Inspection on 05/12/08 for Collyhurst

This inspection was carried out on 5th December 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Collyhurst 04/06/07

Collyhurst 04/09/06

Collyhurst 16/01/06

Collyhurst 14/09/05

Collyhurst 14/10/04

Collyhurst 08/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

CARE HOMES FOR OLDER PEOPLE Collyhurst 31-33 Nuneaton Road Collycroft Bedworth Warwickshire CV12 8AN Lead Inspector Julie Preston Unannounced Inspection 11:00 5 December 2008 th 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 Collyhurst DS0000004206.V372592.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. Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Collyhurst Address 31-33 Nuneaton Road Collycroft Bedworth Warwickshire CV12 8AN 02476 319092 F/P 02476 319092 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) Mr K Taylor Mrs Elizabeth Taylor Mr Charles George Taylor Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: old age, not falling within any other category OP 34 . The maximum number of service users to be accommodated is 34. 2. Date of last inspection 4th June 2007 Brief Description of the Service: Collyhurst Home is a family owned and run care home, which is situated in the Collycroft area of Bedworth. The home is registered to provide care for the older person and one younger adult with specialist needs. Collyhurst is located on the main road, which links to the two towns of Nuneaton and Bedworth and is very convenient for local services, hairdressers and shops, and a community centre, which is within close walking distance. Accommodation is provided both in the main building and a small bungalow, which is situated to the rear of the property. The bedrooms in the main house are accessible via a passenger lift or stairs. The home has been extended and new facilities include a car park, additional bedrooms and bathrooms and an eighteen person passenger lift. The bungalow has it’s own small kitchen and lounge facility and accommodates up to four people. There are pleasant garden areas at the rear of the home, which are accessible to the people who live at Collyhurst. At the time of the inspection visit the fees charged are in the range £300.00 £359.00 per week. The fees do not include newspapers, toiletries, chiropody or hairdressing. Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 5 Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a questionnaire about the home. The questionnaire is called the Annual Quality Assurance Assessment (AQAA). The visit took place over ten hours and staff and people who live at the home did not know that we were coming. Three service users were “case tracked” and this involves discovering individual experiences of living at the home by meeting or observing them, discussing their care with staff, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. We spoke to three four people who live at the home, three visitors and four members of staff about the standard of care provided at the home. The comments we received are included in this report. Staff files and health and safety records were reviewed. We looked around the building to make sure that it was warm, clean and comfortable. What the service does well: There is a statement of purpose that explains what the home is like, who it is for, how much it costs and if there are any rules about living there. This means that anyone wanting to move into the home can make an informed choice about whether they want to live there. People and visitors made positive comments about the staff team When I leave Im happy X is well cared for. X couldnt be anywhere better. Its very positive here Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 7 I have confidence in the managers and staff. The staff here are marvellous. The home is good at helping people stay in touch with their friends and relatives so that they do not lose relationships that are important to them. People are offered good food that they enjoy and which helps them stay healthy and well. There are good systems in place to recruit new staff so that people who live in the home are protected from possible harm. People who live in the home experience a meaningful lifestyle that promotes their independence and is reflective of their individual needs. People told us that they enjoy the activities that are on offer each day. They said There is always something to do. I enjoy the bingo. People who have retained some independent living skills are encouraged to go out and make use of the local community. There are arrangements in place for people to receive religious services within the home in accordance with their spiritual needs. Staff receive regular training to make sure that they are competent to provide care to the people who live in the home. What has improved since the last inspection? What they could do better: Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 8 Care plans that describe how peoples needs are to be met do not always provide clear information about the support that people require. This could lead to inconsistent practice and individual needs not being met. Medicines are not always well managed which could lead to people not receiving the medication they need to stay healthy and well. 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. Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have access to information about the services and facilities provided in the home so that they can be confident their needs will be met there. EVIDENCE: The home has a statement of purpose that offers comprehensive information about the services and facilities provided. The manager told us that the statement of purpose is made available to peoples families and to social workers before they move in to help them decide whether the home can meet their needs. The visitors that we spoke to said that they had had the opportunity to visit the home with their relative before their relative decided to move in. Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 11 There is a procedure for assessing the needs of people before they move in to Collyhurst so that the person can be confident their individual needs can be met within the service. Records sampled for a person recently admitted showed that an assessment of their needs had been completed and that the person had visited the home before deciding whether to move in. The manager told us that the pre admission assessment would usually be conducted in the persons own home and would include input from them, their relatives and health and social care professionals. The records that we looked at showed that care plans and risk assessments had been drawn up in response to the initial assessments made. Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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 using available evidence including a visit to this service. Care plans do not clearly explain how each person should be cared for which could lead to individual needs not being met. Medicines are not always well managed so that people receive their medication in a planned and safe manner. EVIDENCE: We looked at care plans for three people. A care plan describes the level of support a person requires to make sure their needs are understood and met. Each person had a care plan and risk assessments that describe their communication, social, spiritual, health, personal care, dietary and mobility needs. In some cases, the information contained within the care plan made it difficult to establish how people should be cared for. Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 13 For example, a plan referred to the need for regular chiropody, but gave no further information about how often this should be. The last entry in the persons records was for June 2007. A personal care plan did not provide sufficient information to enable anyone reading it to understand how to make sure the persons needs would be met, stating - maintain Xs regular toilet pattern. There was nothing in the plan to indicate what this meant. A risk assessment for pressure care identified a person to be at high risk of pressure wounds. There was no care plan to specify how to avoid pressure wounds and maintain the condition of the persons skin. Some entries in the care plans were difficult to read. The manager and deputy manager agreed that handwriting needed to be legible to make sure that peoples needs were clearly stated. A lack of detail in written care plans could lead to peoples needs not being met. This was discussed with the manager and deputy manager who said they would be reviewing all care plans to address this. We spoke to people who live in the home and their visitors about the care they receive and were told This place is a regular home from home. When I leave Im happy X is well cared for. X couldnt be anywhere better. Very good care here. I wouldnt live anywhere else. We observed staff interacting with people in the home. Staff were respectful towards people and had clearly got to know them well. One person said The staff here are marvellous. Staff at the home have developed good relationships with health care professionals and have implemented guidance from dieticians, chiropodists, GPs and District Nurses to enable people living in the home to continue to maintain good health. Records showed that people have regular appointments with healthcare professionals and the outcome of this contact had been documented so that staff had accurate information about individuals’ state of health. Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 14 The care files that we looked at showed that there were a number of systems in place to monitor peoples health such as weight charts, food records and fluid charts. The system of storing, administering and recording medicines kept in the home was looked at to establish that people are protected by robust procedures. Medicines are kept securely in within the home. We looked at the medicines and records of the three people we had case tracked. Some PRN (as required medicines) are prescribed. Written protocols had not been developed to describe the circumstances under which such medicines should be offered so that people receive their medication in a planned and safe way. Two of the records showed that people had refused medication on several occasions this week. There was nothing recorded to advise staff how to respond to refusal of medicines so that people did not risk becoming unwell. We looked at the number of tablets in stock for one person and matched it against the Medication Administration Record. The numbers did not tally. However the manager promptly investigated the discrepancy and was able to identify that the error had been in recording and not administration. This demonstrates the need to make sure that medicines are audited on a regular basis so that potential errors can be investigated and rectified. The staff responsible for medication had undertaken appropriate medication training. They had provided a sample of their signature at the front of the Medication Administration Record Sheets file so that it is easier to identify who has administered the medication. Photocopies of prescriptions are kept as a check that what has been supplied was ordered by the GP. Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 15 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 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who live in the home experience a meaningful lifestyle that promotes their independence and is reflective of their individual needs. EVIDENCE: The home employs an activity coordinator who works flexible hours including evenings and weekends. This person showed us her notes of planned activities that had taken place over the last few months, which included • • • • • • • • Arts and crafts Flower arranging Skittles Bingo Armchair aerobics Quizzes Card making Painting DS0000004206.V372592.R01.S.doc Version 5.2 Page 16 Collyhurst People told us There is always something to do. I enjoy the bingo. At our visit we saw people making Christmas wreaths and decorations. It was evident that those involved were enjoying the activity. We were told that a theatre trip had taken place as well as shopping trips to Bedworth, visits to Sunday league football matches, themed party nights and a visiting entertainer each week. The activity coordinator had also planned jewellery, perfume and shoe/slipper sales in the home so that people had the option to buy goods if they chose to. The events had been promoted on the notice boards around the home. One person told us - I often go into Bedworth to fetch papers for the others. This person said they enjoyed their independence and had made good relationships with people in the local community. We were told that the home will be taking part in a Care Trust study about the way activities are offered to older people in care homes, with a view to increasing opportunities for engagement and the range of activities provided. Staff were very keen to begin this work so that people benefited from the outcome. We spoke to three visitors who all said that they were made to feel welcome at the home. The home offers visitors refreshments and one person has a relative visit for meals several times each week. People told us that they had invited their relatives to the forthcoming Christmas fancy dress party. The manager told us that whilst there were no restrictions upon visiting times (other than at a persons request), he preferred that mealtimes were avoided, unless planned, so that people were not disturbed during their meal. This had been clearly recorded in the homes statement of purpose. There are arrangements in place for people to receive religious services within the home. Peoples spiritual needs had been recorded in their care files. We were told that the Salvation Army band would be coming into the home after Christmas. We spoke to four people about the choices they make as part of their day-today lives. People said that they chose their meals, activities and when they got up and went to bed. Some people said that they had keys to lock their bedrooms; others said they didn’t want them. One person said that they decided when to clean their room and liked doing this. Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 17 Menus and records of food eaten by individuals were sampled to establish that a balanced and varied diet is provided that meets peoples’ needs and preferences. A range of food had been offered including Sunday roasts and diabetic meals, which is reflective of people’s cultural and health care needs. Since the last visit to the home in June 2007, the temperature of served food is being recorded so that food poisoning risks are reduced. Records were seen to show that this took place at each mealtime. People living in the home said that the food was good, nicely fresh and well cooked. We were told that people are offered a choice of two main meals each day. The home employs two cooks and a housekeeper who take responsibility for menu planning, shopping and cooking. We spoke to one of the cooks who has completed training in Health, Safety, Food and Hygiene at Stage 2. This person demonstrated knowledge of peoples dietary needs and food safety practice and confirmed that a choice of meal was offered each day. There are two dining areas with sufficient space for people to sit together and receive help from staff (if required) to eat their meals. Some people choose to eat in their bedrooms from time to time and the staff team respected this. Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 18 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are effective procedures in place to listen to and act upon people’s concerns and complaints if they have any. The home is taking adequate measures to promote the protection of vulnerable adults. EVIDENCE: The home has a complaints procedure that is made available to people who live there and their relatives or representatives. A copy was seen pinned onto the notice board near the lounge. There has been one concern raised to the Commission in the last twelve months, which was discussed with the manager during this visit. It was evident that the manager had taken appropriate steps to investigate the concern. The home has not received any complaints within the last twelve months. We were told by visitors I have confidence in the manager and his deputy to sort out any problems Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 19 If I tell the staff anything, they sort it out quickly. People who live in the home told us I feel safe here Id complain if I needed to. The staff would listen. Ive never needed to though. This indicates that staff at the home take complaints seriously and have effective systems in place to respond to any raised. There have been no safeguarding referrals made to the lead agency responsible for adult protection in the last twelve months. The home has a policy for promoting the protection of vulnerable adults and also gives staff a copy of the General Social Care Councils code of practice. Staff told us and records showed that training in safeguarding had been provided, or for some staff was due in early January 2009. Recruitment records sampled showed that a robust procedure is followed for the ongoing protection of people living in the home. Property lists are maintained for each person so that staff can keep track if anything goes missing and look after people’s personal belongings. Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 20 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, 22, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, well maintained and comfortable creating a pleasant environment for people to live in. EVIDENCE: The home is situated on a main road in the Bedworth area of Warwickshire, close to local amenities such as shops, cafes, public transport routes and hairdressing salons. This is important to some of the people who live in the home as they make use of these facilities. Extensive building work has been completed since the June 2007 visit, providing extra accommodation, a passenger lift and car parking space. Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 21 The home has a garden with raised flowerbeds and discreet seating areas, which we were told are well used in the summer. Bedrooms are provided in the main building and in a separate annexe (for four people), which is at the end of the garden. We were told that people who live in the annexe have greater independence than people who live in the main building. We looked at the bedrooms of the people we case tracked. Bedrooms were clean, warm and well furnished and decorated. The temperature in each bedroom could be controlled to the persons liking. People told us that they had been able to bring personal belongings to furnish their bedrooms when they moved in. Twenty-one of the homes bedrooms have en suite facilities consisting of a toilet, hand basin and shower. There are also adapted bathing facilities and a number of toilets around the building. A nurse call system is installed throughout the building so that staff can summon assistance in the event of an emergency. Records showed that weekly tests had been maintained to check that the equipment remained in good working order to promote the health and safety of people who live at the home. The home has a contract for the removal of clinical waste so that it is taken from the premises in a safe and hygienic manner. Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 22 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by a trained, caring team of established staff who have good understanding of their individual needs. The home operates a robust system of recruiting staff for the protection of the people who live there. EVIDENCE: Comments received from people who live in the home about the staff who work there were positive. People said that the staff team always listened and treated them well. Visitors told us Its very positive here I have confidence in the managers and staff. It was evident that people have good relationships with the staff team and seek them out frequently for company and to chat. Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 23 The members of staff spoken to at this visit demonstrated good knowledge of the needs of people who live in the home and clearly know them well. Staff recruitment records were sampled and found to contain evidence that satisfactory checks had been made of the person’s suitability to work within the home prior to their appointment for the ongoing protection of the people who live there. From looking at training records and talking to staff we established that regular training is available to the team. A new member of staff told us that they had completed training in First Aid, Moving and Handling and Fire Safety within the first week of her employment. We spoke to a senior member of staff with responsibility for leading her shifts. This person said that she had completed her National Vocational Qualification (NVQ) at Level 3. The AQAA stated that 80 of the staff team had completed NVQs up to Level 2, which should ensure that the staff team have skills that meet peoples needs. Safeguarding training had been planned for January 2009 for those staff who had not previously completed it, which demonstrates that the home is taking adult protection seriously. From discussion with the manager and staff and looking at the homes current rota, it was evident that there were enough staff on shift during the day and night to meet the needs of the people living in the home. Visitors said that staff were always busy but never to busy to talk. Two waking night staff work from 9.30pm until 7.30am. We were told that, at present this number is sufficient to meet peoples needs. The home however has several vacancies. Staffing should be reviewed as vacancies are filled. Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 24 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well managed which should make sure that it is run in the best interests of the people who live there. EVIDENCE: Collyhurst is a family run business. The registered manager and care manager are husband and wife and the parents of the registered manager are the registered providers. Other family members work among the staff team. The manager has completed his registered manager award and NVQ Level 4 in management. The deputy manager has completed her NVQ Level 3 and City Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 25 and Guilds qualification in care. Both the manager and deputy manager have many years experience in working with older people. People who live in the home, staff and visitors made positive comments about the management team. The registered providers visit the home on a regular basis but do not complete written reports of their visits. This is needed to make sure that the service is regularly reviewed and procedures audited to establish that the home is being run in the best interests of the people who live there. There are other systems of quality assurance in place. We saw that financial records had been audited on a regular basis as had medicines and some elements of care planning. A number of checks are made by staff to make sure that peoples’ health and safety is maintained. Records showed that the fire alarm system had been regularly tested and serviced to make sure that it was working properly. Emergency lighting had been tested on a regular basis to make sure it remained in good working order. Hot water temperatures are checked and recorded to ensure that they do not pose a scalding risk to people. Fridge and freezer temperatures are checked and recorded to make sure that food is stored safely. Some incidents that affect the well being of people who live in the home had not been reported to the Commission as is required by legislation. We saw evidence in the form of certificates that the passenger lifts, electrical and gas appliances and lifting equipment had been checked and serviced on a regular basis for the ongoing protection of people who live in the home. Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 26 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1-2) Requirement Each person must have a written plan of care that clearly explains how their needs with regard to health, personal and social care are to be met. Written and agreed protocols must be in place for people who need medication on an as required basis so that staff are clear about the circumstances under which such medicines should be given. There must be clear instruction about the action to be taken in the event that people refuse their medication to make sure that their health care needs continue to be met. The Commission must be informed, without delay of incidents in accordance with this regulation for peoples ongoing protection. Timescale for action 31/01/09 2 OP8 13(2) 01/01/09 3 OP8 13(2) 01/01/09 4 OP38 37 01/01/09 Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP27 OP33 Good Practice Recommendations Care plans should be reviewed so that any difficult to read information is set out clearly. The number of staff on duty during the day and at night should be reviewed when vacancies are filled within the home so that peoples needs continue to be met. Reports of visits by the registered providers should be completed so that it can be demonstrated that the home is being run in the best interests of people who live there. Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Collyhurst DS0000004206.V372592.R01.S.doc Version 5.2 Page 30 - 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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