Inspection on 13/08/07 for Carentan House

This inspection was carried out on 13th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Carentan House 06/08/09

Carentan House 05/09/06

Carentan House 16/01/06

Carentan House 13/10/04

Carentan House 21/04/04

Carentan House 02/09/03

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Snydale Care Home

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Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Ravensworth Lodge

Braeburn House - North Yorkshire County Council

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

CARE HOMES FOR OLDER PEOPLE Carentan House Carentan House Brook Street Selby North Yorkshire YO8 4AU Lead Inspector Kate Shackleton Key Unannounced Inspection 13th August 2007 09:45 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 Carentan House DS0000034630.V343627.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. Carentan House DS0000034630.V343627.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carentan House Address Carentan House Brook Street Selby North Yorkshire YO8 4AU 01757 702 815 01757 706443 carentan.house@northyorks.gov.uk www.northyorks.gov.uk North Yorkshire County Council 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) Mrs Rachel Louise Bowes Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Carentan House DS0000034630.V343627.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All Service Users admitted for Intermediate Care (up to a maximum of 8) will be accommodated in the Homewards Rehabilitation Unit Date of last inspection 05/09/06 Brief Description of the Service: Carentan House is operated by North Yorkshire County Council and provides personal care for 21 older people aged 65 years and over who do not have any specialist requirements and 8 older people requiring intermediate care or who are working towards rehabilitation. The home was purpose built approximately 25 years ago. It is located within a short distance of Selby town centre. Accommodation is provided on 2 floors and the upper floor can be reached by vertical passenger lift. All bedrooms are designed for single occupancy. There are enclosed outdoor seating areas. At the time of this visit the weekly fee is £381-41. There are no additional charges made by the home. The Commission for Social Care Inspection report is displayed in the home for anyone to read. Carentan House DS0000034630.V343627.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following is what has been used to base this report on. • • • Information about the home kept by the Commission for Social Care Inspection. Information provided by the home, asked for before the inspection. This is called an Annual Quality Assurance Assessment. Information from surveys, which were sent to people who use the service, relatives, GP’s and Care Managers 10 were sent to service users and 10 were returned. 3 were sent to relatives/friends and 2 were returned. 2 were sent to GP’s and 1 was returned. 2 were sent to care managers and 1 was returned. 3 were sent to staff and 3 were returned. An unannounced visit was made to the home. This visit lasted about seven hours. It included a tour of the premises. Talking to residents and staff. Examining some residents and staff files. Sampling a small number of health and safety records and observing staff working with residents. • What the service does well: Residents or their representatives are given enough information about the home before they move in. Someone from the home visits them prior to admission and they are offered the opportunity to visit the home for a look around and to ask questions about how the service is delivered. This enables them to make an informed decision as to whether the home is the right place for them to live. Comprehensive assessments are done from which a clear easy to understand care plan is developed. The resident is seen as a “whole person” and the service works well with other services to ensure that health needs are met. Residents are asked what they need and are actively encouraged to be involved in their care plans and reviews. This promotes the residents’ right to have a say in the care delivered and makes sure that all of their needs are considered. Comments heard included “The staff are very good” and “I am very happy and content here”. Carentan House DS0000034630.V343627.R01.S.doc Version 5.2 Page 6 The home is clean and comfortable. One resident said, “It is always fresh and clean” Staff are kind and helpful and make an effort to provide the service in the manner that service users want. Routines are flexible. Emphasis is placed on maintaining the independence of people using the service enabling them to exercise choice in key areas of their lives. Examples given included rising and retiring times, clothes, food and some activities. This ensures that residents maintain some control. Staff promotes the rights of residents to access the health care professionals that they need. A survey received from a General Practitioner comments “very caring staff who respond to clients needs”. A good choice of food and drinks are available. This ensures that service users receive a varied and nutritious diet. One resident spoken to said “The food is very good.” Arrangements are made for religious worship. Visitors are encouraged and made welcome. There is a clear and user-friendly complaints procedure and managers show a positive approach to complaints and ideas for improvement. This promotes openness and transparency, which helps residents to say if they are not happy with any aspect of the service. The staff is provided with comprehensive training to improve their knowledge and skills. This means that service users receive care from a well-informed staff team whose practice is up to date. The safety of residents is an important aspect of the care service delivered. It is demonstrated through good recruitment practices, proper risk assessments, staff training and the servicing of equipment and maintenance of the premises. The home is managed in a manner that concentrates on the needs and wishes of the people who use the service. What has improved since the last inspection? Better pre admission assessments are completed. Everyone being considered for admission receives a visit from a Team Manager employed at the home. These improvements ensure that all of the residents care needs are known about. This enables the service to be confident that they have the skills and resources available to meet the persons’ needs before a decision is taken to arrange admission. The information contained in care plans gives good clear information about how the resident wants the care delivered. Staff are aware of what support they need to give to comply with the residents’ wishes and maintain their independence. To prevent the risk of accidents medications stored in residents bedrooms are kept secure in a locked drawer. Carentan House DS0000034630.V343627.R01.S.doc Version 5.2 Page 7 What they could do better: 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. Carentan House DS0000034630.V343627.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 Carentan House DS0000034630.V343627.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): 2 and 6. People who use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are properly assessed before admission to the home is arranged. This makes sure that the service can deliver the care needed. EVIDENCE: Examination of three resident’s files showed that comprehensive assessments are completed before anyone is offered a place in the home. A community care manager employed by North Yorkshire County Council does the initial assessment and makes a referral to the home requesting admission. A manager from the home then visits the prospective resident in their own home or in hospital to complete their own assessment. Care staff have started to accompany team managers on these visits to help them to fully understand the admission process. Information is gathered from a range of sources including other relevant professionals. Relatives/representatives are involved where possible to find out more information that the prospective resident may not be Carentan House DS0000034630.V343627.R01.S.doc Version 5.2 Page 10 able to provide. This meeting allows people the opportunity to ask questions about living at Carentan House. Multi disciplinary assessments are completed on everyone referred to the rehabilitation unit. There is a range of activities to support people to achieve maximum levels of independence in order to return home as quickly as possible. One service user spoken to spoken is pleased with the support provided by the rehabilitation unit. Everyone is offered the opportunity to visit the home prior to moving in. This provides another chance for prospective residents and their families to assess whether or not they want to go ahead with the admission. On admission a key-worker is allocated to each resident. On the day of admission a member of staff is allocated to help the resident settle in and find their way around. All admissions are subject to a trial period. After six weeks a review is held to decide whether the resident wants to live in the home permanently. The resident and their families are involved in this review. All of the residents spoken to, as far as they could remember, were satisfied with the way they were admitted to the home. Four of the ten resident’s surveys and one of the two relatives surveys returned confirmed that people were given enough information about the home before they moved in. This had helped them to make a decision as to whether or not Carentan House would be the right place for them to live. Staff surveys confirm that they are given enough information about the specific needs of residents before they begin to care for them. They further commented that they had sufficient time to get to know residents and find out about their interests. Admission documents provided good information and included a copy of the care management assessment. The diverse needs of service users are identified. The information is available to staff to enable them to understand the social, personal and emotional needs of people who use the service. Carentan House DS0000034630.V343627.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 the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents receive a care service that meets their needs. Care is delivered in a manner that respects residents’ wishes. EVIDENCE: The home has a strong ethos for involving residents in all aspects of their lives. Staff are expected to work in a manner that takes account of all of the residents needs and delivers the care in a dignified and respectful way. A requirement was made at the last inspection to improve the information in the care plans. Files examined showed that resident’s care plans are comprehensive. Key- workers work with residents to develop their plan. The plan is a working document. It contains good relevant information to ensure that care staff knows the support they have to provide to meet the diverse needs of residents in a manner that promotes independence and respects privacy and dignity. Carentan House DS0000034630.V343627.R01.S.doc Version 5.2 Page 12 All residents have their own bedroom door key to ensure their privacy is respected and staff was observed knocking on doors before entering. Each plan contains a range of comprehensive risk assessments. Management of risks takes into account the needs of service users balanced with their aspirations for independence and choice. Where restrictions are in place there is evidence that residents are involved with any decisions made and agrees to them. Staff meet together on a weekly basis to identify any changes in residents’ well being and to decide any actions necessary to make sure that peoples, needs are met. The plan is reviewed monthly and updated as changing needs dictate. Residents spoken to said that they received a very good service and are treated with respect. Comments like “The staff are very good” and “Everyone is very helpful” were heard. They were able to give examples as to how staff ensured their privacy and dignity. Feedback from residents surveys show that they receive the care and support they need. Comments included “I am very happy and content here” and “The staff are alright, I always get treated properly”. A survey received from a General Practitioner commented “very caring staff, who respond to clients needs”. Staff promotes the rights of residents to access the health care professionals that they need both within the home and in the community. Residents spoken to said that they can see the doctor and other health care providers as and when they need to. Staff training programmes show that training is provided on health care topics that relate to the health care needs of residents. A District Nurse visiting the home was spoken to. She said that staff treat residents with respect and maintain their privacy and dignity. She commented that residents were “very well looked after”. Staff were observed delivering care in a kind and helpful manner. Residents looked clean and well cared for. There are medication procedures to guide staffs’ practice and training is provided on the safe storage, administration and disposal of medicines. Medication is stored and administered in a safe manner. Service users assessed as being able are encouraged and facilitated to keep and take their own medication. A requirement was made at the last inspection to improve the storage of medicines in cases where residents self medicate. The risk assessment to determine how best to manage any risks relating to selfmedication includes safe storage. Residents are provided with a locked facility to securely store medicines in their bedrooms. Carentan House DS0000034630.V343627.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 and 15. People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Routines are flexible. The service provides some opportunities for stimulation and interest for some people living in the home. Meals are nutritious and offer a varied diet. EVIDENCE: Residents spoken to are in general content living at Carentan House. They said that daily routines are flexible and arranged around their particular needs. They were able to give examples of how they are able to exercise control and make choices. They are aware of residents meetings and said that they have the opportunity to get their views heard. The home strongly promotes independence and risk assessments are completed to enable people to be independent in a safe manner. Staff training and the homes policies and procedures focus on residents being in control of their lives. Staff was observed delivering the service in a manner that offered choices to residents and respected their right to remain in control. Carentan House DS0000034630.V343627.R01.S.doc Version 5.2 Page 14 Religious beliefs are respected and clergy visit the home depending on residents’ requests. Christian worship is held in the home for those wishing to take part. Arrangements can be made for people to attend church. A requirement was made at the last inspection to improve the activities in the home. Care plans examined detail the activities that residents are interested in. Feedback from residents’ surveys suggests that more work is needed in this area. Seven of the ten surveys received commented that only sometimes are activities that they can take part in arranged. Four people made additional comments indicating their dissatisfaction with the activities on offer. One relative survey commented that because of her relatives’ hearing and sight impairment “It is very difficult for staff to involve her.” A team manager has been given the responsibility for planning activities on a monthly basis in consultation with residents and a programme of activities is displayed in the dining room. Additional staff hours have been allocated specifically for providing activities. At the time of this visit some residents were engaged in flower arranging. Discussions with staff found that activities are the first thing to be abandoned when there are staff shortages because other care needs take priority. They also said that don’t get much support from the community and the last two trips out that they had arranged, when the transport arrived no-one would go. Visitors are made welcome and are offered a drink. Residents can see their visitors in private. The service provides a range of children’s toys to make visiting arrangements more child- friendly. This will hopefully encourage younger members of residents’ families to visit and maintain contact. The home makes use of a local advocacy service for residents who would benefit from some independent support. Menus are varied and nutritionally balanced. There is a choice of food at each mealtime and special diets are catered for. Residents mostly eat in the dining rooms but can have their meal in their bedroom if they prefer to eat alone. The dining room is a pleasant and comfortable place to eat. Dining room tables were set properly with tablecloths, mats, appropriate cutlery and condiments. New table linen, crockery and cutlery have recently been purchased. A cold drink was provided followed by a hot drink after the meal. Residents were provided with tureens and gravy boats so they could help themselves and be independent. Mealtimes were relaxed and unhurried allowing people as much time as they needed to complete their meal. The mid-day meal was taken with residents. It was nicely presented served hot and very tasty. Residents said they enjoy their food. One resident said that as a result of them airing their views about the tea time menu changes had been made. Surveys received show that residents like the meals. Carentan House DS0000034630.V343627.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 and 18. People who use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents feel able to air their concerns without any fear of repercussions. Robust procedures and staff training protect service users from abuse. EVIDENCE: The home has a clear complaints procedure that highlights the importance of complaining if people are not happy with the service. The procedure is given to every resident and is on display in the home. The procedure can be provided in a variety of formats on request. A local advocacy scheme, which provides independent support for people, is displayed. Records examined showed that complaints are dealt with speedily. Complaints are analysed as part of the quality monitoring process to improve the service delivered. Complaints are discussed in staff meetings to ensure that the team learns from the process and makes positive changes. Discussions have been held with residents and staff to enable people to accept that that complaints will be viewed positively and used to improve the care delivered. Residents spoken to know how to complain. Feedback from residents and relatives’ surveys confirmed that they are aware of the complaints procedure Carentan House DS0000034630.V343627.R01.S.doc Version 5.2 Page 16 and know who to talk to if they are not happy. Residents also confirmed that it would be easy to complain without fear of recriminations. They said that staff are approachable and that they felt very safe living at Carentan House. Residents’ surveys confirmed that staff listen and act on what residents say. The policies and procedures regarding the protection of residents are robust and in line with best practice. Staff have received training around issues of complaints and protection. The management team have received training on the Mental Capacity Act. Management know the procedure to follow if an incident is reported to them. Carentan House DS0000034630.V343627.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 and 26. People who use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a clean safe comfortable home. EVIDENCE: The home is purpose built and meets residents’ personal and collective needs in a comfortable manner. Some parts of the premises are in need of redecoration and arrangements are underway to get this done. Residents are fully involved in the choosing of the décor and furnishings. The premises are easily accessible and provide a safe and well-maintained environment for the people who live there. Since the last inspection a Summer House has been purchased. Aids and adaptations are provided and regularly serviced. The home employs a handyman who is responsible for routine Carentan House DS0000034630.V343627.R01.S.doc Version 5.2 Page 18 maintenance and the monitoring of some health and safety aspects of the premises. Information provided by the manager and the sampling of some health and safety records showed that every effort is made to provide a safe environment. Records show that the staff receives fire training and fire equipment is routinely serviced. A monthly record of hot water temperatures is kept to ensure the delivery of safe hot water and prevent the risk of scalding. The lift is routinely serviced and maintained in a safe condition. A tour of the premises included all of the public areas, some bedrooms, bathrooms and toilets. The home is very clean and smelled fresh. Infection control guidance is followed and systems are in place to prevent the spread of infection. One staff has received training in infection control. Surveys from residents confirmed that the home is always fresh and clean. Carentan House DS0000034630.V343627.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 and 30. People who use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The safety and well being of residents is promoted through a robust recruitment process and a well-trained workforce. EVIDENCE: The rota shows that there is enough staff employed on each shift and especially at times of peak activity. The home has its own relief staff that they can call on in times of staff sickness and holidays. Staff was observed carrying out their duties in a calm and relaxed manner, responding quickly and appropriately to requests from residents and spent time talking to them. Discussions with residents found that they felt that there is enough staff in the home. Residents said that any requests for assistance were dealt with quickly. One resident said, “If you pull the cord they are there in a minute.” Residents’ surveys confirmed that staff is available when needed. Staff surveys confirmed that there is enough staff to allow time for residents needs to be met safely. Staff training programmes are properly planned in order to provide staff with the skills and knowledge to deliver a good care service. All staff completes a proper induction training within the first few months of starting work. Further training needs are identified and the programme includes all the mandatory Carentan House DS0000034630.V343627.R01.S.doc Version 5.2 Page 20 training needed to meet service users basic needs such as lifting and handling, food hygiene, and health and safety. Training is focused on improving the experiences for people who use the service. Training is provided in a number of ways including in house and external trainers. All staff is encouraged to complete National Vocational Qualifications training and the pay and reward structure reflects the benefits of having the qualifications. A high percentage of staff has already completed the award, with more staff currently working towards it. Staff surveys received confirms that regular training is offered to support staff to do their job. Management have introduced a “resource room” for staff where they can access information relating to specific conditions and relevant legislation. Complaints and commendations are monitored and used to address training needs The home has a well - developed recruitment procedure that seeks to ensure that only suitable people are employed. Staff files examined showed that all appropriate and relevant pre employment checks are carried out before anyone is offered employment. All staff is recruited subject to a satisfactory probationary period. Residents are not involved in the choosing of staff that works in their home. Carentan House DS0000034630.V343627.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, 33, 35 and 38. People who use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and in a manner that promotes good service delivery in the best interests of residents. EVIDENCE: The registered manager had left only two days prior to this visit. Interviews for the post were to take place the day after this visit. Once the post is filled the manager will make an application to be registered with the Commission for Social Care Inspection. Resident’s say that they receive a reliable service from staff who are courteous, respectful, communicate well and deliver services in a responsible Carentan House DS0000034630.V343627.R01.S.doc Version 5.2 Page 22 and organised manner. They also say that the management team are approachable and very easy to talk to. The home has sound policies and procedures in line with current thinking and practice. Efficient systems are in place to monitor staff adherence to policies and procedures in their practice. Monthly procedure awareness sheets are given to staff to help them maintain their knowledge and understanding. Staff surveys received showed that they received the support they needed to do their job. Residents surveys confirmed that they receive the care and support that they need. There is a Quality Assurance Scheme which focuses on continuous improvement. Audits of key aspects of the service are regularly monitored. Quality questionnaires are sent to residents to gain their views of the service delivered. The findings are analysed and wherever possible improvements made. A senior manager of the organisation visits the home at least monthly and completes a report. These visits include discussions with residents. A service improvement plan is developed to document, measure and monitor improvements. Management have introduced a system to manage the workload in order to move forward with the service improvement plan. Staff provides support for people who require help in managing their finances. There is a robust procedure in place, which directs staff in their practice and protects residents from financial abuse. Internal audits are in place to ensure the safety of residents’ money. Management work in partnership with a range of other key people to ensure continuous improvement of the service. Advice is sought from relevant professionals such as fire training and implementing risk assessments. The home works to a clear health and safety policy and regular safety checks are carried out. All staff attends mandatory Health and Safety training and safe working practices are maintained throughout the home. Records are of a good standard and routinely completed. Carentan House DS0000034630.V343627.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 X 4 X X X 4 HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 4 X X 4 Carentan House DS0000034630.V343627.R01.S.doc Version 5.2 Page 24 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. 3. Standard OP12 Regulation 16(2) Requirement Following consultation with service users a comprehensive programme of activities that matches their interests must be arranged. Timescale of the 30/11/06 not met Residents should be involved in meaningful daytime activities of their choice and according to their individual interests and capabilities. Timescale for action 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP29 Good Practice Recommendations Where possible residents should be positively involved in the employment of staff. 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