Inspection on 12/07/07 for Cleggsworth Care Home Ltd

This inspection was carried out on 12th July 2007.

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

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

Other inspections for this house

Cleggsworth Care Home Ltd 15/06/09

Cleggsworth Care Home Ltd 15/07/08

Cleggsworth Care Home Ltd 28/11/06

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

CARE HOMES FOR OLDER PEOPLE Cleggsworth Care Home Ltd 7/11 Little Clegg Road Smithybridge Littleborough Lancashire OL15 0EA Lead Inspector Bernard Tracey Unannounced Inspection 12th July 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cleggsworth Care Home Ltd DS0000068123.V343928.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. Cleggsworth Care Home Ltd DS0000068123.V343928.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cleggsworth Care Home Ltd Address 7/11 Little Clegg Road Smithybridge Littleborough Lancashire OL15 0EA 01706 379788 01706 378330 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) Cleggsworth Care Home Ltd Mrs Audrey Bolton Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Cleggsworth Care Home Ltd DS0000068123.V343928.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 38 service users to include: *up to 38 service users in the category of OP (old age not falling within any other category). 28th November 2006 Date of last inspection Brief Description of the Service: Cleggsworth House is registered to provide personal care and accommodation for 38 older people. It caters for both long term and respite stays. The home is located in Smithybridge village, which has a variety of shops and other amenities close by. It is near to public bus routes and the train station is in close proximity. The home consists of a two-storey building with purpose built extensions having more recently been added. With the exception of one double room, all rooms were single. En-suite facilities are provided in eight of the bedrooms. There is ramped access to the front entrance and a passenger lift is provided. Garden areas are provided to the rear of the building. The home’s Service User Guide advised residents and their relatives that the most recent Commission for Social Care Inspection (CSCI) report was available in the entrance area. At the time of this inspection weekly fees ranged from £334.98p to £450 per week. Additional charges are made for hairdressing, podiatry and newspapers. Cleggsworth Care Home Ltd DS0000068123.V343928.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The manager of the home was not made aware that this inspection was to take place. Several weeks before the inspection questionnaires were sent out to doctors, social workers and community nurses, as well as to the residents of the home and their relatives. The questionnaires asked what people thought of the care and services provided by the home. Six residents and two relatives responded and their views have been included throughout the report. The questionnaires sent to visiting professionals asked questions relating to communication, availability of senior staff when visiting, staff having a clear understanding of service users’ needs, management taking appropriate decisions, management of medication, complaints from residents they may be aware of and if they are satisfied with the overall care provided by the home. We also asked the manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what the management of the home feel they do well, and what they need to do better. This helps us to determine if the management of the home see the service they provide the same way that we see the service. Overall, we felt this form was completed satisfactorily. In the last 12 months, a random inspection on 28th February 2007 was undertaken. The reason for the random inspection was to follow up on six separate complaints, reported over a period of seven days, direct to the Commission for Social Care Inspection. These complaints alleged low staffing levels, poor care practices, accidents not being reported and recorded, a trip out that was not properly planned, resulting in an injury to a resident, and the manager not responding to poor care practices reported to her. Some elements of these complaints we found to be upheld. Prior to the site visit the inspector spent time checking the information that had been provided by the manager, such as notifications. This information is required under Regulation 37 of the Care Homes Regulations and tells us about significant incidents/events in the home since the last inspection The inspector spent 5.5 hours at the home. During this time he looked at care records to ensure that health and care needs were met and also studied how information was given to people before they decided to move into the home. Cleggsworth Care Home Ltd DS0000068123.V343928.R01.S.doc Version 5.2 Page 6 A full tour of the building was undertaken and time was spent looking at records regarding safety in the home. We also examined files that contained information about how the staff were recruited for their jobs, as well having a discussion about staff training. The inspector spent time speaking to six residents, as well as speaking to two relatives, five staff, and the area manager. The manager of the home was on holiday. What the service does well: What has improved since the last inspection? The home has met the majority of the requirements and recommendations made following the last inspection. The manager has provided us with copies of the staff rotas, as asked for from the last random inspection, and she has worked hard to put into place everything we asked her to do. New care plans have been introduced which is good and help the staff record what needs each person has and how they will go about meeting them. Cleggsworth Care Home Ltd DS0000068123.V343928.R01.S.doc Version 5.2 Page 7 Staff numbers during the day have been increased. Staff now have one to one meetings with their manager to make sure they are doing their jobs properly and to check what training they may need to do in the future which will help them to provide good care. 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. The summary of this inspection report can be made available in other formats on request. Cleggsworth Care Home Ltd DS0000068123.V343928.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 Cleggsworth Care Home Ltd DS0000068123.V343928.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply. Quality in this area is good. Admissions are not made to the home until a full needs assessment has been undertaken. The manager of the home is able to confirm that staff can meet the needs of the individual through the service they deliver as detailed in the Statement of Purpose. This judgement has been made using the evidence available, including a visit to the service. EVIDENCE: New residents are admitted following an assessment undertaken by members of staff, usually by the registered manager. When the home is contacted, the initial reasons for the referral are established and a pre-admission assessment is then arranged. Because of the nature of the client group admitted to the older people’s service, it is more appropriate that the resident’s representative Cleggsworth Care Home Ltd DS0000068123.V343928.R01.S.doc Version 5.2 Page 10 visits the home to assess the facilities and have the opportunity to meet with the staff to discuss the way their needs of their relatives will be met. Service users and relatives are invited to view the facilities and meet both residents and staff before making a decision to move into the home on a trial basis. Adequate time and opportunity to make a decision regarding the placement is afforded the individual and this opportunity enables them to discuss how the home can meet the person’s individual requirements. Clear and detailed information concerning trial visits and the length of the ‘settlingin’ period is included in the Statement of Purpose. Emergency admissions are avoided as far as possible. The home develops a care plan based on the assessments made prior to admission to the home. There is evidence within the care plans, and in discussion with the residents, that any potential restrictions on choice, freedom, services or facilities, likely to become part of the resident’s daily life, had been discussed and agreed with the individual during assessment. Survey comments from residents at the home include: “I knew from visiting that I would like to live here” and “It was recommended by a family member who had a cousin here and they were very happy as I am”. Cleggsworth Care Home Ltd DS0000068123.V343928.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. There is a clear and detailed care planning system in place that includes residents’ involvement and provides the staff with the information needed to meet the needs of the residents. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Since the last inspection the home has revised the documentation relating to care planning and recording and examination of a selection of these indicated that a satisfactory system has been implemented. Residents receive a formal assessment from a qualified member of staff using a detailed assessment format. The care management assessments and the hospital care plans are obtained prior to admission to the home, and a copy is held in the resident’s notes. Cleggsworth Care Home Ltd DS0000068123.V343928.R01.S.doc Version 5.2 Page 12 Individual care plans are in place for each resident. The care plan is generated from the care management assessment and the assessment provided by the home. The plan sets out how the current and anticipated needs are to be met. The senior carers were able to describe how relatives are involved in the drawing-up of the care plan and understood the meaning of a care plan to describe the assessed needs of a resident and how the needs were to be met. The care plan would also include any changes in the resident’s condition. Signatures in the care plans indicating that the individual agreed with the plan and any alterations made to it after consultation with the individual, confirmed this involvement. Risk assessments are in place for residents and records are maintained in the service user care plan; these included food/fluid/turning charts, weights, risk assessment and review. Residents’ healthcare needs are monitored, with all visits to a healthcare agency or professional recorded. There was evidence of the care plans being reviewed on a monthly basis, which involved the completion of a dependency profile to identify changes in need. Weight is also recorded on a monthly basis; a nutritional assessment is used to monitor dietary needs. Medication storage, administration and recording systems, including controlled drugs, were examined. The systems were up to date and accurate ensuring residents were receiving their medication as prescribed. All the medication was securely stored and the records were maintained in line with good practice guidelines. Relatives and friends are encouraged to visit as often as possible and the home operates an open visiting policy, which is referred to in the Statement of Purpose and confirmed in discussion with residents’ relatives at the inspection. A discussion with the residents identified that they feel their privacy is respected and that they are treated with kindness. It was evident that staff upheld residents’ privacy and dignity. Personal care was provided privately in bedrooms or bathrooms, and door locks or engaged signs were used. Residents wore their own clothes and were dressed appropriately for the weather and their activity. Hair care, nail and teeth care and shaving had been attended to. Cleggsworth Care Home Ltd DS0000068123.V343928.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this area was considered good. Social activities provide daily variation and interest for people living in the home. The dietary needs of the residents were well catered for, with a balanced and varied selection of food being served. This judgement has been made using the evidence available, including a visit to the service. EVIDENCE: The choices residents made each day varied, dependent upon their mental frailty, but residents generally chose what time to get up, go to bed, what clothes to wear, where to spend their day, what food to eat, whether to participate in activities. Overall, residents considered they were encouraged to do what they could for themselves and make appropriate choices through the day. Cleggsworth Care Home Ltd DS0000068123.V343928.R01.S.doc Version 5.2 Page 14 Reviews regarding daily routine are carried out regularly at staff and residents’ meetings in addition to care plan reviews. Residents are offered a range of activities, such as exercise sessions, craft afternoons, clothes parties, day trips out, bingo, board and card games. Live entertainment is provided at intervals in the home. During the summer, and weather permitting, interested residents are encouraged and supported to maintain their interest in gardening. In addition, the mobile shop is taken round regularly and residents are encouraged to visit it. The staff have a good interaction with the residents and encourage participation in activities. Visitors are welcomed at all times and are not restricted to certain visiting hours. Residents are actively encouraged to maintain contact with their relatives and friends, as this enables them to feel involved in the local community. The home has three visiting hairdressers that attend the home on a weekly basis. In addition, one resident enjoys a weekly appointment at a salon in the local community and staff actively support her to attend. Another resident goes out for the day to an over sixties club once a week. Care plans contain information about family history and residents’ hobbies or interests, which the home endeavours to use to identify suitable activities to meet the needs of individual residents. As food and meal times are an important part of a resident’s daily life, the home offers a healthy diet and a choice at main meal times. Drinks are offered on a regular basis and any special dietary needs are highlighted in the resident’s care plan. Records of food provided to residents confirmed that all receive a varied and nutritious diet. The residents were asked what they would like to eat and alternative meals are available. The food was served from a hot trolley that was brought through into the dining room. The tables were nicely set with tablecloths, napkins and cruets. Hot and cold drinks were served. The residents spoke positively of the food provided. Cleggsworth Care Home Ltd DS0000068123.V343928.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. Residents were confident that complaints would be listened to, taken seriously and acted upon. Appropriate systems were in place to protect residents from abuse. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The home had a clear and concise complaints procedure, which told people how and who to make any complaint to. The procedure was well advertised to relatives and visitors to the home. Records showed that any complaints made had been fully investigated and responded to appropriately. Since the last key inspection three complaints had been made to the Commission for Social Care Inspection about care practices and staffing levels in the home and during activities undertaken outside the home. As a result of the information received. a random inspection was undertaken to look specifically at the issues raised with the Commission for Social Care Inspection. A report was compiled and, at a subsequent meeting, an undertaking was given by the owners and management of the home to address the issues raised. It was clear that the manager and staff were willing to learn from complaints and thereby improve their service. Cleggsworth Care Home Ltd DS0000068123.V343928.R01.S.doc Version 5.2 Page 16 The home had policies and procedures in place about safeguarding people from abuse and staff had received training in this subject. The training included a DVD with training booklet and a written questionnaire, for which certificates were issued. Through discussions it was evident that staff had a good knowledge of safeguarding vulnerable adults and what do in the event of any problem arising. Staff were aware of the importance of protecting residents’ rights, especially where residents were unable to make their wishes known. Decisions affecting people’s rights and choices were taken with great care and consideration, and included external advocates, or other professionals. Cleggsworth Care Home Ltd DS0000068123.V343928.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. The home has a planned maintenance and renewal programme for the redecoration and refurbishment of the home to ensure residents live in a comfortable, homely and safe environment. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Cleggsworth Care Home is situated in Smithybridge Village, near to public transport and a train station, and is easily accessible for visitors. There are a variety of local shops, a library, Church and community hall within walking distance. The residents are encouraged to use the community facilities where possible. Cleggsworth Care Home Ltd DS0000068123.V343928.R01.S.doc Version 5.2 Page 18 The home has 28 single rooms and eight single rooms with en-suite facilities. Service users are encouraged to personalise their own bedrooms. The home tries to ensure that residents are involved in any decisions made regarding the re-decoration of the home. There is a large flagged patio balcony on the first floor and a well stocked pleasant garden to the rear of the home and residents are actively encouraged to sit outside during the summer months. The home ensures appropriate referrals are made if service users require specialist equipment or adaptations. There is a passenger lift to all floors to aid residents who are less mobile and have difficulty using stairs. General aids and adaptations are provided within the home, such as grab rails, multi-use hoists and individual slings. Residents live in a homely, comfortable and safe environment. There has recently been a complete refurbishment redecoration of the home. A tour of the home confirmed that the home was well maintained, clean and free from any offensive odours. Ramped access was provided to the front door and level access throughout each of the two floors. A passenger lift was provided and handrails fitted to corridors throughout. Everyone spoken with thought the home was a safe place to live and work in. Grounds were seen to be safe, tidy and accessible. Residents said they looked forward to sitting outside in the good weather. Six residents spoken to were very pleased with their individual rooms and said that they had brought in a number of personal possessions to make them feel more homely. Residents said staff kept the building clean and odour free, inspection of the premises supported this view. Discussion with a domestic verified that sufficient staff and equipment were provided to ensure the home was maintained in a clean and hygienic condition. An infection control policy was in place and training was provided in this area. Staff spoken with described safe infection control practice. Disposable gloves and colour-coded aprons were provided for staff use and liquid soap was available throughout. Satisfactory practice was in place with regard to disposal of clinical waste. The laundry was sited away from the food preparation area and was seen to be clean and orderly. Sufficient and suitable equipment was provided and laundry was attended to efficiently. Five residents said that they were satisfied with the laundry system at the home and that there was a quick turnaround on the clothes sent for cleaning. Cleggsworth Care Home Ltd DS0000068123.V343928.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. Staff are well trained to ensure they have the competencies to meet residents’ needs. The home’s recruitment procedures are robust and these provide safeguards for the protection of residents. Due to the increased dependency of residents, which seems particularly prevalent during the night, the provision of night staff and their deployment does not seem to be sufficient to meet the needs of all residents. This judgement has been made using the available evidence, including a visit to the service. EVIDENCE: Staffing levels during the daytime hours reflected the needs of residents and were consistent. Five care assistants were deployed alongside the manager during these times. During the night hours the off duties confirmed that the home was covered by two waking care assistants and one sleep-in. Some discussion took place with the area manager as to whether this level of staff was sufficient to meet the needs of residents, as it was identified on this inspection (from the accident book) that a high number of falls were occurring during the early morning when residents were starting to waken. Cleggsworth Care Home Ltd DS0000068123.V343928.R01.S.doc Version 5.2 Page 20 It was agreed that the owners would review these levels with reference to residents’ activity and confirm the levels as adequate or otherwise. Staffing levels have been monitored by CSCI since the random inspection with the manager sending copies of the rota into the lead inspector. Staff receive a thorough recruitment procedure and a full employment history is completed on staff application forms. All staff have CRB checks and references are requested and received prior to commencing employment. All staff receive induction training to include the home’s induction and the Skills for Care induction. During the induction period staff are required to complete mandatory training, timescales of the training are dependant on availability. The home has 50 of staff qualified to NVQ Level 2 or above in care and 25 currently enrolled on NVQ Level 2 or above. Staff members spoken with were able to demonstrate a wide variety of skills and experience, creating a well balanced team who are able to interact well with residents. Staff meetings and supervisions are held on a regular basis; these meetings accommodate both night and day staff. All staff have the opportunity to attend these meetings and are encouraged to contribute and highlight any issues they may have. Supervision arrangements also provide staff with the opportunity of one-to-one discussions and future training needs can be identified during these sessions. Care staff undertook their duties in a friendly and caring manner. Residents confirmed that staff were always respectful and met their needs competently. In the main, residents were satisfied with the support they were given and described staff as “nice people, very caring”, “find time to listen” and “good”. Sufficient ancillary staff were employed, e.g., domestics, laundry and kitchen assistants, cook and handyman. Staff were, in the main, knowledgeable about the needs of residents and demonstrated that they understood their own role. Cleggsworth Care Home Ltd DS0000068123.V343928.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. The home was well managed and run in the best interests of the residents. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Since her appointment the present manager had demonstrated a clear sense of direction and leadership and had made positive changes at the home with regard to management systems, day-to-day supervision and oversight of care planning meetings to determine how residents’ care needs will be met. Cleggsworth Care Home Ltd DS0000068123.V343928.R01.S.doc Version 5.2 Page 22 Throughout the inspection the inspector was informed of the professional, capable and approachable manner in which the manager undertook her role when dealing with residents, staff and visitors. Staff and residents said she was easily accessible and welcomed her ‘open door’ policy, as well as providing structure and a sense of direction through more formal meetings. Residents said she made sure she spoke to them on her arrival at the home each day to check out how they were feeling. Quality assurance checks are completed at the home and this identifies any areas which may require attention. We examined a comprehensive range of policies and procedures to promote and protect residents and employees which are available at all times to staff and any residents or visitors upon request. Supervisions and appraisals are held on a regular basis. Accidents are fully documented in the home’s accident book and are removed and stored in accordance with the Data Protection Act. Any residents’ money is stored securely and is treated as an individual belonging of the resident and not pooled. The home’s insurance certificate is displayed in the home and is sufficient to meet any loss or legal liabilities that may be incurred. The home had sound systems in place for promoting the health, safety and welfare of staff and residents. All services and equipment for the building were under contract for regular testing and repair. There was information, and staff had received training in fire safety, safe moving and handling, the safe use of chemicals, food hygiene and first aid. Cleggsworth Care Home Ltd DS0000068123.V343928.R01.S.doc Version 5.2 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Cleggsworth Care Home Ltd DS0000068123.V343928.R01.S.doc Version 5.2 Page 24 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 OP27 Regulation 18, 1(a) Requirement The registered person must ensure that sufficient staff are in place to ensure that people who use the service are properly supported. The registered person must ensure that appropriate interventions are in place for service users identified as at risk of falling. Timescale for action 30/09/07 2 OP8 16 (1) (2) (n) 30/09/07 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 Refer to Standard OP9 Good Practice Recommendations Hand transcribed medications should be witnessed by two staff to avoid errors. Cleggsworth Care Home Ltd DS0000068123.V343928.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Cleggsworth Care Home Ltd DS0000068123.V343928.R01.S.doc Version 5.2 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. 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