Inspection on 09/11/06 for Drewstead Lodge

This inspection was carried out on 9th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Drewstead Lodge 23/02/06

Drewstead Lodge 01/09/05

Drewstead Lodge 16/02/05

Drewstead Lodge 18/08/04

Drewstead Lodge 26/03/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Drewstead Lodge Drewstead Lodge 93 Drewstead Road Streatham London SW16 1AD Lead Inspector Ms Rehema Russell Unannounced Inspection 10:00 9 November 2006 th 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 DS0000022725.V311803.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. DS0000022725.V311803.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Drewstead Lodge Address Drewstead Lodge 93 Drewstead Road Streatham London SW16 1AD 020 8769 4912 0208 769 4912 fowasil@hotmail.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr M Owasil Mrs Sairah Bibi Owasil Mrs Sairah Bibi Owasil Care Home 9 Category(ies) of Dementia (9), Old age, not falling within any registration, with number other category (9) of places DS0000022725.V311803.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd February 2006 Brief Description of the Service: Drewstead Lodge is a large two storey detached house in a quiet residential street with on street parking. It has a small front rose garden and a large landscaped garden at the rear. It has two bedrooms and communal rooms on the ground floor, a chair lift, four bedrooms on the first floor and a selfcontained flat for the proprietors on the top floor. It provides a home for 9 elderly residents in a family-run, homely atmosphere with particular emphasis on providing individualised care that maintains residents independence, privacy and self-esteem. One of the rooms on the first floor is currently being used as an office rather than a bedroom. Prospective service users would be given a copy of the home’s brochure and verbal information about the home, its facilities and a typical day there. A copy of the most recent CSCI inspection report is kept in the dining room for access by staff, service users and visitors. All service users are funded by the local authority, at a fee of £380 weekly. DS0000022725.V311803.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 9th November 2006. Since the previous inspection one service user had died and the home had not admitted any new service users, therefore there were only five service users resident at the home. The inspector spoke with the manager and proprietor, interviewed one care worker and two service users, spoke to other service users in the lounge, toured the premises and looked at documentation and records. What the service does well: 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. DS0000022725.V311803.R01.S.doc Version 5.2 Page 6 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 DS0000022725.V311803.R01.S.doc Version 5.2 Page 7 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): 1, 3, 5, 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 are given the information they need to make an informed choice about the home but the Statement of Purpose/Service User Guide does not fully meet required standards. No service user moves into the home without having their needs assessed and having been assured that these will be met. Prospective service users and their relatives/friends have an opportunity to visit and assess the suitability of the home. The home does not admit service users solely for intermediate care. EVIDENCE: DS0000022725.V311803.R01.S.doc Version 5.2 Page 8 The home has a brochure and a Statement of Purpose which also doubles as the Service User Guide. However, the document has not been fully updated and does not meet the requirements of current legislation. See Requirement 1. There have been no admissions since the last inspection, and the home’s admission procedure has not been changed. This involves the home obtaining the community care assessment from the placing authority and the registered manager visiting the prospective service user. At this visit the manager conducts her own assessment which includes all of the areas required by this Standard. The initial care plan is written from the placing authority’s and the home’s assessments, and any other professional assessments obtained. Community care assessment of needs forms were seen on care plans, along with letters/reports from other professionals such as speech and language therapist, South London & Maudsley Hospital and physiotherapy. The home has never taken an unplanned admission, and the service user is always visited first, even if they are in hospital. Wherever possible the potential service user and their relatives/carers are invited to visit the home prior to admission, and there is always a trial period of 6 weeks. Previous trial visits have included one service user visiting the home with her family for tea and another visiting for lunch. Both had met the other service users and staff and had been shown the bedrooms they were to occupy and the other facilities at the home. The home does not admit service users solely for intermediate care and so Standard 6 is not applicable to the home. DS0000022725.V311803.R01.S.doc Version 5.2 Page 9 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, 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans set out individual’s health, personal and social care needs and service users’ health care needs are fully met. Medication procedures are thorough and service users self-medicate if appropriate. Service users are treated with respect and their right to privacy is upheld. At the time of death, service users and their families are treated with care, sensitivity and respect. EVIDENCE: Two care plans were assessed. They contained thorough assessments of the resident’s self-care ability and lifestyle choices and preferences. Care plans are based on these assessments and set out needs, actions, goals and evaluations, covering areas such as nutrition, social/emotional needs and personal hygiene. Care plans are reviewed monthly/bi-monthly or sixmonthly, according to need and to any changes in circumstances. Reviews are dated and signed and monitoring sheets record any changes to the service users’ needs or wishes. The home has ensured that the placing authority has carried out its statutory obligation of an annual placement review for each service user. These showed that the local authority was pleased with the care being given at the home and supportive of the service users remaining there. DS0000022725.V311803.R01.S.doc Version 5.2 Page 10 There was documentary and verbal evidence that service users have their health care needs provided for by a full range of healthcare professionals, according to individual need. This includes the general practitioner, district nurse, domiciliary optician, psycho-geriatrician, chiropodist, speech and language therapist and physiotherapist. Verbal evidence indicated that the home has established good working relationships with healthcare professionals. Storage, administration and recording of medication was checked and found to be in good order. Although service users have self-medicated in the past, only one current service user could safely self-medicated. She has been given the choice to do this but has chosen not to. All staff have had external medication training. Observation and verbal evidence from the manager, proprietor, staff and service users indicated that service users are treated with respect and dignity. All service users in the home were observed to be well groomed and dressed and to be spoken to with kindness and respect. The manager, proprietor and staff were observed to be patient and understanding with service users who displayed anxious or aggressive behaviour, and to ensure that their dignity was preserved and that they felt valued. Although no rooms are currently shared, screening is provided in the double bedrooms and furniture is arranged to give each service user the maximum privacy possible. The manager has spoken to all service users, or their families as appropriate, to ascertain their wishes in regard to funeral arrangements. One service user, who had been at the home for over 8 years and had almost reached her 106th birthday, had died a month earlier. She had been treated by the GP at the home but the next of kin had refused to have her moved from the home to the hospital. The home had ensured that in her days there were always two staff in attendance and that the family had been informed in good time when rapid deterioration began. Funeral arrangements had already been discussed, and subsequent to the death the next of kin had visited the home to thank them for the care and help they had given. The manager demonstrated sensitivity and understanding of individual service user’ characters and needs in describing how the service user’s death was handled in relation to the other service users in the home. DS0000022725.V311803.R01.S.doc Version 5.2 Page 11 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, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyles reflect their social, cultural, religious and recreational interests and choices. Contact with family, friends and representatives is encouraged and facilitated. Residents are encouraged and supported to exercise choice and control in their daily lives. Residents are given a nutritious and balanced diet in pleasant surroundings. EVIDENCE: The home ensures that service users exercise choice in activities and daily living routines. The home offers service users the choice to partake in a range of activities both inside and outside the home. Television, radio, large print books, cards, dominoes and puzzles are provided in the home, as well as a landscaped garden with patio facilities. The manager encourages service users to go out for car trips to shops and places of interest but only two residents choose to do this. One service user told the inspector that she didn’t go out in the summer because of she was afraid of falling, however she did make a trip to the shops with a relative to make purchases. One service user has her own favourite singer whom she regularly listens to by cassette tape, and one service user likes to read the Bible and listen to tapes of hymns. The home arranges for the mobile library service to visit. DS0000022725.V311803.R01.S.doc Version 5.2 Page 12 Routines in regard to getting up and going to bed, when and where to eat meals, bathing and other routines of daily living are flexible according to individual choice. This was confirmed by one service user spoken with who has a very set routine that she likes to follow. This service user likes to be in control of her own environment – the bedroom – and this is respected by the proprietor and manager, who will make sure she has advanced information if staff are going to hoover her room, wash windows etc. This service user also likes to take part in household activities and has therefore been given one area of housekeeping that she maintains. Another service user likes to be outside and uses the large back garden frequently, even in the winter, when she enjoys feeding the birds. Cultural needs in regard to food, interests and skin care are understood and have been provided for in the past although there are no service users with these needs at the moment. Service users are assisted and encouraged to fulfil spiritual needs at choice. Last Christmas, one service user requested and was escorted to Church on Christmas Eve. Verbal and documentary evidence showed that the home encourages and supports service users to keep in regular contact with family and friends where this is their choice. The regularity of relatives’ visits varies from daily to once in a while but all visitors are made welcome and shown hospitality by the home. Some service users who do not usually like to go out of the home will go out with their families to celebrate special occasions. Service users are encouraged to keep in contact with the local community via trips to shops, and one service user told the inspector she enjoys watching the activities on the street from her window. Service users exercise choice throughout the day, for example, choosing when to go to spend time in their rooms, where and what to eat, when to bathe, and what activities to undertake. Service users are encouraged and supported to keep personal possessions in the home and their rooms, and the manager has made special arrangements so that two service users can have some dailyused possessions kept near to them every day so that they can continue with their individual interests whilst enjoying the company of the others in the lounge. All service users have television and radio facilities in their rooms. Menus have been devised based on consultation with service users. One service user will not eat eggs or milk, another controls her own diet very fastidiously, liking to eat large amounts of vegetables, and a third is on a liquidised diet. Service users have a choice of breakfast each morning, a hot meal at lunchtime and the choice of a light meal or sandwiches and soup in the evening. A bowl of fresh fruit was available in the lounge. The meal given on the day of inspection was home made shepherd’s pie with mixed vegetables, and each service user had a different sweet depending on their individual choice. The inspector sampled the meal and it was very tasty and attractively presented. A separate vegetable dish was prepared for the service user having a liquidised diet to ensure they were receiving sufficient fibre. This service user is also given a suitable nutritional supplement in the evenings. Service DS0000022725.V311803.R01.S.doc Version 5.2 Page 13 users chose where to eat their meal, in the separate dining room, the lounge or their own rooms, all of which are pleasant places to eat. Service users spoken with said they were happy with the meals given at the home and enjoyed them. DS0000022725.V311803.R01.S.doc Version 5.2 Page 14 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, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and interested parties views and complaints are listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: No complaints have been made to the home since the previous three inspections. The home has a complaints procedure and a complaints book and also keeps a Comments and Suggestions box in case residents or visitors would prefer to use this approach. Any comments, suggestions or dissatisfactions are dealt with on a daily basis, and service users spoken with said that they could approach the manager with anything they wanted to know or discuss. This was observed in practice on the day of inspection. As the manager is on duty daily, she is always available for service users, staff or visitors to speak with. The member of care staff interviewed with was familiar with the different forms that abuse can take and was clear about how these should be reported and dealt with. The home has a clear and well-written abuse policy. The inspection report of 23rd February 2006 recommended that the manager obtain a copy of the local borough’s adult protection policy to discuss this and the implications of the POVA list with staff, and this had been done. DS0000022725.V311803.R01.S.doc Version 5.2 Page 15 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, 21, 22, 23, 24, 25, 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users live in a safe, well-maintained, comfortable and homely environment. Service users have access to safe and comfortable communal facilities and there are sufficient and suitable lavatories, washing facilities and specialist equipment. Bedrooms are comfortable and homely with individual possessions. The home is clean, pleasant and hygienic throughout. EVIDENCE: The home is accessible, safe and well maintained, and is comfortable and homely throughout. It is situated in a quiet residential street, a short walking distance from a park/common and within a short walk or car ride from a busy shopping centre with full transport and community facilities. It has a front rose garden and a large landscaped back garden that is attractive and well kept with a peaceful atmosphere and seating for service users. There is a spacious lounge/diner on the ground floor, and a separate dining room off the kitchen which can be used for meals or activities or visitors. The DS0000022725.V311803.R01.S.doc Version 5.2 Page 16 lounge is very attractively decorated, fitted and furnished and an awning has been provided so that residents are shaded in the summer when the French doors are opened. Toilets and bathrooms are suitably located for accessibility. The ground floor toilet and shower are close to the lounge and dining areas, and the separate bathroom and toilet on the first floor is to the bedrooms. The bathroom on the first floor has been refitted to a very high standard. Bedrooms have good décor, furniture and fittings and had all been personalised according to residents’ individual preferences and choice. A service user spoken with said that she was very happy with her room and enjoyed playing her music on the radio/cassette player. There are three double bedrooms but these are all being used singly at the moment so that currently each service user had a single bedroom. All bedrooms currently exceed minimum size standards. There are appropriate aids and adaptations throughout the home, including grab rails and bath seats in toilets and bathrooms and a chair lift for the stairway. The stairway was adapted to be unusually wide, making the use of the chair lift particularly easy. Service users are therefore able to maintain independence by operating the chair lift themselves, and the space taken up does not in anyway restrict other service users from using the stairs. Thermostatic valves have been fitted to all bedrooms and bathroom taps, and to radiators throughout the house. The proprietor has fitted radiator covers throughout the home, with the exception of one service user’s bedroom. This service user hates change and does not want a cover fitted to her radiator so the manager and proprietor are very slowly and patiently trying to coax her to accept it. They have ensured that the furniture in her bedroom is arranged in such a way that there is no danger to her from the uncovered radiator, and the inspector observed that this was the case. The home is well ventilated, lit and heated. On the day of inspection the home was found to be clean and hygienic throughout and free from offensive odours. The domestic washing and drying machines are located in a cupboard on the first floor, well away from the kitchen downstairs. DS0000022725.V311803.R01.S.doc Version 5.2 Page 17 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, 30 Quality in this outcome area is excellent/good/adequate/poor. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by the numbers and skill mix of staff. The home has met the NVQ Level 2 training target for care staff. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. EVIDENCE: The home is registered for 9 places but as it now has 5 service users only, staffing numbers have been reduced. The manager and proprietor live at the home and the manager is on duty each day, along with one care assistant for each of the morning and afternoon shifts. An extra care assistant is used if the manager has to go out or take a service user to an appointment, so that there are always two care staff on duty. The manager and proprietor continue to provide the late evening and night cover, and at weekends, either the manager or proprietor, or both, are on duty with a care assistant. Two of the care assistants employed have NVQ Level 2 and a third is just finishing it, so the home has met the recommended NVQ Level 2 training target. All staff have undertaken first aid, food hygiene, infection control and manual handling training, and in addition all staff have undertaken external certificated training in health and safety to update their knowledge. DS0000022725.V311803.R01.S.doc Version 5.2 Page 18 There have been no new members of staff since the home’s recruitment practice was fully assessed at the previous year’s inspection, and so this Standard continues to be met. All staff have a proficiency records book which records the induction and training undertaken. These were seen and showed that all staff have received training on areas relevant to the client group. As mentioned above, staff attended a two week external training course to update their knowledge of health and safety compliance during the year. This was fully funded by the proprietor and hence the recommendation for 3 days of paid training per year has been exceeded. DS0000022725.V311803.R01.S.doc Version 5.2 Page 19 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, 36, 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 fit to be in charge, of good character and able to discharge her responsibilities fully and service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users and service users finances are safeguarded by the financial procedures at the home. Staff are supervised informally on a daily basis but are not given formal, recorded supervision. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager and proprietor have extensive knowledge and many years experience of working with older people and of managing a care home for this client group. They give clear leadership and direction to staff in an open, approachable and supportive manner. Staff and service users spoken with said that they found both the manager and proprietor very approachable, friendly DS0000022725.V311803.R01.S.doc Version 5.2 Page 20 and supportive and this was observed on the day of inspection. Staff said that there was good teamwork at the home, that the manager always listened to their point of view and always took immediate action if anything was needed. There is a clear commitment to equal opportunities at the home. In the previous year the manager attended an external 3 day certificated course in management skills in care as a periodic training update. The Proprietor has just completed a two year development plan for the home. This included new carpets, the building of a summer house, a new awning for the exterior of the lounge, new electrical wiring, radiator covers, a completely refurbished first floor bathroom and the fitting of thermostats throughout the home. In regard to service quality monitoring, this is achieved by monitoring the health of service users, verbal feedback from them on their satisfaction at the home, and feedback from family and relatives. Last year all service users were asked to fill out a quality of service questionnaire, assisted by staff as necessary. This should be repeated this year, with the results typed up and made available to service users and visitors. The home should also add comments made from relatives, visitors and professionals concerned with the home. See Recommendation 1. The home does not currently manage monies for any of the service users. One service user manages their own money and all of the others have their money managed by relatives. As the manager and proprietor are constantly on the premises they are able to train and supervise staff on a daily one to one basis but at previous inspections it was found that formal documented supervision is not carried out. At the last inspection the manager said that systems of formal supervision and appraisal would be in place by the end of March 2006. This was done in regard to appraisal but not in regard to formal documented supervision. As this is a small home and the manager oversees and supervises staff informally on a daily basis, the inspector is of the opinion that formal supervision need only be undertaken 3/4 monthly (unless circumstances arise that dictate otherwise). The previous requirement in regard to formal supervision therefore remains. See Requirement 2. Evidence from documentation and speaking with management and staff demonstrated that the health, safety and welfare of residents is promoted and protected. Staff have received training in fire safety, first aid, food hygiene, infection control and manual handling. Hazardous material is stored safely in a locked cupboard, windows have suitable locks and restrictors and thorough risk assessments for each service user and for general risks such as electrical appliances, wet floors, hot water, lifting and the stairway have been undertaken and reviewed as appropriate. Environmental Health visited in February 06 and the recommendation for staff to update their food hygiene training was implemented. The fire book showed that regular fire drills and fire procedure training is carried out and documented and that call points are DS0000022725.V311803.R01.S.doc Version 5.2 Page 21 regularly tested as required. The annual gas safety check was carried out in May 06 and the five year electricity check was carried out 3 years ago. The stair lift was given a complete service and overhaul in May 06. DS0000022725.V311803.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 2 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 4 3 3 4 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 3 3 X 3 2 X 3 DS0000022725.V311803.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4(1) & 5(1) Requirement The Registered Person must ensure that there is a Statement of Purpose/Service User Guide that meets all the requirements of legislation. The Registered Manager must ensure that regular formal supervision of staff is conducted and documented. Previous timescales of 31/05/05, 31/10/05 and 31/03/06 not met. Timescale for action 01/04/07 2 OP36 18(1)(c) (i)18(2) 01/04/07 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 OP33 Good Practice Recommendations The Registered Person should ensure that a survey of service users’ views on the quality of care at the home is conducted and a summary of the results printed up for perusal by interested parties. DS0000022725.V311803.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 DS0000022725.V311803.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!