 3 3 3 DS0000018498.V367961.R01.S.doc Version 5.2 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. There are no statutory requirements 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 OP4 Good Practice Recommendations To support people with cognitive impairment, photographs of key workers could be placed alongside their names in people’s rooms All sections of the care plan should be updated immediately following a change in needs Risk assessments outside of the standard care plan should be used to cater for individualised need particularly in relation to end of life care and dementia. Daily notes should be consistently in enough detail to monitor changes in need. People should be provided with opportunities to exercise autonomy and choice for example through a life story, and access to transport. 2 3 OP7 OP8 4 5 OP8 OP14 DS0000018498.V367961.R01.S.doc Version 5.2 Page 25 6 OP19 To improve quality of life for people at risk of isolation, creative ways to reorient people around the house should be sought, as well as use of the garden and upstairs lounge. As people’s physical and mental health needs increase there may be a need to consider resources in the service, to make sure people with both high and low needs receive the same quality of service. As the service develops particularly in the areas of dementia care and end of life care it may be beneficial to consider appointment of a deputy manager or care coordinator. 7 OP27 8 OP31 DS0000018498.V367961.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 DS0000018498.V367961.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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