Inspection on 14/06/06 for Chestnuts

This inspection was carried out on 14th June 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Chestnuts 02/04/08

Chestnuts 03/05/07

Chestnuts 09/03/06

Chestnuts 16/09/05

Chestnuts 06/01/05

Chestnuts 03/08/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Chestnuts 93b Wyke Road Weymouth Dorset DT4 9QS Lead Inspector Hilary Cobban Key Unannounced Inspection 14th June 2006 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 DS0000026781.V297321.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. DS0000026781.V297321.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chestnuts Address 93b Wyke Road Weymouth Dorset DT4 9QS 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) 01305 784996 01305 780918 Mr Brian Stewart-Hart Ms Anna Bodzon Ms Anna Bodzon Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places DS0000026781.V297321.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 2006 Brief Description of the Service: Chestnuts is a detached property situated in a quiet residential area approximately one mile from Weymouth town centre. The home provides care and accommodation to a maximum of 13 older people with low to moderate care needs. The registered providers are Mr Brian Stewart-Hart and Ms Anna Bodzon; the registered manager is Ms Anna Bodzon. Service users accommodation is on the ground and first floors. A stair lift is fitted to one flight of stairs. All bedrooms are for single occupancy only. The home is not suited to the needs of severely disabled people including wheelchair users. There are parking spaces to the front of the house and an attractive garden to the rear of the property. The current fees in the home are £420 per week. DS0000026781.V297321.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over a period of six hours during which all key standards were inspected and various other standards examined. Outstanding requirements and recommendations made at previous inspections were also addressed. The inspector was welcomed to the home by Mr Stewart-Hart and Ms Bodzon who both spent most of the day with the inspector. The inspector took the opportunity of talking with nine Residents, most in the privacy of their rooms, four members of staff and a relative - all of whom were very communicative and full of praise for Chestnuts. Comments were made such as; “Lovely living here” “Quite nice living here” “Happy place” “All staff very pleasant” “Staff kindly, well trained” The Residents at Chestnuts find that the Registered Providers and staff work together to offer many advantages of a small home, with the familiarity and security which is so important to them. The Residents are comfortable with the fact that all individual tastes are catered for. Many little extras are provided as a matter of course, including drinks and sweets. During a tour of the premises the inspector observed the care of other service users and the decorative state of the home and garden. She also examined a variety of records including three care records and medication records and observed health and safety practice. Comment cards had been returned to the Commission for Social Care Inspection and were able to offer further information. There were no vacancies in the home on the day of the inspection. The inspector would like to thank the home for their cooperation on a busy day. DS0000026781.V297321.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The home has met three of the previous requirements but there are still four outstanding from the previous two inspections and the Registered Providers must be aware that these must be addressed within the timescale to prevent enforcement action being taken. There are also six recommendations, which should be pursued to promote good practice within the home. The Registered Manager must ensure that the general risk assessment in the care plan identifies any particular area of concern and that further specific risk DS0000026781.V297321.R01.S.doc Version 5.2 Page 7 assessments ensure that appropriate action is taken. An example of this is the propensity of a Resident to falls, which can be identified from the care plan and also the audit of the accident book. The Registered Providers have not yet carried out risk assessments on the hot water outlets and a further risk of a worn carpet was identified at the inspection. Action must be taken on these matters to ensure the safety of staff and Residents. Water must be tested to ensure that there is no risk to the Residents of Legionella and also that the Water Supply is acceptable. Fire training for all night staff must be carried out at three monthly intervals and records kept of this. An assessment of the premises must be undertaken by an occupational therapist or professional of similar standing. Work to the laundry should be completed and the second bathroom re-commissioned. The storage of the controlled drugs is insecure and action must be taken to rectify this to prevent abuse of the same. The medication sheets should be reviewed and action taken to ensure that any amendments are correctly signed. Further effort should be made to introduce a sound quality assurance scheme which will enable the home to produce an annual development plan. 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. DS0000026781.V297321.R01.S.doc Version 5.2 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 DS0000026781.V297321.R01.S.doc Version 5.2 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, 4, 5 & 6 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has documents in place to ensure that prospective and current Residents understand what facilities the home is able to offer. All admissions are preceded by a full assessment of care needs. The home encourages the Resident to visit the home for a trial stay after which a contract is issued which specifies the terms and conditions of residency. EVIDENCE: The Statement of Purpose has been revised and is available under a table in the front hall. The Registered Providers were able to justify its position as they wish the first impression of the home to be the flowers and fruit rather than an official document. DS0000026781.V297321.R01.S.doc Version 5.2 Page 10 The Registered Providers usually go out together to carry out the preadmission assessment. The inspector examined two of these and found there were some gaps in the documentation but they were appropriately signed and would provide enough information to ensure that the home could meet the care needs. In one case there was an assessment from the previous placement and the Registered Providers had taken trouble to look further into an area where there was cause for concern. The home sends a letter to the prospective Resident to state that Chestnuts can meet the care needs. All Residents are warmly invited to visit the home prior to staying and are offered a trial stay of one month, after which a contract is issued. All this information and more is included in a robust Admissions Procedure policy The home does not offer Intermediate Care. DS0000026781.V297321.R01.S.doc Version 5.2 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 adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The care given to the Residents is good with regular reviews but more risk assessments must be carried out to ensure that their safety is maintained at all times. The Registered Manager ensures that other professionals are involved with the care, either within the home or in the community. The medication is handled appropriately but there must be more secure storage and dispensing sheets to ensure the safety of Residents. The respect of Residents is of paramount importance in the home. EVIDENCE: The care plans of three Residents were examined and these were found to be satisfactory, covering areas including personal hygiene, elimination, mobility, eating and drinking, sleeping, social care, health and safety and communication. General risk assessments were carried out but more work DS0000026781.V297321.R01.S.doc Version 5.2 Page 12 must be done on these to identify specific risks such as falls, and action must be taken to reduce these risks. There is currently a risk assessment for manual handling. The care plans are reviewed regularly and meaningfully and in many cases the Resident is involved. They, or their representative, sign a statement if they do not wish to be involved in this process. The home states clearly that it can only cater for Residents with low to moderate care needs and recognise when a Resident needs more care than they can offer, at which point a referral is made to the appropriate care manager prior to a possible transfer. All Residents have a key worker who takes particular responsibility for their care. Daily records are maintained and were found to cross reference accurately with other records of events, such as the Accident record. Visits by professionals are also noted and this together with discussion with the Residents, provided evidence that other professionals are involved in the care, in line with the recommendations of the National Services Framework for Older People. Some appointments are made within the home and on other occasions one of the Registered Providers takes the Resident for an appointment within the town. It was clear that the Residents had a choice of General Practitioner and the Primary Care Trust is actively involved in the home. In discussion with the inspector the Residents confirmed that they are well cared for and that all the staff respect their privacy and dignity. Several have their own telephones. Doors were knocked before entry and most were called by the name of their choice, although one relative thought that her Resident should be called by her surname. One Resident stated that she was “looked after very well and treated well”. One relative was spoken to on the day of the inspection and she thought the home was “lovely”. A comment card was received from another relative who stated that she visits every other day and “everything is always very calm and friendly”. The inspector examined the medication procedures and found that subsequent to a suggestion made by the pharmacy inspector from the Commission for Social Care Inspection, the home has adopted a new procedure of dispensing so that now each carer is responsible for the medication for which they sign. The home uses a monitored dosage system but the MAR sheets which are used to support this are frequently written by hand. The Registered Manager agreed that she would discuss this with her pharmacist. The ordering, and disposal of medication is in line with the recommendations of the Royal Pharmaceutical Society. The drugs are stored in a locked cabinet but there is no suitable storage for the controlled drugs, for which a requirement has been made. Staff are suitably trained in the handling of medication and were found to be competent in the process. DS0000026781.V297321.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The Registered Manager endeavours to provide a variety of activities to meet the recreational, pastoral and social needs, as identified from the care plans. Visitors are made to feel welcome at any time and contact with the local community is encouraged. The Residents have as much choice about their lifestyle as is feasible. The meals provided are ample in quantity and nourishment and served in a pleasing manner at a leisurely pace. EVIDENCE: A new activities organiser has recently been employed who will assist the Registered Providers and staff to meet the recreational needs of the Residents. Discussions with the Residents and examination of the survey carried out by the Commission for Social Care Inspection confirmed that most of the Residents are satisfied with the variety of activities on offer and that there are DS0000026781.V297321.R01.S.doc Version 5.2 Page 14 also excursions and outings arranged. The pastoral needs are met by the local churches and one of the Residents explained “you only go to the service if you want to.” Many of the Residents have regular visitors, one comment card from a relative said that she “visited her mother every day and she has never walked into Chestnuts and been aware of any crisis or problem.” Visits can be made at any time and can be held in the privacy of the Resident’s own room or in one of the communal areas. The Residents spoken to felt that they could make their own decisions, where feasible, about the activities of daily living- such as bed times, what they wear, who they sit next to and what they do during the day. Many have personalised their bedrooms with ornaments and treasures and others have brought in their own furniture. Most have supportive relatives but there is one Resident who accesses the service of a local solicitor and the Registered Providers are acting further to access a supporting advocate. The inspector talked with the chef and watched a meal being served- it was nicely presented and nutritious, with a variety of fresh vegetables and a bowl of fresh fruit was on the sideboard. The servings were more than ample and food was cut up where necessary and assistance given in a sensitive manner. All cakes and puddings are home baked and snacks are available in between mealtimes. Residents were very complimentary about the food- with comments such as: “food very good”, “food excellent” and “beautiful foodparticularly the trifle” Residents are encouraged to join the main dining room for lunch but a couple chose to have the meal in their own room. Nutritional assessments are not carried out but Residents are weighed regularly and action taken accordingly. DS0000026781.V297321.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. There is a complaints policy in place and the Residents are confident that any complaints or concerns are dealt with by the Registered Manager. The legal rights of the Residents are protected, with access to solicitors and other advocates and inclusion in the electoral role. There are a variety of policies in place, which are clearly understood by the staff, to ensure that all the Residents are protected from abuse. EVIDENCE: The home holds a complaints file but there have not been any entries for several years. The Registered Manager should be aware of the new policies about complaints and ensure that all concerns are duly noted. The Residents and staff spoken to felt that they could freely make a complaint to either of the Registered Providers but were not aware of any other channel for complaint, even though there is a robust policy in place and it is identified in the Statement of Purpose. The service users legal rights are protected – there was mention in the care plans of appropriate solicitors. The Residents are registered on the electoral role and postal votes organised where necessary. Personal money is kept for three Residents and records kept accordingly. DS0000026781.V297321.R01.S.doc Version 5.2 Page 16 The home holds comprehensive policies in connection with Protection of Vulnerable Adults and the local procedure issued by the Department of Health (No Secrets). There is a gifts policy in place. The staff spoken to were aware of their rights under the Whistleblowing policy and stated that they had never seen anything of concern at Chestnuts. DS0000026781.V297321.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 25 and 26 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The Registered Providers have carried out some maintenance to the home since the last inspection. There are still other areas, which need attention to ensure the safety of Residents and prevent the risk of the spread of infection. Requirements have been made for the testing of water for this and also a risk assessment for the hot water outlets. It has been recommended that the walls of the laundry are easily washable and that the top bathroom is recommissioned. The home cannot provide evidence that they meet the general disability requirements for their category of registration, although meeting individual needs. A requirement has been made again that a trained Occupational Therapist is engaged for this purpose. DS0000026781.V297321.R01.S.doc Version 5.2 Page 18 EVIDENCE: Much refurbishment has been done since the last inspection, including new drains and gutters but there is still further work to do. There is a very worn stair carpet for which a risk assessment must be carried out to ensure the safety of Residents, staff and visitors. Most of the home is nicely decorated with a pleasant garden and the home complies with the requirements of the Dorset Fire and Rescue Service and Environment Health Officer. The Registered Providers carried out a full Fire Risk Assessment in 2004. The home has not yet had an assessment of the premises by an Occupational Therapist. The Registered Manager explained that the home accesses advice for individual Residents and it was clear from a tour of the premises and general observation that this is indeed so. There was a variety of disability aids in use, including eating utensils, grab rails and walking aids. However a requirement has been made so that Chestnuts meets the standard required by the Care Standards Act 2000. The home is comfortable with domestic lighting and adequate ventilation. There are still some outstanding safety issues in connection with the environment. The radiators and hot water surfaces have been covered but the water coming from the taps is still too hot and a risk assessment must be carried out on these. The inspector did discuss this issue with one Resident who stated that she would always add cold water and did not regard it as unsafe. There is an Infection Control Policy in place but the inspector felt that there were some serious infection risks. The Registered Providers were unable to provide evidence that the water has been tested to prevent risks of Legionella or that the water complies with the requirements of the Water Supply (Water Fittings)Regulations 1999. Other potential risks are that the laundry walls are not readily cleanable and there are communal toiletries in the bathroom. The upstairs bathroom is out of commission and has become a storage area. The Registered Providers explained that they have a quote to install a new shower in this room, which must be done to ensure that there are sufficient bathrooms for the use of the Residents. At this point alternative storage areas will have to be arranged. DS0000026781.V297321.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. There is a stable team of staff who are well trained and able and willing to meet the care needs of the Residents. The recruitment procedures are in place to ensure that the Residents are in safe hands at all times. EVIDENCE: The home has not employed any new staff since the last inspection but the systems are in place to ensure that any future member of staff is only employed after a robust recruitment process, including the home receiving a satisfactory police check before commencing work. The home has a very stable staff structure with a team of dedicated staff members. The staffing numbers are in accordance with previous requirements, with the Registered Providers providing support but not actually on the care rota. The home never has the need to employ agency staff. A cleaner and chef are also employed five days a week. The inspector found the home to be exceptionally clean and odour free- indeed one comment made by a relative said that “everything is always spotlessly DS0000026781.V297321.R01.S.doc Version 5.2 Page 20 clean”. The staff are highly thought of by the Residents and the inspector was particularly impressed by their attitude and the fact that they created such a happy atmosphere. The staff also feel it is a nice place to work- one stating that “if she was old she would like to live here”. All are issued with an employment contract and a General Social Care Council Code of Conduct. Six of the thirteen staff have achieved their National Vocational Qualification Level 2 in care and a further staff member is nearing completion of the course. A staff member employed six months ago has completed her induction course and will progress towards her National Vocational Qualification. Other staff have recently completed training in the safe handling of medication and basic food hygiene. The Registered Manager explained that a group of staff are shortly to commence a Dementia course. DS0000026781.V297321.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is managed by a committed manager, who is easy to approach and who promotes equal opportunities for her staff and Residents. There is some quality assurance in place but not enough detail to create a meaningful development plan, which would alert the Registered Providers to the weaknesses of the home. Residents are encouraged to control their own money and arrangements. The staff meet with the Registered Providers frequently on an informal basis but there is no formal supervision, which would ensure that employment policies and procedures are put into practice. DS0000026781.V297321.R01.S.doc Version 5.2 Page 22 The Records are kept in accordance with the Data Protection Act 1998, which ensures that they kept confidential and yet accessible for individual Residents. There are suitable health and safety policies in place but there are various areas of poor practice, which have been raised elsewhere. EVIDENCE: The Registered Providers purchased the home some years ago and Ms Bodzon is the Registered Manager. She has completed her Registered Manager’s Award and assured the inspector that this equates to the National Vocational Qualification level 4 in management and care, but she has been asked to provide written evidence of this. Mrs Bodzon completed her assessors award D32/D33 in 2001 and updated it to A1/A2 in 2005. She also keeps abreast of other current care related issues. She is well liked by the staff and the several of the Residents said that she is “easy to talk to”. Ms Bodzon and Mr Stewart-Hart spend a great deal of time in the home and have an open management style. Although they each have specific tasks, such as Mr Stewart-Hart cooks two days a week, much of their work is carried out together. They both join with the staff for lunch, which gives them the opportunity for constant feedback, but there is still the need for formal staff supervision to ensure that they all have the opportunity to discuss confidential issues. The Registered Providers both have a commitment to equal opportunities with a robust policy in place, individual to Chestnuts which refers to the use of the telephone in private and private monies amongst other things. The home has made a start in developing a quality assurance scheme- with a draft list of areas to be covered and the issue of questionnaires to Residents, which was subsequently audited. Progress needs to be made with this to ensure that areas already covered in this report are addressed without delay and to develop an annual development plan based on a systematic cycle of planning action and review. The Registered Providers should address the requirements and recommendations made in this report, particularly those repeated several times, to prevent enforcement action. Most of the Resident’s entrust their financial affairs to relatives, and the home keeps personal money for just a few Resident’s for whom accounts, with invoices attached, were found to be in order. Records are kept securely and are all in good order, except for risk assessments mentioned elsewhere in this report. The home has an accident book, which complies with the Data Protection Act 1998, and this is audited on a monthly basis. DS0000026781.V297321.R01.S.doc Version 5.2 Page 23 The inspector looked at the records of the servicing of equipment in use within the home, including the fire equipment and emergency lighting and found them all to be in order. The safety of water temperatures has been mentioned elsewhere in this report. There is a Health and Safety policy in place and an appropriate poster to alert the staff to this issue. The Registered Providers are confident that the home meets other legislative health and safety requirements. The staff have completed most of their mandatory training, but it was noted that the night staff are still not receiving their fire training at recommended intervals of three months, for which a requirement has been made again. DS0000026781.V297321.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 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 1 X 2 1 X X 1 1 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 3 1 DS0000026781.V297321.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13(4) Requirement Risk assessments must be undertaken and recorded in relation to service users with a propensity to fall. They must be kept under review and updated accordingly. This requirement has been partially addressed; it has been made at two previous inspections 16/09/05 and 09/03/06. 2. OP9 13(2) All controlled drugs must be stored securely so that it complies with the Misuse of Drugs (Safe Custody) Regulations 1973 for storing Controlled Drugs (CDs). This has been a recommendation at two previous reports and has now been made a requirement. 3. OP19 13 (4) A risk assessment must be carried out on the stair carpet and appropriate action taken. 30/09/06 30/09/06 Timescale for action 30/09/06 DS0000026781.V297321.R01.S.doc Version 5.2 Page 26 4. OP22 23(2) An assessment of the premises must be undertaken by an occupational therapist or professional of similar standing. This requirement has been made at two previous inspections 16/09/05 and 09/03/06. 30/09/06 5. OP25 13(4) Risk assessments must be undertaken in relation to hot water outlets to wash-hand basins which fully take into consideration the individual circumstances of service users accommodated at the home. This requirement has been made at two previous inspections 16/09/05 and 09/03/06. 30/09/06 6. OP25 13(3) Water must be stored and distributed at correct temperatures to prevent risks from Legionella. Water Supplies must comply with the Water Fittings Regulations 1999. Night staff must receive fire instruction at quarterly intervals. This was a requirement at the inspection of 09/03/06. 30/09/06 7. OP26 13 (3) 30/09/06 8. OP38 23(4) 30/09/06 DS0000026781.V297321.R01.S.doc Version 5.2 Page 27 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 OP9 Good Practice Recommendations The home should follow guidance from the Pharmaceutical Society on the administration and Control of Medicines which states that when medicines are handwritten on the MAR chart a second competent person should check the details are accurate and countersign or preferably printed by the pharmacist. The second bathroom should be not be used as a storage area and be commissioned back into use. The work to the laundry room should be completed so that the walls are readily cleanable and impervious to liquids. There should not be any communal toiletries in the bathroom. The Registered Manager should provide evidence that her Registered Manager’s award is the equivalent of the National Vocational Qualification level 4 in Management and Care. Progress has been made towards achieving quality assurance but the home should be able to provide evidence that this will lead towards an annual development plan for the home, based on a systematic cycle of planning-action-review and that there is continuous self-monitoring with an annual audit. This recommendation is made for the sixth time. 2. 3. 4. 5. OP21 OP26 OP25 OP31 6. OP33 DS0000026781.V297321.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: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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