Inspection on 02/05/06 for Caroline House

This inspection was carried out on 2nd 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

Caroline House 14/06/07

Caroline House 20/09/05

Caroline House 19/04/05

Caroline House 07/09/04

Caroline House 04/05/04

Caroline House 30/12/03

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Caroline House 7 Ersham Road Hailsham East Sussex BN27 3LG Lead Inspector Nigel Thompson Unannounced Inspection 2nd 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 Caroline House DS0000021067.V289413.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. Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Caroline House Address 7 Ersham Road Hailsham East Sussex BN27 3LG Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01323 841073 Mr Thuraisamy Ravichandran Mrs Radha Ravichandran, Mr N Suganthakumaran, Mrs S Suganthakumaran Vacant Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty four (24). Service users must be older people aged sixty-five (65) years or over on admission. 20th September 2005 Date of last inspection Brief Description of the Service: Caroline House is a large, detached three storey Victorian house situated in a quiet residential area of Hailsham, close to the town centre. It is registered to provide care and accommodation for 24 older people, not falling within any other category. Menus are varied, well balanced and nutritious. Meals are served either in the dining area or in the resident’s room. Service users’ rooms are equipped with a TV point, telephone and alarm call system. Rooms that do not have en-suite facilities are fitted with washbasins. There are two lounges and a dining area on the ground floor. A passenger lift provides access to all floors. At the rear of the house there is easy access to a large, landscaped garden, which is both safe and secure. There are ample car parking facilities at the front of the home. Information about the service, including the Statement of Purpose, Resident’s Handbook (Service User’s Guide) and CSCI reports is made available to prospective service users or their relatives, on request, as part of the admission process. The range of weekly fees, as of 2 May 2006, is £385 - £600. Additional charges, not included in the fees, include hairdressing, chiropody, toiletries and transport. Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven and a half hours in May 2006. It found that the majority of the National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Service users spoken with during the inspection expressed satisfaction with the home, the staff and the service provided. The purpose of this inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices at the home. On the day of the inspection there were twenty service users living at the home. The inspection involved a tour of the premises, examination of the home’s records and discussion with the Acting Manager, the temporary Head of Care and the proprietors. Responses from a CSCI service users’ survey, regarding their views on the home and quality of care provided, now form part of the inspection process and have also been included in this report. Five service users, one relative and two members of care staff were also spoken with. The focus of the inspection was on the quality of life for people who live at the home. In order that a balanced and thorough view of the home is obtained, this report should be read in conjunction with previous inspection reports. What the service does well: The relaxed, homely and welcoming environment at Caroline House has evolved over several years. Service users are encouraged and supported to make decisions about their lives. They are involved and regularly consulted on many aspects of life in the home, including menu planning. Communication and consultation with service users’ family members has significantly improved and is now effective and ongoing. Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: It is recommended that documentation including the Statement of Purpose and Service User Guide be reviewed and updated. Service users and, where appropriate, their relatives should have the opportunity to partake in individual assessments and be directly involved in care planning and reviewing processes. Formal staff supervision – regular and structured one-to-one meetings with individual care staff and their manager – is to be introduced, as required, to ensure that staff have the appropriate skills, knowledge and understanding of service users’ individual care and support needs. Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 Page 7 Satisfaction questionnaires are to be developed, as part of an improved quality assurance system within the home, to obtain the views of service users’ family, friends and other visitors on how care services are being provided. Monthly, unannounced visits by the owners are to be formalised, to ensure that they are aware of any significant issues or changes within the home, including the welfare and ongoing care needs of service users. A structured weekly programme of activities, including outings should be introduced to reflect the individual and collective interests of service users, as identified in residents’ meetings. 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. Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 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 Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The improved admission policy and procedures need to be completed in full to ensure that service users are admitted only on the basis of a thorough needs assessment, undertaken by people competent to do so. Prospective service users have the opportunity to visit the home and know that it is able to meet their individual care and support needs. EVIDENCE: Information for prospective service users including the Statement of Purpose and the Service User Guide (Residents’ Handbook) has been thoughtfully and imaginatively produced to a high standard and both documents were found to be comprehensive and informative. It was however noted that certain information should be updated, including references to a previous manager and the National Care Standards Commission (NCSC – the previous organisation responsible for regulating care Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 Page 10 services). As discussed with the acting manager, it is important that details contained in these documents are kept under review, so as to accurately reflect the services provided and the current situation within the home. There have been four service users admitted to Caroline House since the previous inspection. From care plans examined it is evident that the pre admission assessment process and recording format have been improved. However in certain files it was noted that assessment sheets had not been fully completed and important information, including details of medication and family involvement were not recorded. There was also no indication as to when the assessment had been carried out and by whom. A formal written contract has been developed and implemented and is routinely provided to each new service user or their representative. This contract incorporates a statement of terms and conditions of residency detailing the placement arrangements and clarifying mutual expectations around rights and responsibilities. It was noted, in the cases of service users recently admitted to the home, that contracts had been issued to and signed by the individual themselves or a relative or representative on their behalf. As part of the admission procedure, the acting manager confirmed that prospective service users are invited to visit the home, to look around and meet with staff and existing residents. They also have the opportunity to stay overnight before moving in. Service users, spoken with during the inspection, spoke positively about their experiences of moving into the home: ‘It’ isn’t easy moving out of your own home but now I’m very happy here. I like my room and everyone has made me feel very welcome’. ‘The staff are all very kind. They seem to know what help I need and can’t do enough for you. I’ve no complaints’. Intermediate care is not provided at Caroline House. Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users’ care plans enable staff to meet their assessed needs in a structured and consistent manner. However individual care plans do not always reflect current or changing support needs of service users. The systems for service user consultation and participation are good and service users are encouraged to make decisions about their day-to-day living. EVIDENCE: The temporary Head of Care at Caroline House is clearly working hard to ensure that service users’ assessed health, personal and social care needs are being met. Individual care plans that were examined show areas of significant improvement since the last inspection, particularly in the level of detail regarding action to be taken by staff. Consequently the identified care and support needs are now being met in a more structured and consistent manner. Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 Page 12 However, there is still little evidence of service users or their relatives being involved, as required, in developing or reviewing individual care plans. A relative, spoken with during the inspection, confirmed this situation: ‘I don’t have any concerns about the care she receives but I haven’t seen any care plan’. It was also noted that weight charts had not been completed in respect of three service users recently admitted to the home. All service users are registered with local GPs and have access to other health care professionals, including district nurses, via the surgeries. It was noted, in care plans that were examined, that all appointments with, or visits by, health care professionals are recorded. Satisfactory policies and procedures are in place for the control, storage, safe administering and recording of medication. The Head of Care confirmed that all staff involved in administering medicines receive appropriate training. This was supported by documentary evidence and through discussions with care staff. The home operates an effective key-worker system. The acting manager confirmed that, as part of their induction programme, all staff receive instruction on the principles of dignity and respect. This was evident, through discussion during the inspection, and from direct observation of staff interacting sensitively and professionally with service users. Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Although activities within the home have not significantly improved, service users maintain contact with family and friends as they wish and benefit from menus that are balanced and nutritious, reflecting their individual likes and preferences. EVIDENCE: Service users’ social and recreational interests and preferences are now recorded, as part of the pre admission assessment process, however, there is little evidence of any significant improvement regarding activities. The new acting manager acknowledges the importance of this aspect of daily life within the home and spoke positively about his commitment to ‘enriching service users’ lives’ through ‘stimulating social and leisure activities’. Since the previous inspection, an ‘Activities Coordinator’ has been appointed and currently works for two hours, three afternoons a week. In addition, there are three planned sessions of musical entertainment each month. Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 Page 14 On the afternoon of the inspection, although unfortunately the coordinator was not working, some service users were enjoying tea and cakes and listening to taped music in the lounge. It is evident that there is still no structured weekly programme of activities, including outings, based on individual choice and preferences. Although not all service users enjoy or partake in organised group activities and the acting manager confirmed that the Activities Coordinator regularly visits and spends time with service users who prefer to remain in their room. Comments from some service users indicate that, in addition to having more information regarding in-house activities, they would like to have the opportunity to go out of the home more often: ‘We never know what’s going on – someone just turns up’. ‘I never go out unless it’s with my family’. The acting manager confirmed that visiting in the home is unrestricted and service users may see friends or relatives in one of the lounges or in the privacy of their own room. A relative, spoken to during the inspection, was able to support this: ‘I come here at all times of the day and I’m always made welcome’. The temporary Head of Care confirmed that wherever possible, service users are enabled and supported to make choices and take decisions affecting their life and daily routines, including menu planning. This was supported through discussions with the cook and service users, who confirmed: ‘We are given a choice in what we eat’. Service users are provided with a varied, wholesome and nutritious diet. At lunchtime a choice of main meal is available and special diets are catered for. As part of a four week rolling menu, a weekly menu is displayed, reflecting service users’ preferences and including seasonal variations. A weekday cook has been appointed since the previous inspection and is evidently settling in well and enjoying her new role. The home is in the process of recruiting a cook for weekends, which are currently being covered by care staff. Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The open and inclusive atmosphere within the home enables service users, staff and visitors to feel able to express any concerns, confident that they will be listened to and acted upon. Service users are safeguarded from abuse through relevant staff training and robust policies and procedures. EVIDENCE: Despite the recent managerial changes at Caroline House, service users, members of staff and a relative spoken to during the inspection, confirmed that, although generally unaware of the formal procedure, they would have no hesitation speaking to the acting manager or making a complaint if necessary and each person was confident that they would be listened to: ‘I certainly would do – and I have done!’ However it was noted that the complaint procedure is not currently displayed and readily accessible to service users or other visitors to the home. The current procedure also makes no reference to timescales for responding to complaints. A satisfactory complaints log is maintained and indicates that there have been no formal complaints received by the home since the last inspection. It is also Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 Page 16 noted that no complaints regarding Caroline House were made to the CSCI during the same period. Policies and procedures relating to abuse and including whistle blowing are in place and have been reviewed and updated. The acting manager and temporary Head of Care have a sound understanding of Adult Protection procedures and confirmed that abuse training is provided for all staff. This was supported by training records and confirmed by members of staff, spoken with during the inspection. Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Service users benefit from accommodation that is safe, comfortable, generally well maintained and decorated to a satisfactory standard. EVIDENCE: As with many of the environmental standards, the situation at Caroline House regarding service users’ accommodation remains largely unchanged, however three of the rooms have been redecorated and refurbished. Service users rooms were found to be clean, comfortable and generally well maintained. It was evident that many of the rooms have been personalised, with pictures, family photographs and other small items of furniture and personal belongings, to reflect individual taste, choice and preference. Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 Page 18 In two of the bathrooms, new raised bath seats (elevators) have been fitted and a new gas cooker and water heater have been installed in the kitchen. It was noted that, to ensure the safety of service users, the majority of radiators throughout the home have now been fitted with covers. The proprietors confirmed that the remaining unguarded radiators will be covered within the next few weeks. It was noted that comments had been received from service users about the dining room being ‘too small’. Clearly, due to the design of the building there are limitations with the main communal areas, including the lounge and dining area. The current mealtime arrangement of some service users having to eat in the lounge is unsatisfactory. However, following discussions, the only practical solution would seem to involve an extension or conservatory at the rear of the building, leading out from the ‘quiet lounge’. Since the last inspection and the appointment of the acting manager, the office has been moved from its previous remote location on the second floor to the ground floor. This is a welcome development, benefiting service users, staff and visitors to the home and providing a far more convenient and accessible situation for the acting manager to be based. At the rear of the home, leading out from the ‘quiet lounge, is a large, pleasant and easily accessible garden, where service users are able to sit and relax in the fresh air: ‘I’ll be out there again as soon as it’s a bit warmer’. Infection control procedures within the home are in place and are closely adhered to. Levels of cleanliness and hygiene remain generally high throughout. Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. There are generally sufficient trained and competent staff on duty at all times to meet the assessed needs of the service users. However inadequate training records and some vital gaps in recruitment documentation must be addressed to help ensure the safety and protection of service users. EVIDENCE: As previously documented, there has been significant staff turnover since the last inspection. In total, eleven staff, including the manager and deputy manager have left Caroline House in the last seven months. During that same period, in addition to the acting manager and temporary Head of Care, nine members of staff have been appointed. Despite their understandable anxieties and the obvious upheaval, the general feeling among service users and relatives is that the changes have been handled sensitively, the overall level of care has not been affected and ‘the dust has now settled’. Positive comments from new and established members of staff, spoken with during the inspection, also indicate that morale is generally good amongst the staff and that individuals feel motivated, valued and well supported by the owners and management team: Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 Page 20 ‘It’ not been easy but people genuinely seem much happier now and there’s no more back biting!’ ‘People now are all actually working together, talking to each other and supporting each other’. Appropriate staffing levels are evidently in place, with a minimum of three care staff, including one senior carer, being on duty at all times during the day. At night there are two staff on duty - one waking night and a sleep-in person. An improved staff rota has been developed, showing details of which staff are on duty at any time and their designation. Recruitment procedures have been reviewed and improved and staff files that were examined were found to be generally well maintained, containing necessary information, including proof of identity and satisfactory Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) disclosures. However it was noted that in files for two staff recently appointed to the home there were no written references in place. Despite assurances from the temporary Head of Care that request letters had been sent out, there was no documentary evidence that these references had been applied for. All new staff are provided with and sign a written contract, including a statement of terms and conditions. Following recent changes in the staff team at Caroline House, there is now only one member of staff with National Vocational Qualification (NVQ) level 2, in care. This was discussed with the acting manager, who is aware of the requirement for 50 of staff to hold the qualification and he is to address the issue. In the last six months all staff have undertaken various training courses, including: medication, abuse, infection control, fire safety and moving and handling. Although confirmed by members of staff, spoken with during the inspection, there was little documentary evidence to support this. Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service users benefit from sound management and improved quality assurance systems within the home, however current arrangements for the provision of formal staff supervision are inadequate. There is a potential risk for service users from unsatisfactory health and safety practices. EVIDENCE: The newly appointed acting manager commenced work at Caroline House on 10 April 2006 after previously being Head of Care at a similar service for older people. He holds the City and Guild’s ‘Advanced Care and Management’ award. Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 Page 22 He has been ‘warmly welcomed’ and is clearly settling in well. He is under no illusions about the challenges he faces and readily admits that ‘there is work to be done’. However he confirms that he is receiving valuable support from the staff, proprietors and particularly the temporary Head of Care. It remains a legal requirement that where the proprietors are not in ‘day to day charge’ of the home that they will visit at least once a month, unannounced, inspect the premises, speak with service users and staff and prepare a written report on the conduct of the home. A copy of this report is then to be supplied to the CSCI. Effective quality monitoring and consultation with service users, including regular residents’ meetings, is ongoing. Feedback from service users, regarding the care they receive, is sought by the use of satisfaction questionnaires. Since the previous inspection, the format of the questionnaires has been amended and improved. Following discussion with the acting manager, it is recommended that the satisfaction survey be extended to obtain feedback from service users’ relatives and possibly other visitors to the home. The home maintains responsibility for approximately half of the service users’ money through a ‘Residents’ Deposit Account’. Individual balances are checked on a weekly basis and all financial transactions are recorded. Formal staff supervision is still not currently being carried out. However it is evident that the new acting manager fully understands the concept and potential benefits of formal supervision. In his previous position he had responsibility for providing staff supervision and, following consultation with staff, he is keen to introduce it at Caroline House. The health, safety and welfare of service users and staff remains of paramount importance within the home and staff training is provided in many aspects of safe working practices, including moving and handling; food hygiene; fire safety and first aid. However it was noted during a tour of the premises that fire extinguishers had not been serviced recently and many doors into service users’ rooms were wedged open. This is a clear safety risk, which was brought to the attention of both the acting manager and the proprietors. Following discussion it is required that wedges will not be used in the home and it is proposed that automatic closers are to be fitted to all doors, as necessary. COSHH assessments and guidelines are in place. Temperature regulators are fitted to all hot water outlets, accessible to service users and all accidents, incidents and injuries are recorded and reported, as required. Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 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 2 3 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 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 3 2 X X 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 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. 1. Standard OP1 Regulation 6 (a) Requirement It is required that information regarding the service, including the Statement of Purpose and Service User Guide, be reviewed and updated. It is required that documentation, including preadmission assessment recording formats be reviewed and amended to be more service specific. It is required that each individual care plan, generated from a comprehensive assessment, be drawn up with the involvement of the service user, or relative where appropriate, and provides the basis for the care to be delivered. (Previous timescale of 30/09/05 not met). It is required that that the service users’ care plans, including risk assessments, be regularly reviewed with the involvement of the service user, or relative where appropriate, and updated to reflect changing needs. (Previous timescales of 30/06/05 & 30/09/05 not met). DS0000021067.V289413.R01.S.doc Timescale for action 30/06/06 2. OP3 14 (1) 30/06/06 3. OP7 15 (1) 30/06/06 4. OP7 15 (2) 30/06/06 Caroline House Version 5.1 Page 25 5. OP12 16 (2) (m & n) 6. OP16 22 (1) & (5) 7. 8. OP28 OP29 19 (5) (b) 7, 9 & 19 Schedule 2 26 (1, 2, 3, 4 & 5) 9. OP33 10. OP36 18 (2) 11. OP38 13 (4) (a) 12 OP38 23 (4) (C) (iv & v) It is required that service users be given the opportunities for stimulation through a structured programme of recreational activities, including outings, which suit their needs, preferences and capacities. It is required that a clear, simple and accessible complaints procedure is in place and is made avsilable to all service users. It is required that a minimum ratio of 50 of care staff obtain NVQ level 2 in Care. It is required that the home’s current recruitment procedures be reviewed, including the obtaining of references, ensuring the protection of service users. It is required that the registered providers visit the home at least once a month to inspect the premises, monitor the conduct of the home and prepare a written report. A copy of this report is to be forwarded to the CSCI. (Previous timescale of 31/10/05 not met). It is required that all care staff receive formal, recorded supervision at least six times a year. (Previous timescales of 30/06/05 and 31/10/05 not met). It is required that all parts of the home, to which service users have access are free from hazards to their safety, including door wedges. It is required that all fire safety equipment be regularly tested and well maintained. 30/06/06 30/06/06 30/09/06 02/05/06 02/05/06 31/07/06 30/06/06 30/06/06 Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 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. 2. Refer to Standard OP20 OP30 Good Practice Recommendations It is recommended that consideration be given to providing alternative dining arrangements that do not involve service users eating in the lounge. It is recommended that all staff training be appropriately recorded. Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. Extracts may not be used or reproduced without the express permission of CSCI Caroline House DS0000021067.V289413.R01.S.doc Version 5.1 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. 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