Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 06/04/06 for Catherine Dalley House

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

This inspection was carried out on 6th April 2006.

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

The assessment process of individuals is robust, which ensures that individuals accessing services and care are appropriately placed. Service user initial assessments are then developed into care plans, which detail individual care needs and the role of staff in delivering care, including the wishes and expectations of the service user. The visit evidenced positive relationships between service users and staff, which promoted a relaxing and homely environment for all. Service users during the site visit indicated their satisfaction with the care they receive, and praised the staff in both their attitude and care delivery. Service users spoken with stated they were confident to bring to the attention of others any concerns they have. Service users have the opportunity to participate in organised activities, service users were observed having a game of dominoes, and they spoke of how they were looking forward to the Easter Bonnet Parade. Care staff receive training relevant to the care needs of service users, with a majority of care staff having a National Vocational Qualification in Care. The welfare of service users is protected through robust recruitment practices and a complaints policy and procedure whose profile of is raised with service users through meetings and ease of access to information.

What has improved since the last inspection?

Environmental improvements have taken place since the last inspection, which includes the provision of an entrance foyer, which is accessible to service users with a physical disability. In addition the new entrance foyer promotes the welfare of service users, as all individuals leaving and entering the building can only do so upon request. The bedroom identified in the previous inspection as requiring decoration has taken place, and in addition to some toilet areas have been decorated.

What the care home could do better:

Information to prospective service users and their families is available; improvements to the content, accuracy, presentation and accessibility of this information would support individuals in choosing a placement. For staff to provide high quality care for all service users for whom the care home is registered consideration should be given to providing training in Sensory Impairment, which includes the role of staff in offering support. The health of service users could further be improved by the provision of training in Infection Control. Catherine Dalley does not have an internal quality assurance system, which enables service users and their representatives to comment at defined intervals as to the services offered by the home. Infrequent service user meetings, which are currently in held, do not provide sufficient opportunity for comment by all interested parties.

CARE HOMES FOR OLDER PEOPLE Catherine Dalley House Scalford Road Melton Mowbray Leicestershire LE13 1JZ Lead Inspector Linda Clarke Unannounced Inspection 6th April 2006 09:15 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.V288301.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 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 - over 65 years of age (20), Learning registration, with number disability over 65 years of age (4), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (6), Old age, not falling within any other category (31), Physical disability over 65 years of age (10), Sensory Impairment over 65 years of age (4) Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Categories DE(E) No person falling within category DE(E) may be admitted to the home when 20 persons who fall within category DE(E) are already accommodated within the home Service User Categories MD(E) No person falling within category MD(E) may be admitted to the home when 6 persons who fall within category MD(E) are already accommodated within the home Service User Categories LD(E) No person falling within category LD(E) may be admitted to the home when 4 persons who fall within category LD(E) are already accommodated within the home Service User Categories PD(E) No person falling within category PD(E) may be admitted to the home when 10 persons who fall within category PD(E) are already accommodated within the home Service User Categories SI(E) No person falling within category SI(E) may be admitted to the home when 4 persons who fall within category SI(E) are already accommodated within the home Service Users 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 17th October 2005 2. 3. 4. 5. 6. 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. Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 5 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. The maximum weekly fee is £451.50, which was provided on the day of the Inspection. 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.V288301.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection Report reflects a visit to the service, which included discussions with service users, relatives, and staff and the reading of documents relevant to service user care and welfare, along with staffing records. In addition documents supplied direct to the Commission for Social Care Inspection by the care home, which includes reports of incidents involving individual service users and records of visits undertaken by a representative of the Responsible Individual have been incorporated. What the service does well: What has improved since the last inspection? Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 7 Environmental improvements have taken place since the last inspection, which includes the provision of an entrance foyer, which is accessible to service users with a physical disability. In addition the new entrance foyer promotes the welfare of service users, as all individuals leaving and entering the building can only do so upon request. The bedroom identified in the previous inspection as requiring decoration has taken place, and in addition to some toilet areas have been decorated. 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. Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The content and the distribution of information could be improved to support prospective service users in making a decision as to where to live. EVIDENCE: Information regarding the service and facilities, which Catherine Dalley provides is kept on site, this details the initial assessment and referral process and includes environmental information along with the aims and objectives. Incorporated is information as to how complaints, comments and compliments can be raised. The information provided by Catherine Dalley does not include views or comments of service users who already reside within the home. Service users with sight impairments may experience difficulty in reading the documentation; other formats could be considered, with consideration being given to the range of service users needs for which Catherine Dalley is registered to provide for. Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 10 Information in relation to fees was not up do date within the handout packs, and therefore prospective service users would need to ascertain this information prior to accepting a placement. Service users spoken with said that they had themselves not received any written information as their placements were initially agreed between social/health care staff and their families. The Assistant Manager on duty confirmed that they have few direct enquires, with a majority of referrals being made through a Social Worker. The provision of information could be improved, for example if Social Workers were to provide the individual with the information as part of the assessment and referral process. Individuals accessing the rehabilitation unit are presented with a welcome pack, which is placed in their bedroom prior to their arrival. The records of two service users and one individual accessing rehabilitation services were viewed; all were found to contain an initial assessment of need undertaken by an appropriate person. A discussion was also held with the relatives of one individual who was currently residing at Catherine Dalley in order for an assessment of need to be undertaken. The individuals records were not viewed, however opportunity was taken to speak with relatives where possible. Relatives spoke of the inconsistent information they had received from staff during the initial few days of their relatives stay, and were concerned that information they wished to pass on to staff would impact on the level of care their relative received. Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. Service users are looked after well in relation to health and care needs. EVIDENCE: The care plans and records of two service users and one individual accessing rehabilitation services were viewed. Care plans contained information as to how the care needs of the service users were to be met with reference to the service users views and expectations of care. The care plan of one service user detailed as to how staff were to communicate effectively, due to the sensory impairment of the individual. Risk assessments are in place which detail as to how care is to be delivered, which promotes the health and welfare of both service user and care staff. For the individual accessing rehabilitation services, goals of achievement had been set to maximise independence, the attainment of goals is indicated at which point further goals are set or the individual returns to their own home following a review process involving the service user, care staff and Social Worker. Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 12 One service user, whose records were viewed, spoke positively of the care she received and praised the staff and the care they provided. The service user went onto comment “Deciding to live here is one of the best decisions I have made, I am so happy here”. “It was nice to be able to make the decision myself”. Discussions were held with two service users whose records were not viewed, but had indicated they wished to speak with the Inspector, both ladies said they were happy with the level of care they received, and found staff to be caring and supportive. Opportunity was taken to speak with a service user and her relative who was visiting at the time of the Inspection, both service user and relative commented positively as to the care received, and had no concerns. Records viewed indicated regular access to health care professionals, including General Practitioners, District Nurses, Chiropodists and specialist medical staff including hospital appointments. Members of staff interviewed confirmed that the development and reviewing of care plans is conducted with service user involvement. One member of staff advised that as part of her level 3 National Vocational Qualification award in Care, had undertaken a project, which involved the development of a care plan. The medication and medication records of some service users were viewed; all were found to be in good order. The supplying Pharmacist had recently visited to view medication processes and had found no areas of concern. Throughout the inspection process staff were observed speaking with service users in a sensitive manner, with consideration being given to the promotion of their privacy and dignity, staff ensured that the nursing care of a service user which was delivered by a visiting District Nurse was conducted in private. Managerial staff were also observed delivering post to service users. Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 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 experience a homely life style and visitors are encouraged to visit. Various activities are available to service users, service users wishing to participate in external activities do not do so at the frequency they wish. EVIDENCE: Catherine Dalley employs a Activity Organiser who supports service users both in groups and individually to participate in activities, a formal programme of activities is not in place, however the Assistant Manager said this would be developed for the future. Service users were observed engaging in a game of dominoes; service users who were spoken with also said they enjoyed playing snakes and ladders, and having a sing-a-long. One lady advised that she has a regular delivery of papers and magazines. Records confirmed service users participation in activities. Two service users spoken with said they had recently been to the theatre, however they would like outings to be held with greater frequency, especially upon the arrival of the warmer weather in the summer. Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 14 Future planned events include an Easter Bonnet Parade; service users supported by the Activity Organiser are to make Easter Bonnets, which will be judged in a competition, service users stated they were looking forward to this event. One service user said that she attends the local Baptist Church with a fellow service user on a Sunday evening. A Holy Communion Service is held in the home monthly; in addition to this a session of hymn singing takes place on a monthly basis, which is organised by the Registered Manager. The Inspector sat with a group of service users, and sampled the mid-day meal. The quality of the food was good, and was home made using fresh ingredients. Choices for both the main course and dessert were available. All service users spoken with confirmed that all meals were of a good quality and were enjoyed. The menu for the day is displayed. A member of staff was observed in the afternoon asking service users individually their choice for the teatime meal. Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Processes are in place for service users to affect their daily lives, and promote their welfare. EVIDENCE: Service users when asked were confident that should they have any concerns, they were clear as to whom they should speak with, in addition there is a written complaints procedure, and information as to how to contact advocacy services. Staff who were interviewed were aware of policies and procedures which detail staffs role in protecting service users from abuse, including the policies, which support staff in raising issues of concern. Staff appeared to have positive relationships with service users, and all said that service users spoke with them about any issues they were concerned about, which includes personal concerns, which can be solved by care staff such as sufficient provision of toiletries, and the laundering of their clothes. The Complaints Record was viewed, which evidenced that the home has not received any complaints since the last inspection; the Commission for Social Care Inspection has not received an expressions of concern with regards to Catherine Dalley. Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 16 Opportunities are provided for service users to express their views and opinions, which affect their lives, service users in some instances were able to detail how they achieved this. One service user said that she’d received visits from her Solicitor; whilst records of one service user evidenced that they were registered on the electoral role. Service user meetings are held, however these are infrequent, the next planned meeting was for the following week. Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comfortable and clean standard of accommodation is provided for service users. EVIDENCE: Improvements to the entrance of Catherine Dalley promotes the welfare and safety of service users, anyone wishing to leave or enter the building needs to request for the doors to be opened. The entrance has the benefit of both ramp and stairs, with doors being accessible to those who require the use of a wheelchair or walking aid. Plans are in place for the stairs and ramp leading to the front door to have lighting installed. Service users spoke positively of their environment. Communal areas were decorated to a high standard, one service user commented on the new armchairs. Communal areas including lounges, dining areas and corridors were clean and tidy. Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 18 Equipment is available to assist service users and staff in the delivery of personal care, which includes assisted baths, moving and handling equipment including hoists. The Assistant Manager and care staff confirmed that they had not received any formal training in Infection Control. Staff and service users would benefit from accessing a course in infection control, this is particularly relevant following a recent outbreak of sickness and diarrhoea, staff spoken with also highlighted this as a training need. Laundry facilities are provided, which includes a sluicing facility. Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Trained and qualified staff are employed following robust recruitment checks and are employed in sufficient numbers to meet the care needs of service users. EVIDENCE: Service users are supported by four members of care staff throughout the day, with an additional one or two members of staff supporting individuals within the rehabilitation unit, in addition there is always a member of the management team on duty. Two members of care staff support Service users during the night, with a member of the management team being on call. Staff interviewed felt that staffing numbers were sufficient, and that they were able to deliver good quality and effective care. This was supported by positive comments received by service users on both the delivery of care and the friendliness of care staff. 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, one supervision taking place during the Inspectors visit. Catherine Dalley employs twenty members of permanent care staff, of which seventeen have completed a National Vocational Qualification in Care at level 2 and/or 3, which represents 85 of the staff team. Three members of care staff are currently working towards level 3, which they are funding themselves. Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 20 In addition members of the management team also have National Vocational Qualifications in Care, and are also qualified Assessors for NVQ. Training records were viewed which highlighted a variety of topics, pertaining to the health and safety of service users and staff. Staff have also received training which directly affects the quality of care service users receive, which includes training in Dementia Care and Alzheimer’s Disease. There is a proportion of service users residing at the home who have a Sensory Impairment, it is recommended training in this area be provided. Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager offers a clear sense of leadership, however formal mechanisms for service users and their representatives to comment and shape improvements within the home is limited. EVIDENCE: The Registered Manager is a qualified Social Worker and has attained a Certificate in Counselling and Psychotherapy, and is currently working towards a level 4 National Vocational Qualification and Registered Managers Award. A representative of the management team of the Local Authority, who is external to Catherine Dalley, visits the home on a monthly basis, representing the Responsible Individual. Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 22 A report is generated following each visit, the purpose of the visit being to review documents, speak with service users, staff and the management team, to view the environment and deal with any specific issues. A copy of the report is forwarded to the Inspector, reports since last inspection have evidenced funding for future training, decoration to parts of the home, review of budgeting and development of care plans. Quality assurance needs further development, to formalise the process of gaining service user, relative and friend views. Through this the home will be able to review its practices, to ensure its ability to continue to improve both the care and quality of life for its service users. Although service user meetings take place they are infrequent, and are not attended by all service users. Quality assurance processes will be followed up at the next inspection, when it is expected that significant improvements will have been made to enable service users and their representatives to comment as the services offered by Catherine Dalley. A quality assurance questionnaire has been developed which is given to all service users accessing the homes rehabilitation services, providing individuals with a means of commenting on the care they received, and thus providing a system for the home to continually improve its practice. A significant number of ‘thank you’ cards were on site, evidencing service user and relative satisfaction in the care Catherine Dalley provides. The Inspector viewed the financial records of two service users, service users money is managed either by the finance department of County Hall, Leicestershire County Council, or by the service user themselves and/or their family. Health and safety records were viewed, evidence of regular checks was seen, any concerns are brought to the attention of the appropriate department, and a date when the works are completed is entered into the record. Fire records were completed, which evidenced regular fire drills and tests. A fire risk assessment was also in place, which is reviewed. The accident and incident book was viewed; service user records supported the entries within the accident book. Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 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 3 18 3 3 3 X 3 X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 24 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. 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. 1 Refer to Standard OP1 Good Practice Recommendations It is recommended that the information about services offered is revised and improved, with consideration being given to content, format and distribution, in order that there are effective and accurate processes for the dissemination of information to prospective service users their families and friends. It is recommended that all relevant staff receive training in Infection Control. It is recommended that care staff receive training in Sensory Impairment, which encompasses the role of staff in offering appropriate support to service users. It is strongly recommended that the registered person establish an effective and systematic process, which enables service users and their representatives to comment on all aspects of the home, the results of which are to be published within the homes Statement of Purpose, and used to continually improve services. 2 3 4 OP26 OP30 OP33 Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Catherine Dalley House DS0000032860.V288301.R01.S.doc Version 5.1 Page 26 - 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!