Inspection on 30/01/07 for Carmel Lodge

This inspection was carried out on 30th January 2007.

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

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

Other inspections for this house

Carmel Lodge 27/01/09

Carmel Lodge 29/11/05

Carmel Lodge 29/06/05

Carmel Lodge 01/09/04

Carmel Lodge 28/04/04

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

CARE HOMES FOR OLDER PEOPLE Carmel Lodge 576 Harrogate Road Leeds West Yorkshire LS17 8DP Lead Inspector Sue Dunn Key Unannounced Inspection 30th January 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000001433.V322006.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. DS0000001433.V322006.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carmel Lodge Address 576 Harrogate Road Leeds West Yorkshire LS17 8DP 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) 0113 2371133 0113 2682822 Donisthorpe Hall Limited Mr Tapera Robinson Mahachi Care Home 22 Category(ies) of Dementia - over 65 years of age (22) registration, with number of places DS0000001433.V322006.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the Manager, Mr T R Mahachi, registers to undertake a certified diploma course which relates specifically to adults with a diagnosis of dementia 29th November 2005 Date of last inspection Brief Description of the Service: Carmel Lodge is owned by Donisthorpe Hall (a company limited by guarantee) which operates under a registered Charitable Trust. The company also operates a larger care home in the area. The home is a large detached house in the Moortown area of Leeds, which has been extended to provide residential accommodation for 22 people. The building was altered in recent years to make it a more secure environment for people diagnosed with dementia. The home has a passenger lift between the two floors. Eighteen single and two double bedrooms have en suite toilet and showers with three communal bathrooms offering a choice of bathing facility. The home has off road parking to the front, with double gates to protect service users from the busy main road. The front door is operated by a digital lock which is only accessible to staff and visitors. A fence encloses a pleasant garden with patio so that residents can walk freely and safely in and out of the building. There are a range of amenities in the locality and it is well served by public transport. The home operates for people who wish to follow a Jewish way of life. Fees range from £419 to £530 per week. Hairdressing, chiropody, clothing and toiletries are not included. DS0000001433.V322006.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcomes for service users. The inspection report is divided into separate sections with judgements made for each outcome group. The judgements reflect how well the service delivers outcomes to the people using the service. The categories are “excellent”, “good”, “adequate” and “poor”. More detailed information about these changes is available on our website – www.csci.org.uk. The last key inspection was carried out on 29th November 2005. The manager completed a pre-inspection questionnaire and this with information supplied by the home during the course of the year was used as part of the inspection process. Questionnaire leaflets were sent to relatives, (4 were completed and returned) and social care professionals, whose views have been included in the inspection report. One inspector carried out the inspection visit which started at 9.30 am and finished at 17.30 pm. A second inspector spent time observing the experiences and well being of 5 service users in 5 -minute time frames over a period of two hours. This was done in order to gain an insight into the daily lives of people with dementia who had difficulty using language to express their feelings. The observation took place in the lounge during the morning. Any signs of a positive mood state such as pleasure, enjoyment, relaxation, contentment in each time frame, however brief, took precedent over any other mood states observed during the same period. The number of times each service user engaged with anyone, or anything, was noted as was the quality of the interaction e.g., was it a positive, negative or neutral experience for them. What the service does well: Prospective service users and their families felt they had sufficient information to make an informed choice about the home. Pre admission assessments were detailed enough to provide an initial plan of care. Care staff understood the basic courtesies of how to support new service users and their families to settle into the home. The manager and care staff had a good knowledge of the different personalities and preferences of each service user and responded to each person in a ‘person centred’ way. They fitted their care approach around each person’s wishes rather than expecting people to DS0000001433.V322006.R01.S.doc Version 5.2 Page 6 adapt to routines for the benefit of the staff. Service users were observed for any changes in health or behaviour and staff altered their approach accordingly. No poor interactions were seen or overheard between staff and residents throughout the day, though staff were starting to look tired towards the end of their 12 hours shift. Service users were given time to do things and there was no sense of rushing. Social activity and daily life was taken at a relaxed pace according to the ability of each person. A skilled reminiscence worker was one of two outside workers who regularly visited to offer activities which stimulated and valued service users remaining memories and abilities. Service users moved about the home freely, singing, performing simple and imaginary tasks and expressing their views. There was no effort made to restrict or contradict these expressions of individuality and staff never failed to respond to people appropriately. The quality of the food was good and again mealtimes showed attention to detail and taken at the service user’s pace. Drinks were plentiful throughout the day. The manager is part of the management structure of the organisation and had support from Donisthorpe Hall. What has improved since the last inspection? What they could do better: The good information booklet for relatives explaining about dementia should be made more readily available. Information for relatives could be improved by making clear the services not covered by the fees to avoid future misunderstanding. It is acknowledged that it is difficult to avoid service users moving any notices or documents left within their reach. The manager should seek a solution to the problem of safely displaying information where visitors can see it. Some improvements could be made to the care plans by including more specific details, e.g. rather than ‘tends to wander,’ include where and when, and describe how staff could offer diversion to avert risks. Nutritional plans could include favourite foods and drinks to tempt appetite. Care files should include a plan to show how spiritual will be met. This was raised as a concern for one of the Christian service users. DS0000001433.V322006.R01.S.doc Version 5.2 Page 7 The mini mental state assessment used to identify each person’s level of understanding could be improved by summarising what the scores mean as this may not be understood by staff from a non nursing background. Orientation care plans should give more specific details of how each person is to be helped, for example by the use of signs, significant pictures, colour schemes and prompting. A summary of all complaints and the way they are resolved must be available in the home. The manager should ensure that the home’s adult protection training ties in with the local authority procedures for the Protection of Vulnerable Adults. The manager must ensure systems are in place to keep the home free from fire hazards and that all information required as evidence for inspection is readily available in the home. There should be information to let visitors know when they enter the home who is in charge of the shift. 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. DS0000001433.V322006.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 DS0000001433.V322006.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 and 4 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service, examination of documentation, information from relatives, discussion with the manager and observation. Prospective service users and their families have sufficient information to make an informed choice about the home. People could be sure their needs would be met as they had their needs assessed and a contract telling them what to expect for the fees. EVIDENCE: Statement of Purpose for the home had been updated. The document was in good, clear, and easy to read print. The information could be improved by making clear the services not covered by the fees to avoid misunderstanding by relatives who manage peoples’ finances. DS0000001433.V322006.R01.S.doc Version 5.2 Page 10 The service users guide was said to have been reviewed and at the printers therefore not available for inspection. All the people who returned questionnaires said they had received a contract and felt they had received sufficient information to make an informed choice about the home. The home had produced an excellent information booklet about dementia for relatives. A visiting relative however had not seen it. This should be made more readily available. A notice in the office tells visitors about the information available on request, including the complaints leaflet, but this is not an area where visitors would normally see it. It is acknowledged that it is difficult to avoid service users moving any notices or documents left within their reach. A Perspex fronted shallow wall mounted cabinet in the entrance porch may provide a solution to the problem of safely displaying information where visitors can see it. The case files examined contained good pre admission assessments by the home manager to determine that the home could meet needs. There was sufficient detail in the information to form a basic care plan for admission. A member of staff spoke about the importance of making anyone coming into the home feel welcomed and valued if people were to settle. DS0000001433.V322006.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 Quality in this outcome area was good. This judgement has been made using all the available evidence including a visit to the service, examination of documentation, observation, discussion with residents, staff and the manager and information from relatives. The health and personal care needs of individuals are met because staff had a good knowledge of each person. The principles of respect privacy and dignity are followed and there was a sense that staff liked and valued service users for their individuality. EVIDENCE: The manager said that six service users had recently been re assessed for dementia nursing care, as their needs could not continue to be met in a residential home DS0000001433.V322006.R01.S.doc Version 5.2 Page 12 The care files of three people, who were also part of the focussed observation done by the second inspector, were examined. The care files were set out in a consistent way but unfortunately the format had not been followed in all the files looked at. For example factual details, and a photograph, which may be needed in an emergency, were not all in the front of the files. This may be particularly important if a service user left the home. The home should have a system in place to obtain an up to date photograph as soon as possible after admission. Each file had an ‘overview’ care plan sheet for quick reference to show the level of support needed. Each area of need was then covered by a more detailed care plan, which gave staff enough information to be able to care for people in the way they preferred. The care plans started from the point of view of each person’s ability then described the level of support required. This is good practice as it assists people to retain skills and abilities. Background history in this same file, which is particularly important when caring for people who have difficulty remembering, was very limited in the file of a recently admitted service user. In another file there was a useful personal history regarding the person’s likes and dislikes and past working life and a good enhanced risk assessment. In one care file there was good detailed guidance for staff on arrangements when the service user’s family visited. A visiting relative was very pleased with the care given by the home and the kindness of staff. A returned questionnaire said there were concerns that the spiritual needs of non Jewish people were being overlooked. However none of the care plans seen included details of how spiritual needs were to be met. The manager said that a local vicar visited the home and held a short service at Christmas for Christians and that transport was available on Saturdays to take people to synagogue. More could be done to support peoples’ spiritual needs. Weight charts were completed for those people who needed encouragement to eat therefore at risk. The deputy manager had a good knowledge of health needs and the medication each person was taking. She explained that one person was now taking medication in liquid form since their return from hospital. A pre dispensed medication system was in use and medication records were appropriately recorded and signed for. It was clear from what staff said and what was observed that the manager and all the staff were knowledgeable about the diversity of the people in their care. They were alert to any changes in health or behaviour and took appropriate action. A GP visited one person who staff had concerns about. DS0000001433.V322006.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 Quality in this outcome area is excellent. This judgement has been made using all the available evidence including a visit to the service, information from relatives, observation including a two hour period of focussed observation, examination of documentation, discussion with the chef and staff and a sample of the main meal. Lifestyle and social activity is good, relaxed and adapted to the needs and pace of the service users. A healthy and nutritious diet offers choice and respects the Jewish way of life. EVIDENCE: One of the comment cards said there was a lack of stimulation for service users and another said there were rarely activities, particularly such as cards and dominoes. However, the inspection revealed that activity and interaction in the home was adapted to the abilities and individuality of the service users and conducted at a relaxed pace. During the inspection a reminiscence worker was visiting the home with her dog. This is a twice-weekly event. DS0000001433.V322006.R01.S.doc Version 5.2 Page 14 Two people who were part of the observation were involved in the reminiscence group. Their attention was captured during this time and they showed signs of pleasure and happiness. There was some good interaction seen between the service users and reminiscence worker and some service users and the dog. People in the room were able to join in when they wanted. Some people choose not to be involved at all and this decision was respected. A visitor was encouraged to be part of the group with the person they were visiting. It was clear this was not only a positive experience for the person they were visiting but for others in the group as well. The group provided the opportunity for a quiz about Yorkshire words and sayings. In addition there were discussions about where people had lived and well known people and areas of Leeds. Appropriate music was playing and residents were encouraged and supported to sing-a-long or have a dance. Again this led to discussions about what people did when they were younger and provided the opportunity for people to be valued as individuals. Throughout the observation residents were shown a level of respect that valued and recognised their experiences and age. A motivation worker makes weekly visits to the home and transport is provided weekly for those people who wish to use the facilities at Donisthorpe Hall. Throughout the day there was a relaxed atmosphere with staff working at the pace and inclination of service users. There was good interaction between service users and staff, who worked well as a team and were skilful and patient in adapting their approach to the different levels of communication skill of service users. Service users moved about the home freely, singing, performing simple and imaginary tasks and expressing their views. There was no effort made to restrict or contradict these expressions of individuality and staff never failed to respond to people appropriately. Residents were offered a choice of drinks with milk and sugar. Staff gave time for residents to decide if they wanted sugar, as one person was unsure if they took it. A member of staff also asked what residents would like for their lunch the following day. This was done on an individual basis with the staff member sitting at a level that made sure there was eye contact. Time was taken in doing this and there was no sense of this being rushed. Where one person could not decide, after some time, the member of staff said they would come back later. One resident was observed having a late breakfast in the dining room. When it became clear that the food was uneaten staff responded by making fresh toast and offering help. There appeared to be no hurry in doing this and it was done sensitively. DS0000001433.V322006.R01.S.doc Version 5.2 Page 15 Service users were encouraged to drink. When drinks were served residents were quietly reminded their drink was there. If after a short time the drink was ignored they were offered the cup to prompt them. Staff were very supportive at mealtime offering assistance and discrete prompts. The personal space of those who chose not to eat in the dining room was respected and they were served at a small table where they sat. The food was sampled and found to be of good quality and flavour. Meals were served plated straight from the kitchen, as people were ready for them, which meant the food was hot when it reached the table. Tables were laid with plain white cloths and simple crockery with napkins in a strong contrasting colour. This limited the amount of distraction from the food. DS0000001433.V322006.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area was good. This judgement has been made using all the available evidence including a visit to the service, information received from relatives, discussion with staff and the manager and examination of documentation. Service users’ representatives can be sure their complaints will be dealt with. Service users are protected from abuse. EVIDENCE: All the people who returned comment cards said they knew how to complain. All complaints are logged on a standard pro forma, which is then sent to head office with a copy held in the home. However copies could not be found in the home to show how each complaint had been handled. A summary of complaints and the action taken must be available for inspection. The manager said there had been three complaints since the last visit all relating to laundry and personal clothing, which had been lost or damaged. The organisation had a policy of replacing any garments that are lost or damaged. The manager had been using a professionally developed DVD training package, which included adult abuse. A care worker explained that she had done this training. The manager should make sure that staff also know about the local authority adult protection procedures to follow should an allegation be made. DS0000001433.V322006.R01.S.doc Version 5.2 Page 17 Staff recruitment and selection is undertaken at Donisthorpe Hall. All staff are checked at this time to make sure they are fit to work as carers and do not place service users at risk. DS0000001433.V322006.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26 Quality in this outcome area was good. This judgement has been made using all the available evidence including a visit to the service, a tour of the building, discussions with staff and the manager and observation. The home met the needs of the service users as it was clean, warm and comfortable and had been adapted to allow service users freedom to move about safely in the building and garden with a minimum of restriction. EVIDENCE: The home, a large detached house, has been extended to provide accommodation for older people and more recently adapted to provide a more secure environment for people with dementia. The secure garden could be accessed freely by service users through patio doors from the lounge therefore there was no sense of restriction. During the day service users were observed DS0000001433.V322006.R01.S.doc Version 5.2 Page 19 opening the doors, spending short periods looking out to the garden then, once satisfied, returning inside. When the door was left open staff simply closed it without fuss. Though some parts of the home were starting to show signs of wear and tear the home was clean and odour control was effective. En suite showers in the bedrooms were a nice idea but not really suited to the client group as the raised shower trays meant people had to step up into them. Several showers and shower curtains were damaged and the trays were being used for storage of continence pads. A care worker said this was because some service users became agitated when using the shower. It is recommended that any future refurbishment of the home include the installation of walk in wet rooms. Tiles in the en suite in one bedroom were missing and damaged. There was a plentiful supply of protective clothing and well-laundered bed linen. However spare linen was stacked close to the ceiling and a light fitting in the linen store, which could pose a fire risk. The manager dealt with this at the time of the inspection. Staff must be made aware of such hazards and not store combustible materials on the top shelves of the linen storerooms. The dining room and lounge were spacious and pleasant. More could be done throughout the home to provide prompts and visual stimulation to help service users identify different areas of the home. Work was to start on turning a double room into a single and improving the staff facilities. It had been recognised, that the facilities were very poor for staff who were working 12-hour shifts. DS0000001433.V322006.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is excellent. This judgement has been made using all the available evidence including a visit to this service, information from past inspections reports from Donisthorpe Hall, examination of documentation, discussion with staff, the manager, a visitor and observation. Staff in the home were trained and put their training and skills into practice to respond to the diverse needs of individuals with dementia and their families. EVIDENCE: Staff training included an induction to cover all the basics required by new staff to carry out their work, annual fire safety, dementia care, continence, pressure care, food hygiene and health and safety. Several staff were from overseas and had nursing qualifications from their own countries. One however, said she had no experience or knowledge of dementia care before joining the organisation as there was no such provision in her own country. She said she had learnt a lot in the time she had worked in the home. During the observation and discussion with staff they demonstrated a good understanding of the diverse needs of each person and showed warmth and genuine concern for service users. They said people looked nice after they had DS0000001433.V322006.R01.S.doc Version 5.2 Page 21 their hair done and complimented others on their singing and dancing. They were relaxed and patient with individuals, trying different methods of communication to help understanding. Service users were given reassurances and helped to recognise where they were. No poor interactions were seen or overheard between staff and residents throughout the day, though staff were starting to look tired towards the end of their 12 hours shift. Service users were given time to do things and there was no sense of rushing. Staff recruitment and selection takes place at Donisthorpe Hall where all the records were held. One care worker said she had transferred to the home after training at Donisthorpe Hall. Past inspections found the recruitment and selection practices made sure service users were protected. DS0000001433.V322006.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service, examination of documentation, discussion with the staff and manager and information received from relatives. The management and administration of the home is open and respectful, with effective quality assurance systems in place, which incorporated the views relatives of people who used the service. EVIDENCE: The manager is a trained Registered Mental Nurse (RMN) with business studies knowledge. He had completed part of a Diploma in Business Management DS0000001433.V322006.R01.S.doc Version 5.2 Page 23 before doing the National Vocational Qualification (NVQ) level 4 Management in Care award, which has now been verified. A person who completed a questionnaire said they were never sure who was in charge. Though not fully ‘hands on’ the manager had a good knowledge of the personalities and care needs of all the people in the home, which corresponded with information seen in the care files and observed, and he showed good empathy when talking to people. There was a budget for the home, agreed with the financial manager of the organisation, but all finance and personal allowances were held at Donisthorpe Hall. Any purchases on behalf of service users were charged to their account. The manager was in the process of checking all the homes policies and procedures and not able to lay his hands readily on some of the records. Those records seen were up to date and staff had signed to confirm they had read and understood the COSHH and Health and Safety policies. There were some oversights observed during a tour of the building, which have been detailed in previous sections. The 2006 Quality Audit report included an action plan. Some of the proposals had already been carried out. DS0000001433.V322006.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 2 3 2 x 3 3 3 3 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 3 4 3 3 3 3 2 DS0000001433.V322006.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 Standard OP16 OP19 OP21 OP38 Regulation 22 23 23, 17 Requirement Timescale for action 31/03/07 A summary of all complaints and the way they are resolved must be available in the home. All areas used by residents must 31/03/07 be suitably maintained and kept in a good state of repair The manager must have systems 31/03/07 in place to ensure the home is kept free from any Health and safety risks DS0000001433.V322006.R01.S.doc Version 5.2 Page 26 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 OP1 Good Practice Recommendations The good information booklet for relatives explaining about dementia should be made more readily available. Information for relatives could be improved by making clear the services not covered by the fees. Information for relatives should be suitably displayed in an area where it can be seen. Care plans should include more specific information about risks, nutrition, mental ability and spiritual needs. The manager should ensure that the home’s adult protection training ties in with the local authority procedures for the Protection of Vulnerable Adults. Consideration should be given to making the en suite showers into wet rooms. There should be some system to let visitors know who is in charge of each shift. 2 OP7 3 4 OP21 OP31 DS0000001433.V322006.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 DS0000001433.V322006.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!