Inspection on 09/10/06 for Derriford House

This inspection was carried out on 9th October 2006.

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

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

Other inspections for this house

Derriford House 06/10/08

Derriford House 10/10/05

Derriford House 05/04/05

Derriford House 20/09/04

Derriford House 15/04/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Derriford House Pinewood Hill Fleet Hampshire GU51 3AW Lead Inspector Mr Rodney Martin Unannounced Inspection 9th October 2006 10:00 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 Derriford House DS0000011906.V313555.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. Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Derriford House Address Pinewood Hill Fleet Hampshire GU51 3AW 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) 01252 627364 01252 629481 derrifordhouse@farthingscare.co.uk Derriford House Limited Mrs Carolyn Denise Lunn Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10 October 2005 Brief Description of the Service: Derriford House is a privately owned and operated care home offering care and support for up to 30 persons accommodated in the OP [older persons] category. All residents live in single rooms provided with en-suite toilet and washing facilities. The home is located in the North Hampshire town of Fleet, adjacent to public transport local facilities/shops, the nearby towns of Aldershot and Farnborough (within 5 miles) and the towns of Guilford, Basingstoke and Reading within 30 minutes travelling time by car. The current fees are £560 to £600 per week. This information was obtained on the day of the inspection. There are additional charges for hairdressing, chiropody, newspapers/magazines, toiletries and excursions. Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place between 9.50am and 4.45pm. An opportunity was taken to look around the home, view records and talk to two visitors, several service users and staff members, including the cook, the registered manager and Mr Pope, responsible individual. On the day of the visit twenty-six service users were accommodated, which included one resident in hospital and a respite client. Derriford House has four permanent vacancies. In line with the Commission’s policy, all the key standards were inspected on this occasion. There were no previous issues identified at the last inspection that required following up. What the service does well: What has improved since the last inspection? Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 6 Since the last inspection the home has completely refurbished the kitchen and stockroom. An ozone disinfection system was installed in the laundry room on 9 December 2005, which has provided the home with an excellent infection control system. The home has also had a macerator installed and an extra washing machine installed to provide a more efficient and effective service for dealing with residents’ laundry. Profile beds have been provided as equipment to improve the quality of residents’ life within the home. 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. Derriford House DS0000011906.V313555.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 Derriford House DS0000011906.V313555.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have their needs assessed and are able to visit prior to admission to make an informed choice about whether or not the home is able to meet their particular needs. Derriford House does not provide intermediate care. EVIDENCE: Derriford House was accommodating twenty-five permanent residents, with five male and twenty female service users, which included one resident in hospital, whose ages ranged from 79 to 101 years. All the residents have been in the home since 2001. Since the last inspection, six new residents were admitted. The home has a designated respite bedroom and in the last year has provided seventeen short respite stays. The home previously had two bedrooms for short stays but has now reduced to one bedroom. The manager reported that a number of residents had short stay admissions, prior to making a decision to go into residential care permanently. On the day of Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 9 the inspection the home was accommodating a male resident on a week’s short stay. Referrals come from various sources. Details of the home are sent out, if the person is unfamiliar with the home. Relatives usually visit first and are given a welcome pack. The preferred way is for the prospective service user to come and spend some time in the home, which can also include a complimentary meal. The manager then completes a pre-admission assessment. An admission date is then arranged. On admission the new resident is given a copy of the statement of purpose and service users guide, the home’s brochure and a vase of fresh flowers are left in their room. This also applies to respite clients as well as the home ensuring they have towels and toiletries. An exit questionnaire was discussed, as a means of maintaining the home’s quality assurance system. Various files were viewed, including the last resident admitted and they contained a comprehensive pre-admission assessment, detailing relevant information for the home to make an informed judgment regarding whether they could meet the perceived needs of the resident or not. Although the files were detailed the manager wants to streamline the care plan as well as the paperwork for respite clients. The first month the manager liaises with the family to ensure that Derriford House is an appropriate care home for the resident. Derriford House is only registered to admit older persons and the manager reported that several residents have been asked to leave during the month’s trial because it was apparent they had dementia, for which Derriford House is not registered. There was evidence that the home is able to meet residents’ needs. The inspector spoke to two visitors who were both very complimentary about the home. One relative said, “Derriford House is like a five star hotel”. The other visitor said, “The place is superb. There are no smells and as soon as I first walked in I knew this was the place for X”. Derriford House does not provide intermediate care, although prospective residents can come for a short stay, if there is a vacancy in either the designated respite bedroom or the home has a permanent bedroom free. Short stay residents are assessed in the same way as permanent residents. Short stay residents are advised of the local GP’s, if they are not from the Fleet area. The manager reported that she is working on producing a specific respite care plan. Derriford House DS0000011906.V313555.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for care planning are good, ensuring that the residents’ physical and emotional health needs are met. Medication practices and procedures ensure that residents are protected. Working practices in the home ensure the promotion of privacy and independence for service users. There are clear arrangements in place for supporting terminally ill residents in the way they prefer. EVIDENCE: Each resident has a comprehensive file, containing the personal details of the resident and their photograph, the pre-admission assessment; various risk assessments, the care plan detailing various aspects of activities of daily living and review of the care plan. Although the home has comprehensive and detailed care plans and contain all the information a carer needs to ensure delivery of care; it was discussed changing the home’s care planning files to a ring binder filing system, which is indexed and has sub-headings for ease of reference. Derriford House operates a keyworker system as a means of Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 11 enabling staff to get to know certain residents much better, which in turn helps in the delivery of care to the individual resident. Various care plans were examined and contained information for staff to ensure that all aspects of health, personal and social care needs could be met. There were, for example, clear moving and handling assessments, the resident’s spiritual needs and a record of activities participated during the month. There is also a separate plan detailing the physical, intellectual, emotional and social needs of the resident. Plans are reviewed on a regular basis, with the manager speaking individually to review a resident with their room number the same as the day of the month [the home has potentially thirty residents]. The personal and oral hygiene of each service user is maintained and recorded. A record is kept of all health professional visits. Residents are registered with seventeen different GP’s from Fleet medical centre and Brankeswood and Richmond surgeries. Medical details are recorded in the care plan, including the BMI score [body mass index which is scored after recording the resident’s height and weight and gives a useful indication of the person’s health]. The manager reported that 50 of residents go to the surgery as well as to other health professionals, although there are domiciliary visits by the dentist, optician and chiropodist, for those that require it. There was evidence of a dietician involved with one resident. Residents have access to all other health professionals on an as needs basis. The home has a relevant medication policy, which satisfactorily details the receipt, recording, storage, handling, administration and disposal of medicines. Residents are able to self medicate within the home’s risk management framework. Currently only the resident on respite is self-medicating. They had been risk assessed and signed a declaration regarding taking their own medication. The home operates a monitored dosage system for administering medication. This is kept locked in two drugs’ trolleys, one for each floor, in a locked cupboard. The home currently has some residents on Temazepam and one resident on a controlled drug. The drug administration sheets, which included a photograph of the resident, were found to satisfactorily recorded, including the controlled drugs register, with no omissions. For extra protection the times of the medication on the drug administration sheets were colour-coded to the same as the blister pack, as well as the number of tablets received and counted. The home keeps photocopies of the prescriptions as part of a paper trail, to ensure that correct medication is received, as there have been mistakes made in the past. The drugs’ trolleys were found to be clean, tidy and safe. All staff have received medication training, through Basingstoke College [BCoT]. Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 12 Staff members supported service users with kindness and sensitivity, using service users’ preferred names and supporting gently with care giving. Staff members knocked on service users’ door before entering. One visitor said that staff are very kind and seem to go the extra mile. An example given was that the visitor observed a staff member sorting out the resident’s mobile telephone for them. They also commented that their privacy was respected. Residents, spoken to, also confirmed that the home encourages their independence and this was demonstrated in the way they can get up and go to bed when they want to and can join in activities or spend time in their room, if they wish. The service users wishes concerning terminal care and arrangements after death are routinely recorded, at the point of admission. In one file seen, it was recorded that the resident had a funeral plan. The home has adapted the Liverpool Care Pathway, which is a detailed care plan for staff to follow in the events leading up to a resident’s death and afterwards. One staff member is to commence a foundation course in palliative care and the manager is to start an Open University course on death and bereavement. Derriford House DS0000011906.V313555.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to engage in a variety of appropriate age-related activities in the home. Residents are supported to maintain contact and positive relationships with family and friends. Nutritional needs of residents are well managed and offer variety and choice. EVIDENCE: The home provides various activities for residents to participate in, including bingo, bridge clubs, music and movement, visiting singers, quizzes and reminiscence. Residents attend Red Cross, Towns Women’s Guild, local churches and day centres. The home has a designated carer who is activities co-ordinator. There is a residents’ forum, once a month. The minutes of the last meeting were available. The residents’ forum has requested the need to go out more and the home is looking into this. Derriford House has an annual garden party when respite clients are also invited. All residents have friends or family visiting. Nine residents have their own telephone installed and three residents have a mobile telephone, to enable them to keep in contact with their families. Residents are able to go out Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 14 independently. Residents are encouraged by the staff to make choices in their daily life and these choices include choosing which clothes they will wear and what time they get up and go to bed, this information is contained in the care plans. On the day of the visit the inspector met two relatives and spent some time with them. They were very complimentary about the home, stating, “The food was wonderful”. Residents have a choice of having meals in their room or in the dining room. The inspector was able to have lunch with the residents. Residents are offered a choice at each mealtime. The meal was plated and service users had lamb cobbler or sausages and mash potato, with apple sponge and custard for dessert. Residents can have ice cream, yoghurt or fresh fruit as an alternative dessert. The short stay resident was provided with cauliflower cheese as a vegetarian alternative. Residents are offered wine or sherry with their meal. Residents, spoken to, said they enjoyed the meal and that the food in Derriford House was very good. Residents mainly have a cooked meal at teatime. Derriford House employs two chefs, who are suitably qualified. The home is complying with the new food hygiene legislation that came into force on 1 January 2006, using the ‘safer food better business’ file from the Food Standards Agency. Derriford House DS0000011906.V313555.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure, which residents feel able to use and an adult protection procedure, which protects and safeguards residents from abuse. EVIDENCE: The home’s complaints procedure is contained in the statement of purpose and service users guide. The complaints procedure contains details of the steps for making a complaint and how someone can contact the Commission. The home has a complaints log. One resident, spoken to, was aware of the complaints procedure and stated, “it’s on the notice board!” that they had no issues with the home and were happy with the service the home provided. Since the last inspection the home received a complaint following notice to terminate the resident’s tenancy. It was confirmed that the matter was satisfactorily resolved. Derriford House has all the relevant documentation relating to adult protection, including a whistle blowing and the adult protection policy. The home has sent appropriate notification for incidents within the home. One resident has been referred to the falls clinic. Staff have received adult protection training and were aware of the various forms of abuse and the issues involved. There have been no incidents of abuse notified to the Commission. Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a clean, safe, comfortable and homely environment for residents. EVIDENCE: A tour of the building was undertaken. Derriford House is a large building, which has a passenger lift and stair lift and is mainly doubled glazed throughout. There is an ‘L’ shaped lounge that includes a conservatory, a library room, dining room, kitchen and separate food preparation room and a hair salon. Derriford House provides facilities for staff with a changing room and staff lockers. Since the last inspection the home has completely refurbished the kitchen and stockroom. An ozone disinfection system was installed in the laundry room on 9 December 2005, which has provided the home with an excellent infection control system. The home has also had a macerator installed and an extra washing machine installed to provide a more efficient and effective service for Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 17 dealing with residents’ laundry. Bedrooms are routinely redecorated following vacation by the previous resident. Residents, spoken to including a person on a short stay admission, were very complimentary about the home’s facilities and their rooms. Two visitors also mentioned the quality of the building. One visitor said Derriford House was “like a five star hotel”. There was evidence of residents’ personal belongs in the rooms. There were no adverse smells noted. Carers collect and bring the dirty laundry down to the laundry room. As noted above the laundry room has been improved, with a disinfection system that has separate chemicals for the various tasks. Derriford House employs a laundry assistant and, on the day of the inspection, the housekeeping supervisor was doing the laundry, as the assistant was not on duty. The families of prospective service users are asked to label clothes for ease of identification. Derriford House has a machine that can produce labels, if required. Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff members who work in the home are employed in sufficient numbers to care for service users. The home has a rigorous recruitment procedure to ensure that staff members working in the home are suitable to work with service users. There is continuous monitoring of training requirements to ensure that staff members are suitably skilled and updated to meet the needs of people living at the home. EVIDENCE: Derriford House employs thirty care staff, including a bank carer, two chefs, two kitchen assistants, a housekeeping supervisor and housekeeper, an administrator, maintenance staff and the registered manager. The home employs four senior care assistants and one is to be promoted to assistant manager. On the day of the inspection there were sufficient staff on duty to meet the needs of residents. A visitor said, “The staff are very good, hard working, kind and will go the extra mile”. The inspector was able to speak with the staff as a group, as well as the chef and administrator. The care staff had all worked in the home some time and enjoyed working in Derriford House. They appreciated the training they received and were complimentary about the manager’s style of management. Staff had a good understanding of residents’ Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 19 needs as well as those who had some age related mental health problems. Although the home is not registered to take new service users with a diagnosis of dementia, some residents had developed the illness since coming to Derriford House. Staff confirmed that they had received training in dementia and were aware of what constituted abusive issues. Over half the staff have obtained NVQ [national vocational qualification] in care at level 2 or level 3. Staff have an appraisal once a year, in January, when they have a one-to-one session with the manager. Staff have two-monthly supervision, when they can highlight any concerns they have. There are regular senior staff meetings, every three weeks. Various staff files were examined. These contained evidence of a sound and comprehensive recruitment process and further details of short courses undertaken. The manager has completed the ‘train the trainer’ course and is able to cascade training to staff members. New staff have a twelve-week induction and foundation-training programme, which is in-house. The home also uses courses available from Basingstoke College [BcoT]. Staff receive mandatory bi-annual training updates on food hygiene, infection control, emergency procedures for manual handling and fire safety. Staff confirmed that any training needs highlighted in supervision is provided. The non-care staff receive appropriate training, with food hygiene training for the kitchen staff and COSHH [control of substances hazardous to health] training for the domestic staff. One staff member is to do a foundation in palliative care and the rest of the staff receive in-house the MacMillan foundations in palliative care. Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is approachable and has an open style of management. She provides good leadership that ensures staff are supported and residents’ welfare and finances are promoted and protected through the home’s practices. EVIDENCE: Carolyn Lunn, registered manager is suitably qualified to run Derriford House and has worked in the home since June 2003. She has achieved the registered managers award for NVQ level 4 in both management and care and is updating her experience and knowledge by attending various course, including manual handling update, adult protection training, a course on diabetes and back to nursing theory, as well as ‘train the trainer’, a foundation course in palliative care and an open university course on death and bereavement. The Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 21 manager is in the process of re-registering her nursing qualification, having allowed her nursing registration with the Nursing Midwifery Council to previously lapse. The home is about to appoint one of the senior care assistants to the post of assistant manager, to help with day-to-day management of the home. There is an open, friendly and transparent atmosphere within the home. The two visitors spoke warmly of staff and the way the home is run. One visitor said, “The manager is very good and business-like”. The home is committed to improving the standards within the home for both residents and staff. This was evidenced by the home sending questionnaires to two different residents’ relatives every month. The home has an improvement plan. As previously noted elsewhere in this report, the kitchen has been refurbished and a disinfection system installed in the laundry room. The manager reported that if she requires any piece of equipment to aid residents’ comfort or support needs, she could obtain it. An example of this is profile beds have been provided as equipment to improve the quality of residents’ life within the home. There are regular monthly visits by the proprietor as requested under Regulation 26. The home is not appointee for any service user. The home does not look after residents’ money. Derriford House employs an administrator, who has an extensive background in financial management. Records are kept on the home’s computer and Derriford House is registered under the Data Protection Act 1998 until 11 March 2007. The fire log was inspected and the records indicated that the fire safety equipment had been tested and serviced within the guidelines. Staff have received fire safety training and new staff members receive fire induction training, as well as completing a fire questionnaire. The home had a fire drill on 13 April 2006. Staff, spoken to, were aware of what to do in the event of a fire. The manager ensures the safe working practices by planning courses on health and safety within Derriford House, including first aid, adult protection, manual handling, food hygiene, fire and medication. Risk assessments are in place. There are current and up to date contracts on electrical equipment as well as kitchen and domestic appliances et cetera. COSHH [control of substances hazardous to health] policies and procedures are in place. Window restrictors are in place on the windows above ground level, to ensure safety for residents. From a check of the records and practices observed in the home during the inspection, the health and safety measures taken in the home ensure the welfare and safety of the residents. Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 22 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 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 4 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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. Refer to Standard Good Practice Recommendations Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Derriford House DS0000011906.V313555.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!