Inspection on 11/05/06 for East Riding

This inspection was carried out on 11th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

East Riding 22/09/09

East Riding 05/12/08

East Riding 05/12/07

East Riding 30/10/06

East Riding 24/11/05

East Riding 23/05/05

East Riding 05/11/04

East Riding 06/05/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE East Riding Whoral Bank Ashington Road Morpeth Northumberland NE61 3AA Lead Inspector Mrs Irene Bowater Key Unannounced Inspection 11th May 2006 08:30 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 East Riding DS0000000506.V288926.R02.S.doc Version 5.1 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. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service East Riding Address Whoral Bank Ashington Road Morpeth Northumberland NE61 3AA 01670 - 505444 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) east.riding@fshc.co.uk Four Seasons Health Care (England) Ltd Mr William George Guy Care Home 67 Category(ies) of Dementia - over 65 years of age (34), Old age, registration, with number not falling within any other category (33) of places East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Two named service users are known to be under pensionable age, receiving EMI nursing care. No further admissions are to take place without the prior agreement of CSCI Two named service users are known to be under pensionable age receiving general nursing care. No further admissions are to take place without the prior agreement of CSCI Date of last inspection Brief Description of the Service: The home is a two-storey purpose built facility situated on the outskirts of Morpeth. It is within walking distance of local shops and the town centre. The approach to the home is via a steep driveway, which leads to generous car parking from which there is level access to the home. The home comprises of two units. Millview Unit is situated on the ground floor and caters for thirty older persons with nursing care needs and there are three beds for residents who require social and personal care only. The Wansbeck Unit is situated on the first floor and has thirty-four beds for mentally ill service users requiring nursing care. Bedroom facilities are mainly single en-suite with a total of six double rooms throughout the home. Each unit has lounges and dining rooms and there are specialist bathrooms and shower rooms located on each floor. The kitchen and laundry is located on the ground floor, stairs and a passenger lift access the first floor. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place over eight hours and was carried out by two inspectors. The home has been subject to two additional unannounced visits since the last inspection. This resulted in an Enforcement Notice being issued in April 2006. Letters and other correspondence in relation to the Notice are available at the CSCI office. The Company have responded to the issues raised and have complied with the Notice within timescales. They continue to work with CSCI and other Agencies. Over the course of the day a tour of the building took place and a number of records were inspected. Eight residents and ten staff were spoken to throughout the day. Ten surveys were sent to the home before the inspection, none have been completed or returned to the CSCI office. What the service does well: The staff have all the necessary information before any resident moves into the home to ensure they can meet their needs. There is a core of staff that have worked hard at the home for some time and they are keen to improve the standards in the home. There is good communication with other professionals to ensure residents health care needs are met. The activities organiser works hard to provide activities inside and outside of the home. Visitors are made welcome and there are good links with the local community. Residents spoken with said they knew who to complain to should if they were unhappy. Residents said “they work hard”, “I like my room”, “the staff are nice” and “I like the food”. The staff receives the training they need to care for the residents needs. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Although there have been improvements made to the care plans, work is still needed to ensure they are clear and detailed about all aspects of the care provided. Improvements are needed to the medicine charts. The menus need to be reviewed to enable more varied and nutritious meals to be available. Further training for staff is needed so that they can continue to improve the lives of the residents living in the home. The cleaning in the home needs reviewing to make sure all areas are clean and fresh at all times. Staff records need to be reviewed to make sure all staff including volunteers have the same robust recruitment procedures carried out. The problems with the under floor heating needs to be looked at so that temperatures are maintained at a satisfactory level throughout the home. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 7 The consultation with residents and their representatives needs to improve to ensure the home continues to develop and provide a good service. The systems to enable residents receive interest on their money need to be resolved. The health and safety issues including monitoring and recording of water temperatures need to be addressed to make sure the residents are safe at all times. The refurbishment and redecoration of the home needs to continue within given timescales to make sure the home is safe and comfortable for the residents. The requirements from this report need to be actioned within the completion dates. 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. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 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 East Riding DS0000000506.V288926.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 is not applicable. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The admission assessments ensure the residents care needs will be met. EVIDENCE: Six care plans were inspected and showed that the senior nurses or the manager carries out comprehensive assessments before any resident is admitted to the home. The care managers and the nurse’s assessments were also available. These records form the basis of the care planning process for the resident. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9,10 The quality in this outcome is poor. This judgement has been made using available evidence including a visit to the home. The care plans need improvement to provide staff with the information they need to meet resident’s needs. The resident’s health care needs are met with evidence of interagency working. Lack of suitable identification on the Medicine records could place residents at risk of harm. The staff have an understanding of the residents support needs, which ensures residents’ are treated with respect and their privacy maintained. EVIDENCE: Each resident has a plan of care that is based on the admission assessment. The care plans use a recognised nursing model that covers the “activities of daily living”. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 11 The six care plans inspected showed that the staff have been working hard to improve the record keeping. There was evidence that assessment tools are in place for fall prevention, dependency, safe use of bed rails, nutrition and mental health status. One care plan did not have a risk assessment in place for moving and handling. The care staff manually lifted this resident. Another care plan showed that the preadmission assessment was completed and the admission records started, however six days after admission the care plan was not completed. Social assessments and care plans are not completed in detail. Two care plans were completed to a satisfactory standard in regards to personal and health care needs. Two showed that monthly assessments and reviews were not completed. None of the social assessments and care plans were completed in detail. The residents have access to all NHS facilities. There are regular visits from GP’s and other health professionals. Again it was observed that the care practices on the units differed. Residents on the ground floor are able to discuss their needs and preferences and were readily consulted about their care. The residents on the upstairs unit are unable to express how they want to be cared for. The main focus of the staff was to attend to personal and health care needs and not on individual’s psychological or social needs. There has been an improvement in the care provided in relation to dealing with challenging behaviours. The home has policies and procedures for staff to follow to ensure the safe administration of medicines. The storage systems were generally organised. There are plans to change the suppliers in the near future, which will “streamline” the systems. A random inspection of Medicine Administration Records (MAR) showed no gaps in recording and Controlled Drug records were correct. Eleven MAR sheets did not have any identification of residents although the registered manager confirmed that photographs had been taken. All personal care was given in private. Staff were observed to use residents preferred names and to knock on doors before entering. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 12 The needs of the residents on the two floors differ greatly. As previously stated the residents on the first floor have dementia and their individual wishes or views about what was happening were not always taken into account regarding daily life and activities. Residents are able to maintain contact with their relatives and friends as they wish. There is easy access to a payphone and several residents have a phone in their own room. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected 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 is adequate. This judgement has been made using available evidence including a visit to the home. The social activities are well organised and creative on the ground floor unit. Further stimulation and variation is needed on the mental health unit to meet resident’s needs. There are good links with the local community, which supports resident’s social opportunities. Residents are not always able to exercise choice and control over their lives. The menus do not always offer choices and variety on a daily basis. EVIDENCE: The home benefits from a designated activities person who works extremely hard to arrange events inside and outside the home. Her time is now shared between the two units, either morning or afternoon. When new residents are admitted she visits them to have a chat about their interests and the staff also supply information from their assessment records. Records are kept of individual residents who attend the activities. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 14 There is evidence of various activities taking place including music and movement, painting, board games, coffee mornings, in house entertainment, sing a longs, fund raising events and day trips. The residents have been assisted with making various greeting cards, which are displayed, and for sale in the reception area. On the day of inspection a group of residents were painting butterflies, which were to be laminated and placed in a themed garden. Since the last inspection some improvements have been made to make sure the residents on the upstairs unit have some meaningful activity during the day. The staff on this unit are now recording what they do with individual residents. The charts show when staff sit and talk to residents or do anything to reduce their anxiety level. Staff still have little time to interact on an individual basis and more thought needs to be given on how this can be changed. The residents still sit in the main lounge and reception areas or wander the corridor with little aim or purpose. There is open visiting. Residents said that visitors are welcome at any time and can stay as long as they like. The organised activities include visits to the town and local events. Visits from the church, choirs and library also take place. Residents are able to maintain control over their finances for as long as they are able. Bedrooms show that residents have been encouraged to bring personal possessions with them, making their rooms homely and individualised. Information about access to advocacy is readily available in the reception area. There are restrictions on residents being able to exercise choices especially on the upstairs unit. All of these residents have mental health problems and although some progress has been made about personal lifestyles there is evidence that the main aim is on personal and health care needs rather than exploring what individuals want or need. On arrival at 8:30 am the majority of residents on both units were still asleep or being assisted by care staff to get ready for the day. The residents on the downstairs unit are served their breakfasts on trays in their own bedrooms. The trays were worn and stained with some having broken sharp edges. The staff on the upstairs unit now makes sure the residents are ready before giving them breakfast in the dining room. Neither dining room had tables set with cloths, cutlery or condiments at breakfast time and both rooms were generally dusty, with food spillage on floors and dining chairs. The menus do not detail the food for each meal .The first choice for tea on five nights is recorded as soup and sandwiches. Two nights a week the tea meal consists of soup and buffet. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 15 The dining table son both floors were not set with cloths, appropriate condiments or napkins. The lunchtime meal consisted of roast pork, sprouts, carrots, roast potatoes, Yorkshire pudding and gravy. Fruit and cream was served for dessert. Orange squash was offered through the meal. The meal was well cooked, of ample potion size and well presented. Residents were offered choices about sitting in their wheelchairs or being transferred to dining chairs. The person serving the food consulted with the care staff about residents likes and dislikes but was evidently aware of their needs. Staff assisted residents quietly and sensitively throughout the meal. Improvements have taken place on the upstairs unit at mealtimes. Two dining rooms are now used which made the mealtime quieter and unhurried. Staff assisted the residents who needed help in a sensitive manner. The dining tables are not set and condiments were not available as “residents would not be able to use them” and “tablecloths are just for show”. There is little evidence that staff know how to increase the nutritional value of meals for those who have poor appetite or have lost weight. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 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 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 is good. This judgement has been made using available evidence including a visit to the service. The complaints procedure is clear. Residents are confident that their views are listened to. Arrangements for the Protection of Vulnerable Adults are satisfactory and protect residents from harm. EVIDENCE: The home has policies and procedures for residents and staff to use should they have any concern or complaint about the care or other services. There have been no reported complaints to the Commission for a year. One concern from a relative had not been recorded and this was brought to the attention of the registered manager for action. The concern had been appropriately dealt with. Three residents said that they felt able to use the procedure if necessary. Policies and procedures are in place to protect residents. Staff have received training since the last inspection and said they would know what to do should there be any allegation of abuse. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. There has been some investment in the home, which is slowly improving the conditions for people who live there. The current quality of the furniture and fittings do not create a pleasant, safe and hygienic place to live. There are still some outstanding requirements that have the potential to place residents at risk. EVIDENCE: All areas of the home are accessible to residents with disabilities and those who need to use wheelchairs. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 18 Since the last inspection, subsequent additional inspections and letters to the responsible persons improvements have been made to all areas, and a programme of redecoration and refurbishment is now in place. There are lounges and dining rooms on each floor. There is evidence that new furniture; carpets and lighting have been provided. Lounges and corridors have been redecorated to a good standard and replacement of the patio doors is expected 18 May 2006. A tour of the building found the following that need attention. The door to the lift on the ground floor needs to be shaved as it is catching on the new patch of carpet. The carpet in reception needs to be replaced as bare concrete flooring is visible where the reception unit has been removed. The carpets in both corridors were generally grimy. Lounge 52, the video cabinet drop down door opens freely and the furniture was not clean. The central lounge upstairs had a strong odour and the carpet was stained. The upstairs dining room was generally untidy with plastic aprons lying about and dust covering the dresser. The ceiling needs further decoration following water ingress. There is a breakdown in the double-glazing, which obscures the view. The toilets and bathrooms were generally dusty and cluttered. Bathroom 61 is used as a storeroom still has a stale odour and the water is not flushed. Bathroom 45 has no bin and the floor is stained. Toilet 54 was out of order Bathroom 50. There were three commodes stored one was covered in talcum powder, one had a hand washbowl in place instead of a commode and the commode was rusty. There was no bin. Bathroom 87 has had new flooring, however the room has a strong odour and the walls are gouged where either wheelchairs or hoists have caught the wall. The shower attachment was broken and the drain cover was missing. Bathroom 81 .The commode was dirty, there was no water from the bath and there was no bin. Bathroom 2 .The bin was overflowing and had no lid. The shower attachment was broken and dirty. Many of the residents have brought some of their own possessions with them resulting in individualised rooms reflecting their previous lifestyles. Replacement of bedroom furniture is taking place. Several of the bedrooms had an odour problem and several of the bedroom carpets were stained. Two identified bedrooms had torn mattress covers and one mattress was stained with body fluids. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 19 Eleven bedroom carpets have been replaced since the last inspection. It was confirmed that some relatives had refurbished their relative’s bedrooms. There have been ongoing problems with the under floor heating and it was confirmed that the problems are still being addressed. Temperatures on the day of inspection reached 29 C in some areas of the home. The laundry has been deep cleaned and the flooring has been replaced. The room is more organised as individual laundry baskets have been provided but a plastic box filled with soiled laundry blocked the door. Both sluices were locked when not in use. One sluice disinfector has been provided and a further one is due delivery. Both of the sluices were cleaner and tidier although one sluice still had a deckchair stored under the sluice hopper. Liquid soap and paper towels were available and staff were observed to follow infection control procedures. The home was generally dusty with a strong odour of urine on the upstairs unit. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 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 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 is adequate. This judgement has been made using available evidence including a visit to the service. The staffing levels currently meet the resident’s needs. Staff are receiving training to meet residents care needs. Improvements are needed with recruitment procedures to ensure residents are fully protected. EVIDENCE: The home operates the staffing levels according to its own “grid” which is based on occupancy levels. There is a stable core staff team who have worked at the home for some considerable time. The staffing levels are: Ground floor unit: 1 Registered level nurse throughout 24 hours 4 Carers during the day 3 Carers in the evening 2 Carers overnight. First floor Unit: East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 21 1 1 4 2 3 Registered Mental Nurse throughout 24 hours Registered Mental Nurse 4 mornings Carers during the day Carers overnight mornings 5 carers on duty The home has adequate domestic and laundry staff when fully staffed. The staff said there were difficulties when staff were off sick or on holiday. There is a full time administrator and maintenance person and the home benefits from a designated activities organiser. There is a cook and kitchen assistants. NVQ level 2 training has restarted and there is evidence that 50 of staff have completed this training. Two staff have NVQ level 3. There are recruitment and selection procedures for staff to follow. Six staff records were inspected. Four showed that two references, Criminal Record Bureau checks, proof of identity, application form and staff contracts were available. One record did not have two references and one did not have a photograph. One volunteer who has recently started had no checks completed. Staff have a training and development file. There was evidence of induction ongoing training and formal supervision. Recent training has included dealing with Challenging Behaviours, Moving and Handling, Health and Safety, Abuse Awareness, Infection Control and First Aid, Fire Training, Wound Assessment and care planning. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The registered manager is now showing guidance and direction to staff, which should promote a quality service. The systems for consultation and quality monitoring are poor with little evidence to show that views of residents and their representatives are sought to develop the home. Residents personal accounts are not managed to ensure their best interests are protected. There are some health and safety practices, which pose potential risks to residents. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 23 EVIDENCE: The registered manager has been in post since the summer of 2005. He is a first level Registered Mental Nurse with many years clinical and management experience. He has started to address the many issues the home has in aspects of service provision. Monthly visits and reports from the Company’s representatives are completed. The registered manager has held one resident and relative meeting. Further information about how residents and their representatives are involved in the home is not available. There is limited evidence to support that resident’s views are taken into account. One staff meeting and a health and safety meeting took place in April 2006. Resident’s personal allowances are held in a central non-interest bearing account. The Company is planning to change this system to enable residents to get interest on their own money. This has not happened yet. The home maintains detailed records of all transactions with cross-referenced receipts. All transactions are signed by two people and descriptions of purchases provided. All utility contracts were available and up to date. Accident recording and reporting is in place with monthly audits carried out. Staff have received mandatory training with records kept and an ongoing training programme is available. Risk assessments for the use of air fresheners and upstairs windows have been implemented since the last inspection visit. Weekly in house maintenance checks were not up to date. The laundry door was held open by a plastic box of linen which would prevent the door closing should there be a fire. East Riding DS0000000506.V288926.R02.S.doc Version 5.1 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 X X 2 X 2 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 2 East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 25 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 OP7 Regulation 13,15 Requirement The registered persons must ensure that all care plans and risk assessments are evaluated at least monthly and updated to reflect the changing needs of the residents. Timescale of 08/05/06 not met. The registered persons must ensure that appropriate identification is available on all individual Medicine Administration records. The registered persons must progress further, with providing suitable stimulation for residents with dementia. The registered persons must ensure that residents are enabled to make decisions with respects to the care they are to receive. The registered persons must review the menus to ensure the diet is varied, nutritious and offers choices according to assessed need. The registered persons must ensure that the home is of sound DS0000000506.V288926.R02.S.doc Timescale for action 01/07/06 2 OP9 12,13,23 01/07/06 3. OP12 12,16 01/09/06 4. OP14 12 01/07/06 5. OP15 12,14 01/08/06 6. OP19 23 01/09/06 East Riding Version 5.1 Page 26 7. OP20 16,23 8. OP21 23 9. OP21 23 construction and kept in a good state of repair externally and internally. The door requires refitting in the front area where a new piece of carpet has been laid. The patio door mechanism in the downstairs dining room requires repair or the doors replacing. Outstanding since 28/02/06 Timescale of 08/05/06 not met. The registered persons must ensure that the corridor and communal carpets are deep cleaned or replaced and the faults in the double-glazing repaired. Outstanding from 31/8/04. Timescale of 08/05/06 not met. The registered persons must ensure that all bathrooms and toilet floorings are deep cleaned. Where stains and ingrained debris cannot be removed the flooring must be replaced. The shower drains require cleaning and the scum removed. The plastic on one drain is peeling off and needs replacing. All of the bathrooms, toilets and shower rooms, which are not used, require the water to be drawn at regular intervals. The odour from the drain in bathroom 61 and 81 requires investigation. Outstanding from 20/5/03 Timescale of 08/05/06 not met. The registered persons must ensure that the shower attachments are replaced and toilet 54 is repaired. The walls in bathroom 87 require repair and redecorating. 01/09/06 01/09/06 01/07/06 East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 27 10. OP24 16,23 11. OP24 16,23 12. OP25 23 13. OP26 12,16,13, 23 14. OP29 12 15. OP33 24 16. OP35 17,20 The registered persons must ensure that the stained worn carpets and bedroom furniture is replaced as part of the planned refurbishment programme. The registered persons must ensure that an audit of all bedding and mattresses is undertaken. The identified mattresses must be replaced. The registered persons must ensure that the problems with the under floor heating are identified, resolved and the ambient temperatures are maintained throughout the home. Outstanding from 23/05/05 Timescale of 08/05/06 not met. The registered persons must ensure that the premises are kept clean, hygienic and free from offensive odours. The second sluice disinfector must be fitted. The registered persons must ensure that all staff have two written references before appointment. The recruitment and selection of volunteers involved in the home must be thorough and include police checks. The registered persons must establish a system of reviewing the quality of all care provision in the home and develop systems for consultation with residents and representatives with records kept. The results of resident surveys must be published and made available to all interested parties. The registered persons must ensure that any interest accrued on residents money is paid into their individual account. DS0000000506.V288926.R02.S.doc 01/09/06 01/07/06 01/09/06 01/07/06 01/07/06 01/09/06 01/07/06 East Riding Version 5.1 Page 28 17. OP38 13 The home must ensure that all 01/07/06 parts of the home to which service users have access are so far as reasonably practicable free from avoidable risks. Unnecessary risks to the health and safety of service users must be identified and so far as possible eliminated. The laundry door must not blocked at any time. All weekly maintenance checks must be recorded and signed. Water temperatures must checked and recorded to ensure water close to 44 C. All obsolete, broken items including empty cardboard boxes must be removed from storerooms and bathrooms. Timescale of 08/05/06 not met. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 East Riding DS0000000506.V288926.R02.S.doc Version 5.1 Page 30 - 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!