CARE HOMES FOR OLDER PEOPLE
Cumberworth Lodge Graizelound Haxey Doncaster South Yorkshire DN9 2NB Lead Inspector
Theresa Bryson Key Unannounced Inspection 3rd October 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000002912.V352156.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. DS0000002912.V352156.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Cumberworth Lodge Address Graizelound Haxey Doncaster South Yorkshire DN9 2NB 01427 752309 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 Maheslall Boodhoo Mrs Rajkumari Boodhoo Mrs Rajkumari Boodhoo Care Home 22 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (22) of places DS0000002912.V352156.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. To create a secure garden area to allow the service users in this category to have access to a safe outdoor space. 19th October 2006 Date of last inspection Brief Description of the Service: Cumberworth lodge is situated in a quiet lane in the village of Graizelound near Haxey. The home provides a variety of accommodation between the older part of the home and the new extensions. All the service users are in single accommodation some of which have ensuites. The accommodation is spacious comfortable and homely. The home is registered to accommodate up to twenty-two male/female service users within the category of old age, not falling within any other category including five service users with Dementia who are over sixty five years of age. The current scale of charges is £320 - £385 per week. There are additional charges for hairdressing and for private chiropody services. The Statement of Purpose and Service User Guide is given to each prospective new service user and is on display in the main entrance hall. DS0000002912.V352156.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This site visit took place over one day in October 2007. Prior to this visit a number of surveys were sent out to people using the service and staff, of which 5 were returned from people resident in the home or their relatives and 8 from staff. On the day 6 people living in the home were spoken to individually and 5 in a group setting as well as 5 staff. The home had completed the AQAA documentation and sent it to the inspector prior to the site visit, as well as supplementary documentation. Other documentation was seen at the site visit, as well as 3 peoples care plans tracked in depth and 4 staff files tracked in depth. Records kept by CSCI were also checked prior to the visit. The owners and manager were present on the site visit day and all staff were very cooperative. What the service does well:
The management style of the home is open and transparent. Each team member ensuring the views of people using the home, visitors, other agencies and staff are sought, on a regular basis. Records are kept of surveys completed and how comments are actioned and practises, in some cases changed for the benefit of the people living and working at the home. This has ensured the home has gained two major awards. One looking at training and staff issues, predominately, with the Investors in People Award and the other the Gold Standard Quality Award given by the local authority for good practise in looking after people in the home and how the home is run. Comprehensive documentation is provided to ensure that people wishing to use the home can make informed decision as to whether the home is suitable to meet their needs. They are then assessed, using an holistic tool to prepare staff to help them meet that person’s needs. Care plans are then formed and up dated on a regular basis to ensure current needs of service users can be met. DS0000002912.V352156.R01.S.doc Version 5.2 Page 6 A balanced and varied menu plan is offered on a daily basis with lots care taken to ensure that individual needs are also catered for. All meals are prepared in a safe and clean environment. Robust systems are in place to ensure that staff are checked prior to commencing employment and are safe to work with the people who live in the home and are then supervised and trained to do their jobs. The management team and all staff ensure checks are made on a regular basis to ensure the building is safe to live and work in and all relevant certificates are in place. There are sufficient staff on duty at all times to ensure the needs of service users can be met and they work very closely as a team to support each other. What has improved since the last inspection?
All requirements and recommendations from the last inspection had been completed at this site visit. The Statement of Purpose had been revised to show the categories the home is registered for, to enable prospective service users to make informed decision. Care plans had been reviewed to ensure people using the service were not at risk from staff using restraint methods and safe practises were in operation. Staff are now aware of the boundaries of their competences when administering medication and that changes cannot be made without the consent of a medical practioner and all people requiring medication to manage challenging behaviour have suitable care plans in place. Records are now kept on the activities provided in the home to meet peoples’ expectations and each person is assessed to ensure their current needs can be met. A new fire escape has been put in place and the old one destroyed, so people can feel safe in the case of fire breaking out and their exit now being secure. An alarm mat and freestanding heater mentioned, as requirements in the last report are no longer in use. The manager has now achieved NVQ level 4 in management and care.
DS0000002912.V352156.R01.S.doc Version 5.2 Page 7 AS stated in the body of this report the training skills matrix has been updated and there was written evidence on individual staff training records, the training planner, supervision records of staff, certificates seen and on talking to staff that all mandatory training is up to date, which ensures people using the service are cared for by adequately trained staff. What they could do better:
There were no requirements needed to be set at this inspection but 5 recommendations were made to show good practise guidelines were being followed. Temperatures readings although being taken were not written down when taken in the medication storage room and also for the fridge where medication is stored. To do so will enable staff to see that all medication is stored at the correct temperature and not put people at risk from wrongly stored drugs. The recent environmental health officer’s report recommended that the kitchen cupboards needed repairs as this will prevent crockery and other items from becoming dusty and cause a hygiene risk. Staff currently administers the residents’ fund, but the manager was in the process of reviewing this to ensure the management team are aware that accurate records are kept and the account is run efficiently. Water temperatures are taken at all outlets where people using the service have access but not written down. To do so will enable the management team to see there are no failings in the system and people are not at risk from using too hot or too cold water. When the new guidance was issued regarding the use of bed rails the management team ensured all rails where checked. Those in use have not been checked regularly to ensure they are in working order, which needs to be recorded to ensure people are not put at risk from ill fitting rails. DS0000002912.V352156.R01.S.doc Version 5.2 Page 8 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. DS0000002912.V352156.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 DS0000002912.V352156.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive information is available to ensure that prospective service users can make informed decision about the services provided. Each person has an holistic assessment to ensure the home can meet their needs. EVIDENCE: During the course of this inspection Standards 1,3 and 6 were checked. Since the last inspection the Owners have revised the Statement of Purpose to ensure it reflects the services provided in the home and categories of service users it is registered to take. DS0000002912.V352156.R01.S.doc Version 5.2 Page 11 This is given to all prospective service users and is on display in the main entrance hall. This will ensure that people can make informed choices and ensure the home can meet their needs. Prior to admission the manager or one of the owners will visit the prospective service user to ensure the home can meet that person’s needs. They have refused some people in the past as unsuitable to fit into the family atmosphere at Cumberworth Lodge and knowing staff would not be able to meet their needs. The document seen was very comprehensive and looked at each person in an holistic manner. The assessment chart is then graded, with indicators to show at what level of dependency a person is on admission. A prosptive service user’s file was seen of a person awaiting admission and the preparation was very detailed. This will ensure that staff can be prepared for an admission and help make the person feel at home when first coming into a care home setting. The home does not provide intermediate care and therefore Standard 6 is not applicable. DS0000002912.V352156.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are recorded and evaluated on comprehensive documentation to ensure current needs are being met. EVIDENCE: During the course of this inspection Standards 7,8,9 and 10 were met. The home has a key worker system, which ensures that each person resident in the home has a named staff member who gets to know them well. Individual time is recorded in the care plan notes and this person will also liaise with family and out side agencies, sometimes under the guidance of more senior staff. Prior to the site visit service user surveys were sent out and 5 were returned. All wrote very positive comments about the standard of care in the home. 6 service users were spoken to in private on the day and 5 chatted to the
DS0000002912.V352156.R01.S.doc Version 5.2 Page 13 inspector, collectively over lunch. Comments were made such as “ there isn’t a better home” and “ every one is so nice” and “ they look after me”. 3 care plans were tracked in depth and found to be very comprehensive. There was good follow through from accident recording and visits by GPs’ and other health professionals. Current needs had been identified on each one seen and regular evaluations recorded to ensure those needs were current and being met. There was also written evidence that service users or their families had seen each care plan and signed to agree to the care being provided. A couple of people stated this to the inspector on the day, as well. The manager aims to review each care plan at least twice a year and there was written evidence to support this happens. The staff supervision notes also recorded that these were checked with the key workers on a more personal level to ensure staff fully understand the reasons for accurate recording. The owners acknowledged that there is always room for improvement and search the internet for ideas, which are shared with staff at meetings. Staff stating this helps them understand the reasons for completing all documentation carefully. A senior carer went over the administration of drugs records and was able to give a confident précis of the process used in the home. The home is supported by two local GP practises who appeared to give good support to the home. Records seen appeared to be accurate and the storage area was clean and tidy. Safe practises appeared to be in place to ensure that service users are free from harm and given accurate dosages of medication as prescribed. The home currently does not take a daily temperature reading of the medication storage room or drug’s fridge, which is good practise to do, to ensure that all medication is stored safely. Staff were observed during the day assisting service with such tasks as meals, activities and personal care. Each person was approached using their preferred name and asked what they wanted or told what was happening. Such as “ hello…..its lunch time now and here is the meal you asked for, chicken and vegetables, can you manage?” Or “would you like to come down for Holy Communion or play some dominoes?” Staff assisting a person for toileting needs were observing good practise guidelines by wearing gloves and an apron, disposing of then correctly and using a good hand washing technique. Service users spoken to also made such comments as “ at night they come and check on me, they checked me 4 times last night, which I like” and “they help me a lot because I am virtually blind” and “the girls see I have every thing I want”. DS0000002912.V352156.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are offered a variety of activities to meet their social, religious and cultural needs. Balanced meals are provided in a clean and safe environment. EVIDENCE: During the course of this inspection Standards 12,13,14 and 15 were checked. Since the last inspection there has been better documentation of activities which have taken place and these have been recorded in various pieces of care note documentation. Each service user’s social needs are assessed on admission and evaluated regularly. The key worker for each person also writes quality time notes when they have spent time with each person or assisted them with a specific task. A social events record is also kept by the activities co-ordinator and completed as an event occurs. This may be a one to one session such as chatting or reading to them or a group event such as games or entertainers. These
DS0000002912.V352156.R01.S.doc Version 5.2 Page 15 recorded participation of each person, whether they enjoyed the event and benefits to that person. Helping staff to see if each person’s expectations were being met and planning if they were not met. Regular trips out to local events and the surrounding area were recorded and a local Christian church was visiting the day of the site visit. A famous local event the Haxey Hood race also visits the home to sing to the service users, which some people remembered. A monthly plan of events was on display and other items recorded in the threemonthly newsletter. One person stated, “ I like the stories with a meaning” and another “ I’m happy in my corner, but people come and see me to chat”. There was ample evidence in service users rooms that people had been able to personalize their rooms. One person showed the inspector their mini fridge, (which is checked regularly by staff) and another the personal paintings on display in their room, which they obviously had lots of enjoyment in looking at and discussing. Service users and staff spoken to also stated how well the manager and owners consult them about the running of the home. One service user was able to inform the inspector that the home had gained the Gold Standard Quality Award from the local authority. The three-week cycle of menus had been sent prior to the site visit and showed a varied and balanced diet was on offer daily, with choices. On the site visit day the cook was able to inform the inspector that 4 choices had been cooked to suit service users needs. All meals seen were presented well on the crockery and the tables set with clean linen and condiments. The home was currently catering for service users with diabetes and who needed extra thickening in their food. This ensures that all meals are varied, service users have a balanced diet to suit their individual needs and all food is prepared in a safe and clean environment, with staff using safe practise guidance. A cook showed the inspector around the kitchen, which was clean and tidy. They were able to give a good précis of how items are ordered, control checks made for preparation and after cooking and replacement items such as crockery and pans. The local environmental health officer had visited the previous week and the report, seen, showed that the visit was satisfactory, with only comments made concerning the cupboards. One of the owners informed the inspector the kitchen is the subject of a possible refurbishment and new cupboards will be purchased. DS0000002912.V352156.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected from abuse by staff using safe practise guidelines and written policies available on how to deal with complaints. EVIDENCE: During the course of the inspection Standards 16 and 18 were checked. The AQAA documentation returned before the site visit did not indicate any complaints received since the last inspection. On checking the complaints log whilst on site it was seen that one had occurred since that information had been compiled. All appeared to be correct with documented evidence to show how it had been dealt with and the satisfactory outcome. Service users spoken to stated they felt confident any concerns would be addressed promptly and in confidence by the management team. One person stated that it would not “worry them” approaching the management side to raise an issue. Copies of the policy and procedure were seen and this was also on display around the home. All information on who to complain to appeared to be accurate. The open and transparent management style at Cumberworth Lodge ensures that service users, visitors and staff feel able to refer any concern to the
DS0000002912.V352156.R01.S.doc Version 5.2 Page 17 management team and confident it will be dealt with promptly and in confidence. All but 6 staff had attended up dated training in the safeguarding of adults policies, which will ensure that service users are not put at risk from ill equipped staff. One of the owners sits on a local committee looking at such issues and keeps abreast of current legislation, which is kept in a file, to which staff have access. DS0000002912.V352156.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are living in a safe and clean environment adapted to their needs. EVIDENCE: During the course of this inspection Standards 19,23,25 and 26 were checked. Since the last inspection the owners were able to show the inspector how they had tackled the outstanding requirements and recommendations, which had now all been completed. A new fire escape had been installed and checked as safe to now use. A freestanding heater was no longer in use or an alarm mat, which was no longer required.
DS0000002912.V352156.R01.S.doc Version 5.2 Page 19 A room, which appeared to be undersized, has currently been taken out of use. The inspector toured the home alone for a short period and then toured the main part of the house with one of the owners and manager. All areas appeared clean and tidy and there was evidence of some redecoration and refurbishment in some areas. Fro example a new bath, handrail and toilet seat had been purchased in one area. Some new carpets put down and some painting had taken place. All equipment in the laundry was in working order and the area very clean and tidy. Linen supplies were plentiful and all in a good state of repair. There is ample car parking space and all exits were hazard free. The gardens were colourful and a secure space provided for those who may wander out of the safety of the grounds due to their memory state. A copy of the maintenance plan had been submitted prior to the site visit and this showed that approximately 4 to 5 items are tackled monthly, which appeared on a variety of check lists seen. This ensures that service users are living in a safe and secure environment which is maintained to a high standard, with their individual needs taken into consideration. DS0000002912.V352156.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust systems are in place to ensure staff are safe to work with service users prior to employment. EVIDENCE: During the course of this inspection Standards 27,28,29 and 30 were checked. Prior to the site visit the staff rota had been submitted with the AQAA documentation. This was again checked on site. The home uses the Residential Forum Matrix to determine the amount of staff required according to the dependency of the service users. Of the 5 service user survey forms returned, 11 service users spoken to and 8 staff spoken to, no one indicated that needs could not be met and staff stated they try and work as a team to ensure sufficient staff are always on duty. Apart from care staff the management team ensure that other staff are employed to ensure the smooth running of the home. These include; administration, maintenance, gardening, activities coordinator and general staff. The management team were able to explain the system in place to ensure that staff are adequately trained to do their jobs. This includes all mandatory
DS0000002912.V352156.R01.S.doc Version 5.2 Page 21 training as well as service specific training such as dementia and infection control. Each staff member has a separate training file which details individual training undertaken and certificates obtained. The supervision records show how training is a part of the staff’s working life and a skills matrix identifies who requires update mandatory training as well as topics suited to their individual needs. 5 staff were spoken to on the day and 8 staff survey forms returned. These stated how valuable they feel training is to their role and how much they appreciated the effort put into organising events by the management team. 4 staff personal files were tracked and all showed the relevant information to prove safety checks had been made prior to staff commencing work and that they were safe to do their jobs and look after service users with adequate training in place. DS0000002912.V352156.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to live in a safe and secure environment where adequate safety checks are completed and their views sought on the running of the home. EVIDENCE: During the course of the inspection Standards 31,33,35,36 and 38 were checked. The manager has now completed the outstanding NVQ level 4 award in management and also attended other training. The owners too had attended many training and conference events since the last inspection and work closely with outside agencies to improve not only their knowledge base, but also
DS0000002912.V352156.R01.S.doc Version 5.2 Page 23 services to the wider community and other care homes. The management team appeared to support it each other and had a good knowledge base of all issues about running the home and the needs of individual service users. The home has been awarded the Gold Standard for Quality Award by the local authority and currently also has the Investors in People Award. The management style was open and transparent and written evidence was seen on how service users, visitors, staff and outside agencies are surveyed through out the year on the services provided. The audit results are discussed at staff and service user meetings as well as being on display individually and in the annual service review. All audits have action attached, which is then shared and tasked to other checking processes through out the year. All documentation seen by the inspector appeared to be very through. Some topics covered have been care plans, service provided, satisfaction and respect and dignity. This ensures that all parties’ views are valued and taken into consideration by the management team. Service users and staff stated to the inspector on the day that they are consulted and made such comments as “its nice to be asked my opinion” and “I feel valued when they ask me about the home” and “the owners ask me about life here and I say its good”. The supervision records of staff were tracked and these showed very detailed discussion, which had taken place. The documentation showed that previous topics were reviewed, future topics discussed, including training and work performance. There was also opportunity recorded for discussion by both parties. Staff spoken to were able to tell the inspector how often they had supervision and whether it was useful to them as individuals. This ensures the management team can keep abreast of staff needs; ensure they are aware of whether or not they are doing their job and how to address lack of knowledge to make them safe practioners. Other documented evidence was seen, as well as the completed AQAA document to show that the management team are ensuring the building is safe to live and work in and audit checks are maintained on a regular basis. Some good practice advice was given on some topics. Water temperature checks are made on outlets accessible to service users, but not recorded. As parts of the building are old there could be fluctuations in water temperature and the inspector advised it was safe practise to record where there could be variances of temperature to ensure service users are safe at all times. The initial bed rail checks had been completed to ensure all rails in use conform to present safety standards, but the on going maintenance could not be proved. To ensure all bed rails are safe the maintenance person should check they are used safely and in working order.
DS0000002912.V352156.R01.S.doc Version 5.2 Page 24 The home holds no personal finances for any service users, but does have a residents fund maintained by staff. The manager was in the process of reviewing the way this is run and ensuring all money is accounted for at all times. This will ensure it is run for the benefit for service users and has accurate recording. On the site visit day all staff were very cooperative and helpful to the inspector and the comments appeared very open and honest. Service users looked well cared for and many expressed how happy they were in the home. One comment from a service user was “I would recommend the place”. DS0000002912.V352156.R01.S.doc Version 5.2 Page 25 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 X 3 3 STAFFING Standard No Score 27 3 28 3 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 3 X 3 DS0000002912.V352156.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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. 4. 5. Refer to Standard OP9 OP15 OP35 OP38 OP38 Good Practice Recommendations It is good practice that the storage room and fridge used for medication is checked daily to ensure all medication is stored at the correct temperature. It would prevent items of crockery and cutlery and dry goods and other items from becoming dusty if all cupboards in the kitchen area were fitted correctly. The manager is aware that the residents’ fund accounts need to be ultimately under management control and not just of staff and all records accountable. The water temperatures on all outlets used by service users need recoding regularly to ensure they are safe to use. Bed rails in use need regular maintenance checks to ensure they are being used safely and not putting service users at risk. DS0000002912.V352156.R01.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: 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
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