CARE HOMES FOR OLDER PEOPLE
Darwin House Darwin Lane Sheffield South Yorkshire S10 5RG Lead Inspector
Sue Turner Key Unannounced Inspection 4th September 2007 07:45 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 DS0000002955.V347185.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. DS0000002955.V347185.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Darwin House Address Darwin Lane Sheffield South Yorkshire S10 5RG 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) 0114 230 1414 0114 230 6017 whitaker.hilary@tiscali.co.uk Darwin House Limited Post Vacant Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places DS0000002955.V347185.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 6th September 2006 Brief Description of the Service: Darwin house is a home providing personal care for 25 older people. It is situated in a residential area of Sheffield. The facilities are on three floors accessed by a lift. Seventeen single and five double rooms are available. Each of the bedrooms is provided with en-suite toilet facilities, five rooms have ensuite showers. A variety of communal lounge space, and communal library room and dining room are provided. A central laundry and kitchen serve the home. Sufficient bathing facilities are available. The home has pleasant landscaped gardens with seating for service users. The home has a car park. A copy of the previous inspection report was on display and available for anyone visiting or using the home. Information about how to raise any issues of concern or make a complaint was on display in the entrance hall. The manager confirmed that the range of monthly fees from 1st April 2007 were £510 - £600 per week. Additional charges included newspapers, hairdressing and private chiropody. DS0000002955.V347185.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out by Sue Turner regulation inspector. This site visit took place between the hours of 7.45 am and 3:30 pm. Hilary Whitaker is the acting manager and was present during the visit and the responsible individual; Vanessa de Roeck attended the home to receive feedback. Prior to the visit the acting manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Questionnaires, regarding the quality of the care and support provided, were sent to people living in the home, their relatives and any professionals involved in peoples care. The Commission for Social Care Inspection (CSCI) received eleven from people using the service, four from relatives, two from professionals and one from a carer. Comments and feedback from these have been included in this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to five staff, two relatives and six people living in the home. The inspector checked all key standards and the standards relating to the requirements outstanding from the agencies last inspection in September 2006. The progress made has been reported on under the relevant standard in this report and any requirements that continue to remain outstanding have been carried forward with a short timescale. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. What the service does well:
It was positive to note that the majority of the feedback received was extremely positive particularly in relation to the support provided by the carers. Comments about the service provided included statements such as: “ I know who to speak to if am unhappy but I don’t usually feel unhappy”.
DS0000002955.V347185.R01.S.doc Version 5.2 Page 6 “The staff here are all extremely friendly, caring and kind”. “We have a very high standard of catering and they will make special dishes on request”. “I am very pleased I chose Darwin House. I recommend it thoroughly and I am very happy here”. Health professionals made comments such as: “The general care and hygiene are excellent, peoples social needs are met very well and staff and client interaction is excellent”. Relatives said: “The staff are very friendly and any problems we have are solved efficiently”. “The home keep us well informed about mums health and well being and this is reciprocated”. “There isn’t a better home in Sheffield”. The inspector observed that people were well dressed in clean clothes and had received a very good standard of personal care. People’s health care was monitored and access to health specialists was available. People confirmed that staff were always respectful towards them. People said they enjoyed the activities available at the home. Activities available included quizzes, arts and crafts, gentle exercise and coffee mornings. People said that they had a choice of food and that the quality of food served was “jolly good” and “very wholesome” and “the sweet courses are fantastic and remarkable”. There was a complaints procedure in place, to promote peoples safety. People said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. People said that they felt safe living at the home. The home was clean and tidy. No unpleasant odours were noticeable in the home. People living in the home and their relatives said that the home was always kept “immaculately clean” and “very tidy”. Agreed levels of staff were being maintained. A staff training record was in place, and individual training records were maintained. A recruitment procedure was in operation to ensure the safety of people living in the home.
DS0000002955.V347185.R01.S.doc Version 5.2 Page 7 Records within the home were stored securely, to safeguard confidentiality. Health and safety procedures were identified and carried out, and in the main systems were checked and serviced to maintain a safe environment. What has improved since the last inspection? What they could do better:
The statement of purpose and service user guide needs to be reviewed and updated so that it provides an accurate account of the service provided. Prior to being admitted to the home each persons individual needs and wishes must be ascertained and recorded so that everyone is confident that the home will be able to meet peoples personal and specific needs. The care needs, wishes and preferences for each person must be recorded in detail in their care plan. Plans of care should contain specific information on the staff action required to meet personal care needs. Care plans and risk assessments must be regularly monitored and reviewed, then signed and dated to confirm that this has been done. The person making the entry must sign handwritten entries on Medication Administration Records (MAR) sheets. A witness must also sign to confirm the instructions are accurate. The pharmacist who supplies the medication should check the home’s medication system. To ensure peoples health, safety and well being all staff should receive updated/refresher training in Adult Protection, Moving and Handling and any relevant specialist training for the role they are to perform.
DS0000002955.V347185.R01.S.doc Version 5.2 Page 8 To further improve the service provided, a quality assurance system must be developed. The outcome of the quality assurance process should be published annually, supplied to the CSCI and made available to everyone who has an interest in the home. Fire alarms must be tested every week. 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. DS0000002955.V347185.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 DS0000002955.V347185.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 and 5. Standard 6 is not applicable to this home. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A statement of purpose and service user guide was available and contracts were drawn up with each person to inform them of their rights and obligations. Further pre admission information is necessary to ensure the home was able to meet peoples health, social and care needs. EVIDENCE: The homes Statement of Purpose (SOP) and Service User Guide provided lots of useful and informative information about the home and what services they could and could not provide. However some information was out of date, documents still referred to the National Care Standards Commission (NCSC) and this had changed to the Commission for Social Care Inspection (CSCI) in
DS0000002955.V347185.R01.S.doc Version 5.2 Page 11 April 2004. The SOP and service user guide also needed to be updated to reflect the changes in the management and staff team. Individual contracts (guest agreements) were drawn up with each person upon admission; these were kept on file and had been agreed and signed by each person or their representative. Assessments of needs were undertaken prior to admission and trial visits were encouraged to enable people to look around the home, meet other people living in the home, see the staff and gather the information needed to make an informed choice. Staff said that they were not always given sufficient information about people before they were admitted into the home. The majority of the homes guests were self-funded and this meant that the only information was provided by the manager’s own assessment. The inspector believes that the pre admission assessment should be more detailed to ensure that the home is confident that they can meet people’s needs before they are admitted into the home. DS0000002955.V347185.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s plans of care were vague and did not contain all of the required information, which could result in people not being supported as needed or as they preferred. Medications were generally well managed, however the new system will ensure that people are further protected from medication administration errors. People and their relatives were very complimentary about the way staff cared for them and the ways they promoted their privacy and dignity. EVIDENCE: Two peoples care plans were checked. One person had been living at the home for six weeks. Many sections of their care plan had not been completed, which made it very difficult to assess what staff needed to do the ensure that all the persons health, emotional and social needs were met. Some parts of the plan
DS0000002955.V347185.R01.S.doc Version 5.2 Page 13 were not signed or dated and this made it difficult to assess if they was a system in place for reviewing and updating. The other care plan seen did not reflect the care that the person them self said they were receiving. They said their health had deteriorated and staff had to assist them much more, they were very pleased with this, but none of the changes made were recorded in the plan. People said that a range of health professionals visited the home to assist in maintaining peoples health care needs. District nursing services visited the home as required and GP’s, dentist, opticians and chiropodists also visited the home as requested. In one care plan seen there was no information recorded regarding health professional visits, although there was a place for recording this and the person said they had received visits from the GP and district nursing services. Risk assessments were in place however these were brief and in some cases out of date. Relatives said that the managers and staff were very good at involving them in their loved ones care. They spent time talking to them and keeping them informed if their loved one was ill or had had an accident. Medicines were securely stored around the home in locked trolleys within locked cupboards. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. The manager said that they were in the process of changing to a safer medication dosage system. The pharmacist had agreed to provide training to the staff prior to the new system being introduced. The pharmacist on a three monthly basis would also check the new system, as this was a requirement at the previous inspection. MAR’s seen continued to have handwritten entries that had not been signed and witnessed, this previous requirement is therefore carried over in to this report, however the manager said that the new medication system would prevent this being an issue. People spoken to said that staff administered their medication at appropriate times and one person who had chosen to self administer had been provided with a lockable drawer to keep their medications safe. People and relatives spoken with, and via their questionnaires, confirmed that the carers treated them with respect and provided personal care and support in a way that maintained their dignity and privacy and was sensitive to their individual needs and wishes. People said that staff addressed them by the name that they preferred and from discussions it was obvious that carers had developed positive relationships with the individuals that they supported. DS0000002955.V347185.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had a choice of lifestyle within the home and were able to maintain contact with family and friends ensuring that they continued to be involved in community life. A range of activities was on offer, which promoted choice and maintained interests. Meals served at the home were of a very good quality and offered choice, which ensured people received a healthy balanced diet. EVIDENCE: People said they were able to get up and go to bed when they chose, and were seen to walk freely around the home, if able. Relatives spoken to said they were able to visit at any time and were made to feel very welcome. The inspector saw that everyone coming to the home was offered hospitality and staff took time to make sure friends and family were made to feel comfortable whilst visiting their loved one. Some people said they preferred to stay in their room at certain times of the day and that the staff respected their decision. A friendly and welcoming feel was very evident at Darwin House.
DS0000002955.V347185.R01.S.doc Version 5.2 Page 15 People said that they enjoyed taking part in a number of social activities within the home. Particular favourites were chair aerobics, crosswords and puzzles. The activities coordinator had recently left and a carer had taken on this additional role. People spoke very highly of the carer and enjoyed his/her sessions and said that they would like to do even more activities. Trips out of the home were less frequent, however the manager had successfully applied for a government grant to assist with the purchase of a people carrier, which would enable the range of current activities and excursions to be extended. At mealtimes the ambience in the dining room was pleasant and relaxed. Tables were set nicely with matching cutlery and crockery, condiments and fresh flowers. The dining room had been redecorated and new furniture made the room homely and appealing. People said that the meals at the home were always of a high standard with plenty of choices available. When talking about the food people said such things as “I’m not fussy, I like everything they give me”, “the choice of desserts make it like a five star hotel”, “I can’t grumble about the food” and “the meals are jolly good, I have no complaints”. One professional that visits the home commented, “The smell of the fish and chips on a Friday is mouth watering”. People were able to bring personal items with them into the home. All of the bedrooms seen were individually personalised, spacious and very homely. One person and one relative said they had made specific requests for particular rooms and the manager had arranged for this to be possible. DS0000002955.V347185.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place and people and their relatives felt confident that any concerns they voiced will be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were protected from abuse. EVIDENCE: People and their representatives had been provided with a copy of the homes complaints procedure, which was also on display in the entrance hall. This contained details of who to speak to at the home and informed the reader of who to contact outside of the home to make a complaint should they wish to do so. People and relatives said they had no concerns about the home, staff or service provided. They said that they felt very comfortable in going to any member of the staff or management team, knowing that any concerns they may have would be addressed without delay. The home kept a record of complaints, which detailed the action taken and outcomes. The home had received one complaint/issues since the last inspection. The manager had responded to this and a positive outcome had been reached. The CSCI had not
DS0000002955.V347185.R01.S.doc Version 5.2 Page 17 received any complaints about the home. Staff spoken to were clear how to respond and record any complaints received. Policies and procedures relating to Adult Protection were in place at the home and staff spoken to were aware of their responsibilities for reporting and responding to any potential abuse. Staff said they had undertaken training in adult protection, but for some this was several years ago and they had not had any updated or refresher training. DS0000002955.V347185.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 24 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was maintained to a high standard. The environment was very clean and fresh smelling. Homely touches had been provided to create a comfortable environment. Communal areas were well maintained, and people’s bedrooms were well decorated and personalised. Controls of infection procedures were in place, which promoted people’s health and welfare. EVIDENCE: The home is surrounded by very pleasant gardens, which have a variety of shrubs, flowers and an ornamental pond. Many rooms overlook the grounds and people said they got great pleasure from looking out of their windows and sitting outside in the nice weather.
DS0000002955.V347185.R01.S.doc Version 5.2 Page 19 The home was very clean and tidy. Lounge and dining areas were domestically furnished to a good standard. The manager had a programme of refurbishment and redecoration that ensured that the home was very aesthetically pleasing and free from hazards. The manager said that the provider would carry out any work that she deemed necessary for the comfort and well being of the people living in, working and visiting the home. Bedrooms checked were comfortable, homely and reflected peoples personal tastes. People said their beds were comfortable and bed linen checked was clean and in a good condition. One person said she had specifically requested a room on the ground floor overlooking the gardens and the manager had “made this possible”. No unpleasant odours were noticeable in the home and relatives said that the home was always kept “immaculately clean”. Controls of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. DS0000002955.V347185.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were employed in sufficient numbers and recruitment procedures promoted the protection of people. Newly employed staff had completed induction training, however some staff required refresher training and specialist training to ensure their skills were kept up to date. Access to NVQ training was provided to staff, to improve their knowledge. EVIDENCE: Staff and relatives said that there was “usually” enough staff working at the home to ensure that people’s individual needs were met. Staff were very willing to cover any holidays and sickness. The manager and responsible individual acknowledged that they had recently had difficulties securing the employment of a part time chef/cook. This had an impact on the remaining staff, as it had been necessary for others to cover this role. The managers were continuing to actively employ to this post and were also recruiting bank staff to cover any shortfalls. DS0000002955.V347185.R01.S.doc Version 5.2 Page 21 Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. Staff were able to talk about the various training courses that they had attended, however for some staff updated and refreshers in mandatory training, for example, Moving and Handling, Adult Protection and Fire was necessary. The manager had recently undertaken a review of staff training and had identified the shortfalls. Mandatory training had been booked and further training in specialised topics for example diabetes and falls prevention was to be delivered by the Sheffield Partnerships for Older Peoples Projects (POPP’s) team. One health professional said: “There is a need for a structured in house training programme for health care needs. Staff require training in catheter care and pressure area care”. On the day of the inspection staff were receiving training in catheter care. Over 50 of the staff team had achieved their NVQ Level 2 or above and others were due to commence this training shortly. It was positive to note that domestic staff and administration staff had also completed NVQ training. Staff interviewed said that when they started work they received induction training in the first two months of their employment. Three staff files checked identified that the member of staff had received induction training when they commenced work. Three records of employment were checked. These included all of the required information including interview assessment, verification of identity, references, certificates of training, health checks and evidence of CRB and POVA check. Application forms fully recorded previous employment. DS0000002955.V347185.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager’s leadership approach benefited people and staff. A quality assurance system and people, relative and staff meetings need to be developed to ensure that the home is run in the best interests of everyone. People’s monies were safely handled, which ensured that finances were accurate and safeguarded. In the main people’s health and safety had been promoted and protected in all areas. DS0000002955.V347185.R01.S.doc Version 5.2 Page 23 EVIDENCE: The acting manager was hard working, competent and carried out her role to a very high standard. She was clearly very committed to ensuring that people living in the home were consistently well cared for, safe and happy. She was aware of and in the process of applying to be registered with the CSCI. Everyone spoken to and information from questionnaires confirmed that people, staff and relatives were all happy to approach the manager at any time for advice, guidance or to look at any issues. They all said that they were confident that she would respond to them appropriately and swiftly. The responsible individual (RI) confirmed that monthly monitoring visits had taken place, however the last written report in the home was from March 2007. The RI said these would be forwarded to the home immediately. The inspector discussed the homes quality assurance process with both the manager and RI. The manager said that she had begun to look at ways in which to ensure quality at the home was maintained. She had designed a survey/questionnaire that was to be sent to people and their relatives that would give them the opportunity to comment about the service provided at the home. She was to extend this to also include any professionals that visited the home. People, staff and relatives said that meetings were not happening on a regular basis. The manager agreed that this was an area for development and would be actioned as part of the quality assurance implementation. The home handles money on behalf of some people. This was checked for two people. Account sheets were kept, receipts were seen for all transactions and a second individual witnessed all transactions. Monies kept balanced with what was recorded on the account sheet. The equipment at the home was serviced and maintained. Fire records evidenced that fire alarm checks took place, but could sometimes miss a week, which was not in line with the fire services recommended “weekly” check. Staff said fire drill training took place on a regular basis. DS0000002955.V347185.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 2 X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 DS0000002955.V347185.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP1 OP3 Regulation 6 14 Requirement The statement of purpose and service user guide must be reviewed and updated. Prior to being admitted to the home each person must have a needs assessment that covers the points listed in Standard 3.3 of the National Minimum Standards for Older People. The care needs, wishes and preferences for each person must be recorded in detail in their care plan. Plans of care must contain specific information on the staff action required to meet personal care needs. Care plans and risk assessments must be regularly monitored and reviewed, then signed and dated to confirm that this has been done. Timescale for action 01/11/07 01/11/07 3. OP7 15 01/12/07 4. OP7 15 01/12/07 DS0000002955.V347185.R01.S.doc Version 5.2 Page 26 5. OP9 13 (2) 6. OP9 13 7. OP18 18 8. OP30 13 (5) 9. OP30 18 10. OP33 24 11. OP38 23 (4) (c) (v) Handwritten entries on MAR sheets must be signed by the person making the entry. A witness must also sign to confirm the instructions are accurate. (Previous timescale of 30/10/06 not met) The home’s medication system must be checked by the pharmacist who supplies the medication. (Previous timescale of 30/11/06 not met) To ensure that people are safeguarded from any form of abuse all staff must receive updated/refresher training in Adult Protection. All staff must have updated training in moving and handling service users. (Previous timescale of 30/11/06 not met) All staff must be provided with the relevant specialist and mandatory training for the role they are to perform. To further improve the service provided, a quality assurance system must be developed. The outcome of the quality assurance process should be published annually, supplied to the CSCI and made available to everyone who has an interest in the home. Fire alarms must be tested every week. (Previous timescale of 30/10/06 not met) 01/12/07 01/12/07 31/12/07 31/12/07 31/12/07 31/01/08 04/09/07 DS0000002955.V347185.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations The views and opinions of the service users should be included in the written reviews of the care plans wherever possible. DS0000002955.V347185.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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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