Inspection on 17/07/08 for Crouched Friars Residential Home

This inspection was carried out on 17th July 2008.

CSCI found this care home to be providing an Adequate service.

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

Crouched Friars Residential Home 20/06/07

Crouched Friars Residential Home 14/07/06

Crouched Friars Residential Home 27/11/05

Crouched Friars Residential Home 28/05/05

Crouched Friars Residential Home 11/11/04

Crouched Friars Residential Home 30/06/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Crouched Friars Residential Home 103-107 Crouch Street Colchester Essex CO3 3HA Lead Inspector Sara Naylor-Wild Unannounced Inspection 17th July 2008 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 DS0000017799.V368714.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. DS0000017799.V368714.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Crouched Friars Residential Home Address 103-107 Crouch Street Colchester Essex CO3 3HA 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) 01206 572647 01206 763622 Weldglobe Ltd Monika Reid Care Home 56 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (56) of places DS0000017799.V368714.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 56 persons) One person, who name was made known to the Commission in December 2006, who requires care by reason of dementia The total number of service users accommodated in the home must not exceed 56 persons 10th July 2008 Date of last inspection Brief Description of the Service: Crouched Friars is a period property that has been extended to offer care to 56 older people on three floors. The upper floors are accessed via a passenger lift. Most of the bedrooms are single occupancy and all have en-suite facilities. There are several communal areas offering a choice for people to use, and a large pleasant garden at the rear of the property. The property is situated close to Colchester town centre and has access to local amenities, including libraries, shops, post office and public transport. The fees charged by the home range from £367 to £570 per week. In addition to the weekly fee, service users pay £4 for hairdressing and £12 for the chiropodist where those services are used. DS0000017799.V368714.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced key inspection was carried out on the 17th and 25th July 2008. As part of the inspection we checked information received by Commission for Social Care Inspection (CSCI) since the last inspection in 20th June 2007, looking at records and documents at the care home and talking to the manager, Ms Monika Reid, care staff and the people living at the home. In addition the Annual Quality Assurance Assessment (AQAA) completed in April 2008 was considered as part of the inspection process and a tour of the premises was completed at the visit to the care home. The service sent us their Annual Quality Assurance Assessment (AQAA) when we asked for it. This contained information about what they felt they did well. Although this information was brief and did not always tell us how the service was seeking to improve the outcomes for people living at the service, beyond their present provision. We sent surveys to people living in the home and their relatives. There was a good response and the information contained in these was used to inform us on some of the outcomes for people using the service. The manager assisted the inspector at the site visit. Feedback on findings was given during the visit with the opportunity for discussion or clarification. We would like to thank the manager, the staff team, and people living at the service and their relatives for their help throughout the inspection process. What the service does well: The service provides information to people interested in moving into the home. They encourage people to visit and ask questions about what it is like to live in the home. Before any person is admitted the manager will conduct a preadmission assessment of the person’s needs to ensure that the home can support them. The ways in which people like to be supported in their daily routine is set out clearly and is available in people’s bedrooms for them and staff to consult. DS0000017799.V368714.R01.S.doc Version 5.2 Page 6 There are regular activities provided in the home everyday, and people are consulted about what they would like to participate in. The service employs staff specifically for this purpose and provides equipment to support this role. Meal times are flexible and people are provided with a choice of menu for each day. People told us that the food was good and they liked the way the meal was served. People living at the service were confident about their right to raise concerns with the manager and felt they would be listened to. Staff have a good understanding of what would constitute abuse and gave indications that they knew their responsibility in reporting this. The service has a clear complaints process that includes maintaining a record of all complaints received and their outcomes. People were confident about raising their concerns with the manager they said, “They are always willing to meet in private to discuss”. The staff are all trained to understand their role in safeguarding people from abuse. Staffing arrangements meet the assessed needs of people living at the home. People living there told us “The staff are good and friendly and will always help you when needed” The quality assurance system operated in the service seeks to understand how they can improve the experience that people living at the home have. What has improved since the last inspection? 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. DS0000017799.V368714.R01.S.doc Version 5.2 Page 7 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 DS0000017799.V368714.R01.S.doc Version 5.2 Page 8 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 to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People considering moving into the home can be assured that the service will understand their needs prior to any agreement to their moving into the home. EVIDENCE: The service had reviewed the documentation used to assess people prior to their admission to the home since the last inspection. The new format asks for greater detail in the information and those completed on file provided a clear picture of the individual’s needs and the issues the service may need to consider when agreeing to their admission. The AQAA completed by the manager stated, “The manager, deputy manager or senior carers will carry out a needs assessment of all prospective residents. We now have introduced a pre-assessment form. A team meeting follows on from this so as to have an unanimous opinion” DS0000017799.V368714.R01.S.doc Version 5.2 Page 9 People who had moved to the service recently said they had been able to visit the service prior to moving in, they felt they had been provided with information in the service users guide and from discussions with staff to help them make their decision. They said, “My family member received information about the home and they came to visit before I came”, “By chance vacancy available was just what my sister and I looking for” and “My family member dealt with the move and chose here.” Eight of the surveys returned to us from relatives of people living at the home said “I think there is a contract but I have not seen it”, “Contract straightforward, it invites service users and family to make compliments and complaints whole of contract gives impression of working together with residents and families” and “it gives best possible support to the resident.” Contracts held on peoples files gave information required by the National Minimum Standards for Older People 2001. The service does not provide intermediate care. DS0000017799.V368714.R01.S.doc Version 5.2 Page 10 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. People living at the home can expect some of their needs to be included in their plan of care. However, they cannot be confident that all the information known is provided in sufficient detail to meet all of their identified needs. EVIDENCE: The care plans of five people living at the home who had a range of needs were considered during the inspection. In all of the examples seen the front sheet of the plan was a diagram that explained some of the person’s history and personal relationships. This is intended to give a quick at a glance understanding of the background of the individual. The next sheet contained a description of the person’s care needs within a daily routine of morning help needed, help during the day, help during the night, help with the toilet and bathing. The sheet was divided into a table DS0000017799.V368714.R01.S.doc Version 5.2 Page 11 format with headings of client routine, possible problems and managed how and by whom. Additional sheets provided information about the person’s social, emotional and nutrition needs. There were risk assessments for the persons’ initial admission, feeding assessment, nutritional assessment and mobility assessment, moving and handling assessment and a risk assessment for the use of bedrails in one plan. Other documents included a weight record, a monthly review chart of care plan, a body map and record of professional visits. The manager stated that the document had been arranged in this way to provide any person reading the plan with an immediate understanding of the person’s needs for the segment of the day and how they should address these, without having to read through separate pages of care planning documents detailing each area of the daily lives. From discussions with staff and people who use the service it was apparent that everyone was aware of the plans and the descriptions they contained fitted generally with how people understood their support should be provided. People living at the home told us “I had help with dressing a few weeks but now I manage myself quite well, if need help they will give it”, “Staff are prompt to act on my concerns”, “When I need something they help me Most of the time”, “ they are very supportive especially with my mobility problem” and “The staff are good and friendly and will always help you when needed”. There were some issues with the way the accuracy of the information held in the plans and how the information from other documents such as risk assessments and monthly reviews of plans were monitored. In one example the person’s nutrition needs stated that they were able to feed themselves and required no special assistance or equipment. Whilst their nutritional risk assessment stated that they had no weight problem and fell in a low risk category. However from other records it was known that the person was not eating well and had in fact lost a significant amount of weight during a short period. This appeared to demonstrate that risk assessments do not have their outcomes recorded in care planning. In a separate section of the care plan the Social and Emotional element of the person’s care plan describes the difficulties the person has in engaging in activities and their challenging behaviour at times. There is not any conclusion in the guidance to staff in managing neither the most appropriate support nor what goals the service is hoping to achieve. The significance of these omissions was demonstrated shortly before the inspection visit, during the investigation of a safeguarding referral. This was made in respect of the support a person with increasingly complex emotional and physical health care needs that had challenged the skills of the service. DS0000017799.V368714.R01.S.doc Version 5.2 Page 12 This required staff to maintain a clear record of the action they were taking and how well this was working to address the person’s needs. Although medical advice was sought and some action taken by the service the decline in the person’s wellbeing had continued. The records maintained did not provide sufficient levels of detail to understand how the staff were to respond to the challenging behaviour they encountered, the person’s declining appetite, the management of medication and falls the person experienced. The safeguarding strategy meeting convened to consider the evidence in respect of the safeguarding alert concluded that the service needed to address its care planning and risk assessment record management as well as seek guidance for staff in management of medication. The medication element of the safeguarding alert related to the administration of medication that is prescribed Pro re nata (PRN) or as and when. The issues had arisen when staff responsible for determining whether to administer a medication prescribed by the GP as PRN did not have clear guidance of the indicators or contra indictors for the administration. This had resulted in the medication continuing to be administered (within the stated dosage) despite adverse responses to the drug. The service had following the recommendation of the strategy meeting instigated a more robust system for giving medication under these directions. This required two staff signatures for any administration of a PRN medication. They had also sought guidance from the GP for indicators for any PRN medication. From the observation of a medication round and discussions with staff it was demonstrated that there was generally a robust method for the dispensing, recording and management of medication in the home. The staff member was precise in their administration and carried out their duties with all due care and attention. All staff that were responsible for the dispensing of medication had been trained to do so. DS0000017799.V368714.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Most people living at the home can be assured that they will be provided with a range of activities to suit their preferences. However development is required to ensure that opportunities are provide to all the people living there. EVIDENCE: The service employs two staff working alternately Monday to Friday between 2pm and 5 pm. They maintain a logbook of activities they have offered during their shift and include details of who has taken part. The entries for the period prior to the inspection included sessions of quizzes, hangman, crosswords, knitting, darts, dice games and dominoes. There were approximately 12 people enrolled in each session, and many took part in a number of activities. During both visits to the home people were observed taking part in the activities and said they enjoyed what they were able to do. One person who was independently mobile told us about being able to go out for walks and enjoying the garden as part of their activity although they did join in some things in the home. They told us “Yes for some afternoons we have different DS0000017799.V368714.R01.S.doc Version 5.2 Page 14 activities bingo, questions in different subjects and darts. A lady comes in for that”, “I do not take part” and a relative told us “Activities available but my relative sometimes doesn’t have the capacity to take part. Staff try to provide as much social interact as possible”. People who did not wish to join group activities or were not so independent were not so obviously catered for in respect of their social and emotional needs and this requires greater consideration and collaboration amongst the staff team to ensure that everyone has opportunity to express these needs in whatever setting is most appropriate. The services visiting policy is provided in the service users guide and relatives, advocates and others were seen visiting residents throughout the inspection day. A person living at the home told us that their family member visited regularly and was always made welcome by the staff. They said that the staff offered refreshments and encouraged people to feel at home. Another person told us about how they went out with their family and the arrangements for them being collected and dropped off were well known to the home. The mealtime during the inspection was served in an unhurried manner, and only when everyone was seated. The meal was enjoyed in a relaxed way and the atmosphere was pleasurable. The service aims to provide flexibility where required and One person who had an early appointment had been provided with their meal in advance of the rest of the diners in order to accommodate the time of their transport. There was a choice of food available, and residents spoken with were aware of the choices of menu on offer that day. DS0000017799.V368714.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the service can be confident that their views will be listened to and staff will take action. They can be assured that staff understand how to protect them from abuse. EVIDENCE: The services complaints policy has been previously viewed at inspections and meets the criteria set out by the Care Homes Regulations 2001, with appropriate descriptions of how to make a complaints and timescales to which the service responds. As part of this policy the service maintains a complaints log, which held good records including action taken in response to complaints. The complaints log on this visit contained reference to six complaints. These were all recorded with the investigation and responses to the concern. The Commission had directed one of these concerns to the home and had monitored the services response to the issues. There had been a full and prompt response made to the complainant, although the Commission felt that the tone of the services response was defensive and did not adhere to its own policy. As a result the service was asked to review its practice against the published policy. Subsequent complaints had been appropriately dealt with. DS0000017799.V368714.R01.S.doc Version 5.2 Page 16 People who live at the service told us they were confident about their rights to make a complaint and were able to tell us who they would approach to do so. Some people told us they were less confident although they were unable to tell us of any reason they felt this way. This was discussed with the manager during the inspection as a point of quality assurance. The service had been the subject on one safeguarding referral as detailed elsewhere in this report. The strategy meeting convened by Essex Social Services as a result of the referral heard the evidence from all parties and concluded the meeting with an action plan for the service to address the issues raised. At this inspection visit, the Commission was able to determine that the service had responded to its part in the action plan and all items had been addressed. One of the issues raised in the Safeguarding referral related to staffs awareness of the wellbeing of the person they were supporting and alleged that their actions during the events did not improve the positive outcomes for the person. During the inspection the services policy in safeguarding and staffs awareness of their role in protecting people from abuse was considered. The policy was robust in its description of abuse and the services responses to the reporting of an allegation. Staff spoken with during the inspection were clear about their role in protecting people who live in the service and how they should make their concerns known. This was tested across the range of the staff team and included ancillary staff. All staff receive safeguarding training as part of their induction and at regular intervals thereafter. DS0000017799.V368714.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home can enjoy an environment that meets their needs. EVIDENCE: The premises and grounds of Crouched Friars had not had any significant alterations to their layout since the last inspection. There had been redecoration to the communal dining rooms that included new flooring and curtains. The dining furniture had also been replaced and people living at the home had been involved in the colour choices agreed. Redecoration of the external walls has also been undertaken. Although it is a fairly large home, the layout of the building gives an impression of smaller units and is not institutional. Accommodation is largely, but not wholly, in single rooms. There is some variation in the quality of accommodation provided to individuals, however it is felt that overall the DS0000017799.V368714.R01.S.doc Version 5.2 Page 18 accommodation is good. The home is on a number of levels but there is a lift in place to ensure people can move about the building. The front garden was tidy and well presented with a variety of flowering plants. The home has a generous sized rear garden. The rear garden was also maintained although the fixed gazebos had been removed the manager outlined plans to erect fabric gazebos to provide shade. Independent accessibility for residents with walking aids and in wheelchairs to the garden continues to require attention. The home is situated in the centre of Colchester making it easy for people, where suitable assistance is available, to access the town centre. The home was clean, free from odour and well maintained on the day of the inspection, and people spoken said they never found the home unclean. Staff were observed wearing gloves and aprons when appropriate and records demonstrated that they had undertaken training in respect of infection control. DS0000017799.V368714.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home can expect to be assisted by a group of staff that are supported and trained to meet their needs. EVIDENCE: The staff rosters for the period before and following the inspection demonstrated that the service worked with six staff during the waking day with the addition of the activities coordinator, housekeepers, catering staff and the handyman. There were four staff working at night on a waking shift. The staff training programme covered subjects that included safeguarding adults, infection control, moving and handling, fire safety, health and safety, basic food hygiene and first aid. Senior care staff had also completed medication training. Other subjects such as Dementia care, communication and counselling had been included in the programme at the specific request of staff. There was matrix maintained of all training individual staff had undertaken with dates for when the renewal is due. External providers were carrying out the staff training at the time of the inspection. However, the manager stated that she and the deputy manager DS0000017799.V368714.R01.S.doc Version 5.2 Page 20 were attending a train the trainer course that would provide them with a qualification to lead training in house and provide greater flexibility to respond to training when required. There were 18 staff employed who held the National Vocational Qualification (NVQ) level 2 or above at the time of the inspection with a further 8 staff undertaking the course. This brings the current percentage of staff with a recognised qualification to 64.2 and will rise to 92.8 when the remaining 8 staff qualifies. Staff induction programme was made up of a four day in house induction using a worksheet used by managers to chart the staff member’s competence. This is then followed by the Skill for Care Common Induction Standards over a longer period. The recruitment records for the three newest staff were considered to determine the services approach. All records such as a completed application form, two references and proof of identity. Checks against the Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) lists were present. Overseas workers had copies of Home Office working permits on file. This documentation supports the service in demonstrating a robust system of recruitment that seeks to protect people living at the service from abuse. DS0000017799.V368714.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, 32. 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home can be assured that a competent manager who listens to their views and takes action leads the home. EVIDENCE: The service had recruited a new manager Monika Reid. Ms Reid had been registered by the Commission and completed her NVQ level 4 Registered Managers Award prior to the inspection. Ms Reid has a number of years experience in care and nursing settings and prior to taking up the manager’s post had worked in the home as the deputy manager for three years. DS0000017799.V368714.R01.S.doc Version 5.2 Page 22 Ms Reid has instigated a number of initiatives since her appointment and was keen to address the requirements made of the service. She had completed an AQAA when required to do so, and although the information in this was brief from discussions with staff and service users it was clear that this was an oversight of completion rather than lack of action. People who lived at the service and staff spoke highly of the manager, the deputy and the proprietor. They felt that they could speak to any one of them with confidence and assurances that action would be taken. There are very few people who ask the service to support them in managing their monies and their families deal with the majority of people’s financial affairs. The service was able to demonstrate a robust audit trail for the transfer of funds it did hold. All staff working at the home received line management supervision on a regular monthly basis. The service used a matrix to monitor the dates of past and present supervision for each individual. Copies of the supervision records were held on file and these referred to a mixture of observation sessions and one to one discussions. The service conducts an annual quality assurance system that includes surveying the views of people who use the service and their supporters. The results of these were audited and an action plan drawn up in response to the issues raised. The whole process is published and on display in the home. The manager was advised to ensure that this feedback was included in the Annual Quality Assurance Assessment provided to the Commission annually. Records relating to the maintenance of health and safety equipment were examined. These included electrical and electrical safety certificates, passenger lift and moving and handling maintenance check and the fire system safety checks. DS0000017799.V368714.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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 DS0000017799.V368714.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 OP7 OP8 Regulation 15 Requirement Residents’ plans of care must contain all the information gathered about them and is updated when additional information is provided. This will assist staff to support residents consistently in a way that provides the best benefits to the individual. This is a repeated requirement Residents’ choices and preferences in relation to daily living, activity, social emotional and spiritual needs must be recorded and care staff as well as the activities co-ordinator must have sufficient skills to be able to provide opportunities to exercise these choices This is a repeated requirement Timescale for action 31/10/08 2. OP12 15 30/11/08 DS0000017799.V368714.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000017799.V368714.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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