Inspection on 08/08/06 for Castle Hill House

This inspection was carried out on 8th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Castle Hill House 22/10/07

Castle Hill House 09/01/07

Castle Hill House 10/01/06

Castle Hill House 03/11/05

Castle Hill House 23/02/05

Castle Hill House 24/09/04

Castle Hill House 16/03/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Castle Hill House Bimport Shaftesbury Dorset SP7 8AX Lead Inspector Gloria Ashwell Key Unannounced Inspection 8th August 2006 12:30 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 DS0000026778.V306334.R02.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. DS0000026778.V306334.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Castle Hill House Address Bimport Shaftesbury Dorset SP7 8AX 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) 01747 854699 01747 858760 Community Health Association of Shaftesbury Limited Mrs Immacula Ballard Care Home 30 Category(ies) of Dementia - over 65 years of age (17), Old age, registration, with number not falling within any other category (13) of places DS0000026778.V306334.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 2 bedrooms, measuring 15.5m sq metres or more, may be used for double occupancy at any one time. 10th January 2006 Date of last inspection Brief Description of the Service: Castle Hill House is owned by the Community Health Association of Shaftesbury (CHAS); a charitable company limited by guarantee. The home is managed by Mrs Ballard. The home is registered to accommodate up to thirty older people including a maximum of seventeen who are mentally frail and suffering from dementia. The home also offers respite care to up to three older persons. Resident accommodation is on three floors; there are two double and twentysix single bedrooms. The home has two passenger lifts; all residents areas are accessible by the lifts and there are no steps or ramps in corridors or bedrooms. The home has a range of baths including one of variable height with a fixed hoist, and another with a fixed hoist only. A visiting ‘activities coordinator’ leads regular activities in the home (at extra charge to service users). In addition to personal care and support the services provided include all meals, laundering and housekeeping. The home has mature private gardens where residents can sit and relax in the warmer weather. There is a parking area to the side of the house and a public car park is situated a short walk from the home and close to the town centre. Arrangements can be made for a hairdresser, chiropodists, opticians and other health and social care professionals to visit individual residents. Fees are charged weekly and at present range between £339 and £550 per person. DS0000026778.V306334.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a statutory inspection required in accordance with the Care Standards Act 2000. The inspection was unannounced; the inspector arrived at 12.30 toured the premises and spoke to residents and staff. Together with deputy manager Mrs Wilson the inspector discussed and examined documentation. At present 29 residents are accommodated. During the inspection, particular residents were ‘case tracked’; for example, for evidence regarding Standards 3, 7 and 8, records relating to the same resident were examined, and the resident spoken with. Additional information used to inform the inspection process included the Pre-inspection Questionnaire completed in advance of the inspection by the registered manager. Since the previous inspection a number of completed Comment Cards/booklets were sent to the Commission: 10 from residents, 11 from the relatives of residents, 2 from local doctors, and 2 from health and social care professionals. Comments indicated general satisfaction; a number were very positive and one observed “Castle Hill House is exceptional – comfort and care of residents 100 . The kindness and gentleness of the staff are outstanding”. During this inspection compliance with all key standards of the National Minimum Standards was assessed. What the service does well: Castle Hill House is a well established home where elderly people are encouraged to remain as independent as their frailties allow. The home promotes service users choice regarding their daily lives and routines. Comments received by the Commission in advance of the inspection included “The care and attention … is excellent. ”.”. The social care provision is central to residents’ lives and reflects their individual choices. Service users said they are treated with respect at all times and their privacy is respected. DS0000026778.V306334.R02.S.doc Version 5.2 Page 6 The standard of food supplied to service users is very good, offering alternative options at each meal. The home is well maintained, attractively decorated and comfortably furnished, with a mature private garden where residents can sit and relax. 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. DS0000026778.V306334.R02.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 DS0000026778.V306334.R02.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 (The home does not provide intermediate care so Standard 6 does not apply) Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Prospective residents (or their representatives) are provided with information about Castle Hill House and are encouraged to visit in advance of admission to establish their impressions of life at the home and the standard of available accommodation. Prior to admission, the needs of each proposed resident are assessed and the home then writes to prospective residents confirming the ability to properly care for them. EVIDENCE: The records of a recently admitted resident included details of pre-admission assessment which had been carried out by Miss Witt when she visited the prospective resident at her previous address. DS0000026778.V306334.R02.S.doc Version 5.2 Page 9 In advance of making the decision to enter the home the closest relatives of the prospective resident visited Castle Hill House to view the premises on her behalf because she was too frail to do this herself. The inspector spoke to the resident who and confirmed her satisfaction with Castle Hill House and had previously done so by returning her written comments to the Commission stating: “I was in hospital at the time and it was not possible for me to return home. The decisions in most cases were made for me. I was visited by staff and then taken to view the home. Relatives were also allowed to make visits.” Comments received from the relatives of residents by the Commission in advance of the inspection included “We were given a thorough visit and compared to other homes we visited Castle Hill House was by far the friendliest with a full description given on procedures and care plans etc.” and “Very friendly welcome and joined the residents for a coffee!” DS0000026778.V306334.R02.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 & 10 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The standard of care is good and in accordance with a written plan of care for each resident ensuring that staff have sufficient information upon which to base their care practice. Residents health needs are met and periodic audit of accidents is recorded to minimise risks of recurrence. Medicines prescribed by doctors are safely stored and carefully administered to residents by staff trained in this work, thereby protecting residents from medicine errors. Residents receive prescribed medicines at the correct times and in correct amounts. Residents wishing to do so can manage their own medicines. Some minor improvements to medicine related record keeping are necessary to ensure the continued safety of residents in these regards. Residents are treated with respect and their privacy and dignity is protected at all times. DS0000026778.V306334.R02.S.doc Version 5.2 Page 11 EVIDENCE: Residents believe they are properly cared for; comments received by the Commission in advance of the inspection included “Occasionally I have to wait when I ring my bell but there is normally a reason for the delay. I have a number of medical issues and the home always contacts the doctor when necessary”. A doctor wrote stating that the home is “Excellent all round”. Care records of 4 residents were examined and contained risk assessments forming the basis for care plans and daily records describing the care of each resident. To ensure correct identification of residents records contain a recent photograph of each resident. Records are kept of all accidents but it is recommended that these be expanded to include details of investigation and that an accident policy and procedure with particular regard to falls management be developed and implemented. Medication administration records were properly kept indicating that residents receive prescribed medicines at the correct times and in correct amounts those wishing to do so can manage their own medicines in accord with a risk assessment process; two of the currently accommodated residents manage their own medicines. For all other residents the handling of medicines is carried out by staff trained in this work. To further improve the medicine recording systems it is recommended that the index of pages used in the Controlled Drug register include the name of the resident, (i.e. not only the drug), to ensure accuracy of the audit trail, accountability for all Controlled Drugs and the consequent provision of prescribed health care to residents. The Commission has recently received a number of ‘comment responses’ from the relatives of residents including the observation “The care and attention given to my mother is excellent. When I want to wheel her out in a wheelchair it is never too much trouble for them, even though hoisting is essential for this”, “X was hospitalised recently and on return to Castle Hill House the care received was wonderful – getting her up and back into her routine and building her strength back up. The same happened a year ago when she was very ill with bronchitis. Day to day care is A1, looking to her physical and mental care. X has been in Castle Hill House for 3 years – the care she receives is faultless” and “I am filling in this form for X who has been at Castle Hill House for 2½ years – during that time X has been very well looked after”. DS0000026778.V306334.R02.S.doc Version 5.2 Page 12 Residents expressed similar satisfaction and in the presence of staff appeared relaxed, confident and at ease; staff interactions with residents were of a friendly and considerate manner. DS0000026778.V306334.R02.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 & 15 Quality in this outcome area is very good. This judgment has been made using available evidence including a visit to the service. The quality of daily life in the home is good with residents assisted to maintain as much independence as possible. Social and leisure activities are suited to the preference and ability of each resident. Residents are encouraged to maintain contact with the local community and visits by their friends and relatives are welcomed by the home. Meals are appetising and of good quantity and quality. Most residents take meals in the large dining room on the ground floor; others receive them in their bedrooms. EVIDENCE: The inspector spoke to a number of residents; all indicated satisfaction with the home, including the range of activities, meal provision, staff and premises. On a sessional basis the home employs an Activities Organiser who arranges local excursions, visiting entertainers, one-to-one and small group social and recreational activities. DS0000026778.V306334.R02.S.doc Version 5.2 Page 14 Visitors are welcome at any time and in responses during the inspection and in written responses made to the Commission in advance of the inspection confirmed they are always made to feel welcome and placed at ease by the staff; comments included “Always informed in any change in X’s condition”, “Castle Hill House is wonderful for residents and comforting/helpful for residents visiting” and “menu looks good and when I visit before meals always smells good. Lunch trolley looks very appetising”. Other written comments included “I visit without an appointment and there are staff in lounges with residents and a calming atmosphere”(Care Manager/Placements Officer), “always a warm friendly feeling when you enter. Castle Hill House staff always greet you in a friendly way. The residents appear well cared for and happy. Much is done to relieve boredom and give stimulation” (Health & Social Care Professional). During the serving of lunch in the dining room there was animated conversation between residents and evident enjoyment of their meal. To further improve catering standards it is recommended that facilities be provided enabling residents and their visitors to obtain drinks and snacks. Residents said they were very satisfied with the quality, choice and quantity of food provided; one resident stated” The meals are generally very good. My family are made welcome to stay and eat with me”. Following the death of a resident the relative wrote to the home stating “X was lovingly cared for during her stay…she always spoke in the most glowing terms of her care…and there was always a particular mention of how lovely the food was!”. DS0000026778.V306334.R02.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 & 18 Quality in this outcome area is good with regard to complaint management, but improvements must be made to ensure that all staff have received training in the understanding and prevention of abuse to ensure that they remain vigilant to protect vulnerable residents from such risks. These judgments have been made using available evidence including a visit to the service. The complaints procedure provides information on the procedure to follow to persons wishing to make complaint and service users know how to complain. The home adheres to a policy/procedure for the prevention of abuse. EVIDENCE: Residents feel confident that if they had concerns or complaints they will be listened to and taken seriously. Written responses made to the Commission in advance of the inspection included “the staff are always most diplomatic and caring” and “I would always feel happy to speak to Mac (registered manager) or Ros (deputy manager)”. To ensure residents and their representatives have access to the complaints procedure it is included in the service user guide to the home and a copy is provided to each residents’ relative/representative. Residents know how to complain and feel confident that if they had concerns or complaints they will be listened to and taken seriously. Comments received during the inspection included “If I had a problem they would deal with it”. DS0000026778.V306334.R02.S.doc Version 5.2 Page 16 The home keeps records of all complaints received and investigated. Since the last inspection no complaints against the home have been received or investigated. The home has developed and implemented written policies and procedures for the protection of residents from abuse or neglect and endeavours to provide all staff with training in the understanding of abuse and their role in protecting residents from abuse in its many forms, including neglect. However, examination of a sample of training records for 7 staff indicated that only 2 had received this training. An associated recommendation is included in this report. Since the previous inspection the home received an allegation regarding an incident of verbal abuse of a resident by a member of staff. The home took appropriate action, including informing the Commission of the circumstance; the staff member is no longer in the home’s employ. DS0000026778.V306334.R02.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 & 26 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Castle Hill House is a well-appointed and comfortable home. On the day of inspection the home was clean, pleasant and hygienic and there was evidence indicating that this is the usual standard of provision. EVIDENCE: Castle Hill House is a partly traditionally built house, and partly purpose built extension. It offers good sized bedrooms, bathrooms equipped for the use of persons requiring assistance and comfortable communal rooms. On the day of inspection the home was clean, tidy and comfortable throughout; there were no unpleasant odours. DS0000026778.V306334.R02.S.doc Version 5.2 Page 18 In written responses made to the Commission in advance of the inspection there was evidence that this is the usual high standard; a resident stated “My room is cleaned well every day”. Another resident confirmed overall satisfaction but noted “Occasionally clothes sent to the laundry go missing”. This matter was discussed during the inspection and the deputy manager explained that every effort is made to ensure all clothes are clearly labelled, but sometimes labels fade or fall off. On such occasions staff take the unnamed clothing through the home, until it is claimed by the particular resident. To ensure the comfort of residents during the recent heat wave the home has obtained portable air conditioning units and used them in the lounges and dining room. It is intended to construct a conservatory suited to year round use, to provide an additional lounge facility. DS0000026778.V306334.R02.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 & 30 Quality in this outcome area is adequate with regard to the number of staff and their competency but improvements must be made to employment processes to ensure the protection of residents against the employment of unsuitable staff who may place them at risk of harm. This judgment has been made using available evidence including a visit to the service. EVIDENCE: Staffing levels are provided in accordance with the assessed needs of residents to ensure that at all times sufficient staff are available to properly meet their needs. However, comments received by the Commission in advance of the inspection included “occasional staff shortages can mean delays in getting help washing, dressing and undressing” and “…provision of basic care staffing numbers is never sufficient” (relative/visitor). From information provided to the Commission by the home in advance of the inspection there was evidence that the home provides staffing hours in accord with the Staffing Forum calculation but does not exceed the calculated minimum so that if on occasion the needs of any resident increase, or a member of staff does not function at full capacity, delays will probably occur. It is recommended that the home’s management consider opportunities for providing more staff hours to ensure that minor increases in need can be properly met. All staff spoken to during the inspection were enthusiastic about their work and felt that they provided a good standard of care to residents. DS0000026778.V306334.R02.S.doc Version 5.2 Page 20 Employment records of three recently employed staff were examined; for one of the staff there was no evidence of any reference having been obtained in advance of employment and for all 3 of the staff the history of employment was incomplete, because the form provides space for only 3 past employments to be recorded. For all new staff, in advance of employment, the home must obtain at least two written references and an accurate history of past employment to ensure residents are not placed at risk by the employment of potentially unsuitable staff. At present 68 care staff currently employed by the home hold a National Vocational Qualification in care; the home thereby exceeds the standard for at least 50 of the care staff to hold an NVQ in care. Notwithstanding the weaknesses in their employment records, the three staff whose records were examined had received induction training and had attended training in fire safety. An external training provider is engaged by the home to supply training to staff in a variety of relevant subjects. However, the training records of 7 other staff were examined with particular regard to training in fire safety and it was noted that one care worker was no recorded to have received training in this subject since February 2005. It is required that all staff receive training in fire safety at least twice each year, to ensure they know the correct action to take to protect residents and other service users in the event of an accidental fire occurring at the home. To further assist the training of care staff there is available a range of opportunities including www.picbdp.co.uk (the Partners in Care web site), www.skillsforcare.org.uk (the Skills for Care web site), www.traintogain.gov.uk (a programme and funding stream supported by the Learning and Skills Council and Business Link) and www.lsc.gov.uk/bdp/employer/eggt_intro.htm (the Employer Guide to Training website, which is aimed at assisting employers to choose the most suitable training provider to meet their workforce needs by the use of a search facility). Comments received by the Commission in advance of the inspection noted that recently employed staff from overseas “all work so hard but in several cases communication and building up a relationship can be difficult due to the poor English skills these carers have” and “I am very happy with all the staff at Castle Hill House, however some of the new members seem to have difficulty communicating with me and talk to one another in their own language. This is not a criticism of their care for me.” The deputy manager confirmed that these problems were known to the home’s management and showed to the inspector a copy of Minutes from a Resident’s Meeting held on 30 June 2006 in which the subject was raised. In DS0000026778.V306334.R02.S.doc Version 5.2 Page 21 consequence the home requires all staff to speak English at all times while on duty, whenever possible places overseas staff to work with English staff and is endeavouring to find training courses in English language skills for those who would benefit from such assistance. DS0000026778.V306334.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is generally good; the home is well managed and suitably staffed, much liked by residents and their representatives and well maintained although staff training in fire safety and some fire safety equipment checks must be improved to ensure the continued safety of all persons in the home. This judgment has been made using available evidence including a visit to the service. Residents are satisfied with the home and feel staff care for them well and put them at their ease. The home does not manage the finances of residents. The premises and equipment are properly maintained in good condition. DS0000026778.V306334.R02.S.doc Version 5.2 Page 23 EVIDENCE: Mrs Ballard is the registered manager of the home; she has extensive experience in the care of older persons and is well regarded by residents and their relatives/visitors, staff and health and social care professionals; one described it as “a homely well run home”. The home has ongoing systems for quality assurance; satisfaction surveys are periodically issued and Residents Meetings take place regularly. To ensure continuity of approach the home operates in accord with a selection of policy and procedure documents; it is recommended that at the earliest opportunity these are extended to include all those referred to by the Commission in the pre-inspection questionnaire, including the subjects of accidents, clinical procedures and First Aid. With the exception of safe keeping some amounts of cash (for which all transactions are confirmed by receipt), the home does not manage the finances of residents. Staff trained in First Aid are on duty in the home at all times. All staff are supervised and each has a personal profile containing records of appraisal. Details of equipment servicing and maintenance were provided to the Commission in advance of this inspection. The inspector examined some records to verify this information including regular checks/tests of fire safety equipment and noted that monthly checks/tests of emergency lighting and extinguishers are not recorded to have taken place. An associated requirement is included in this report. The home has not recorded Health & Safety risk assessment of the premises and working practices, designed to identify potential risks and introduce measures to manage/reduce them. This report contains a related requirement, to ensure that risks are systematically identified, assessed and minimised. DS0000026778.V306334.R02.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 3 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 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 DS0000026778.V306334.R02.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. Standard OP29 Regulation 19 & Schedule 2 Requirement There must be evidence that the home operates a robust recruitment procedure including obtaining at least 2 written references in advance of employment. All staff must receive training in fire safety at least twice each year. Tests and checks of fire safety equipment must be carried out at the frequencies determined by the local fire and rescue service and accurate records must be kept of these events. The home must record a Health & Safety risk assessment of the premises and working practices, designed to identify potential risks and introduce measures to manage/reduce them. Timescale for action 08/09/06 2. OP30 23 (4) 08/09/06 3. OP38 23 (4) 08/09/06 4. OP38 13 01/12/06 DS0000026778.V306334.R02.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 OP8 Good Practice Recommendations It is recommended that accident records be expanded to include details of investigation and outcome. It is recommended that an accident policy and procedure with particular regard to falls management be developed and implemented. It is recommended that the index of pages used in the Controlled Drug register include the name of the resident, (i.e. not only the drug), to ensure accuracy of the audit trail, accountability for all Controlled Drugs and the consequent provision of prescribed health care to residents. It is recommended that facilities be provided enabling residents and their visitors to obtain drinks and snacks. It is recommended that all staff receive training in the understanding of abuse and their role in its prevention and detection. It is recommended that the home’s management consider opportunities for providing more staff hours. It is recommended that at the earliest opportunity written policies and procedures be developed and implemented for all subjects referred to by the Commission in the preinspection questionnaire. 3. OP9 4. 5. OP15 OP18 6. 7. OP27 OP38 DS0000026778.V306334.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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