Inspection on 28/08/07 for Durban House

This inspection was carried out on 28th August 2007.

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

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

Other inspections for this house

Durban House 11/09/09

Durban House 09/10/08

Durban House 25/09/06

Durban House 06/02/06

Durban House 10/10/05

Durban House 19/01/05

Durban House 24/05/04

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

CARE HOMES FOR OLDER PEOPLE Durban House Hodgsons Road Blyth Northumberland NE24 1PN Lead Inspector Suzanne McKean Unannounced Inspection 11:00 28 & 29 August 2007 th 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 Durban House DS0000000507.V346281.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. Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Durban House Address Hodgsons Road Blyth Northumberland NE24 1PN 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) 01670 - 354181 01670 362236 durbanhouse@schealthcare.co.uk Exceler Healthcare Services Limited Mrs Ann Mielnik Care Home 45 Category(ies) of Dementia (45) registration, with number of places Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Dementia - Code DE, maximum number of places: 45 The maximum number of service users who can be accommodated is: 45 25th September 2006 Date of last inspection Brief Description of the Service: Durban House is a two-storey building of traditional brick and tiled roof construction. It has a car park to the front of the building, which allows level access to the main entrance. The home is situated in a predominantly residential area with easy access to the centre of Blyth town with its shops and other public amenities. It is also on a main bus route being only about one mile from the main bus terminal. The home is registered to provide care to a maximum of forty-five people with a dementia who have nursing and social care needs. The home also has a small unit registered for adults who have a dementia and also have a learning difficulty. The home charges fees of between £383.52 and £555.62 per week depending upon individual needs and requirements. As the home provides nursing care the free nursing care element of the funding is provided in addition to the costs charged to the resident. The home provides information about the service through the service user guide and a copy of the last inspection report from The Commission for Social Care Inspection is available in the entrance to the home. Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • Information we have received since the last visit on 25th September 2006. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 28th August and a further visit was made on 28th August 2007. During the visit we: • Talked with people who use the service, relatives, staff, the manager & visitors. • Looked at information about the people who use the service & how well their needs are met, • Looked at other records which must be kept, • Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, • Looked around the building/parts of the building to make sure it was clean, safe & comfortable. We told the manager what we found. What the service does well: The home is very well managed to provide good care in the best interest of the people living in the home. There are effective lines of communication and the staff are aware of their roles and responsibilities. They are well supervised and trained to make them prepared for the job they do. The manager is clear about the ways she plans to further improve the care being provided. She is aware of the need to provide specialist dementia care to meet the needs of the people living in the home. The relatives were very positive about the care being given, and those residents who could give information were complementary about the staff. An example of relative’s comments was “the staff are do their best for my relative” and “the are lovely, she is happier here than anywhere else”. Contact Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 6 between staff and residents was respectful and suggested genuine fondness. There are a large number of social activities being offered in both groups and on an individual basis and these are changed frequently to meet the abilities and choices of the residents. The residents were taking part in activities during the visit and were being encouraged to spend their time in different ways. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. 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. The home has a good statement of purpose and service user guide and the prospective residents and their representatives. This provides the right information to help people make an informed choice before admission. Residents are admitted into the home after they have had a comprehensive assessment by the home staff. This then forms the basis for the development of the care plan. Prospective residents are given good information to show that they can be cared for by before they move in which is available in both written or audio formats. The home does not offer intermediate care. Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 9 EVIDENCE: The care plans contained a comprehensive pre-admission assessment. The Manager or the senior staff had carried this out. The records are detailed enough to form the basis of the care planning. The information is obtained from a variety of sources including the people caring for the resident, their carers or relatives. Information is also obtained from the hospital or the care home if the resident in living in one at the time of the admission. The care plans also contained a care management assessment, provided by the residents Care Manager who works for the Social Services department. This information is given to the home on, or just before admission and from all of these documents an individual care plan is developed. During the second day of the site visit a relative arrived and asked to be shown around the home so that they could see if it was suitable for their relative. Even though this visit was not pre-arranged they were made welcome by the staff and was shown around all of the areas of the home. They were given the homes service user guide and the newsletter for this month so that they could take the information home to read at their convenience. Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The care planning in the home is good and ensures the standard of care given is person centred and have their needs met effectively. They are being given their care in a courteous and caring manner which respects their privacy and maintains their dignity. The residents receive their prescribed medication according to safe working practices. The medicines in the home are well managed and safely disposed of as necessary. EVIDENCE: Every resident has a comprehensive care plan which are completed to a good standard. They are up to date and all care plan sections had been reviewed monthly and the daily records of care given are complete. The review of the Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 11 care package is carried out six monthly with a representative of the social services, which is arranged by the home. Relevant risk assessments are completed for, prevention of falls, wound care, moving and assisting, and continence promotion. There is an assessment to look at the resident’s food and fluid intake and if needed a plan is then drawn up to prevent any further weight loss. This includes getting advice from a dietician and speech therapist or speaking to the residents General Practitioner. The care plans are regularly updated to make sure they are accurate and include both the mental health and general health care needs of the residents. They are also discussed with the residents (when possible) and their relatives or representatives. The care plans showed that the home staff make sure that the residents use NHS services and facilities. There has been recent advice sought from the NHS Challenging Behaviour Team. They were asked by the home to assist with the care of an individual and they then worked with the staff to assess a residents needs and look at ways of improving the care provided. Action by the home around social activities and stimulation also contributed to helping the resident. There is a good range of pressure relieving mattresses to reduce the risk of resident getting pressure sores. The pressure mattresses in use are labelled with the resident’s name, and their weight to make sure that it is set correctly for them. Staff have a good understanding of the need to change the residents position throughout the day and encourage them to walk around or change the position in their chairs or bed. The home has no residents with pressure damage. But staff know how to get expert advice for wound care for individual residents if necessary. The home also gets specialist advice for residents with different conditions for example, physiotherapist or occupational therapist. Two visiting relatives were positive about the care their relative received. Examples of what they said were, “she is very well looked after here” and the other said, “she has been in other places in the past and none were as good as this one” and “she is happy here and she gets well cared for”. Medicines management was appropriate. The staff record the medicines correctly when they are ordered. The prescriptions are then checked when they are received in the home from the General Practitioners and are then sent to the Chemist for dispensing. The medicines that are sent from the pharmacy are then again checked against the record of what was ordered and prescribed so that any errors can be picked up. There are no residents who manage their own medication. Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents are offered a great variety of social activities and are encouraged to take part in those they find interesting and able to take part in. The residents are well supported and encouraged to maintain contact with their families. The home is very active in involving relatives and representatives in the care of the people living in the home. The residents are given a balanced, nutritious diet given at appropriate times in a satisfactory environment. The home has developed an effective way of giving residents support to make choices about the food they eat. EVIDENCE: There are now more detailed social assessments, which have been developed alongside the care plans. This is innovative and examples seen were effective in giving a good history of the person’s life and what kind of things they liked throughout their lives. The manager said that this identifies information about Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 13 the residents past life, experiences and aspirations and gives then the change to find activities the residents would find interesting. It also gives the staff suitable topics for day-to-day conversations, which are more relevant to the individual resident and make them feel more valued. Not all of these are available yet, although all residents have a good social care plan, which meets the standard. The bedrooms are personalised according to the taste of the resident and where they are can express their choices they are asked to pick the colour of the decoration when it is necessary to redecorate. Two residents asked about their bedrooms said they were happy with the decoration and that they had a lot their own personal items around them. Each room has a nameplate outside and a picture of the resident beside a picture of something they or their family have chosen and that they would recognise. This might be a football team badge, a familiar object or pet. There are few residents who could say how they are encouraged to take control of their daily routines. However, the care plans have information about their past lives so staff know the way they chose to live prior to admission into the home. This includes the time they prefer to get up, what and when they eat and how they spend their time. The home has an activities co-ordinator who works 30 hours per week. There are a lot of organised activities in the home and these are displayed in both writing and pictures, some have items attached to the board to show the activity for example cooking utensils for the cookery activity. Examples of the activities are Arts and crafts, Pie and Pea supper, cheese and wine parties, as well as Prize bingo, weekly trips out in the mini bus, and baking days. These are available to all residents and relatives are invited to take part. Staff said that residents could choose if they want to take part. The staff write in the care plans if the resident has taken part and if they enjoyed it. Depending on the resident’s dependency level and ability to take part they may be offered less active and more “one to one” activities. There is also a coffee morning, which is arranged by the domestic staff. The involvement of different staff gives the people living in the home the opportunity to have different experiences and the staff benefit from having positive contact with the residents. The manager has introduced a Social activities group where staff meet to agree ways of improving the social lives of the people living in the home. The group includes the manager, nurses, care and domestic staff. All care staff are given the task of organising one activity a week resulting in a number of things going on throughout the week. This might only be a simple activity but results in a number of things going on each day. The home now has activity boxes, these contain a number of different items of interest that the people living in the home can either look at themselves or be assisted by the staff to enjoy. Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 14 The Manager and staff support residents to maintain their contact with their families. This is particularly evident where a resident has a partner/husband/wife. Two relatives said that, on their wedding anniversaries, the home arranged a celebration for them, including a present bought for them on behalf of the resident. The resident is also given flowers and or chocolates or something they would enjoy. The relatives also said that at holiday times they are encouraged to be with their partner to have meals and spend time together. Cards and presents are exchanged at these times even though the resident may no longer be able to manage this themselves and rely on the staff to do it for them. This is funded by the home. A recent 64th wedding anniversary was celebrated by a resident and partner and photographs were available of the family party which included the other people living in the home and the staff. Residents have visitors at any time and use their own rooms or the lounges to see them. Relatives said that they are welcomed into the home; they said they were given information within the residents’ guide about visiting arrangements. Residents said they were happy with the arrangements for visitors. The Manager continues to review and improve the practices in an attempt to improve the resident’s food intake, particularly those who are at risk due to either their chronic conditions or their behaviour/high level of activity. This has meant changing the layout of the lounge and dining room, although further changes are planned. The residents are now eating their main meals in two sittings areas. The home has introduced a new management system for menu planning which makes sure that the meals are balanced. The staff spend time with residents who need help on a one to one basis. The residents are offered the two main choices for the main meal by it being shown to them in different combinations. When they choose one it is given to them or the combination is given to them in an appropriate portion size. This alternative is then replaced on the trolley. There were also other choices available on the day so that “finger food” was available for those residents who need that option. This allows choice and portion control. The effectiveness of these changes is to be determined by the Manager so that she can further change it if necessary and or maintain the changes if they are effective in increasing the diet intake of the residents. The morning “tea trolley” offered a selection of both fluids and food. There was tea, coffee, choice of four cold drinks including Cranberry Juice, and milk. There were biscuits, cake, and small snack sized sandwiches. There was a selection of fruit available. These were prepared if necessary by peeling and chopping it into small bite size pieces. Cooler jugs and glasses are kept with a choice of juices in the lounges and residents were being given drinks during both of the visits. Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good system for managing and dealing with complaints. It makes sure that they can react and take action as necessary to improve the service. The residents are protected from abuse by good standards of staff training, recruitment and selection and effective documentation. EVIDENCE: The complaints procedure is available in the service users guide and a copy is displayed in the home. The record of complaints made and investigated was looked at. There have been eight complaints received in the last twelve months for which records were available. These were detailed and included the response to the complainant. It also identified if any action was taken to improve the service as a result of the issue being raised. The Manager records all expressions of concern so she can use the information in the companies quality assurance system. There is also a mechanism for analysing the complaints and a monthly report is sent to headquarters to that the company can monitor it centrally. Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 16 There have been two protection of vulnerable adult investigations in the last twelve months. One of the issues was raised by the Manager and the other by a visiting professional. Both of these have been resolved and the manager has taken action to make sure that they have learned lessons from the issues being raised both in improving the documentation and changing practice as necessary. Three relatives who were visiting the home were aware of the complaints procedure but had not needed to use it. Staff are given protection of vulnerable adults training both as part of the inhouse training package as “Residents welfare training” and from external Northumberland Care Trust. The Qualified nurses also have more extensive training in this area, as they are responsible for being the “person in charge” of the home when the Manager is not present. Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is well decorated and maintained. Good records are maintained of the health and safety practices and maintenance of the building and facilities. The home is clean and well organised and the staff are knowledgeable regarding the ways to prevent the risk of cross infection in the home. EVIDENCE: The residents’ and relatives who were asked about the bedrooms said they were happy with the decoration and that they were kept clean by the staff. The bathroom and toilet areas were tidy and clean. Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 18 There have been significant improvements to the décor in the home. There are areas, which have been made into small sitting areas, including the entrance. The corridors are decorated with three-dimensional pictures including activity boards with items, which can be touched and have different textures and items to stimulate and add interest to the environment for the residents. Items such as hats, and ornaments are placed around the home and are picked up by the residents and moved about. Resident bedrooms have a “front door” appearance with a brass door number, door knocker and a letter box, they also have a sign next to the door, with a picture of the resident and a picture of something they would recognise for example a sporting sign or pet. There was also one with a photograph of them when they were younger. Bathrooms were pleasantly decorated and tidy. The main lounge area was particularly busy, this is the main shared area for the residents. This results in some positive contact between the residents but there as some times when the behaviour of residents is upsetting for others as they have different needs and there is differing support and care required. The Manager has plans to separate the lounge and dining areas into different “units” this would allow the staff to manage the care more effectively. The laundry was clean, organised and well equipped. The sluices were tidy, clean and odour free and the disinfectors operational. Staff follow infection control policies and use appropriate equipment. The kitchen area was clean and well organised and there is an up to date cleaning schedule which identifies all areas to be cleaned, how often they are completed and who was responsible for undertaking it. Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an effective recruitment and selection system, which makes sure that residents are cared for by well-trained, skilled staff and are in safe hands. A good and varied training programme ensures that staff are up to date with the latest practice and ensures the safety and well-being of people using the service. EVIDENCE: Staff records are completed according to the company policies and procedures, including two references and a completed application form. The requirement to have a CRB and POVA check is applied to all of the staff in the home. On both of the visits there were sufficient staff to meet the needs of the residents. The first day of the visit there was the Manager, two qualified nurses, five carers, one domestic, the cook, one kitchen assistant, the administrator and the handyman. The training records kept by the Manager are well managed so that she can plan training and make sure that all staff are given the appropriate training for Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 20 their role. There is a large amount of training in both statutory and clinical areas and all staff now receive training in line with the company policy and statutory requirements for moving and handling and fire training. The manager has targeted specific training programmes including recently enrolling on an NHS – Essential Steps to safe clean care. The qualified nurses also carry out some in house training. Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 21 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 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The Manager, Mrs Mielnik, has good systems in place to manage the home effectively. This takes into account the needs and wishes of the residents, their families and representatives and ensures their needs are well met. The home has effective health and safety systems, which include staff training and risk assessments. Good systems are in place to safeguard residents personal finances are managed appropriately. EVIDENCE: Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 22 There is a system and records to review health and safety; it involves all of the staff. There are records of regular staff meetings and the contents suggest that there is broad spectrum of relevant issues discussed. Those staff unable to attend these meeting are required to look at the notes from the meetings to make sure they are up to date with the information they need. Mrs Mielnik has weekly head of department meetings and these are used to set targets depending upon the changes or improvements needed. The Manager also arranges meetings with the relatives and residents as appropriate. The Manager continues to consult the residents, staff and other interested parties to review the service provided and manage the staff in a way to improve care delivered. The Manager has recently used resident and relative questionnaires to find out their opinions on the home. The relatives were given them to complete. The residents were asked for their views individually by the activity coordinator asking set questions and the responses were recorded. This was either their verbal reply of any facial expressions or reactions without a judgement being made. The Manager then interpreted the outcome of the questionnaires as part of the quality assurance process. The responses form all of the questionnaires were anonomised, and put onto the wall as part of a display. Positive feedback displayed on one side and negative ones on the other side. The ones, which identified any concerns, were also displayed with a response as to how the home was improving around these issues. Regular audits are carried out in a number of areas. These include Medication; care planning and nursing documentation, kitchen, and domestic audits. These are ongoing and are used for quality assurance at both the local home level and by the company. There is a system in place to review health and safety in the home involving the staff for which records are available. Training records around health and safety are in place and are up to date. The staff are given supervision six times a year and as well as the core issues discussed the Manager uses them to focus on improvements being made to ensure that staff are aware of the changes and understand them. Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 4 Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations It is recommended that the home pursue the plan to separate the communal areas and give a more structured space for the residents to spend their time. Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Durban House DS0000000507.V346281.R01.S.doc Version 5.2 Page 26 - 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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