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Inspection on 05/09/07 for Catherine Dalley House

Also see our care home review for Catherine Dalley House for more information

This inspection was carried out on 5th September 2007.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

Information provided to prospective and existing service users now contains up to date information about the services and care offered by staff of Catherine Dalley including information on fees. Care plans have continually improved providing information as to service users preferred daily living arrangements, and focus on the specific care needs and support offered to service users, with particular reference to those service users who have a diagnosis of Dementia. An Activity Organiser is now in post offering a range of individual and group activities including trips out. Staff have received training in Infection Control and Sensory Impairment which directly impacts on the quality of care, and health and safety of service users. A quality assurance system has been established which is available to prospective and existing service users, and provides information as to how all aspects of Catherine Dalley, are regulated and maintained. The quality assurance report also includes an analysis as to the views of service users and their relatives, and contains an action plan for improvement.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Catherine Dalley House Scalford Road Melton Mowbray Leicestershire LE13 1JZ Lead Inspector Linda Clarke Key Unannounced Inspection 5th September 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Catherine Dalley House DS0000032860.V342222.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. Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Catherine Dalley House Address Scalford Road Melton Mowbray Leicestershire LE13 1JZ 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) 01664 562487 01664 562487 www.leicestershire.gov.uk Leicestershire County Council Social Services Mrs Marian Hovell Care Home 31 Category(ies) of Dementia (8), Dementia - over 65 years of age registration, with number (20), Learning disability (4), Learning disability of places over 65 years of age (4), Mental disorder, excluding learning disability or dementia (8), Mental Disorder, excluding learning disability or dementia - over 65 years of age (6), Old age, not falling within any other category (31), Physical disability (8), Physical disability over 65 years of age (10), Sensory impairment (4), Sensory Impairment over 65 years of age (4) Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Catherine Dalley House Care Home is registered to provide personal care to male and female service users who fall within the following categories: Old age not falling within any other category (OP) 31. Dementia over 65 years of age (DE(E)) 20. Dementia (DE) 8. No person falling within the category DE can be accommodated at Catherine Daley House when there are 8 persons within this category already residing at the home. No persons falling within the categories DE(E) or DE can be accommodated at Catherine Dalley House when 20 persons who fall within these categories/combined categories are already residing at the home. Learning Disability over 65 years of age (LD(E)) 4. Learning Disability (LD)4. No persons falling within the categories LD(E) or LD can be accommodated at Catherine Dalley House when 4 persons who fall within these categories/combined categories are already residing at the home. Mental Disorder, excluding learning disability or dementia over 65 years of age (MD(E)) 6. Mental Disorder, excluding learning disability or dementia (MD) 8. No person falling within the category MD(E) can be accommodated at Catherine Dalley House when there are 6 persons who fall within this category residing at the home. No Persons falling within the category MD(E) or MD can be accommodated at Catherine Dalley House when 8 persons who fall within these categories/combined categories are already residing at the home. Physical disability over 65 years of age (PD(E)) 10. Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 5 Physical Disability (PD) 8. No person falling within the category PD can be accommodated at Catherine Dalley House when there are 8 persons who fall within this category residing at the home. No Persons falling within the category PE(E) or PD can be accommodated at Catherine Dalley House when 10 persons who fall within these categories/combined categories are already residing at the home. Sensory impairment over 65 years of age (SI(E)) 4. Sensory impairment (SI) 4. No Persons falling within the category SI(E) or SI can be accommodated at Catherine Dalley House when 4 persons who fall within these categories/combined categories are already residing at the home. No person within any of the following categories; SI, PD, DE, LD, MD, may be admitted unless they are aged 55 years or older. Service users between 55-65 years who fall within the above categories and were resident in the care home at the date of registration may continue to reside there. The maximum number of service users to be accommodated at Catherine Dalley House is 31. 6th April 2006 2. 3. Date of last inspection Brief Description of the Service: Catherine Dalley is a care home providing personal care and accommodation for up to thirty-one older persons, who may have associated conditions, which may include dementia, mental disorder, learning disability, physical disability and sensory impairment. The home also provides four rehabilitation and two respite beds. The home is located in the market town of Melton Mowbray, which provides a range of shops and has public transport links. A majority of the rooms being single without en-suite facilities. The home has a garden surrounding the property including a secure garden with a seating area. Accommodation is provided over two floors with access between the floors being via stairs or a passenger lift. Information is located on site detailing the range of services offered, which includes the Statement of Purpose, in addition to this Catherine Dalley has copies of the Commission of Social Care Inspections, Inspection Reports, which are located in the main office and are available upon request. Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 6 The maximum weekly fee is £476.00; information as to fees is contained within literature supplied to prospective service users, including information about individual savings and financial contribution to care. There are additional costs for individual expenditure such as Chiropody, Optician and hairdressing services, and the fee will depend on the services received. Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 7 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process consisted of pre-planning the inspection, which included viewing the previous Inspection Report, reviewing of the Annual Quality Assurance Assessment (AQAA), and Comment Cards sent to service users and their relatives by the Commission for Social Care Inspection, seven service user and seven relative Comment Cards were returned. The unannounced site visit commenced on the 5th September 2007 and lasted 1 day. The focus of the inspection is based upon the outcomes for the service users. The method of inspection was ‘case tracking’. This involved identifying service users with varying levels of care needs and looking at how these are being met by the staff at Catherine Dalley. Four service users were selected and discussions were held with two of them, additionally three service users and their relatives who were visiting were spoken with. The method of case tracking included the review of service users’ individual care records, discussions with staff of various delegated responsibilities within the home and reviewing the records, training records and the minutes of service user and team meetings. A number of comment cards received from service users and their relatives highlighted concerns as to the proposal that Leicestershire County Council will no longer own and manage Catherine Dalley. What the service does well: Catherine Dalley provides detailed information to prospective and existing service users and their relatives, as to the care and services offered by the Home. Mechanisms are in place for service users and their relatives to be consulted as to the care they receive through quality assurance questionnaires, and meetings. Catherine Dalley is well maintained and provides a homely atmosphere and a range of communal areas for service users to relax, participate in activities and receive visitors. Service users benefit from staff that are qualified and trained in delivering care, with reference to the individual and collective needs of service users. The Commission for Social Care Inspection (CSCI) sent out surveys to a number of service users and relatives when asked what the home does well the following comments were made: - Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 8 • I feel the care home goes out of its’ way to make the life and care of its’ residents as good as possible, and as close to a normal life, as is possible. My wife settled in very quickly. Everything Extremely well Catherine Dalley and the staff who work there take every care to make sure the personal, medical and physical needs are well catered for. I really can’t complain about the home in any way. My mother is always looks clean and smart, and when we visit she’s usually colouring, playing snakes and ladders, bingo or singing. This care home looks after their care, health and welfare. The staff are jolly and helpful and encourage those residents in the home. I have nothing but praise for this home. • • • • • What has improved since the last inspection? What they could do better: The Key Inspection on this occasion has not highlighted any areas for improvement or shortfalls to the service. Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 9 The Commission for Social Care Inspection (CSCI) sent out surveys to a number of service users and relatives when asked what the home could do to improve the following comments were made: • • • • • As I see it, there isn’t too much room for improvement on present care. What I see when I ring or go to see my sister is how they are very caring. More than satisfied Think it’s fine just the way it is. We don’t think it can improve we are well pleased. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 10 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 Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that the information supplied by the Home, and their needs assessment will enable them to make an informed choice as to where they receive care, and can be confident that the Home can meet their needs. EVIDENCE: An information pack is provided to prospective service users containing information as to the services provided by Catherine Dalley, and includes information on staff, fees, how to raise concerns, how service users and their relatives are consulted and how the home operates along with information as to the admission process. A prospective service users relative visited on the day of the Inspector’s site visit, and was given a tour of the Home, and was provided with written and verbal information about Catherine Dalley. Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 12 The assessments of four service users currently residing at Catherine Dalley were viewed, two were of service users living at the Home. Assessments provide a detailed report as to the needs of the individual, which enables a decision to be made as to whether the staff of Catherine Dalley can provide the appropriate care. For individuals accessing the rehabilitation unit, service users are assessed by a representative of Social Services; in addition assessments in some instances are carried out by Health Care professionals including Occupational Therapists. The rehabilitation unit is sited on the first floor of Catherine Dalley, access being via the stairwell or passenger lift. There is a dedicated staff team who work closely with other professionals providing support in the rehabilitation of service users; the aim in the main is for service users to be able to return to their own homes. During the site visit a service user arrived at Catherine Dalley to access the services of the rehabilitation unit having been transferred from hospital. Conversations with the service user highlighted that they had been welcomed to the unit by a member of staff and were introduced to the other occupants and given a tour. Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are well cared for having their tailored health and daily care needs met through personalised care. EVIDENCE: The records of three service users two in receipt of residential care and one accessing a short stay (respite) were viewed as part of the ‘case tracking’ process, this included looking at their care plans. In the first instance a care plan is produced by the Social Worker, following the initial assessment of the service users needs. An additional care plan is written from the perspective of the service user, and includes information about a service users previous life and any significant events, this enables staff to have an understanding of a service users life prior to their residence at Catherine Dalley, information is also detailed as to a service users views and wishes as to their expectations of care. The care plan Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 14 details those who are involved in the day to day lives of the service user and include personal relationships and health and social care professionals, including their contact details. Care plans provide information as to the support an individual requires with regards to their physical and mental health well being. Care plans focus on service users independence and abilities, and where assistance is required how this is to be delivered, with the views of the service user recorded. Service users who have specific health care needs for example Dementia can be confident that their care plan will provide information as to how their condition affects their daily lives, and provide information as how staff need to be sensitive in offering support and care. The care plan of one service user accessing the rehabilitation unit was also viewed, the care plan focuses on the goals the individual needs to achieve to enable them to return to their own home and live independently. A detailed record was kept of the individual’s progress, the progress of the individual being discussed with health and care professionals to ensure a smooth transition for the individuals return home. Conversations were held with a group of service users who reside at the Home, all spoke positively as to the care they receive, and made positive comments as to the staff and their approachability. Conversations were also held with service users accessing the rehabilitation unit, including the relative of one service user. All made positive comments as to the rehabilitation service and the support they had received from staff. The service user on a short stay (respite) placement said they were unsure about coming into Catherine Dalley, however had found the staff to be welcoming. Care plans provide specific information on individual’s health care needs and Daily records of the four service users, whose records were viewed, evidence contact with health care professionals, which included where appropriate reviewing of their medication. The medication and medication records of two service users residing at Catherine Dalley were viewed and were found to be in good order, staff responsible for the administration of medication receive accredited training. The Commission for Social Care Inspection (CSCI) sent out surveys to a number of service users when asked as to their views on the care and support they receive the following comments were made. • • The care in Catherine Dally is very good indeed, and staff are excellent. I appreciate everything they do for me. DS0000032860.V342222.R01.S.doc Version 5.2 Page 15 Catherine Dalley House • • • • • Staff are very caring and considerate to personal and emotional needs. I find talking very hard but they always bear with me until they understand what I mean. On the occasions I’ve been unwell I’ve always had excellent care and medical support. It is an excellent home in every respect. My cousin is very well supported and cared for by the staff. The keyworker is exceptional and looks after his needs and helps him in every way. I am cared for extremely well. My key care worker is so kind and tends to my needs above what would be expected. • Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 16 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users make choices about daily living; with choices offered as to activities and meals. EVIDENCE: An Activity Organiser is employed at Catherine Dalley and provides both group and individual activities for service users, a weekly programme of activities is in place, which includes memory games, floor games, jigsaws, dominoes, glass painting, crafts to name some. Service users spoke of their trip to Skegness and a boat trip during the summer, and the planned trip to the theatre in Melton Mowbray. The Inspector sat with a group of service users and the Activity Organiser for a game of dominoes; the service users comments were very favourable towards the Activity Organiser, talking of her sense of humour and joy to be around. Service users if they so choose have newspapers and magazines delivered. Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 17 The Commission for Social Care Inspection (CSCI) sent out surveys to a number of service users when asked as to their views activities arranged by the home and their view as to the meals the following comments were made:• • The activities leader is very good and gets the best out of everyone. The meals are good and I enjoy the food. The quality and quantity are both good. As part of the site visit the Inspector sat with a group of service users at lunchtime. Service users comments as to the quality and quantity of food were positive, and observations confirmed that service users are asked as to their meal preferences each day. Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by a robust and accessible complaints procedure and by staff trained in safe guarding adult processes. EVIDENCE: Documentation supplied by the Registered Manager prior to the site visit detailed that Catherine Dalley has not received any complaints or concerns in the last twelve months. The Commission for Social Care Inspection (CSCI) in the last twelve months has not received any complaints or concerns with regards to Catherine Dalley. Information as to how concerns and complaints can be raised and how they will be handled is provided in documentation supplied to prospective service users. Opportunities are provided for service users to express their views and opinions, which affect their lives, through attending service user meetings and taking part in the quality assurance process. Staff receive training in how to look out for signs of abuse and how they are to respond if they have any suspicions or concerns. Policies and procedures detail Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 19 the action that staff are to take should that have any concerns with regards to service user welfare. Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with a warm, safe, clean, comfortable and wellmaintained environment suitable for their needs. EVIDENCE: Catherine Dalley has car parking facilities to the front of the Home, and access to the front door is via steps or an access level ramp. Mechanisms on the front door prevent individuals entering or leaving the building who do not have the access code. Catherine Dalley has an on-going programme of re-furbishment and maintenance. Communal dining and lounge facilities for long term and short stay residents are located on the ground floor, as are some of the bedrooms and bathing facilities. The first floor, which is accessible via the stairwell or Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 21 passenger lift, provides additional bedrooms and bathing facilities and the separate area for service users accessing rehabilitation services, which comprises of bedroom, bathing and toilet facilities, and an open plan lounge/dining and kitchen area. All areas of the Home are decorated to a good standard, creating a homely environment in which service users can relax. Staff receive training with regards to infection control and are provided with protective clothing such as aprons and gloves. Laundry facilities are designed to reduce the risk of cross infection. The Commission for Social Care Inspection (CSCI) sent out surveys to a number of service users when asked as to the cleanliness of the home the following comments were made: • • The cleanliness is very good. The standard is exceptionally good. Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are met by staff that are experienced and trained in the delivery of care, having their needs timely and safely met. EVIDENCE: Catherine Dalley employs twenty-one members of staff, of which 96 have attained a National Vocational Qualification in Care at level 2 or 3, which directly affects the ability of care staff to provide effective and high quality care. Sufficient staff on duty ensure that the needs of all service users are met, service users spoken with confirmed that staff respond appropriately when they ask for assistance, observations on the day of the site visit showed that care staff were sensitive to the needs of service users and spoke courteously and professionally, this was particularly evident with service users who had Dementia, staffing showing an understanding of the service users needs and were patient in offering assistance, reassurance and care. Staff receive training in topics related to health and safety which includes moving and handling, fire awareness and first aid. In addition staff receive training in topics specific to the care of service users including Dementia and Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 23 Alzheimer Awareness, Sensory Impairment, and conditions associated with health. Service users supporting service users within the rehabilitation unit receive training with reference to promoting the independence of service users. The Inspector viewed a selection of staff recruitment records, all necessary employment checks, which included written references and a Criminal Record Bureau check. Staff receive regular supervision from a member of the management team. Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38. 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 a well managed home with good leadership, having opportunity to shape and improve the service, whilst ensuring that service users health, safety and welfare are promoted. EVIDENCE: The Registered Manager, Marian Hovell is a qualified Social Worker and has attained a Certificate in Counselling and Psychotherapy, in addition has attained a level 4 National Vocational Qualification and the Registered Managers Award. Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 25 A quality assurance system has been developed which provides information to prospective and existing service users and their families as to how quality is measured and maintained, in addition a system is in place, which actively seeks the views of service users and their relatives as to the care and services offered by Catherine Dalley. A quality assurance report is available and is incorporated within the information pack. The quality assurance process provides a précis of documents and reports which are undertaken by the Local Authority and other regulatory bodies, including the Audit Report, Complaints, Staff and Service User Meetings, Environmental Health and Catering Reports, Fire Officer Report, and the analysis of service user and relative surveys including an improvement plan as to how the service intends to improve the quality and care for service users. Information as to the management of service users financial affairs is detailed within the service users care plan, and often involves their family or legal representatives such as Solicitors. Information submitted prior to the site visit detailed the regular maintenance of health and safety systems within the home, including fire systems and equipment, environmental health visits, central heating systems and emergency call systems. Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X 3 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 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Catherine Dalley House DS0000032860.V342222.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!