Inspection on 13/09/07 for Down House

This inspection was carried out on 13th September 2007.

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

Down House 25/10/06

Down House 02/02/06

Down House 06/09/05

Down House 22/02/05

Down House 14/07/04

Down House 04/12/03

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Down House Down House 277 Tavistock Road Derriford Plymouth Devon PL6 8AA Lead Inspector Mandy Norton Unannounced Inspection 13th September 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 Down House DS0000030358.V345155.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. Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Down House Address Down House 277 Tavistock Road Derriford Plymouth Devon PL6 8AA 01752 789393 01752 769747 down.hs@btinternet.com mayhaven.co.uk Mayhaven Healthcare Limited 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) Vacancy Care Home 49 Category(ies) of Old age, not falling within any other category registration, with number (3), Physical disability (49), Physical disability of places over 65 years of age (49) Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - [Code PC] To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories Physical Disability - [Code PD] Physical Disability - [Code PD (E)] Old Age, not falling within any other category - [Code OP] - Maximum number of places: 3 The maximum number of service users who can be accommodated is: 49 25th October 2006 2. Date of last inspection Brief Description of the Service: Down House is a Care home that is registered to take up to 49 service users of either gender, from the age of 40 years old, who require nursing care, and a maximum of 3 Service Users who require personal care only. The home is situated in the Derriford area of Plymouth close to Derriford Hospital, and is on a main bus route to Plymouth city centre. It is a large adapted old house with a modern, purpose built, single storey extension. The main house has two floors that have client accommodation with access to the first floor via a stair-lift. The home currently has no passenger lift, but the first stage of the new extension is nearing completion and this incorporates a shaft lift that will stop at each floor that clients are accommodated on. The home is tastefully decorated and the furnishings are of good quality. There is good provision of equipment for the disabled and those needing support such as a wheel in large shower room, a good sized disabled bathroom, mobile hoists and en-suite facilities to most bedrooms. Externally there is a well-maintained patio and garden area that has a mix of shrubs, and gravel areas with attractive pot plants. The fees range from £475 to £520. In addition people will pay for such things as hairdressing, personal telephone line and newspapers they have ordered for Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 5 themselves. The previous inspection report is available in reception and the ‘patient information’ brochure (given to all people that are enquiring about the home and those that move in) provides details of how the previous inspection reports can be accessed. Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this unannounced inspection that took place from 09.30am until 2.10 pm. It was conducted with the manager, provider and the administrator. A tour of the home was carried out and many of the people living in the home were spoken to during the visit. This report also contains information taken from discussion with people living in the home, relatives and staff on duty on the day of the inspection. There were 34 people living in the home at the time of the inspection. The home is currently undergoing redecoration in places. There is also building work ongoing as part of the new extension that is currently being built. People spoken to during the inspection did not seem affected by the ongoing work. There are notices up around the home apologising for the inconvenience. What the service does well: People who are thinking of living at the home are assessed in their current setting (where possible) to see if the home can meet their needs. In addition care plans are obtained from social and other health care professionals. Once admitted to the home peoples needs are set out in a care plan, the plans provide sufficient information for care staff to be able to meet the individuals’ health, social and psychological needs. People themselves and /or their relatives are asked if they want to be involved in setting up their care plan and its ongoing review. People spoken to said they are able to maintain contact with family and friends and exercise some choice and control over their lives. They can eat their meals where they like and spend time with others in communal areas or in their own rooms. People said that they can go to bed and get up when they like. People spoken to said the meals provided are of good quality and they enjoy them. Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 8 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 Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service or are planning to move into the home have information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. The home is not registered to provide intermediate care. EVIDENCE: The manager said that people who are considering moving into Down House are assessed by herself or one of the 2 deputy matrons using a pre admission Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 10 assessment form (2 completed ones seen during the inspection). They are visited in their current situation if at all possible. The home has a Statement of Purpose issued to all people who move into the home and a brochure that summarises the key points of the Statement of Purpose. Both documents are under review and are being amended to include staff changes and the ongoing building work at the home. Some people living at the home were spoken with about their admission. Several were able to confirm that they had received information prior to moving in and another said, “My daughter visited the home before I moved in as I was unable to”. The home also has admissions via the RITA scheme (admission of people who need some immediate care that does not require hospital admission), continuing care (highly dependant people who need care but does not need to be in a hospital environment) and supportive discharge/ onward care team (for people who can be discharged from hospital but need a little more time or care before going home). These people are not always assessed in person before admission but comprehensive information is forwarded to them from the various care managers before a placement is made to give the home time to assess whether they think they can meet a persons needs or not. One lady spoken with had been admitted recently under the RITA scheme (admission of people that cannot stay at home but do not require hospital treatment) and confirmed that she had come in to the home for additional support and the home were providing continuing care which included specialist visits by therapists to aid her recovery. Each person is issued with a contract. The one examined had clear information about terms and conditions of occupancy and fees to be charged. Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at this home receive consistent health and personal care as appropriate. The homes well managed medication systems protect the welfare of people living in the home. People are treated with respect and their right to privacy is upheld. EVIDENCE: Several care plans were examined; in all of those seen there were assessments that provided information about skin condition, moving and handling, safety, wellbeing and hobbies and interests. The information from Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 12 the pre admission assessment or the care manager prior to admission generates the plans of care, which provide the basis for the care to be delivered. There was evidence that some people are consulted about their care plans and what is written in it. Letters are also sent to people’s next of kin to ask if they want to be involved with the initial care plan and its ongoing review (with the permission of the Service User if at all possible). The plans are kept in the office and in each room there are charts for fluid balance, turns, and general care activity which are completed by the person carrying out the care. Records are maintained for all visits to the home by social or health care professionals. All residents are registered with a GP. Several people were able to confirm that the home meets their health care needs and one person was attending an out patients appointment in the afternoon of the inspection. This person said, “I have had some operations recently and the home have been marvellous in helping me get better”. The medication system is well managed. Nobody is currently able to self medicate. The home is divided into wings and each wing has its own drugs trolley or box that is taken to the area for the medicines to be dispensed. The procurement, storage, dispensing and disposal of medicines is carried out using robust procedures. During a tour of the home staff were overheard interacting with people appropriately, joining them into conversations and talking with them individually. Doors were closed when personal care was being delivered. All the people who were able to stated that the staff treat them with respect and maintain their dignity and shut doors when personal care is carried out. A relative visiting their terminally ill relative was spoken too and stated that the care the homes staff were providing for their dying relative was excellent. That at all times their relative was treated with respect and health professional input was provided when needed including a recent visit from the local priest. Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are happy with the amount of social activity that is offered and are content with their lifestyle within the home. People maintain contact with family and friends and exercise choice and control over their lives. People receive a wholesome appealing diet and are not rushed. EVIDENCE: Some of the people living at the home said that there are some activities organised however most people said they choose not to participate. One person said the staff had offered to read to them. There is an ongoing activities programme for those able to take part. The local clergy visit the home Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 14 regularly and people can go out on trips in the mini bus owned by the company. Visitors are welcome at any reasonable time and can visit their friend/family in the privacy of their own room, in one of the lounges or in the large wellpresented garden & patio where seating is provided. One visitor was spoken with and said they were able to visit whenever they wished. Most of the people living at the home said that they were able to have regular visits from family and friends. During a tour of the building most bedrooms were visited and provided evidence that each contains personal possessions. A new kitchen has been built but is not able to be used yet. The cook who has been at the home for a number of years is providing good meals using the existing facilities. During discussion with people about food they said it was, “OK at times”, “not very good could be better”, “very good also willing to provided things you like”, “excellent”, “Lovely! I eat it all”. Most people living at the home were able to made positive comments about the food provided. Both the cooks on duty were spoken with during the inspection and confirmed that the food budget was satisfactory and that the provisions available were “very good quality and plenty of it”. The meal observed being served at lunchtime was evidence that it was home cooked using fresh products. The meal was well presented and freshly prepared and consisted of roast pork, 3 vegetables and all the trimmings. The cook informed the inspector that puddings are prepared for lunch times and special diets are catered. Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home and their relatives/friends know how to make a formal complaint. People are safe living in this home. EVIDENCE: The Commission has received no complaints since the last inspection. The home has no ongoing complaints. Any complaints made are investigated using the homes complaints procedure. This is displayed in a number of places in the home and is in the Statement of Purpose and referred to in the brochure. Some people spoken to said they were aware that the home had a complaints procedure but have never needed to use it others stated they were not aware there was one. Most however stated that they would inform their family if they had any concerns. One person said they had made a complaint about the special diet offered however it had been resolved satisfactory. Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 16 The training records examined show that staff have regular ‘protection of vulnerable adults’ training via Plymouth City Council and also during their induction and National Vocational Qualification training. Most of the care staff have completed or are studying for National Vocational Qualifications along with the administrator and some of the domestic staff. These activities ensure that all staff are aware of protection issues giving the people living in the home the confidence that staff are concerned about their best interests. Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is safe and well maintained and clean and hygienic ensuring the people living in the home live in a satisfactory environment. EVIDENCE: A tour of the home was carried out. Evidence obtained from people living at the home, a relative and staff is that the home is well maintained clean and safe. One relative said, “ The home is always lovely and clean”. Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 18 It presented as clean and homely. There is a decorating programme ongoing at the moment but the disruption to people living in the home is being minimised. There is also building work ongoing that is going to increase the number of rooms the home has to offer and is improving some of the existing facilities. Several staff commented that the work had taken longer than expected but it did not generally affect their work. People living at the home spoken to did not find either the decoration or building work a problem. Appropriate disability equipment is provided in the home, and these include a passenger lift, hoists, wheelchairs, and a call bell system. This equipment provides the people living at the home with a building that is appropriately adapted to meet their needs. Equipment examined during a tour of the home had recent servicing dates on it. Risk assessments are in place and are reviewed annually or as necessary if anything changes. It was recommended that a rolling risk assessment be put in place during the building and decorating process. It was also advised that the Statement of Purpose currently given out could include information about the current situation so people are aware of what to expect if they come to view the home prior to admission. There is a large lounge on the ground floor (being decorated at the time of inspection). It has good views of the well-kept grounds and level access to the outside areas. People’s rooms contained personal items including furniture, ornaments and pictures that reflect their personality and interests. People were seen moving about the home, some with the assistance of staff. The laundry has sufficient equipment for the amount of laundry the home produces and is in a suitable position within the home. The laundry room door was held open however the laundry assistant was in attendance and stated that it would be closed when they left. The tour of the premises and feedback obtained from people living at the home, relatives and visitor was that the home is always clean, tidy and free from any odours and the people living at the home can be assured that they will live in an attractive and comfortable home that is regularly maintained. The process for the removal of clinical waste was discussed and was satisfactory dealt with and one staff member confirmed they had completed infection control training. Other staff confirmed that the home provided disposable aprons and gloves for their protection. Many of the rooms are en-suite and there are a number of toilets and bathrooms situated throughout the home. Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 19 Examination of the fire – logbook showed that the weekly fire alarm test is not consistently recorded. All other information was recorded as required. Down House DS0000030358.V345155.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): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff with appropriate skills and knowledge to meet the needs of the people living at the home. The homes recruitment procedures protect people living at the home from being placed at risk of harm or abuse. EVIDENCE: The manager who was appointed in February 2007 has a registered manager award and has managed a care home previous to this appointment. The duty rota was examined and it shows sufficient numbers of staff for the amount of people living in the home and their dependency. Nursing and care staff are supported by catering, cleaning, administrative staff and Mr Sutherland, the registered provider. Most of the staff interviewed felt that the home had sufficient staff on duty and the home employs domestic and other ancillary staff to assist with the running of the home. Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 21 The manager said that most of the care staff have achieved National Vocational (NVQ) 2 and/ or level3. The administrator and some of the domestic staff are currently undertaking National Vocational Qualification training relevant to their roles. At the time of the inspection 4 care staff are undergoing their induction training. Records indicate that staff have more than the required statutory 3 paid days training per year. Some staff spoken with confirmed that they held a NVQ certificate and other are hoping to start this qualification soon. Three (3) staff files were examined – they had all of the required documents in them including 2 written references, a criminal records bureau check, application form, contract of employment and job description. The manager said that the recruitment process includes standard interview questions. The staff files are stored securely. The files also included training certificates that confirmed that a variety of training is undertaken by staff, including fire safety, protection of vulnerable adults and moving and handling. The manager said that an outside training company provides much of the training. Two newly appointed staff were interviewed and both confirmed that they had completed a CRB (Criminal Record Bureau) check and one staff member stated that they had shadowed other staff members while waiting for clearance. However one staff member said they had been carrying out personal care on people living at the home without support. The owner spoken with informed the inspectors that this was not company policy and would investigate immediately. The manager said that she has not yet instigated staff and/or residents meetings as a lot of changes have been put in place in a short time. She said that all staff are seen regularly and any changes are discussed with them. She said that anybody could see her or any other staff members at any time to discuss any issues or concerns they may have. She hopes to instigate formal meetings in the near future. All staff interviewed confirmed that Down House supports staff training and training is regular and updated. Two recently appointed staff members confirmed that they had completed an induction programme. One staff member said, “I enjoy working here” and another staff said, “It’s a good staff team, a relative said of the staff, “They are marvellous”. Down House DS0000030358.V345155.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): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An experienced nurse manager manages the home. The staff actively seeks the views of people living in the home so that they can find ways of ensuring continual improvement of the service. Personal money held on behalf of Service Users is managed appropriately. The registered provider shows a responsible attitude toward promoting and protecting the health, safety and welfare of people living in the home. Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager had several years of working in and managing nursing homes prior to her appointment at Down House in February 2007.She has been able to define peoples roles within the home and has/ is putting in place robust procedures in a variety of areas. People spoken to spoke very highly of the manager and the seniors and comments received included, “Very approachable” and “Lovely”. The manager said she has not started to hold formal meetings yet as a lot of changes have already been put in place lately, but she will consider the best way forward on meetings in the future. She said the staff meet regularly during handover periods and any changes are discussed with staff prior to them been instigated as feedback form others is important to ensure good cooperation. The manager has recently sent out questionnaires to the Service Users and has had several completed ones back. Once she has left sufficient time for them to be returned the management team are going to collate the results and decide on any actions that need to be taken. The manager said she would continue to do quality assurance audits like this on a regular basis so that ongoing improvement can be measured. The owner and the manager explained that they do not deal with any people’s personal finances. The home gets receipts from the hairdresser for example and these are forwarded to the next of kin or the person themselves for payment. Other bills such as for newspapers are sent directly to the person or their representative. The manager is reviewing the current policies and procedures to ensure they meet with current legislation. The current file is available to staff at all times. The fire log - book and accident books were examined. The fire alarm checks were not consistently recorded as evidence that the alarm is tested each week. All other checks are recorded as required. The handyman was involved in the decorating that has just been started within the home and is available for ongoing maintenance tasks. Outside contractors are used for ongoing maintenance of equipment and services. Down House DS0000030358.V345155.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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? 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. Refer to Standard OP27 Good Practice Recommendations The staff should receive some dementia care training to improve their awareness of the condition and needs of the individual service users who suffer from this condition. (Carried over from the previous inspection) The registered provider should ensure that staff are working under direct supervision until they have completed their induction programme and have been assessed as being competent. The registered provider should ensure the weekly fire alarm tests are documented in the fire logbook. The registered person should ensure there is a ‘rolling’ environmental risk assessment in place whilst the building work and redecoration are ongoing. 2. OP30 3. 4. OP38 OP38 Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Down House DS0000030358.V345155.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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