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Inspection on 27/11/06 for Dunollie Care Home

Also see our care home review for Dunollie Care Home for more information

This inspection was carried out on 27th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service provides a well-maintained and pleasant environment for younger adults and older people who are in need of general nursing care and/or who because of physical disability require nursing input to promote all aspects of their daily living. People said that staff are approachable and pleasant, that the food provided is good and the environment is of a high quality. There are sufficient staff employed within the service. The service employs an activities organiser.

What has improved since the last inspection?

All staff now receives induction appropriate to their role in the home The service has employed an experienced manager who it is expected will apply for registration. Clinical testing required by individuals is carried out in a timely fashion. The organisations own recruitment policies and procedures are carried out appropriately.

What the care home could do better:

Any need and/or risk identified by initial assessment, regular review or continuing care should be transposed on to the individuals care plan record. This issue was raised at the previous visit. Where bedrails are fitted they must fit high enough above the mattress to minimise the risk to the resident from falling out of bed. The services Safeguarding of Adults procedures should be in line with locally agreed Multi-Agency Adult Protection Policy. Care staff could receive more robust day-to-day supervision. There could be a system in place to ensure that residents and/or their representatives are able to access a member of senior staff when they require to. The service should make sure that all prospective residents and/or their representative has access to a range of information about the services provided, that they receive a copy of and are helped to understand their/relatives contract. All residents including respite care users should receive a comprehensive assessment of need prior to admission. All residents and/or their representatives should have access to a clear and comprehensive complaints policy and procedures that support them to raise concerns and have them dealt with effectively. When prescribed medications and preparations including dressings are no longer required for the person named on the prescription, these should be disposed of appropriately. People should be provided with lockable facilities in which to keep valuables.

CARE HOMES FOR OLDER PEOPLE Dunollie Nursing Home Dunollie Nursing Home 31 Filey Road Scarborough North Yorkshire YO11 2TP Lead Inspector Mavis Pickard Key Unannounced Inspection 27th November 2006 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 DS0000043116.V322698.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. DS0000043116.V322698.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dunollie Nursing Home Address Dunollie Nursing Home 31 Filey Road Scarborough North Yorkshire YO11 2TP 01723 372836 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) dneuropeancare@aol.com European Care (SW) Ltd *** Post Vacant *** Care Home 49 Category(ies) of Old age, not falling within any other category registration, with number (49), Physical disability (49), Terminally ill (5) of places DS0000043116.V322698.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users to include 49 OP, 49 PD and 5 TI up to a maximum of 49 service users. Service Users in the category PD to be aged 40 years plus. Date of last inspection 11th May 2006 Brief Description of the Service: Dunollie Care Home provides nursing care and accommodation for a maximum of 49 people. The maximum numbers may include older people over 65 years who need general nursing care, people who are terminally ill and/or younger adults over the age of 40 who have a physical disability and require nursing care. The current scale of charges are from £378-£620 a week. The home which is owned by European Care (SW) Limited is located in Filey Road, on the Southcliffe area of the Scarborough, North Yorkshire, close to the Spar complex, Ramshill shopping area the Italian gardens and about 1 mile from the town centre. The home is set in extensive, well maintained, grounds that afford patio areas with seating for residents and visitors. The accommodation provided is divided between the main house and the garden wing, which is specifically designed for people with a physical disability. There is both single and shared accommodation available. Both wings of the home provide a range of communal space and all the specialist equipment required of the people accommodated. There is a passenger lifts to all floors and ample car parking for visitors and staff. DS0000043116.V322698.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall view of this service is that some concerns raised regarding the assessment and planning of care for residents raised at the previous inspection remain unmet. Additionally there are concerns raised regarding health and safety and the safeguarding of residents. The service remains without a registered manager albeit a new manager has been appointed who it is understood has applied for registration as manager. People who use and/or visit the service raised concerns that the service has had several changes of management within the last few months. During this visit part of the inspection day was given over to conducting a ‘themed probe’ following which some services nationally will receive a Thematic Inspection. Thematic Inspections are as a response to a report by The Office of Fair Trading in respect to services provided nationally to residents and/or their representatives. This would include their contract, their needs assessment and the accessibility of the home’s complaints policies and procedures. These issues are covered in the National Minimum Standards by standard 1,2,3 and 16.the outcomes of the themed probe are recorded in the summary and in the body of the report in the appropriate sections. What the service does well: The service provides a well-maintained and pleasant environment for younger adults and older people who are in need of general nursing care and/or who because of physical disability require nursing input to promote all aspects of their daily living. People said that staff are approachable and pleasant, that the food provided is good and the environment is of a high quality. There are sufficient staff employed within the service. The service employs an activities organiser. DS0000043116.V322698.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Any need and/or risk identified by initial assessment, regular review or continuing care should be transposed on to the individuals care plan record. This issue was raised at the previous visit. Where bedrails are fitted they must fit high enough above the mattress to minimise the risk to the resident from falling out of bed. The services Safeguarding of Adults procedures should be in line with locally agreed Multi-Agency Adult Protection Policy. Care staff could receive more robust day-to-day supervision. There could be a system in place to ensure that residents and/or their representatives are able to access a member of senior staff when they require to. The service should make sure that all prospective residents and/or their representative has access to a range of information about the services provided, that they receive a copy of and are helped to understand their/relatives contract. All residents including respite care users should receive a comprehensive assessment of need prior to admission. All residents and/or their representatives should have access to a clear and comprehensive complaints policy and procedures that support them to raise concerns and have them dealt with effectively. When prescribed medications and preparations including dressings are no longer required for the person named on the prescription, these should be disposed of appropriately. People should be provided with lockable facilities in which to keep valuables. DS0000043116.V322698.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. DS0000043116.V322698.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 DS0000043116.V322698.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 and 3. [Standard 6 is not applicable to this service.] Quality in this outcome area is poor. Not all residents have received a service user guide or a contract of residence. Not all people accommodated have been assessed in respect to their current needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Of the 4 people case tracked the assessment of one resident was very good giving a pen picture of them and insight into their personality and former life. The others however were poor. One returning respite resident had no current assessment of need. The information in their case file related to previous visits. DS0000043116.V322698.R01.S.doc Version 5.2 Page 10 The resident’s daughter was due to bring her mother to the home on the day of the site visit. When the relative was contacted later the she said that she had brought her mother in and waited an hour and a half to see someone who could admit her. Ultimately she spoke to the activity person as she was advised that the manager was busy with an inspection, no other senior staff was made available to the resident and relative at this time. Other resident’s case tracked had been assessed however the information had not been transposed into a working care plan. Some of the initial information was later contradicted in the care plan. An example of this is that a resident who on assessment had ‘no mental health concerns’, was in later documents shown to have dementia. Where it was is stated that the resident had ‘no previous health concerns’, later the record shows that this resident has sustained a fractured femur some time previously and has thyroid problems. Special attention was taken in assessing standards 1, 2 and 3 as part of a themed probe. Of the 3 people case tracked for this purpose: 1. All said that they had not received a copy of the Service User Guide. 2. All said that they now nothing of a written contract from the service nor had they knowledge of any changes to contracts or costing. 3. One person who is capable of making her own decisions said that her family and not she had been consulted with about her needs. 4. 2 families said that they had input into the assessments of their relatives who would not be able to make their own decisions. 5. 1 relative said that although she had been consulted about her mothers respite needs previously; no assessment was undertaken for her current respite care. DS0000043116.V322698.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 poor. Not all identified needs are transposed into individual plans of care. The health and personal care provided to residents’ remains poor. Not all people are treated with respect This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although the presentation of care plans is clear it remains the case that not all identified needs are transposed into individual plans of care. A case tracked resident who cannot communicate verbally was met with whilst receiving their lunch. The carer who assisted was pleasant and careful and communicated well with the resident who smiled and achieved some communication. DS0000043116.V322698.R01.S.doc Version 5.2 Page 12 The resident’s case file showed that they had been in the home some years but had not received any physiotherapy input following a stroke nor had they received any stimulation in respect to mobility. The resident’s relative is confident that the lack of social and physical stimulation has led the residents being immobile and having limited communication. The residents case file showed that they had been found on the floor in their bedroom. It wasn’t noted how they may have got onto the floor. There was no accident/incident record nor did the Commission receive a report of the incident. The record shows that the relative was alerted about the incident, however they have said this was not the case. The resident has an overlay mattress and bed rails are in place. However the type of bed rail used are not advised to be used where overlays are in place. The manager who has a copy of the current bedrail guidance provided by Commission staff said she was unaware of the guidance. An immediate requirement was issued requiring that the risk to the resident from the use of bed rails be minimised. The manager has replied in writing to the Commission stating that additional height rails have been ordered and that in the meantime the resident will be closely monitored whilst in bed. A concern was raised that a resident in the sitting room has a very badly bruised eye. No one appears to know how this occurred. The resident cannot say and staff say they do not understand what happened. A GP has visited the resident and prescribed some medications however the incident has not been reported to the Commission or recorded as an accident. Although there is a note in the resident’s case file. The manager confirmed that prescribed dressings no longer required by the person named on the prescription are still being retained for other resident’s use. Overall the way care plans are set out is appropriate however there is evidence of the duplication of daily records. There are 3 sets, one for qualified staff, one for care staff and one for key workers. Some of these contain the same or similar information. This leads to DS0000043116.V322698.R01.S.doc Version 5.2 Page 13 confusion and it is advised that 1 set of daily records are maintained that can be inputted and used for guidance by all staff. Whilst spending time observing the care provided it was noted that a carer when asked for something by a resident said sharply “I can’t do anything about that” then realising an inspector was present, ‘laughed off’ the incident. This was related to the manager for her attention. Another carer was heard to refer to a resident as ‘Babsy’ even though the residents care plan evidenced that her preferred name is Barbara. This was related to the manager for her attention. DS0000043116.V322698.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): All. Quality in this outcome area is poor. The activities provided by the service are not tailored to meet the individual and diverse needs of all people accommodated. The food provided is good however there is no system to record when less able residents have taken their meals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service employs an activities organiser and she was observed and heard taking part in leisure pursuits and activities with service users who were able to congregate in the entrance hall of the home. Those people are encouraged and supported to take part in activates. However from direct observation and speaking with case tracked residents and their representatives it became clear that only those who are willing and able to come to the activities organiser receive regular activity input. DS0000043116.V322698.R01.S.doc Version 5.2 Page 15 Those people who are less able either physically or cognitively or who spend their time in their private rooms or in other communal space in the home do not present as receiving the same level of service. People who were part of the case tracking were asked how they joined in the activities provided. One person could speak for herself and said that she was not encouraged to be part of activities and because she had to spend all of her time in bed she did not take part. The activities organiser had not visited the resident in her room. This was confirmed by the resident’s family who said that their relative was very isolated and that it was only when the family visited, if a carer ‘happened’ to have to pass their room or when she needed personal support that she were visited at all. 2 other residents were not able to say directly about activities however both families were spoken with and said that their relatives were not really provided with any stimulation, activities or pass times that had been tailored to their situation. Both service users have a level of dementia and both have mobility concerns. All people spoken with said that the food provided is good and that there is plenty of it. However a resident in a small lounge was observed after lunch had finished, with a beaker of cold soup on her table. When asked if the lady had taken her lunch, no one was clear. A carer then went to the kitchen and returned saying that “the meal had been dished up so she must have had it”. The manager said there is presently no system of recording when a resident has received their meal. This is particularly concerning should the resident not be able to say if they had been fed or not. DS0000043116.V322698.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 18. Quality in this outcome area is adequate. The service has appropriate recruitment and complaints policies and procedures. However the complaints policy and procedures are not provided in an accessible way to service users and/or their representatives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit a themed probe was undertaken to look at among other areas standard 16, complaints. 3 case tracked residents or their relatives were asked specific questions regarding the complaint policies and procedures. Of the people identified all said that they had not been provided at any time with a copy of the services complaints policy and procedures. One relative said that they knew where the complaints procedures were available, [a copy is in the entrance of the service] but that there is no named person on the document and that they would in any case complain to the manager. DS0000043116.V322698.R01.S.doc Version 5.2 Page 17 All people spoken with and other people who returned survey forms to the Commission said that they found it difficult to speak with a senior staff member or the manager should they need to. Either because they was ‘never anyone around’ or because of communication difficulties when speaking with nursing staff whose first language is not English. When examined the complaint procedures available in the entrance of the home was out of date and did not give a named person to contact or the address of the organisations head office. The service does have appropriate complaints policies and procedures and has in the past dealt with concerns raised by residents or visitors, appropriately. However the service does not make their Complaints Policy and Procedures available in an accessible way to service users and representatives. The services recruitment procedures were examined and found to be good and to have been followed when recruiting staff recently. DS0000043116.V322698.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, 22 and 26. Quality in this outcome area is adequate. Residents live in a clean, well-maintained environment. However the use of specialist equipment is not always assessed against the risk posed to residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is clean and is in the main well maintained and pleasant. The bedrooms of people case tracked were visited. One person who remains in the main in bed is situated in a room isolated from the central areas of the home and says she seldom sees any staff and has not been visited by the activity organiser. DS0000043116.V322698.R01.S.doc Version 5.2 Page 19 The resident cannot see out of the window from her chair or bed and has no radio, although she said she doesn’t now listen to the radio. The resident’s relatives are very dissatisfied with her present room and have asked that when a room becomes vacant she be moved. During the visit a room was identified and it expected that she will move into it as soon as is possible. A resident who requires to have bedrails fitted was observed to have an overlay on her bed which mean the rails were inappropriately low above the mattress. This can cause a risk of falling out of bed. The resident’s case file records show that she was ‘found on the floor’ by staff and that her daughter had been made aware. It is not known if she fell out of bed. No accident record was made and the incident was not reported to the Commission. The resident’s daughter said she had not been made aware of the incident. An immediate requirement was issued to ensure the minimising of the risk to this resident from the use of inappropriate bedrails. The manager said she was unaware that higher rails could be fitted. Although the manager has access to current guidance about this issue that was provided by Commission staff following a previous visit. Since the site visit the manager has given her written assurances that appropriate bedrails have been ordered and that in the meantime the resident will be monitored hourly whilst in bed. It was discussed that during the previous site visit not all service users had a lockable facility provided by the service. The manager said that those people who to care of their own medication have a lockable facility but not all people have one in which to keep valuables. DS0000043116.V322698.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): All. Quality in this outcome area is adequate. Resident’s needs are met by sufficient numbers of qualified and unqualified staff. However it is not clear that care staff receive appropriate training and day-today supervision. Although staff know what steps to take to protect residents it is not clear that they understand the locally agreed Multi-Agency Adult Protection Policy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels were sufficient to meet the needs of people accommodated and appropriate recruitment policies are followed. Some people but not all have received training in respect to safeguarding adults. In general it is understood that people are safe. However the home’s policy and procedures do not meet with the guidance of the locally agreed Multi-agency Adult Protection Policy. And the manager was not fully conversant with this locally agreed policy. DS0000043116.V322698.R01.S.doc Version 5.2 Page 21 The service deploys qualified and care staff along with ancillary staff to ensure that the service is run appropriately. However observations during the site visit evidence that care staff are not always effectively supervised in their day-to-day work. In the period just following lunch 4 carers were congregated into a small lounge where some residents who require assistance with taking meals were sitting. One resident had a feeder cup with cold soup in it, on her table but no sign that she had received her lunch. Care staff were asked if the resident had received her lunch. When asked the resident could not remember. A carer said she must have, another carer went to the kitchen and came back saying that it had been ‘put up’ so she must have had it. The manager confirmed that presently there is no system in place to record when a resident has eaten or how much they have taken. At this point one carer left the room with a resident in a wheel chair. The other three remained for a significant period talking with each other. Two bells were sounding that indicated that residents needed attention. However it was some time before anyone answered the calls. This incident was later related to the manager. DS0000043116.V322698.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 and 38. Quality in this outcome area is poor. The manager has the qualifications and experience to run the home. However there are some shortfalls in respect to the ethos, the quality assurance outcomes and the health and safety of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager, who has been in post at the service for a short time is not yet registered. She has been a registered manager previously is experienced in the management of services for older people and is familiar with the conditions of old age and of physical and mental deterioration that some of the current residents exhibit. DS0000043116.V322698.R01.S.doc Version 5.2 Page 23 It was clear from the site visit that the manager is enthusiastic to raise the standards of the service however she is only just starting to have an effect. And says that she is “aware of the enormity of the task” It would be unfair to judge management progress in the service at this stage however there are some concerns noted in respect to management issues. There is not a wholly open, positive and inclusive atmosphere. Residents /or the family’s of people case tracked said that they did not feel included. One resident said that they felt physically and socially isolated. Relatives said that they have concerns that they cannot get to see the manager or a senior person when they wish. A service user admitted on the day of the site visit for respite care was kept waiting for one and a half hours to be admitted and to speak with a senior person. Their relative said that in the end she told the activities organiser that ‘mother is here’ as she had to leave. The service have not yet implemented an effective quality monitoring system that seeks the views of service users and people associated with the home and shows the action taken where concerns are raised. Following this site visit a complaint has been raised in respect to a resident whilst being transferred from chair to wheelchair. It was reported that the resident had required hospital treatment. The investigation of this complaint is being conducted by the service and is currently ongoing. The outcome of this investigation will be in a subsequent inspection report. Health and Safety concerns are also noted in the Environment Standards, regarding bedrails. Care staff supervision concerns are also noted in Staffing Standards. Health and personal care issues are also noted in Health and Personal Care Standards. Information accessibility and sharing concerns are also noted in Choice of Home Standards. All these issue impact on the overall administration and management of the service, which is currently judged to be poor. DS0000043116.V322698.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 1 1 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 1 X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 1 X 1 DS0000043116.V322698.R01.S.doc Version 5.2 Page 25 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. 1 Standard OP1 Regulation 5(2) Requirement Prospective residents and/or their representatives must be provided with a copy of the services service Users Guide prior to admission. Each resident must be provided with a statement of terms and conditions of residence at the point of moving into the home or a contract if purchasing their care privately. Timescale for action 31/12/06 2 OP2 5(b)(c) Schedule 4(8) 31/12/06 3 OP3 14Schedul Each resident must only be e 3(1)(a) admitted following a full assessment of their need to which they and or their representatives have been party. 15(1)(2) (b-d) That needs identified at preadmission assessment or subsequently are accurately transposed to form a comprehensive plan of care for the individual. This was a requirement of the previous inspection. People accommodated must at all times be treated with respect. All people accommodated must DS0000043116.V322698.R01.S.doc 31/12/06 4. OP7 31/12/06 5. 6. OP10 OP12 and 12(3) 18 (1)(c)(i) 16(2)(m) 31/12/06 31/12/06 Page 26 Version 5.2 (n) be provided with activities and leisure pursuits that meet their individual need. Residents must be able to choose how to be addressed and their choice respected. The registered person must be confident that all people receive their meals regularly and that a system is in place to monitor the situation The registered person must ensure that where bedrails are fitted they are appropriate to the need of the resident. 31/12/06 7. OP14 12(2)(3) 8. OP15 12(1) 31/12/06 9. OP22 23(2)(n) 13(4) 31/12/06 10. OP30 OP36 12(1)(a) Care staff must be provided with 31/12/06 18(1)(c) & day-to-day supervision to ensure that they can fulfil the aims of 18(2) the home and meet the changing needs of residents. 12(1) 13 (4)(5) The registered person must at all times ensure the health and safety of people accommodated. 31/12/06 11. OP38 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 2. 3. Refer to Standard OP9 OP24 OP28 Good Practice Recommendations Dressings prescribed for individuals who no longer require them should be returned to the pharmacy. Residents should be provided with lockable facilities in which to keep their valuables. All staff should understand locally agreed Multi-agency Adult protection policies. DS0000043116.V322698.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 DS0000043116.V322698.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. Re-publishing this information is in breach of the terms of use of that website. 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