Inspection on 14/06/07 for Cerne Abbas Care Home

This inspection was carried out on 14th June 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.

Other inspections for this house

Cerne Abbas Care Home 26/06/08

Cerne Abbas Care Home 26/03/08

Cerne Abbas Care Home 11/05/06

Cerne Abbas Care Home 24/01/06

Cerne Abbas Care Home 24/01/06

Cerne Abbas Care Home 25/08/05

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

CARE HOMES FOR OLDER PEOPLE Cerne Abbas Care Home Cerne Abbas Dorchester Dorset DT2 7AL Lead Inspector Gloria Ashwell Key Unannounced Inspection 14th June 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000065834.V345875.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. DS0000065834.V345875.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cerne Abbas Care Home Address Cerne Abbas Dorchester Dorset DT2 7AL 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) 01300 341008 01300 341111 cerne.abbas@ashbourne.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Vacant Care Home 66 Category(ies) of Dementia - over 65 years of age (40), Mental registration, with number disorder, excluding learning disability or of places dementia (26) DS0000065834.V345875.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. To provide care for five persons (as known to the Commission for Social Care Inspection) with mental disorder over 65 years of age, within the total of 40 places in the category DE(E). Service users over the age of 65 years may only be accommodated within the total of 40 places in the category DE(E). The agreed staffing notice must be adhered to at all times. Date of last inspection 11th May 2006 Brief Description of the Service: Cerne Abbas Care Home is situated on the outskirts of the village of Cerne Abbas in West Dorset. It is within reasonable walking distance of the village centre with amenities including a post office, church, public houses and tearooms. There is a GP practice in the village. Car parking for visitors is provided at the rear of the home. A public transport bus service serves the village of Cerne Abbas, neighbouring villages and the nearest towns (Dorchester and Sherborne). The home is registered to provide specialist nursing care for 53 older people with dementia and 18 younger adults who have acquired brain injury including Huntingtons Disease. This report relates to all the 3 units, knows as ‘Houses’. The part of the home delivering care to the younger adults is Cloisters House, situated on the first floor. A passenger lift provides access to the House. An electronic number keypad is used on the door leading to Cloisters House which provides residents private accommodation and for communal use a lounge, a smoking room and dining room. The parts of the home delivering care to the older persons are on the ground floor; Orchard House and Atrium House, each with lounge and dining areas. The home provides nursing and care staff on a 24-hour basis and also employs full complements of catering, domestic and maintenance staff. In addition to the nursing, personal care and accommodation provided, the scale of charges for the home includes the provision of social activities, catering for all meals and laundry and housekeeping services. Fees are charged weekly; the fee range quoted in the service user guide at the DS0000065834.V345875.R01.S.doc Version 5.2 Page 5 time of inspection was £500 to £750 on Atrium House or Orchard House, and between £800 and £1550 for residents accommodated on Cloisters House. Up to date fee information may be obtained from the service. Information regarding the subjects Value for Money and Fair Terms in Contracts can be obtained from the web link: www.oft.gov.uk A report entitled Care Homes in the UK - A Market Study is available on web link http:/www.oft.gov.uk/NR/rdonlyres/5362CA9D-764D-4636-A4B1-A65A7AFD347B/0/oft780.pdf DS0000065834.V345875.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place at the home over three visits, comprising a total of 11.5 hours. Additionally, time was spent in preparation for the visit, looking at previous inspection reports and other relevant documents and preparing a plan for the inspection visit. Accompanied by a Dorset County Council ‘contracts monitoring officer’ the inspector arrived at 10.00 on 14 June 2007 and spoke to the manager, deputy manager, residents and staff, toured the premises and examined a sample of clinical and administrative records. By arrangement with the manager, the inspector returned to the home at 11.30 on 19 June 2007 and assisted by the acting manager discussed and examined documentation relating to the care provision and administration of the home. On 19 June 2007 the inspector was accompanied by an expert-byexperience, who visited Cloisters House to assess the quality of service provided to the residents accommodated at the time. At 14.00 on 20 June 2007 the inspector returned to the home to provide feedback on the inspection to the manager, and to obtain some outstanding information. During the inspection compliance with key standards applicable to the care of older people accommodated on the ground floor of the home, and of the adults accommodated on the first floor was assessed. The outcome of both aspects of registration is reflected in this single report. The inspection process included observed staff interaction with residents, the carrying out of routine tasks and speaking to residents and some visiting relatives/friends of residents. The care records of eight people who live at the home were examined in detail. The inspector was able to meet and speak with most of the residents both individually and in small groups in the communal areas. Additional information used to inform the inspection process included the reports periodically sent to the Commission by the provider, the Annual Quality Assurance Assessment completed for the Commission by the manager and five ‘Have Your Say’ CSCI questionnaires completed by the relatives of residents accommodated at the service. Since the previous key inspection a random inspection took place during November 2006 to monitor the maintenance of the good standards found at the previous key inspection of May 2006. DS0000065834.V345875.R01.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? DS0000065834.V345875.R01.S.doc Version 5.2 Page 8 There is an ongoing programme of improvements and modernisation. Throughout the home the nurse call system has been modernised and 12 profiling (adjustable) beds have been provided. The Nutmeg system of food assessment/provision has been implemented to ensure that each resident receives meals suited to their individual needs. In Orchard House some carpets have been replaced, a new fence has been erected to enclose the orchard style garden and a ‘wet room’ has been installed in a bathroom. Atrium House has also been provided with a ‘wet room’ and funding has been obtained for provision of a sensory room and improvements to the garden area. In Cloisters House some floor coverings have been replaced, including provision of a hard floor in the lounge/activities room. 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. DS0000065834.V345875.R01.S.doc Version 5.2 Page 9 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 DS0000065834.V345875.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not provide Intermediate Care so Standard 6 does not apply. The Statement of Purpose does not give clear relevant information about the home so is unlikely to provide prospective residents and their representatives with an accurate understanding of the people for whom the service is intended. The service user guide is available in audio format as alternative to a standard typed document. Prior to admission, the needs of each proposed resident are assessed to ensure the home will be properly able to meet them. DS0000065834.V345875.R01.S.doc Version 5.2 Page 11 EVIDENCE: The service user guide is made available to all residents and prospective residents; a copy is placed in each bedroom. The document contains general information about the home but does not include full details of the arrangements made for provision of medical care; residents medical needs are met by the local GP practice but there is also involvement of a privately engaged Consultant Psychiatrist – this must be clearly described in the service user guide. The Statement of Purpose and service user guide are available in audio and standard printed format; there are intentions to provide this information in additional alternative formats including a picture-based system. The Statement of Purpose does not fully describe the service and the people for whom it is intended; in particular, it omits reference to the current ‘conditions of registration’ stated in the introductory pages of this report prospective service users may thereby not have sufficient information upon which to base their decision to enter the home. The records of a recently admitted resident included details of pre-admission assessment carried out by the manager who visited the person in hospital. The assessment records identified the needs of the prospective resident and enabled the staff to determine that the home would be able to properly meet them. The inspector spoke to the resident and to another recently admitted resident and her visiting relatives who all confirmed satisfaction with the home. DS0000065834.V345875.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of nursing care is good and care documentation ensures that staff have sufficient information upon which to base their care practice and to ensure that residents are all treated with respect and their rights are upheld. Medicines prescribed by doctors are safely stored and correctly administered. EVIDENCE: Care records of 6 residents were examined (2 from Orchard House, 2 from Atrium House and 2 from Cloisters House) and found to contain risk assessments forming the basis for care plans and daily records describing the care of each person. There was evidence that individual residents or their DS0000065834.V345875.R01.S.doc Version 5.2 Page 13 representatives had been involved in the development and review of planned care provision. Medicine handling is carried out by registered nurses and medication administration records were properly kept indicating that residents receive prescribed medicines at the correct times and in correct amounts. Residents wishing to do so can manage their own medicines; at present none have chosen to do so. Residents are treated with respect and their privacy and dignity is protected at all times. Residents believe they are properly cared for; comments received from a relative visiting a resident during the inspection included “It’s very good….they seem to love X….they really care”. ‘Have Your Say’ questionnaires stated that “the care staff keep me informed of any issues regarding X….they are very dedicated people…” and “they are a good team”. DS0000065834.V345875.R01.S.doc Version 5.2 Page 14 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 adequate. This judgement has been made using available evidence including a visit to this service. In general, social and leisure activities are suited to the preference and ability of residents; the service has acknowledged the shortcomings in provision to Cloisters House and is in the process of making the necessary improvements. Residents are encouraged to maintain contact with the local community and visits by their friends and relatives are welcomed by the home. Meals provide good nutrition and are liked by residents. Most residents take meals in the dining room of each House; others receive them in their bedrooms. DS0000065834.V345875.R01.S.doc Version 5.2 Page 15 EVIDENCE: Orchard House and Atrium House: The inspector spoke to a number of residents; all those able to express an opinion indicated satisfaction with the home, including the range of activities, meal provision, staff and premises. The home employs a full time Activities Organiser who works mainly in these two Houses and arranges local excursions, one-to-one and small group social and recreational activities. Additionally, during one morning every week a visiting therapist leads an activities session on Orchard and Atrium House. Parts of the sessions were observed during the first day of this inspection; residents were enthusiastically participating in ‘movement to music’ and clearly enjoying the experience. Cloisters House: The ‘expert by experience’ compiled a report stating “My overall impression of the unit was that it was very pleasant and that there was a caring atmosphere with peoples’ individuals needs attended to at a relaxed pace. Users seemed happy and those I spoke to expressed their satisfaction. I do think that more activity could happen on the unit and more effort made to involve carers and locals to get more involved in the unit to get a better sense of wider community as it is in such an isolated setting. There seems to be genuinely pleasant engagement by staff with users. There was a relaxed atmosphere and staff moved at users pace, showing respect and genuine concern for example when helping people eat. I observed lunchtime in the dining room, although some people could eat in their own rooms. Users were helped to eat where necessary and pureed food was available for those in need. There appeared to be a choice of two meals and one pudding with the addition of smoothies, which were enjoyed by those partaking.” The manager explained that an Art Therapist was later that week to commence work in the House for one day each week, and arrangements are in hand for employment of a physiotherapist. Discussion took place with the manager regarding the potential drawbacks of accommodating adults in a home without nearby shops selling clothes, CDs and other probable requirements, with particular regard to those unable to travel to towns offering these resources. It is recommended that consideration be afforded to methods of overcoming this circumstance, to promote opportunities to lead purposeful and fulfilling lives as independently as possible. DS0000065834.V345875.R01.S.doc Version 5.2 Page 16 General: The home has a minibus adapted for use by disabled people, with wheelchair facilities including a ‘tail lift’. Four staff are designated drivers of the minibus having each completed associated training with Dorset County Council; they work in association with a specific policy giving guidance on accompanying residents on excursions. Visitors are welcome at any time and those the inspector spoke to said they are always made to feel welcome and placed at ease by the staff. The home has sought to provide a ‘restaurant environment’ to each House by careful design and decoration of the dining rooms. Since the previous inspection the home has introduced the ‘Nutmeg system’ which provides assessment of the nutritional value of each meal, ensuring that every resident receives adequate nutrition and ‘healthy eating’; is actively promoted. Residents select meals in advance from menus, each House has a regular supply of ‘smoothies’ (nutritious and refreshing cold milk and fruit based drinks) and ‘snack boxes’ containing crisps and other individually wrapped items and the evening meal provides to each House a selection of ‘finger foods’ for supper. Fresh fruit is available as a healthy option for desserts. DS0000065834.V345875.R01.S.doc Version 5.2 Page 17 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. This judgement has been made using available evidence including a visit to this service. The complaints procedure provides information on the procedure to follow to persons wishing to make a complaint; all complaints are recorded and investigated and the home has implemented and adhered to its policies and procedures for safeguarding adults. EVIDENCE: 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 displayed on the inside of a wardrobe door in each bedroom. The home keeps records of all complaints received and investigated. Since the last inspection two minor complaints have been received by the home; one related to the cancellation of a planned Relatives Meeting, the other to the incorrect recording of a relative’s contact details. ‘Have Your Say’ questionnaires stated that “any concerns my family and I have had…have been dealt with in a professional efficient manner”. The home adheres to a policy/procedure for the prevention of abuse and all staff have received training in this subject to ensure that they remain vigilant DS0000065834.V345875.R01.S.doc Version 5.2 Page 18 to protect vulnerable residents from risks of abuse and know how to properly manage any allegation or suspicion of abuse. Since the previous key inspection there have been 9 investigations involving aspects of adult protection. Of these, 6 have been unsubstantiated following investigation by Dorset County Council’s Social Services, (the lead statutory agency) one was partly substantiated and 2 investigations remain ongoing. Any requirements or recommendations arising from the conclusion of these investigations will be issued in a separate letter to the home. On occasion, residents of the local village visit the home for religious services and other events; to ensure the safety of all service users it is recommended that the home develop and implement a related policy and procedure, describing arrangements for supervising and escorting visitors to the home who are not the relative/friend/representative of an accommodated resident. DS0000065834.V345875.R01.S.doc Version 5.2 Page 19 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 judgement has been made using available evidence including a visit to this service. This is a well-appointed and comfortable home with a continuous programme of improvements. On the dates of inspection the home was clean, pleasant and hygienic and there was evidence indicating that this is the usual standard of provision. EVIDENCE: The provider organisation has extensively and thoroughly improved the premises and maintains an ongoing programme of refurbishment and redecoration. DS0000065834.V345875.R01.S.doc Version 5.2 Page 20 In Orchard House some carpets have been replaced, a new fence has been erected to enclose the orchard style garden and a ‘wet room’ has been installed in a bathroom. Atrium House has also been provided with a ‘wet room’ and funding has been obtained for provision of a sensory room and improvements to the garden area. In Cloisters House some floor coverings have been replaced, including provision of a hard floor in the lounge/activities room. The ‘expert by experience’ noted “each room had a named picture of the nurse, and/or key worker that user had assigned to them with an explanation of their role” and suggested the installation of additional handrails to assist residents to maintain independent walking. It was noted that to access the Cloisters House garden area there are two small steps up which could present a tripping hazard and would prevent wheelchair users from freely entering the garden. It is recommended that a review of all parts of the home be conducted, to identify areas for improved accessibility. Based on assessment of users ability to use and keep the key each resident can have their own key to their bedroom if they wish to keep it secure. A number of first floor rooms have been unused during recent months; these have now been fully redecorated and refurbished, and include creation of a ‘snoezelum room’ providing sensory stimulus by use of specifically installed sound and lighting. Innovative use of decoration promotes and maintains the orientation and mental awareness of the elderly residents on the ground floor. For example, ‘staff use only’ doors have been painted the same colour as the walls to minimise residents confusion/frustration at finding these doors locked, ‘tactile boards’ have been affixed to walls and doors to indicate the purpose of the room within (e.g. cutlery and a plate laid as a place setting on a mat indicate that the door leads to a dining room). Throughout the home each bedroom door is painted a different colour and fitted with door furniture including a knocker to promote a ‘front door’ aspect and associated feelings of ownership and privacy. The inspector toured the premises and found the home to be clean, tidy and comfortable throughout; on Cloisters House the air in the immediate vicinity of the ‘smoking room’ bore smells of smoke – it is recommended that improvements be made to the ventilation of this window-less room to ensure that smoke does not flow into other parts of the home. DS0000065834.V345875.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. The home employs enough staff to meet the needs of residents and to ensure their safety and comfort and maintenance of the good condition of the premises. Recruitment practices ensure the protection of residents from potentially unsuitable staff. Staff receive appropriate training and are competent to carry out their jobs. EVIDENCE: The home is at all times in the charge of a trained nurse and 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. All staff spoken with during the inspection were enthusiastic about their work and felt that they provided a good standard of care to residents and are properly supported by the management and training provision. DS0000065834.V345875.R01.S.doc Version 5.2 Page 22 The records of two recently employed staff members were examined and found to contain all essential information including written references, interview assessment, health details and evidence of identity. Criminal Records Bureau (CRB) disclosures are obtained for all staff in advance of employment. The home has developed and implemented a comprehensive induction process for all new staff, designed to ensure their familiarity with all aspects of the home and a clear understanding of their responsibilities. There is an enthusiastic approach to staff training; the deputy manager is also the training coordinator. Clear records of staff training, supervision and appraisal are kept, indicating that all staff receive training appropriate to their needs. Care staff are required to undertake (and as necessary update) training in core subjects including fire safety, moving and handling, food hygiene, adult protection and emergency aid. At present at least 50 of the care staff hold National Vocational Qualification in care, or an equivalent qualification; the home thereby meets the associated standard. DS0000065834.V345875.R01.S.doc Version 5.2 Page 23 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 good. This judgement has been made using available evidence including a visit to this service. The home is properly managed and maintained in the best interests of service users. EVIDENCE: Since the last key inspection the previous manager has left the homes’ employ; the application of the current post holder to become the registered manager is currently being processed by the Commission. The manager receives support and supervision from the Head of Operations and is supported by a deputy manager. DS0000065834.V345875.R01.S.doc Version 5.2 Page 24 The manager intends to improve systems for quality assurance to provide a systematic cycle of planning-action-review, reflecting aims and outcomes for residents. Occasional residents and relatives meetings take place, but these do not attract large attendance. The manager intends to introduce a periodic newsletter and alternative methods of encouraging participation and communication with residents relatives/friends are under consideration. The manager operates a ‘surgery’; on a regular half day each week he is openly available to residents, relatives and staff – at other times he operates an ‘open door’ policy but may of course be engaged on other matters. There are good processes for staff induction and training and for the formal supervision of staff. The home manages small amounts of money for the personal expenditure of some residents; clear records are kept of all transactions and the money is securely stored. Records are kept of all accidents and a periodic audit is carried out to identify any trends and to then determine means of minimising risks. It is recommended that fuller records are kept of all accident/incident investigation and outcomes, to ensure that due consideration is afforded to all aspects including environmental or other potentially contributing factors. The use of bedrails by some residents is in compliance with relevant Health & Safety guidance; persons involved in assessing, installing, maintaining and checking bed rails receive training in this work. Staff trained in emergency response are on duty in the home at all times; all staff receive periodic training in fire safety. All staff are supervised and each has a personal profile containing records of appraisal ensuring that performance standards are monitored and training needs are identified, in the interests of providing good care to residents. During the inspection a sample of records regarding equipment servicing and maintenance, including those regarding fire safety equipment were examined and confirmed that regular safety checks take place. DS0000065834.V345875.R01.S.doc Version 5.2 Page 25 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 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 2 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 2 X 3 X X 3 DS0000065834.V345875.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 4 (1) also 6 Requirement The Statement of Purpose and service user guide must be improved to provide prospective service users with sufficient information to enable them to make an informed choice regarding admission to the home. Timescale for action 01/10/07 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. 3. Refer to Standard OP1 OP12 OP18 Good Practice Recommendations The statement of purpose and service user guide should be made available in alternative formats. The home should do more to promote opportunities for residents of Cloisters House to lead purposeful and fulfilling lives as independently as possible. The home should develop and implement a policy and procedure, describing arrangements for supervising and escorting visitors to the home who are not the relative/friend/representative of an accommodated resident. DS0000065834.V345875.R01.S.doc Version 5.2 Page 27 4. 5. 6. OP22 OP26 OP38 A review of all parts of the home should be conducted, to identify areas for improved accessibility. Improvements should be made to the ventilation of the Cloisters House smoking room to ensure that smoke does not flow into other parts of the home. Comprehensive records should be kept of all accident/incident investigation and outcomes. DS0000065834.V345875.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000065834.V345875.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. 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