Inspection on 13/07/06 for Cassandra House

This inspection was carried out on 13th July 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

Cassandra House 18/03/08

Cassandra House 26/10/05

Cassandra House 13/06/05

Cassandra House 31/01/05

Cassandra House 23/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Cassandra House 19 Dunswell Lane Cottingham Hull East Riding Of Yorks HU16 4JA Lead Inspector Diane Wilkinson Unannounced Inspection 13th July 2006 09:10 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 Cassandra House DS0000019656.V305235.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. Cassandra House DS0000019656.V305235.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cassandra House Address 19 Dunswell Lane Cottingham Hull East Riding Of Yorks HU16 4JA 01482 876150 01482 876111 carol@mellandene.karoo.co.uk 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) Carol Lesley Olive Murrey Carol Lesley Olive Murrey Care Home 42 Category(ies) of Dementia - over 65 years of age (42), Old age, registration, with number not falling within any other category (42) of places Cassandra House DS0000019656.V305235.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th October 2005 Brief Description of the Service: Cassandra House is a care home situated in a semi-rural area of Cottingham in the East Riding of Yorkshire. The home is registered to provide care and accommodation for 42 older people, including those with dementia. Fees paid range from £328.80 to £375.30 per week, and there is an additional charge for toiletries, hairdressing, chiropody and newspapers. Forty residents were accommodated at the home on the day of the site visit. The home is a detached Tudor style property built in 1910, with a modern extension. It is set in quiet surroundings and has an enclosed courtyard that is equipped with tables and chairs for residents to utilise. Private accommodation consists of both single and shared bedrooms, some with en suite facilities. Communal living space consists of five lounges, a dining room and a conservatory. Cassandra House is a family run business and is one of two care homes owned and managed by the family. Cassandra House DS0000019656.V305235.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information obtained from the pre-inspection questionnaire, information received by the Commission for Social Care Inspection (CSCI) since the last inspection of the home and from the site visit on the 13th July 2006. This unannounced site visit is part of a key inspection and was undertaken by one inspector over one day; the site visit commenced at 9.10 am and finished at 4.40 pm. The site visit consisted of a tour of the premises and examination of documentation, including five care plans. On the day of the site visit the inspector spoke on a one to one basis with three residents and four care staff, as well as senior carers and the registered manager. Following the site visit the inspector spoke to three relatives of people accommodated at the home. Prior to the site visit, seven comment cards were sent to health and social care professionals and five comment cards were sent to GP’s. Five were returned by health and social care professionals and two were returned by GP’s. All responses were positive and this feedback was given (anonymously) to the registered manager. Comments from service users, staff, relatives, health and social care professionals and GP’s are included in the main body of the report. The inspector would like to thank service users, staff and the registered manager for their assistance on the day of the inspection. What the service does well: The health care needs of service users are well met. One service user said, ‘I don’t think anyone could get more care’ and another said, ‘the staff are very kind and caring’. Suitable activities are provided for service users. One service user said, ‘If there is anything going on, I’ll be there!’ and another said, ‘Staff are always willing to have a bit of fun’. The home is clean and well maintained and laundry services are good. The home employs sufficient staff to care for the numbers of service users accommodated. Staff are skilled and well trained and are equipped to care for the service users accommodated at the home. Cassandra House DS0000019656.V305235.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Cassandra House DS0000019656.V305235.R01.S.doc Version 5.2 Page 7 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 Cassandra House DS0000019656.V305235.R01.S.doc Version 5.2 Page 8 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): 3. Standard 6 not applicable, as the home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are assessed prior to their admission to the home to ensure that their individual care needs can be met. EVIDENCE: The inspector examined the records for a newly admitted service user and these evidence that the service user was assessed prior to admission to the home. The registered manager stated that she had visited this service user in hospital to commence the assessment process and that this information was used to commence the individual plan of care. Care planning records include two different assessments forms – a preadmission assessment and an admission checklist/assessment. Ideally all service users should be assessed using the same process and records should evidence this. Cassandra House DS0000019656.V305235.R01.S.doc Version 5.2 Page 9 One service user told the inspector that they had not looked around the home prior to admission, but knew that the home ‘had a good reputation’. Another said that a relative had looked around the home on their behalf, and ‘had made the right choice’. All staff have undertaken dementia care training that was facilitated by the mental health team at Castle Hill Hospital. The registered manager informed the inspector that any advice given by health care staff would be recorded on the initial assessment and transferred to the care plan. Cassandra House DS0000019656.V305235.R01.S.doc Version 5.2 Page 10 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 and 10 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The health and personal care needs of service users are met in a way that respects the privacy and dignity of service users. Medication is administered safely but staff should be more robust in adhering to procedures. EVIDENCE: The home obtain community care assessments and/or care plans from care management (where appropriate) and this information, along with the assessment undertaken by the home, is used as a basis for an individual care plan. Care plans include appropriate risk assessments for the risk of falls and for handling requirements. One newly admitted service user had an environmental risk assessment form in their records that had not been completed. This was rectified on the day of the inspection. Care plans include a ‘medication changes’ record and a record of any contact with GP’s and other health care professionals. Daily records are very detailed. Key workers record any input/time spent with service users and these records Cassandra House DS0000019656.V305235.R01.S.doc Version 5.2 Page 11 are checked by the registered manager. Staff informed the inspector that they arrange chiropody appointments, undertake nail and hair care and spend time talking to service users that they are key worker for. One member of staff has the responsibility for ensuring that formal reviews of the care plan take place. The inspector was informed that, if staff from the local authority do not ask for a review to be arranged, the member of staff ‘chases them up’. The home hold annual reviews for privately funded service users. The inspector observed that a communal record is used to record bathing, bowel movements and weight for service users. The registered manager was advised that communal recording does not comply with the Data Protection Act and that these details should be recorded in service user’s individual care records. There are input/output charts in place for some service users where this is felt to be an area of concern. The inspector observed that there is pressure care equipment in use and that some service users were using footstools to elevate their legs. These details were recorded in care plans. The inspector was informed that district nurses assess service users for continence equipment and that this is supplied by the National Health Service. This service is reassessed every six months. One care plan included a ‘cot side agreement’ but this had not been signed by the service user or their representative. All relatives said that they were very satisfied with the care provided by the home and one service user said, ‘I don’t think anyone could get more care’ and another said, ‘the staff are very kind and caring’. Medication administration records were seen by the inspector and these were found to be an accurate record of medication administered. All staff that administer medication have undertaken accredited training. Medication to be returned to the Pharmacy was ready to be collected by the Pharmacist the next day – the Pharmacist signs to confirm receipt. There is a medication fridge in the senior carers office and this has an external display to show the fridge temperature. Some excess creams were stored in this office and staff were advised that these creams should be kept in the medication cabinet or in the service user’s own room. Controlled drugs are stored safely and records for the administration of controlled drugs were examined by the inspector and were found to be satisfactory. The inspector observed that some service users were given medication to take whilst they were seated at the dining table, before they had been given a drink. This could pose a risk of someone else taking that medication in the interim period. This was discussed with the registered manager at the end of the inspection. There is no list of sample signatures for the staff that administer medications to enable medication records to be checked. The inspector observed that staff knock on bedroom doors before they enter. There are various areas around the home where service users can see relatives Cassandra House DS0000019656.V305235.R01.S.doc Version 5.2 Page 12 and other visitors in private, and some service users have a single room. All GP’s and health and social care professionals reported that they are able to see the service user in private, and this was confirmed by relatives. One relative commented that the service user occasionally wears clothes that do not belong to them, as their own clothes have been ‘lost in the wash’. However, they added that clothes are always found and returned to the service user concerned. Cassandra House DS0000019656.V305235.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are supported to take part in activities both inside and outside of the home, and visitors to the home are made welcome. Meal provision at the home is good. EVIDENCE: Care plans record social histories and leisure interests for service users. An activities coordinator is employed for four days per week and there is an activity programme in place. Key workers record any activities undertaken by service users in care plans, as well as visits out of the home and any visitors seen. One service user said, ‘If there is anything going on, I’ll be there!’ and another said, ‘Staff are always willing to have a bit of fun’. Some service users go to church with their family and others are visited at the home by a vicar or a priest. One relative said that, when they ring the home to say that they will be collecting the service user, staff ensure that the service user is ready to go out. Staff informed the inspector that service users are asked about their choice of clothes for the day and where they wish to spend the day. Some service users Cassandra House DS0000019656.V305235.R01.S.doc Version 5.2 Page 14 choose to spend the day in their room and others spend the day in one of the lounges. There are five lounges in total so service users have plenty of choice, but tend to sit with service users with similar interests and capabilities. Care plans include requests for service users to have a postal vote where they have requested this. There is a four-week menu in operation. There are notices on the dining room wall advertising the alternative choices available to the meal recorded on the menu. Some service users have meals in their room but most take meals in the dining room. There are two ‘sittings’ at lunchtime to ensure that there is always a member of staff available to assist those service users that need assistance. There are adaptations available such as plate guards to enable service users to eat and drink independently, and special meals are provided for service users with diabetes. Those service users that need help were assisted appropriately. Any food allergies are recorded on the front page of the service user’s care plan. One service user described the food as, ‘nice, plain, home-cooked food’ and said that the puddings are especially nice and another service user said, ‘Staff have said that if there is anything I fancy, they will get it for me’. The inspector observed that ample drinks are provided throughout the day. Cassandra House DS0000019656.V305235.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users and relatives are confident that any complaints would be listened to and acted upon, but not all staff and service users are not aware of the home’s complaints procedure and complaints are not recorded appropriately. The lack of staff training and understanding results in a less than robust system to protect service users from the potential to be abused. EVIDENCE: The inspector observed that there was a complaints procedure on display in the entrance hall. None of the care staff spoken with by the inspector were able to explain the home’s complaints procedure but all said that they would refer any adverse comments to a senior carer or the registered manager. Service users were not aware of the complaints procedure but told the inspector that they would be quite happy to speak to staff about any concerns and feel that they would be listened to. One service user said, ‘I’m sure staff would listen and would be helpful’. The registered manager should ensure that staff and service users are clear about the complaints procedure at the home and how to use it. There is a ‘niggles’ book in place and this evidences that these concerns have been dealt with appropriately by the home. The Commission for Social Care Inspection are aware of a complaint that was recently investigated by the home. This was dealt with in a satisfactory manner and the complainant was satisfied with the outcome. However, details Cassandra House DS0000019656.V305235.R01.S.doc Version 5.2 Page 16 of this complaint investigation should be recorded in a complaints log. There is no complaints log in use at the home – the inspector was informed that complaints are recorded and retained in the office, and copies of correspondence are available on the database. There are appropriate policies and procedures in place on the protection of vulnerable adults from abuse. All senior staff and eight care staff have undertaken training on Adult Protection. All members of staff spoken with were not sure about the term whistle blowing and some did not understand the term POVA. Two of these staff had completed NVQ Level 2 in Care and the inspector feels that they should have understood this terminology. There have been no recorded incidents or allegations of abuse at the home since the last inspection. Cassandra House DS0000019656.V305235.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users live in a clean, safe, well-maintained and homely environment apart from the provision of radiator covers to control the risk of service users being burned. EVIDENCE: The location and layout of the home is suitable for its stated purpose. It is accessible and well maintained with an ongoing programme for refurbishment and decoration. There is a maintenance book in use and it is evident that minor repairs are dealt with on an on-going basis. The inspector was informed that a maintenance programme is included in the quality assurance audit of the home. Fifteen new chairs have been purchased to replace soiled chairs and the lounges looked pleasant and comfortable on the day of the inspection. There is an enclosed courtyard and members of the gardening club ensure that Cassandra House DS0000019656.V305235.R01.S.doc Version 5.2 Page 18 the garden is full of flowers and a pleasant place to sit out and enjoy the sunshine. Some bedrooms overlook the courtyard area. The programme to cover radiators to control the risk of burning for service users is not yet complete, but a further delivery of radiator covers is expected next week. This should result in the programme to cover radiators being completed shortly. The inspector was informed that a thermostatic valve is fitted in the hairdressing room and that water temperatures are tested in there as well as bathrooms and shower rooms. Water temperatures are not tested in washbasins in bedrooms and the registered manager said that this procedure is to be introduced shortly. Emergency lighting is provided throughout the home and bedrooms are suitably lit for service users, including table-level lighting. Laundry facilities are satisfactory and a dedicated laundry assistant is employed by the home. The home was clean and hygienic on the day of the inspection, with the exception of odours in two bedrooms. This was discussed with the senior carer and it is evident that efforts are being made to alleviate this problem. Service users told the inspector that the home is always ‘nice and clean’ and that the bedding is changed regularly. One service user said, ‘if any laundry ever goes missing, it is always found and returned’. Cassandra House DS0000019656.V305235.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Staff receive appropriate induction training and ongoing training to prepare them for working with the service users accommodated at the home. There are sufficient staff on duty to ensure that service users’ needs can be met. Current recruitment practices do not fully protect the service users from the potential to be abused. EVIDENCE: The inspector examined the staff rotas. These do not identify the role of each member of staff, but there are separate rotas for care staff, ancillary staff and night staff. The rota records that there are four or five staff on duty throughout the day, and on the day of the site visit the staff recorded as being on duty were actually on duty. There are three ‘waking’ care staff on duty during the night. Staff told the inspector that they feel there are enough staff on duty and that they usually have enough time to spend with service users. One service user said, ‘the staff are wonderful, right from the top to the laundry assistant’. Twelve care staff have achieved NVQ Level 2 or 3 in Care, and another five care staff are working towards this award. The home is therefore on target to meet the 50 qualification requirement. One of the senior carers is undertaking the NVQ Assessor’s award. Cassandra House DS0000019656.V305235.R01.S.doc Version 5.2 Page 20 Recruitment and selection records were examined for five members of staff. There is a record of questions asked and answers given at staff interviews. Some of the details recorded were not clearly dated so it is difficult to determine that POVA first checks or CRB checks are received prior to staff commencing work at the home. There are two written references in place for all staff but some of these are not dated and it is difficult to identify whether they have been provided by staff or requested by the registered manager. The registered manager assured the inspector that, when references are supplied by a member of staff, she contacted the referee to confirm the content. The registered manager was informed that references should always be requested by the home, and that references should always be signed and dated to confirm their authenticity, and that verbal references are not acceptable. Any staff disciplinary issues are recorded appropriately. There is a training and development programme in place. There are appropriate arrangements in place for staff to receive induction training that meets Skills for Care specifications. Staff spoken with on the day of the inspection had undertaken health and safety training such as moving and handling, health and safety, food hygiene, first aid and fire safety. Staff records include a record of their individual training achievements and training needed as part of short-term, medium term and long term development, including NVQ training. Various training programmes have taken place over the last year, including fire training, moving and handling, vulnerable adults, staff supervision and first aid. Future training planned includes diabetes care, arthritis care and staff supervision/appraisals. Cassandra House DS0000019656.V305235.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is managed and led by a suitably experienced and skilled person but arrangements to protect the health and safety of service users and staff are not robust. The quality monitoring system enables the views of service users and others to be listened to and acted upon. Service users monies are held securely but service users do not have access to their monies at all times. EVIDENCE: The registered manager is skilled and experience to run the home but has not yet achieved NVQ Level 4 in Care and Management. An action plan should be developed to evidence how these qualifications will be achieved, to include acceptable timescales. The registered manager informed the inspector that she attends in-house training with care staff to ensure that her practice is kept Cassandra House DS0000019656.V305235.R01.S.doc Version 5.2 Page 22 up to date, and that she attends meetings of a care home’s association and with the local authority to ensure that she is aware of any new developments within the care industry and current good practice guidelines. The home has been awarded QDS parts one and two – this is the local authority quality scheme. Staff spoken with informed the inspector that they attend staff meetings and that they are encouraged to contribute towards these. Surveys are sent to service users or relatives on such topics such as ‘food’. The results of these surveys are collated and there is a record of any action that needs to be taken. The outcome of these surveys is published via staff meetings and resident/relative meetings. Regular quality audits also take place. An annual service review is compiled and results of in-house surveys are recorded in this document. The inspector noted that the employer’s liability insurance certificate on display in the senior carer’s office was dated 22/01/05 to 21/01/06. The registered manager should send a copy of the current insurance certificate to the inspector. Some service users manage their own financial affairs, others are assisted by a family member and two service users are assisted by a solicitor. Records are in place for monies held on behalf of service users and receipts are obtained for any expenditure or items purchased on their behalf. Personal allowances for service users are retained in a separate bank account – the registered manager should ensure that any interest accrued is the property of service users. A monthly bank statement is received and the home’s administrator should reconcile the details of this bank account on a regular basis to ensure that it equates to monies held for service users – this check should be recorded. Service users do not have immediate access to this money, as it is not held on the premises, and this needs to be addressed by the registered manager. Some service users have been provided with lockable storage to ensure that their money and valuables can be held securely. Notifications to inform the Commission for Social Care Inspection of any accidents or incidents at the home are now received within appropriate timescales. The records for in-house checks on emergency lighting, the fire alarm system, fire extinguishers and the call system were seen by the inspector and were found to be satisfactory. A qualified contractor checked the fire alarm system in April 2006, and the passenger lift and bath/mobility hoists are serviced regularly. There is a gas safety certificate in place. The portable appliance test certificate had expired but this work was being undertaken on the day of the site visit to the home. There are arrangements in place to ensure safe working practices at the home, including appropriate risk assessments. Cassandra House DS0000019656.V305235.R01.S.doc Version 5.2 Page 23 The Environmental Health Officer visited the home in June 2006 and their report states that hygiene arrangements at the home are satisfactory. The registered manager informed the inspector that the work required as a result of a visit from the Fire Officer (i.e. all fire doors have been realigned or replaced) has been completed, but that the Fire Officer has not returned to the home to check this. This has been recorded on the Annual Service Review. Cassandra House DS0000019656.V305235.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X 3 3 Cassandra House DS0000019656.V305235.R01.S.doc Version 5.2 Page 25 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 OP25 Regulation 13 Requirement The home should complete the programme of covering radiators to protect service users from the risk of burning. The current timescale has not yet expired. Timescale for action 30/09/06 Cassandra House DS0000019656.V305235.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. 2. Refer to Standard OP8 OP9 Good Practice Recommendations The inspector recommends that personal details about a service user should be recorded in their individual care plan rather than in a communal record. There should be a list of sample signatures to enable medication administration records to be checked to ensure that only trained staff administer medication. More care should be taken with the storage of creams, and with the administration of medication at meal times, i.e. staff should ensure that service users are observed to take their medication. Complaints should be recorded appropriately. The registered manager should ensure that all service users and staff understand how to make a complaint. The registered manager should ensure that all staff understand the purpose of the whistle blowing policy, and that all staff have had training on adult protection. Water temperatures should be tested at washbasins in service user bedrooms as well as in bathrooms, shower rooms and the hairdressing room. These water temperature tests should be recorded. All recruitment and selection records should be clearly dated. References should always be requested by the registered manager and should be received in writing before the member of staff commences work at the home. Verbal references should not be accepted. There should be an action plan in place (that includes acceptable timescales) to identify how the registered manager will achieve NVQ Level 4 in Care and Management. There should be evidence that bank statements for the Mellandene client’s account has been reconciled with records held at the home. The registered manager should ensure that any interest accrued is the property of the service users. Service users should have access to their money at all times, and should ideally have their own bank account. DS0000019656.V305235.R01.S.doc Version 5.2 Page 27 3. 4. 5. OP16 OP18 OP25 6. OP29 7. OP31 8. OP35 Cassandra House Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Cassandra House DS0000019656.V305235.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. 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