Inspection on 23/05/06 for Candle Court Care Home

This inspection was carried out on 23rd May 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Candle Court Care Home 04/06/07

Candle Court Care Home 01/12/05

Candle Court Care Home 07/06/05

Candle Court Care Home 25/11/04

Candle Court Care Home 06/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Townley Road, 2-3

Orchard House Nursing Home

St Josephs Rest Home

Foxley Lane (121a)

Tudor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Candle Court Care Home Bentley Drive Off Cricklewood Lane London NW 2 2TD Lead Inspector Tom McKervey Key Unannounced Inspection 23rd May 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 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. Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Candle Court Care Home Address Bentley Drive Off Cricklewood Lane London NW 2 2TD 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) 0208 731 7991 0208 731 7992 Rockley Dene Homes Limited Mr Robert Titchener Care Home 93 Category(ies) of Dementia - over 65 years of age (0), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (0), Old age, not falling within any other category (0) Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2005 Brief Description of the Service: Candle Court is a nursing home for people with mental health needs and dementia. The home is owned and managed by Rockley Dene Homes Limited, a company based in Harrow, Middlesex. The company also owns three other care homes elsewhere in the U.K. The home was registered with the Commission for Social Care Inspection in April 2004. The home provides nursing care and support for 93 service users over the age of 65, who have a mental disorder, and/or dementia. The residents are accommodated on two floors, each with its own staff team. Two passenger lifts service the first floor. Fifty-six residents live on the ground floor and thirty-seven on the first floor. Each floor is sub-divided into three named wings. The two-story building has a rectangular structure with an attractive central courtyard, which is accessible by all the residents. Each floor has its own bathrooms, toilets, lounge, dining room and small kitchen areas. There are 59 single and 17 double bedrooms with en-suite facilities. The basement of the premises contains a large and a small kitchen, a laundry area, staff changing facilities and a staff training room. Candle Court is situated near a busy junction between Cricklewood Lane and the A41. The home is easily accessible by public transport and there are shops and other amenities within walking distance on Cricklewood Lane. The homes stated aims are to provide long-term personal and nursing care, to 93 older people of both genders, over the age of 65 suffering from dementia, enduring mental health problems and physical disability. The fees for the service range from £586 to £950 per week. Following “Inspecting for Better Lives”, the provider must make information about the service, including inspection reports, available to service users and other stakeholders. Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 5 Copies of this report are also available on the Commission for Social Care Inspection website. Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days in a period of thirteen and a half hours. The inspection was carried out as part of the Commission’s inspection programme and to check compliance with the key standards. The deputy manager was present during the first day of the inspection and the manager was present for the second day. Both fully cooperated in the process. The inspection process involved visiting all areas of the home, reading residents’ and staffs’ files, and examining various documents relating to the management of the home. Fourteen residents, eight relatives and twelve staff were interviewed during the inspection about their views and experiences of the service. These interviews were carried out independently of the mangers. It was not possible to converse with some residents because of their mental capacity. However, through observing how staff interacted with the residents and cared for them, it was possible to form impressions and conclusions about the quality of the service. What the service does well: The quality of the environment is very good and is safe and well maintained. The proprietor ensures that furniture and equipment, curtains and beds are regularly upgraded and the décor is maintained, all of which enhances the appearance of the home, and the comfort of the residents. There are thorough systems in place for recruiting staff, which safeguards residents’ safety and welfare and there is a strong commitment to training the staff to equip them for their roles and responsibilities. An external tutor said how much they appreciated the enthusiasm and interest shown by the manager in the staffs’ development. Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 7 From observation during the inspection, there was an obviously warm relationship between visiting relatives and the managers and staff. What has improved since the last inspection? What they could do better: A contract must be provided for a resident whose care is privately funded to ensure they are aware of what is covered by the fees charged. Dividing screens have to be provided where bedrooms are shared to protect residents’ privacy and dignity. Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 8 Personal toiletry items must be available for all residents and must not be shared. Staff must also take care that residents are always dressed appropriately. The amount of social activities must be increased to ensure that residents receive appropriate stimulation. All complaints about the service must be recorded to assure residents and their representatives that their concerns will be addressed. Some bedroom furniture needs to be replaced and several maintenance issues have to be addressed. Managers must review the future use of a bathroom on the first floor, and depending on the outcome, decide whether it is to be used by staff or residents. Staff rotas need to be adjusted to ensure that sufficient numbers of staff are available to best meet residents’ needs at peak times of the day. A requirement is repeated from the last inspection that a programme of formal supervision of staff is implemented. 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. Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 9 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 Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 4 & 5. Standard 6 does not apply. The quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home’s Service User Guide is made available for residents and their representatives, and they are able to visit the home prior to moving in. The home is able to meet residents’ assessed needs. A privately funded resident does not have a contract of the terms and conditions of the service, which could result in them not being aware about what the fees cover. EVIDENCE: The Service User Guide has been updated to provide full information about the service. The Service User Guide was seen in the residents’ bedrooms. The majority of places in the home are funded by local authority block contracts. However, one resident was funding their care privately, but no contract had been provided, which is required to inform the resident and their Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 11 representatives what service is covered by, or excluded in the fees. A requirement is made to provide a contract of terms and conditions of service. The records of three recently admitted residents showed that they had full needs assessments by care managers and senior staff from the home. Relatives confirmed that they were able to visit the home to assess its ability to meet service users needs. The family of a prospective service user was observed being shown around the home at the time of the inspection. The home was purpose-built in 1996 and meets the space requirements of the National Minimum Standards. All bedrooms and communal areas are accessible by wheelchair users. The home is registered to provide care for people with dementia, and qualified mental health nurses are on duty at all times. Service users and relatives who were spoken to, stated that they were satisfied with the care provided. Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 The quality in this outcome group is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. There are individual care plans for residents, which are reviewed monthly to ensure that staff are aware of residents’ changing needs. The healthcare needs of the residents are being met and the medication policy provides appropriate guidance for staff about the safe administration of medicines, Although staff are complimented by relatives about the care of residents, improvements are required to ensure that residents are always dressed appropriately and they always have their own personal toiletries. The privacy of two residents who share a bedroom, is being compromised by not having a dividing screen. EVIDENCE: Eight care plans were examined. A new, clearer care plan format had been introduced. They covered assessment, goals of care and guidance about the Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 13 actions to be taken to achieve the goals. The care plans were reviewed every month. Waterlow and Braden risk assessments were in place to assess the risk of pressure ulcers. Other tools were used to assess challenging behaviours. The case files contained evidence that residents were seen regularly by the G.P and a range of other healthcare professionals, which included dentists and chiropodists. A psychiatrist was visiting the home during the inspection, to see three residents and review their medication. At the time of the inspection, a resident whose wrists were swollen, was attending a hospital for a check-up in the company of a relative. Two groups of relatives said that the residents had shown great improvement since being admitted to the home. Other relatives who were spoken to, were also complimentary about the quality of care in the home. Typical comments were; “ The residents are well looked after”, and “The staff speak very tenderly to the residents”. Three residents had a pressure ulcer, one of whom, also had MRSA. Their records indicated that advice from the Trust’s tissue viability nurse had been obtained about treatment and that the wounds were responding. There were records of residents’ weight and blood pressure, which were being monitored regularly. The accident book showed that proper recording took place and appropriate action was taken to investigate any injuries. The inspector was concerned to see a resident who was wearing trousers that were too short and was not wearing socks. When pointed out to the staff, this was immediately attended to. Room FB9 is a shared bedroom. However, no screen was provided between the beds to afford privacy. A requirement is made about this issue. Each resident has been provided with a named toilet bag. However, the inspector found that several of these were empty. In some instances, there were no face cloths or hand towels in residents’ bedrooms. The inspector was also informed that sometimes, one disposable razor was used to shave more than one person. Requirements are made to address these issues. The medication stock was checked on both floors. Medication was stored safely and the temperatures of the clinic rooms were being recorded. The administration of medicines records were in order. The medication policy now contains information about covert administration of medicines. Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 14 There are quiet areas, in addition to the residents’ rooms, available for them to receive visitors in private. The inspector observed that bathrooms and toilets were closed to respect service users’ privacy when they were being given personal care. All toilets and bathrooms could be locked. Staff were observed to knock on service users’ doors before entering. Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 The quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents’ religious and cultural needs are being met and they are able to exercise choice about meals, which are well balanced and nutritious. More social activities are needed to provide more stimulation for residents. EVIDENCE: There is no activities organiser in the home, and advertising for the post has been unsuccessful. The manager said that a current member of staff was interested in taking on this task and might be appointed within the next two weeks. Some staff commented that they missed having an activities organiser. The manager also stated that the arts and crafts sessions had been terminated because few residents were able to participate. This void had not been filled. On the first day of the inspection, some residents on the ground floor were engaged with staff, passing a ball around, and some residents were sitting outside in the enclosed garden. However on the first floor, although there was Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 16 ample equipment available, no stimulating activities appeared to be taking place. On the second day of the inspection, when the senior nurse was on duty, more activities were in evidence on the first floor. The manager said that outings were planned for groups of residents to go to Southend and the Air Force Museum later this year. However, a requirement is made for stimulating activities to be provided for residents on a daily basis. The inspector visited two residents in their rooms. They said that the staff respected their preference to spend most of their time watching the television, listening to the radio and reading. Two other residents go out most days, spending time in the local community. The manager said that residents’ religious observance is adhered to by regular visits from all ministers of religion, and a variety of meals are provided that reflect particular preferences and cultures. The home has a very open visiting policy, and the visitors’ book showed frequent visits to the home at various times of the day and evening. The inspector observed visitors being welcomed by senior and care staff in a very warm and courteous manner. Both floors have dining areas that are pleasantly decorated and newly furnished. The menus showed that there was a good variety of nutritious food provided, including fresh fruit. An inspection of the kitchen showed that good hygiene procedures were in place, and catering staff had been trained in handling food properly. Residents’ requests for alternatives to the planned menu are sent each day to the kitchen staff, and are provided separately. Supplementary dietary products are provided for residents who have difficulty eating and are underweight. The inspector was pleased to see that staff no longer wore disposable gloves when serving food, and when supporting residents who required assistance to eat. This previous practice was regarded as undignified. Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The quality in this outcome group is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are safeguarded from abuse by appropriate procedures and staff being trained in abuse awareness. Not all complaints are being recorded, which could lead to complaints not being responded to within reasonable timescales and could also result in a lack of confidence in the complaints procedure. EVIDENCE: At the time of the inspection, there was one complaint from a resident’s relatives remaining to be resolved. This complaint had originally come through the Commission for Social Care Inspection (CSCI). The complaint had been responded to by the home within the required timescales, but the complainant was not satisfied with this response. Senior managers have now offered to meet the relatives to resolve the issues raised. Two other complaints, one of which had also been referred to the CSCI had been responded to, but these complaints had not been recorded in the home’s complaints log. A requirement is made about this issue. Relatives who were spoken to, said they were satisfied with the service, but if necessary, they knew how to make concerns known. Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 18 The deputy manager is an accredited trainer in adult protection, which authorises her to train staff in these procedures. A training programme was currently underway. The staff that were spoken to, were knowledgeable about their responsibilities to report suspected abuse of service users. Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21 & 26 The quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is generally well maintained, clean, and has an attractive appearance. However, several repair and maintenance issues need to be addressed for the comfort and well being of the residents EVIDENCE: Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 20 A tour of the property was carried out. The company employs a full-time maintenance person, who is also responsible for health and safety in the home. The building was generally well maintained and there were good records of repairs and health and safety checks. However, several issues were identified, including: Rooms B 40 – the chest of drawers was broken. B 26 & 30 - the bedroom doors were difficult to open B 25 – the ceiling curtain track was missing and the wardrobe drawer was broken B 9 – (Double room), no dividing screen between the beds. The majority of bedrooms had photographs of residents on the doors to aid their orientation. New planting of flowers and plants have given the front and internal garden areas a pleasant appearance. The armchairs and dining room furniture that were recently provided, made the communal areas in the home attractive and comfortable. The laundry was well equipped and windows had restrictors for the protection of the residents. Call bells in bedrooms were tested and found to be satisfactory. There are sufficient toilet and bathing facilities with adaptations provided for people with disabilities. However, a bathroom which was designated for residents’ use, appeared to be used as a storage area and a toilet for staff. A requirement is made for an assessment of the toilet and bathroom facilities on the first floor, and depending on the outcome, to identify the future use of this room. A team of cleaners is employed, and at the time of the inspection, the home was very clean and tidy and there were no unpleasant odours. There is a control of infection procedure in place and staff have access to disposable gloves and aprons as appropriate. Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The quality in this outcome group is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Although there are sufficient numbers of staff on duty, staff availability needs to be better targeted at meeting residents’ needs at the busiest times of the day. The residents’ welfare is safeguarded by thorough recruitment procedures. There is a commitment to training and developing the staff, but the lack of training in safe handling could put residents and staff at risk of injury. EVIDENCE: At least one registered nurse is always on duty on each floor during the day and night. The staff rotas showed that the number of staff on duty meets the London Staffing Guidelines. However, staff told the inspector, that there was an insufficient number of staff on duty on the ground floor at peak times, when many residents required support with meals. A requirement is made to review the staffing levels on the ground floor at peak times. At the time of the inspection, several staff were studying for the Certificate in Dementia Care, which was funded through the Social Skills Council and the Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 22 training was organised via Barnet College. The inspector spoke to the tutor who was at the home. The tutor spoke highly of the staff and particularly welcomed the interest and support of the managers in the training. The records of staff who were recruited since the last inspection were examined. There was evidence that Criminal Records Bureau, (CRB) checks had been made and references had been obtained. The manager said that new staff undergo an induction when they start work, and a recommendation is made that this is in a written format. Staff were also undergoing training in mandatory subjects and a programme of training in adult protection was underway. However, several staff had not been trained in moving and handling, which could lead to residents and staff being injured through faulty techniques. A requirement is made to address this issue. Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36 & 38 The quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. The manager is qualified and experienced at running the home and there is a strong commitment to continual improvement of the service. There has been an improvement in the relationships between relatives, staff and management, but the company should meet with staff to discuss their remuneration, which is adversely affecting some staffs’ morale. A programme of supervision for staff needs to be implemented to support them in their work with residents. There are good systems in place to safeguard the health and safety of residents, staff and visitors to the home. EVIDENCE: Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 24 The manager, who is a registered nurse, has been in post since November 2006, and has applied to be registered with the Commission for Social Care Inspection. She has recently attained the Certificate in Dementia Care. There is a deputy manager, and two senior nurses on the ground and first floors respectively. The inspector saw letters and cards from relatives, expressing thanks to the staff. Several compliments were also made during the inspection by visitors about how the home was managed; for example, “This home is well run“, and “The managers and staff are more than perfect”. Another relative also stated that they were “much happier with the management” Staff who were spoken to, said they were happy with the line managers in the home and that relationships had improved. Several staff said that the atmosphere in the home was much better now. However, several staff also told the inspector that they were very unhappy about a recent pay award, which they said was unfairly implemented. They said that this issue was affecting their morale. Staff confirmed that regular meetings are held with the manager, at which the staff are able to express their views. A recommendation is made for representatives of Rockley Dene meet with the staff to discuss their grievances about pay. The inspector was informed that options were still being considered for the provision of another staff changing facility, so that male and female staff do not have to share. The inspector was informed that an audit of the quality of the service had been carried out recently. A recommendation is made for the outcome of the survey to be summarised in the Service User Guide. Quarterly meetings are held with relatives and a newsletter is published to inform them about matters affecting the service. At the last inspection, a requirement was made for a programme of staff supervision be implemented. This had still not taken place. This requirement is restated. There were good records of health and safety checks for all gas, fire electrical and water installations. Hoists and lifts were regularly serviced, and fire alarms were tested and drills carried out. Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 25 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 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 2 X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X X 1 X 3 Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 OP2 Regulation 5(1)(b) Timescale for action The registered person must 31/07/06 ensure that a contract is provided for a specific resident and is signed by the home manager and the resident’s representatives. The registered person must ensure that a screen is provided where residents share a bedroom. The registered person must ensure that residents are provided with personal toiletry items and are dressed appropriately. The registered person must ensure that stimulating activities are regularly provided for residents. The registered person must ensure that all complaints about the service are recorded. The registered person must ensure that the maintenance issues identified are addressed. The registered person must review the toilet and bathroom facilities on the first floor and DS0000053368.V290026.R01.S.doc Requirement 2. OP10 12(4)(a) 31/07/06 3. OP10 12(3) 31/07/06 4. OP12 16(2)(m)( n) 22 Sch 4 23(2)(b) 23(2)(j) 31/07/06 5. 6. 7. OP16 OP19 OP21 31/07/06 31/08/06 31/08/06 Candle Court Care Home Version 5.1 Page 27 8. OP27 18(1)(a) 9. OP36 18(2) designate the future use of a bathroom for staff or residents. The registered person must 30/06/06 ensure that staff are available when residents’ needs are highest. The registered person must 31/07/06 ensure that staff receive at least six formal supervisions a year, to support them in their roles as carers. This requirement is restated from the last inspection. The previous timescale for this requirement was 31/03/06. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP30 OP32 OP33 Good Practice Recommendations The registered person should provide a written record of staffs’ induction to the home. Representatives of Rockley Dene should meet with the staff to discuss their grievance about pay. The registered person should publish the outcome of the quality assurance survey to be sent to the Commission for Social Care Inspection and a summary inserted in the Service User Guide. Candle Court Care Home DS0000053368.V290026.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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