Inspection on 29/05/08 for Down House Residential Care Home

This inspection was carried out on 29th May 2008.

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

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 Residential Care Home 21/07/09

Down House Residential Care Home 28/04/09

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Down House Residential Care Home Alum Bay New Road Totland Isle Of Wight PO39 0ES Lead Inspector Annie Kentfield Unannounced Inspection 29th May 2008 11:30 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 Residential Care Home DS0000071110.V363570.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 Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Down House Residential Care Home Address Alum Bay New Road Totland Isle Of Wight PO39 0ES 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) 01983 752730 01983 753624 clacktmc@aol.com Mrs Trina Marie Clack Miss Sarah Compton Care Home 17 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0), Physical disability (0) of places Down House Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) Old age, not falling within any other category (OP) 2. Physical disability (PD). The maximum number of service users to be accommodated is 17. Date of last inspection Brief Description of the Service: Down House offers residential care for up to 17 older people. The new owner of Down House took over the home in December 2007. The home already had a registered manager – Sarah Compton. The new owner – Mrs Trina Clack – has already carried out some refurbishment work in the home and has plans to develop and upgrade the home further. The home is a period property set in spacious grounds and provides bedrooms on the ground and first floors with a passenger lift to access the first floor. The home has two small sitting rooms and a dining room that has recently been extended and refurbished. Residents have access to a sunny garden area with seating and tables. The current fees are £400 per week with additional charges for chiropody and hairdressing. Any additional charges are listed in the home’s ‘service user guide’. Down House Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This report summarises the outcome of the first inspection of Down House since it was registered to a new owner in December 2007. We made an unannounced visit to the home on 29th May 2008. The visit lasted 6 hours, with one inspector (Annie Kentfield) and we spoke to the owner and some of the residents and staff. We also looked at a sample of the home’s records, including care plans and assessments, medication records, the service user guide, and staff recruitment and training records. We looked around the building with the owner and spoke to three of the residents in the privacy of their own rooms. The registered manager was on holiday on the day that we visited. Before the visit we received the Annual Quality Assurance Assessment (AQAA) from the home. This is a self-assessment that all registered services have to complete each year and gives us information about how well the service is providing good outcomes for people using the service. The AQAA also gives us some numerical information including the numbers of residents and staff. We sent surveys to the home for distribution to all of the residents (12) and staff (9). We received completed surveys from 5 residents and 2 members of staff. What the service does well: Down House offers a homely, friendly, and comfortable environment for the people living there. This is confirmed by some of the comments that we received from residents in the home: “Excellent service”. “Good listeners”. “I love them”. The new owner of the home has started a programme of training and development for the care staff, this means that people living in the home can be confident that their care needs will be met by a staff team who have the necessary skills and knowledge to care for the residents. Down House Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The registered manager should develop an organised process for carrying out the assessment of need before residents move into the home. The assessment should be person centred and comprehensive to identify prospective residents’ social, psychological, health care, and religious or spiritual care needs. This will ensure that care staff have all of the information they need to provide personalised care to each resident that is consistent and thorough. The information that the home provides about the service should be available in suitable formats for the needs of the residents. The registered manager must ensure that any risks to residents are identified in the care plan. The risk management plan must include clear written guidance for care staff on the action they must take to manage or eliminate any risk and what they must do to manage any event that may put a resident at risk of harm. This is a regulatory requirement. The registered manager must make suitable arrangements to make sure that residents’ medication is safely stored and dispensed. This will ensure that residents receive their medication, as prescribed, at all times. This is a regulatory requirement. The registered manager must ensure that the storage of controlled drugs meets the requirements of the amended regulations. This is a regulatory requirement. The registered manager must ensure that there are effective quality assurance and quality monitoring systems in place to measure how well the home is providing good outcomes for residents, and demonstrate compliance with the requirements of the Care Homes Regulations 2001 and meeting the National Minimum Standards. This is a regulatory requirement. Down House Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 7 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 Residential Care Home DS0000071110.V363570.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 Residential Care Home DS0000071110.V363570.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 and 3 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has developed a statement purpose, which includes a service user guide. The guide is available in a standard written format and provides basic information about the service. The home has a process for making sure that people only move into the home when their care needs have been assessed and been assured that these will be met. However, the assessment process is not consistent and organised and may mean that prospective residents do not receive a comprehensive and person centred assessment of their care needs before they move into the home. The home does not offer specific rehabilitative care but does offer respite care if a room is available. EVIDENCE: Down House Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 10 We looked at how the home makes arrangements for new residents to move into the home and looked at the records for the two newest residents. We also looked at a copy of the information about the home that is given to prospective residents/friends/family/carers. The owner has updated the information about the home with details of the new ownership, services that are provided, fees etc. This information is available in a written format and some of it is in quite small print. The owner told us that she would like to produce better information about the home, with photos. The home also needs to consider how prospective residents might want information about the home in other formats, for example, large print, Braille, audio tape or other languages, or a format suitable to their needs and abilities. When we looked at how the home had assessed the needs of the two newest residents, we could not find any record of a comprehensive assessment of those residents’ needs. It was evident that the home had requested some information from the community care services and had done some assessment of their own, but there does not appear to be an organised way of recording the assessment that has been undertaken. If the home does not have an organised process for assessing the needs of people who move into the home, there is a risk that residents do not receive a comprehensive and person centred assessment that covers all of their personal, social, spiritual, health and psychological care needs. This may also mean that care staff may not have all of the information they need in the personal care plan, to provide care in the way that people prefer or choose, and some care needs may be overlooked. Down House Residential Care Home DS0000071110.V363570.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 and 10 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their health care needs will be monitored and appropriate action taken to meet health care needs. Every resident has an individual care plan but there are some gaps in the information recorded. The home is aware of the need to assess any risks to residents but clearer guidance for care staff should be recorded on how risks are to be managed or minimised. The policy and procedures that staff must follow to comply with the safe storage and administration of residents’ medications must be reviewed and updated. Medication systems in the home do not always follow good practice or safe practice guidelines and action is needed to ensure that residents receive their medication as prescribed, at all times. The registered person must ensure that the storage of any controlled drugs meets the requirements of the amended legislation. EVIDENCE: Down House Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 12 We looked at the care plans and daily records for four of the residents. We also looked at the arrangements for the storage of medicines and the medication records. Comments received in the surveys and from residents that we spoke to during our visit confirm that residents are happy with the way that care is provided. One person told us “I am OK”, there is nothing that I unhappy with”. Another person told us that care staff are very quick to come and help them when they need it and said, “I am very satisfied thank you”. We found lots of evidence that care staff listen to the residents and provide care in the way that residents prefer or choose. With the exception of someone who had moved into the home the previous day, all of the residents had an individual care plan. There are some gaps in the information in the care plans, although staff were able to give a good verbal update on the care needs of all of the residents. However, where staff are reliant on communicating care information verbally, there is a risk that some care needs may be overlooked or the care provided to residents may be inconsistent. Some of the care plans that we looked at had not been reviewed for some time and did not reflect the current care being provided because care needs had changed. The care plans reflect that the registered manager is aware of any risks to residents and some risks have been assessed such as the risk of falling. However, the risk assessments do not provide clear written guidance for care staff on how those identified risks or events must be managed to ensure that residents are protected and what action care staff must take. For example, a risk assessment for the risks attached to some behaviours due to cognitive impairment does not give care staff clear and written instructions on how they must act to ensure that risks or events are managed for those residents. These concerns were discussed with the registered provider who agreed to review care plans and risk assessments/risk management plans. The policy of the home is to allow residents to smoke within certain agreed restrictions. We spoke to one resident who was happy with these restrictions. There are large notices on each bedroom door that guide residents and staff on the smoking restrictions in place – the home could consider whether privacy and dignity may be compromised by these notices although the resident we spoke to did not have a problem with the notice. These restrictions should be agreed with the residents and written into the care plan and risk assessments. When we looked at the medication records we found some gaps in the daily records. This means that residents may not have received their medicine as prescribed, or staff may have forgotten to record medicine that was given. We were told that staff would check on whether medicine had been given and the medication administration records updated. Although some of the staff have done accredited medication training and more is planned, the home must ensure that checks are in place to make sure that residents receive their medication as prescribed and there are clear and up to date records that Down House Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 13 account for all medication that comes into and goes out of the home. The written policy and procedure for staff on medication is very old and needs to be updated. The manager must ensure that care staff are following the home’s policy and procedures for the safe administration of all medicines. We recommend that the registered manager obtains a copy of the newest guidance for care homes – ‘The Handling of Medicines in Social Care’ to review their policy and practice in the home in line with this best practice guidance. This guidance can be freely downloaded from the Commission website www.csci.org.uk The home does not have dedicated storage for controlled drugs that meets the amended regulations. The home are now aware that guidance on the storage and administration of controlled drugs is also available on the Commission website. We have also made a requirement for the home to meet the amended regulations for the storage of controlled drugs. Down House Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. People living in the home are given the opportunity to take part in social and leisure activities. The home is aware that they could offer a wider range of events and activities and plans are in progress to do this. The registered manager must also consider how activities can be arranged that are suitable for the different needs and abilities of the residents, including residents with dementia. The home places importance on offering residents wholesome meals served in pleasant surroundings. EVIDENCE: Social activities in the home are a mix of regular musical events from a community group and group activities with staff and residents such as games or bingo. We were told that since the new owner has taken over there are plans to offer residents the opportunity for trips out and a 7-seater vehicle has been purchased to arrange this. Residents are also enjoying new garden furniture for use in the warmer weather. The home recently held a coffee morning and raised money to buy, and plant, flower bulbs and install a fish tank in the sitting room for the enjoyment of all of the residents. The owner Down House Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 15 told us that she would like to plan a programme of events and activities for the residents to offer more choice and new opportunities for social interaction. The atmosphere in the home is informal and friendly and residents’ wishes are respected, for example, if they wish to spend time in their own room, or be in the sitting room. When we visited the home, a hairdresser was available for residents to have their hair cut or washed. The dining room has been extended and refurbished and offers residents a pleasant and attractive room to take their meals. Comments from residents confirmed satisfaction with the meals provided and some residents told us that the quality of the food has improved. Down House Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 19 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure and the registered manager is aware that the home needs to make sure that the complaints information is made available in suitable formats for the needs of the residents. The registered manager is aware of the need to protect residents from the risk of abuse and ensures that staff receive training in this area. However, more work is needed to ensure that any identified risks for residents are robustly managed or minimised. EVIDENCE: We looked at the way that the home manages complaints or concerns, we also looked at how the home protects the residents: by looking at the complaints procedure, policies and procedures for safeguarding residents, and records of staff training. We saw a copy of the complaints procedure on display in the entrance hall. However, we know from speaking to residents and staff that the home has not received any formal complaints. Some residents told us that they are confident about speaking to the manager or staff if they have any concerns about anything. In the AQAA, the registered manager told us that the home plans to improve the information that is available to residents and they would like to produce a leaflet that is more easily accessible, however, the AQAA did not say how the home are going to do this. Down House Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 17 Staff are aware of their responsibilities to protect residents from the risk of harm or abuse. It is good practice for all staff to receive specific training in ‘safeguarding procedures’ and training records demonstrate that staff have recently done this training, provided by an accredited trainer. We looked at care plans and how the home assesses and manages any risks to people living in the home. Some of the residents are at risk of harm due to their psychological health or frailty of age. The actions that staff must take to protect residents from identified risks are not clearly recorded in the care plan. This means that residents may be at risk of harm because of inconsistent knowledge and practice in the home. Down House Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in a warm, comfortable and homely environment that is suitable for their needs. Action is taken to make sure that the home is clean, hygienic and pleasant for the people living there. EVIDENCE: We looked around the home with the registered owner and we also spoke to some of the residents in their rooms. The home was clean, tidy and pleasant and residents told us that the home is “always very clean”. The home is comfortably furnished with furniture and decoration that is domestic in style and creates a homely atmosphere for the residents who live there. Down House Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 19 The fourteen residents have their own bedrooms and have personalised their rooms with their furniture or possessions. Since taking over the home, the new owner has already carried out lots of improvements to the dining room, kitchen and some of the bedrooms and bathrooms. The new owner has plans for further improvements and refurbishment that includes improving and extending the sitting room and upgrading the ground floor toilets. Specialist equipment is in place for those residents who need it and records show that equipment is regularly serviced. Communal bathrooms have hand-washing facilities for safe practice in the control of infection and staff have updated their training in good practice in infection control. Down House Residential Care Home DS0000071110.V363570.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 and 30 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are cared for by a team of staff who are experienced and knowledgeable. The registered owner of the home is aware of the importance of making sure that staff have the appropriate skills to do their job, and receive ongoing training. Residents are protected by the home’s recruitment procedures. EVIDENCE: We looked at the recruitment records for 2 new staff, training records and the staff rotas. The recruitment records confirm that the home carries out the necessary checks on new staff to ensure that they are suitable to work with people in the home. Since taking over the home, the new owner has started a programme of training and development for the staff. The owner is aware that staff must have specific skills training to do their jobs to ensure that the needs of the residents will be met by skilled and competent staff. Care staff have recently completed fire safety training and training in ‘safeguarding adults’. The owner also confirmed that staff training in safe practice for moving and lifting, is regularly updated. The owner also confirmed that the cook has a current Down House Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 21 certificate in food hygiene and it is planned for the cleaner to undertake training in the safe use of cleaning materials in the home (COSHH training). In the AQAA, the registered manager told us that plans are being made to provide staff with a supervision structure, this will ensure that staff receive regular supervision in their work, and also have the opportunity to discuss work issues and their training and development needs. We saw evidence that new staff follow an induction programme that meets the agreed standards of the national organisation for skills in care. The AQAA also tells us that 8 out of the 9 staff have already achieved the minimum qualification in care, the National Vocational Qualification (NVQ) in care level 2. Comments received from residents indicate that they have confidence in the staff that care for them and one resident told us that staff respond quickly when they need assistance. The staff rota shows that there are two care staff on duty during the day and one person at night with another person available ‘on call’. In addition, there is a cook and cleaner and the homeowner is also in the home on a regular basis and has a background and experience in care. The home does not use agency staff and existing staff fills any gaps in the rota. Down House Residential Care Home DS0000071110.V363570.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, 37 and 38 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the residents and the management approach of the home is open and friendly. The registered manager must demonstrate that there are systems in place to monitor practice in the home to ensure that residents receive their medication as prescribed at all times. The registered manager must ensure that all practice in the home is monitored and regularly audited to ensure that the home is complying with regulatory requirements and residents are protected from the risk of harm. EVIDENCE: Down House Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 23 We looked at health and safety records, care plans and risk assessments and the information that the home gave us in the Annual Quality Assurance Assessment (AQAA). We also spoke to the registered owner and some of the residents and staff. The manager is improving and developing systems that monitor practice and compliance with the policies and procedures of the home but more work is needed in this area, particularly in the areas of safe medication practice, and risk assessment and risk management. The manager told us that she has completed the National Vocational Qualification in Care level 4 and now needs to achieve a management qualification. The manager completed all sections of the AQAA but more evidence could have been provided to illustrate what the service has done in the last year, or how it is planning to improve. The AQAA tells us that the home have not got all of the necessary policies and procedures in place that demonstrate how practice is monitored or audited. More work is needed to demonstrate that the registered manager regularly audits how well the home is meeting the Care Homes Regulations 2001 and providing good outcomes for the residents. More information could have been provided to demonstrate how the home promotes equality and diversity for the benefit of the residents in the home. The owner told us that she would be making monthly inspections of the home. This is a requirement for registered providers under Regulation 26 of the Care Homes Regulations 2001. The owner will make a written report of her inspections and use these to plan where improvements need to be made to practice in the home. The service has started to develop a quality assurance system and has sent out a questionnaire, the results of this need to be summarised to demonstrate how the home listens to residents and visitors and takes action on any feedback received. We looked at health and safety records and this confirms that the home has a fire safety risk assessment and action has been taken to comply with the relevant legislation. The owner is aware that the use of door wedges to prop doors open is a fire safety risk and is taking specialist advice on fitting safety devices to doors. The home does not have a food safety star rating yet and was last inspected for food safety in May 2007. The policy of the home is for residents to manage their own finances or with independent support. The home assists one resident to access their personal allowance and maintains records of any monies received and paid to the resident. Down House Residential Care Home DS0000071110.V363570.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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 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 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 2 2 Down House Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 25 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. 1. Standard OP7 Regulation 13(4) Requirement The registered manager must ensure that any risks to residents are identified in the care plan. The risk management plan must include clear written guidance for care staff on the action they must take to manage or eliminate any risk and what they must do to manage any event that may put a resident at risk of harm. The registered manager must make suitable arrangements to make sure that residents’ medication is safely stored and dispensed. This will ensure that residents receive their medication, as prescribed, at all times. The registered manager must ensure that the storage of controlled drugs meets the requirements of the Misuse of Drugs (Safe Custody) Regulations 1973 as amended. The registered manager must ensure that there are effective quality assurance and quality DS0000071110.V363570.R01.S.doc Timescale for action 30/07/08 2. OP9 13(2) 30/07/08 3. OP9 13(2) 30/09/08 4. OP33 24 30/09/08 Down House Residential Care Home Version 5.2 Page 26 monitoring systems in place to measure how well the home is providing good outcomes for residents, and demonstrate compliance with the requirements of the Care Homes Regulations 2001 and meeting the National Minimum Standards. 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 OP9 Good Practice Recommendations The policy and procedures for the safe administration of medicines in the home should be reviewed in line with the good practice guidance in ‘The Handling of Medicines in Social Care’. Down House Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Residential Care Home DS0000071110.V363570.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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