Inspection on 05/09/06 for College View Care Home

This inspection was carried out on 5th September 2006.

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

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

Other inspections for this house

College View Care Home 13/09/07

College View Care Home 16/01/06

College View Care Home 27/09/05

College View Care Home 06/12/04

College View Care Home 23/06/04

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Snydale Care Home

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Larchfield Manor

Hawkhills

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The Grove Waltham

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Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE College View Care Home 71 Bargate Grimsby North East Lincs DN34 5BD Lead Inspector Mrs Jane Lyons Unannounced Inspection 5th September 2006 09:00 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 College View Care Home DS0000002851.V308339.R02.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. College View Care Home DS0000002851.V308339.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service College View Care Home Address 71 Bargate Grimsby North East Lincs DN34 5BD 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) 01472 879337 Mrs Katrina Peerbux Mrs Katrina Peerbux Care Home 12 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (12) of places College View Care Home DS0000002851.V308339.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 Brief Description of the Service: College View is a long established home situated in a pleasant central location of Grimsby, it is close to the local amenities of Scartho Village and local public transport. The building is Victorian in style maintaining much of the character and original features providing care for up to 12 service users. The home consists of two storeys serviced by stairs and a passenger lift. There are six single rooms, none of which are en-suite and three shared rooms, one of which is en-suite. All rooms apart from one are spacious. On the ground floor there is one unassisted bathroom containing a WC and on the first floor there is an assisted bathroom without a W.C. On each floor there are two W.C.’s for service users use. There are two lounges and one dining room, all of which are located on the ground floor. The home is surrounded by pleasant mature gardens including a paved area at the rear of the property. There is car parking space at the front of the property. The home is owned and managed by Mrs K Peerbux. There is a well established staff team who have considerable experience working with this service user group. Weekly fees are: £329- £387. The home operates a system whereby the fees for single accomodation include a third party contribution. Additional charges are made for the following: toiletries, newspapers/magazines, hairdressing and chiropody. Information on the service is made available to prospective and current service users via the statement of purpose, service user guide and inspection report. Documents are made available prior to and following admission, copies are available on request. College View Care Home DS0000002851.V308339.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. • The visit to the home lasted from 9 a.m. until 2.30 p.m. however the inspector returned to the home the following week for 2 hours when the manager was present to access a number of records which had been locked away in her absence. All nine residents spent some time chatting to the inspector. Three staff, six relatives and the manager also talked to the inspector. Records about the care provided, and other records about the running of the home were looked at. Questionnaires about the home were sent to all the residents, staff, relatives and three healthcare professionals involved in supporting residents. All the residents and relatives questionnaires and one of the staff ones were returned at the time this report was written. The inspector observed how staff and service users worked together throughout the day. People’s views about the home and what was found during the visit have been used to write the report and make judgements about the quality of care. This was a positive inspection visit; the management had actioned thirteen of the previous requirements and no new ones were made. • • • • • • What the service does well: There was a very relaxed and homely atmosphere in the home, residents were observed to be very comfortable in their surroundings. The home was clean and tidy. Staff spoken to were enthusiastic and liked working at the home, they were keen to ensure that residents receive high standards of care. Observation of staff support and interaction with the residents was seen to be very positive; staff displayed a very good knowledge of the individual resident’s needs, their approach was very patient, kind and supportive at all times. College View Care Home DS0000002851.V308339.R02.S.doc Version 5.2 Page 6 Residents liked the food provided, are well fed and encouraged to eat a healthy diet. The standards of care support were good; comments received from relatives included “College View is an outstanding care home, the ethos is one of care and commitment, the smallest needs are noticed and addressed, there is an excellent balance of humour and realism” another relative wrote “I think the care is excellent and most of the staff go above and beyond to keep residents happy, its this extra care that makes a difference”. There were good visiting arrangements and visitors were made to feel welcome, discussions with a number of relatives confirmed this. Proper recruitment checks were made before new staff start in the home to ensure they are safe to work there. Staff reported that access to training was good, this means residents’ care is delivered in a way that is up to date and based on current good practice. What has improved since the last inspection? The manager has reviewed the staffing levels in the home and makes sure there are enough staff on duty to provide the care support each resident requires. Care plans were well developed and took account of the service users needs and preferences. Improvements had been made to the maintenance of the records. The supervisory arrangements for the home have improved to provide staff with the necessary guidance, leadership and support to ensure residents living in the home are safe and well cared for. Recording and handling of resident’s personal money accounts has improved which demonstrates that there are no irregularities. Staff training records had been better maintained which demonstrated that all the staff have had all the training they need to ensure the safety and welfare of the residents. The kitchen sink had been replaced and the tiling in that area replaced which better ensures standards of hygiene can be maintained. College View Care Home DS0000002851.V308339.R02.S.doc Version 5.2 Page 7 Staff have completed regular monitoring and recording of the hot food and fridge/ freezer temperatures. This will better ensure that staff are following the required food hygiene practices and promoting the safety of residents. 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. College View Care Home DS0000002851.V308339.R02.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 College View Care Home DS0000002851.V308339.R02.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): 1,2,3,4 and 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 varied their registration category to include persons with needs associated with dementia; potential residents have their needs assessed, are able to visit the home and are provided with clear information to help ensure that College View is the right choice of home and can meet their needs. EVIDENCE: Following the last inspection visit the management have varied the registration to accept up to six residents with needs associated with dementia; there were four persons residing in the home requiring support in this area. Staff have accessed training in dementia care and were seen to interact positively with the residents providing support in a kind and patient manner. The home admission procedures had improved; the format of the homes needs assessment covers all required areas; copies of completed assessments were detailed and appropriate. Copies of the Local Authority assessment and care plans are obtained prior to admission for those residents referred through the College View Care Home DS0000002851.V308339.R02.S.doc Version 5.2 Page 10 local Social Services care management teams. In addition to the pre admission assessment the home undertakes a further assessment of strengths and needs once the resident has arrived. It is on the basis of both these assessments that the residents plan of care is formalised. The written contract/statement of terms and conditions documents were agreed with residents and held on file. Copies of the letter written to potential service users following the manager’s assessment visits to confirm that the home can meet their needs were also held on file. Residents spoken to were very happy that their care needs were being met, one resident told the inspector “It was home from home”. Staff spoken to demonstrated a good understanding of residents’ care needs. Visiting relatives were also happy with the care being provided. There was good evidence to demonstrate that care staff were accessing a broad range of service specific training which will help ensure that they have the skills to enable them to deliver up to date care methods and have a better understanding of the varied conditions common to the elderly. The home does not provide intermediate care support. College View Care Home DS0000002851.V308339.R02.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 good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents health and personal care needs are well met, the quality of the ongoing maintenance and up dating of the care plans has improved and is more consistent. Medication recording procedures need to improve to demonstrate that staff have made sure residents get the medication they need. EVIDENCE: Residents told the inspector that the staff were always very kind and were very patient, they also said that they didn’t have to wait for assistance and that the staff had time to sit and chat with them. Relatives also commented on the kindness of the staff; they confirmed that communication was good and that they were always informed of any changes. One visitor told the inspector how well her relative had settled in to the home and how her health had improved considerably. College View Care Home DS0000002851.V308339.R02.S.doc Version 5.2 Page 12 Case tracking of three service users was completed, which included examination of care records and discussions with service users and staff. Care programmes for one existing service user and two more recent admissions were looked at. The format of the documentation remains the same and the care plans were well developed; the documentation system was well thought out and user- friendly, improvements had been made to ensure greater consistency and no gaps were identified during case tracking. Detailed individualised plans had been developed from the assessments; there was good evidence that the plans had been updated when changes in need had occurred. Risk assessments were in place for tissue viability, moving/ handling, nutrition and falls; these had been reviewed regularly and all high-risk areas had associated care programmes in place. The quality of the evaluation records was good with evidence of formal review meetings taking place. Care plans did detail clearly the support required from staff to meet resident’s needs associated with their dementia. There was good evidence that the home sought support from the health care professionals such as Community Psychiatric Nurses, dieticians and District nurses when necessary. Following the inspection the inspector spoke to one of the District Nurses who regularly visits the home; she confirmed that the communication was good, staff were always very helpful and she had observed that they demonstrated a very caring and supportive attitude towards the residents. There are clear procedures in place for receipt, storage, administration and return of medication; other areas such as covert administration, administration errors and self medication are covered. The policy to support self- medication requires still requires review to include assessment of suitability and capability although there have not been any residents able to or wanting to self medicate since the previous inspection. There was evidence that the staff are proactive in ensuring that service user’s medication is reviewed by the G.P. Storage of medication was satisfactory. The majority of staff have now completed the accredited medication course. Examination of the medication administration records still revealed a small number of recent gaps where the staff had not signed or used a code to account for the omission. The registered manager confirmed that she regularly audits the records and improvements had been made to the records, that the recent omissions had occurred when she was on leave and that she would continue to monitor this issue very closely. College View Care Home DS0000002851.V308339.R02.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 arrangements for providing activities, visiting, meals and supporting residents to make choices met with the expectations of the residents. EVIDENCE: Residents and visitors were happy with the visiting arrangements and it was clear that residents are supported to keep in touch with friends and family. One resident recently celebrated her 90th birthday and her relative told the inspector that the home had provided a lovely tea party. Residents also said that they felt able to make their own choices about how they spend their time. They can rise and retire to bed at times to suit themselves, choose where to have their meals and what clothes they wanted to wear. They also commented that they could spend time in their rooms if they wanted to but usually preferred to sit during the day in one of the lounges or the hall area. There was evidence from observation and interview that residents have the opportunity to speak to staff and management on a one –to –one basis; advice College View Care Home DS0000002851.V308339.R02.S.doc Version 5.2 Page 14 was given to arrange residents meetings which would provide an opportunity for residents to discuss issues collectively. The activity and entertainment programme continues although it was clear from observation and discussions with staff that due to the general frailty of the majority of the residents they currently preferred to access more one-to one time with individual staff members looking through family photographs and talking about their lives, although manicures and sing a long sessions remained very popular. Very positive comments were received from the residents and relatives about the quality of the meals provided at the home. Residents told the inspector that the food was always lovely and the staff always knew what they liked. The meal served during the visit looked tasty and well presented. The majority of residents use the dining room and the mealtime was seen to be a relaxed and social occasion with the staff interacting well with the residents; individual support was provided patiently and discreetly. Menu boards in the room display the weekly and daily choices; the cook confirmed that the menus were scheduled for review. Resident’s weights are monitored regularly and any concerns are referred to community health services for support; one resident was having a supplemented diet. There had been an improvement in the monitoring and recording of fridge/ freezer temperatures in the kitchen. Works to replace the kitchen sink and replace the tiles above the sink had been carried out following the last inspection visit. College View Care Home DS0000002851.V308339.R02.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 and 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Although relatives and service users knew who they would make a complaint to efforts should be made to better inform relatives of the process. Recruitment and selection practises protect service users from abuse. EVIDENCE: The homes complaint procedure was clear, appropriately worded and displayed in the staff office; a copy should be provided in the entrance area. Three of the relatives surveys identified that they did not know how to make a complaint therefore the management need to address this. The home had not received any complaints since the previous inspection. The service users and relatives spoken to felt able to make any complaints they may have either to the manager or staff members. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint in place. There was evidence that the staff had accessed training in adult abuse and management of challenging behaviour. When asked about abuse, what it was and what they would do if they saw a service user being abused, the staff answered correctly. College View Care Home DS0000002851.V308339.R02.S.doc Version 5.2 Page 16 The inspector found that recruitment practices were satisfactory; examination of staff files demonstrated that CRB checks/ POVA First checks had been obtained for new staff prior to employment. College View Care Home DS0000002851.V308339.R02.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 and 26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are provided with a safe, warm and comfortable environment that is homely and welcoming. EVIDENCE: The home was comfortable; generally decorated and furbished to a good standard. Resident’s rooms were personalised to the extent chosen by the individuals. The communal areas were all well utilised during the visit; service users commented on how happy and settled they were at the home. The registered providers submitted plans in 2005 to support major alterations to the home which are currently awaiting approval. The works programme will provide a first floor extension with two single en- suite rooms, alterations to shared rooms to provide single, en- suite accommodation, new bathing facilities and an extension to the lounge. Along with this work the electrical and plumbing systems will be upgraded. The service users have been made aware College View Care Home DS0000002851.V308339.R02.S.doc Version 5.2 Page 18 of these planned works and consulted where possible. Residents spoken to during the visit did not seem unduly concerned by the planned works and upheaval in fact they considered the activity would be interesting. Works to upgrade a number of the facilities will take place over the next few weeks with a number of residents rooms scheduled for redecoration and the bathroom to be refitted. One of the resident’s rooms has been redecorated and a number of new chairs provided in the lounge. All areas seen were clean and tidy, there were no odour issues identified. All residents spoken to confirmed that they liked their rooms and the staff kept them clean and tidy. The rear garden was very attractively planted and well maintained. Repairs to the front garden fence were scheduled and this area required weeding and tidying. One of the relative surveys detailed that ramp provision to the doors at the side and rear of the home would enable easier access for wheelchairs; the manager confirmed that works to provide permanent ramps for all doors was included in the alterations however due to delays in the start of the programme a temporary ramp would be provided. Staff carry out weekly checks of the hot water temperatures at all outlets accessible to service users; records and random checks during the visit evidenced that the hot water systems are managed effectively and safely. College View Care Home DS0000002851.V308339.R02.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 were robust staff recruitment procedures, staff training and staff supervision programmes in place, which provided protection for the service users health, safety and welfare. EVIDENCE: There had been improvements made to the monitoring of the dependency of the residents and the numbers of staff deployed to meet their needs, the home now utilises the Residential Staff Forum staffing tool; although the manager needs to maintain formal records of the weekly dependency studies and staffing hours required. There were nine service users residing at the home at the time of the inspection; staff confirmed that the dependency levels were stable and that the current staffing levels were satisfactory. Some weeks ago the occupancy had risen to eleven and the dependency had increased; there was evidence that the staffing levels had been increased in the evenings at that time. Staff told the inspector that the manager rosters more staff when needed and residents said that the staff had time to provide the support they needed and they didn’t feel rushed. The home had recruited one new staff member since the previous inspection visit; there was evidence that a Pova first check had been obtained prior to employment and a new CRB check had been obtained. Four staff files for were College View Care Home DS0000002851.V308339.R02.S.doc Version 5.2 Page 20 examined and contained all relevant documentation to evidence compliance with regulations. The home meets and exceeds the standard for having at least 50 of the care staff trained at level 2 NVQ; with 66 of the staff having gained qualification. The deputy manager has recently enrolled in the Level 4 course in care and management. The home provides a good staff training programme with staff accessing annual updates in statutory courses and a good variety of general and service specific courses. Improvements had been made to the recording of courses accessed by staff in their individual files; the manager develops an annual training and development programme which is linked to the staff appraisals. Staff at interview were very complimentary about the training they received. College View Care Home DS0000002851.V308339.R02.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 and 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. Improvements had been made to the quality and consistency of a number of the management and administration systems. Although a formal quality assurance system has yet to be implemented the home demonstrates a commitment towards improvement of the service and residents were satisfied with the service provided and considered that they lived in a home that was well managed. EVIDENCE: The management practices at the home were found to be more consistent; the manager had actioned the majority of requirements set at the previous College View Care Home DS0000002851.V308339.R02.S.doc Version 5.2 Page 22 inspection. The manager is a qualified nurse, has many years experience in providing care for the elderly and demonstrates sound management practices. One of the senior care staff had been appointed to the deputy manager position two months earlier; she confirmed that she enjoyed her new role and was well supported by the manager and that the care staff had accepted her promotion. It was clear from discussions that she had a sound understanding of the day-to-day management of the home. There were accurate and up to date records relating to any personal allowances the home keeps on behalf of residents. Improvements had been made to the staff supervision programme; records showed that care staff had accessed the appropriate number of sessions to meet the annual targets. The quality of the supervision sessions was seen to be very good; sessions were thorough, covering all the required areas and there was evidence that any concerns about practice and disciplinary issues were followed up. The home has a good range of policies and procedures to support equality and diversity in the home, these include: dietary and religious needs, sexuality/ relationships, hearing / sight needs, dementia and challenging behaviour needs. No progress had been made to implement a formal quality assurance system; although during the visit the manager received confirmation that a consultant in this area would be providing support in the near future to assist in developing and implementing a system which would suit the home. The manager understands how crucial the implementation of a system which effectively gains service users, relatives and stakeholders views about the service provision and demonstrates continuous improvement is now to the overall management of the service. Safety checks had been carried out on installations and equipment in the home; the electrical systems have been checked; however as significant rewiring will take place as part of the works programme the electrical certificate will be issued on completion. The home has a detailed Health and Safety policy. Safe working practices are maintained by the provision of training to staff in the form of moving and handling, basic food hygiene, first aid at work, basic first aid, infection control and fire safety. Bed rails were provided for two service users; risk assessments were in place however the registered manager should ensure regular checks of this equipment takes place in line with guidance from the Medical Devices Agency. Records showed that regular testing of the fire equipment was taking place and that staff accessed fire drills through their fire training sessions. College View Care Home DS0000002851.V308339.R02.S.doc Version 5.2 Page 23 Improvements had been made to the recording of food, fridge and freezer temperatures in the kitchen area. College View Care Home DS0000002851.V308339.R02.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 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 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 3 1 X 3 4 X 2 College View Care Home DS0000002851.V308339.R02.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 OP33 Regulation 24 Requirement The registered person must establish and maintain an effective quality assurance system Previous timescale of 31/12/05 Unmet The registered person must ensure that there is a five-year electrical certificate in place. On completion of the works programme The registered person must ensure that staff complete the medication administration charts in accordance with NMC and CSCI guidance. Previous timescale of 16/01/06 unmet. Timescale for action 30/11/06 2. OP38 23(2)b and 4(a) 31/01/07 3. OP9 13(2) 15/09/06 College View Care Home DS0000002851.V308339.R02.S.doc Version 5.2 Page 26 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 registered person should the self- medication policy includes procedures for assessment of service users suitability and capability. The registered person should display the complaints procedure in a more public place such as the entrance hall and provide a copy to all service users’ next of kin. The registered person should ensure regular checks of bed rails(when in use) are carried out in line with guidance from the MDA. The registered person should ensure that the front garden areas are kept tidier. 2. OP16 3. OP38 4. OP19 College View Care Home DS0000002851.V308339.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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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