Inspection on 17/01/08 for Eastbourne Villa

This inspection was carried out on 17th January 2008.

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

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

Other inspections for this house

Eastbourne Villa 20/06/06

Eastbourne Villa 17/11/05

Eastbourne Villa 30/06/05

Eastbourne Villa 14/01/05

Eastbourne Villa 01/09/04

Eastbourne Villa 11/03/04

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

CARE HOMES FOR OLDER PEOPLE Eastbourne Villa 21 Eastbourne Road Hornsea East Riding Of Yorks HU18 1QS Lead Inspector Diane Wilkinson Key Unannounced Inspection 17th January 2008 10:00 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 Eastbourne Villa DS0000019664.V358292.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. Eastbourne Villa DS0000019664.V358292.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastbourne Villa Address 21 Eastbourne Road Hornsea East Riding Of Yorks HU18 1QS 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) 01964 533253 01964 533449 Mr George Trevor Hart & Mrs Susan Lynn Hart Position Vacant Care Home 15 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (15) of places Eastbourne Villa DS0000019664.V358292.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 only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP and Dementia - Code DE(E) The maximum number of service users who can be accommodated is: 15 20th June 2006 2. Date of last inspection Brief Description of the Service: Eastbourne Villa is a privately owned care home that is registered to provide accommodation and care for 15 older people, including those with dementia. The home is in the seaside town of Hornsea in the East Riding of Yorkshire, and is close to local amenities and to the sea front. Private accommodation is provided in two shared rooms and 11 single rooms. Shared accommodation consists of a living room, a dining room, a quiet room and a conservatory. Fees paid range from £334.80 to £384.00 per week, and there is an additional charge for hairdressing, chiropody and newspapers/magazines. All areas of the home, including the garden, are accessible to service users via the provision of a passenger lift, a stair lift and ramps. The garden is well stocked with plants and flowers and provides a seating area for service users. There is on street parking for visitors and staff. Eastbourne Villa DS0000019664.V358292.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last Key Inspection of the home on the 20th June 2006, including information gathered during a site visit to the home. The unannounced site visit was undertaken by one inspector over one day. It began at 10.00 am and ended at 4.30 pm. On the day of the site visit the inspector spoke on a one to one basis with two residents and the acting manager, as well as chatting to other residents, relatives and staff. The inspector spent two hours sitting in the lounge with the people who live at Eastbourne Villa, watching how residents and staff interact. This is to get a picture of peoples well-being and the amount of activity that takes place. This is known as a short observational framework for inspection (SOFI). Inspection of the premises and close examination of a range of documentation, including three care plans, were also undertaken. The registered provider and acting manager submitted information about the service in advance of the site visit by completing and returning the Annual Quality Assurance Assessment (AQAA) form. Survey forms were sent out prior to the inspection; four were returned from residents, four were returned from relatives, four were returned from staff and three were returned from health and social care professionals. Comments recorded in surveys and from discussions with residents on the day of the site visit were positive, such as, ‘Always someone there to help me. This comforts me, to know I have the care and support and that everyone is friends, and we are safe’ and ‘Staff always listen to me and are helpful’. Other anonymised comments are included throughout the report. A random inspection was undertaken on the 18th April 2007 following receipt of information from the registered providers. The findings of this inspection are included in this report. What the service does well: Care plans are well maintained and are a good record of how the health care needs of residents are met. Residents are encouraged and supported to live their chosen lifestyle and to take part in appropriate activities. Eastbourne Villa DS0000019664.V358292.R01.S.doc Version 5.2 Page 6 Food and drink provided by the home is good and meets the needs of residents. The home is maintained and decorated to a high standard. It was clean and hygienic on the day of the inspection and health and safety practices are good. Residents are protected by the recruitment practices at the home, and by staff training on safeguarding adults. Staff take part in training programmes that equip them to meet the needs of residents accommodated at the home. The quality assurance system gives residents and others the opportunity to affect the way that the home is operated. 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. Eastbourne Villa DS0000019664.V358292.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 Eastbourne Villa DS0000019664.V358292.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): 3. Standard 6 was not assessed as there is no intermediate care provision at the home. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are assessed prior to their admission to the home and only admitted if it is considered that their assessed needs can be met. EVIDENCE: The inspector examined the care records for a newly admitted resident. These included a basic care plan and care assessment that had been completed and supplied by the local authority, as well as an assessment of needs that has been completed by the home. Information has been sought from a relative of this resident to supplement information already collected by the home. The home has completed various risk assessments, including the risk of falls, pressure care, dependency and nutrition. This information has been used to formulate an individual plan of care for the resident. Eastbourne Villa DS0000019664.V358292.R01.S.doc Version 5.2 Page 9 The acting manager told the inspector that she had recently been to visit a prospective resident in Hornsea Cottage Hospital to assess their care needs, and their suitability to become a resident for Eastbourne Villa. Eastbourne Villa DS0000019664.V358292.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 and 10. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Health care needs are met in a way that respects a person’s privacy and dignity; this is recorded in and supported by well-maintained care planning documentation. EVIDENCE: The inspector examined two care plans in addition to the care plan for a newly admitted resident. These contained an individual care plan that was based on the needs assessment undertaken by the home as well as information gathered from care management and family members. There is evidence that people are involved in developing their plan of care; various agreements have been signed by them, including a care plan agreement, consent to the sharing of information and agreement to the use of bed rails. Care plans include risk assessments for moving and handling, pressure care, nutrition and dependency levels. More specific risk assessments for the needs of individual Eastbourne Villa DS0000019664.V358292.R01.S.doc Version 5.2 Page 11 residents are undertaken, such as the risk of falls, the use of bedrails and the risk involved in leaving the building. Records were seen on the day of the site visit to evidence that risk assessments are updated regularly. The inspector advised the acting manager that, in addition to risk assessments, there should be regular safety checks on bed rails, and that these checks should be recorded; the acting manager told the inspector that the registered provider does check bed rails when he undertakes Regulation 26 visits, but agreed that they would start to check bed rail safety on a more regular basis. Care plans are reviewed regularly via a monthly summary of a person’s needs and a six monthly in-house review. The acting manager has recorded in the AQAA that all residents, including those residents that are self-funding, now have a six monthly in-house review. This was seen in care plans examined on the day of the site visit. A member of staff recorded in a survey, ‘A full update of each clients requirements is given at the start of each shift’. Care plans include a person’s medical history and details of the medication that they are currently prescribed by their GP. People are weighed on a regular basis as part of nutritional screening. Some residents were seen to be sleeping for long periods on the day of the site visit. The acting manager explained that this was due to the medication they were prescribed and said that the residents’ GPs had told them that this would be the effect of the medication they were taking. Staff were seen to gently wake these people to ensure that they were taking sufficient food and drink, and were very patient when assisting them with eating and drinking, letting them eat at their own pace. A random inspection was undertaken in April 2007 as a result of information given to us by the registered providers. There were concerns that unused medication had not been returned to the pharmacist and that there were some inconsistencies in the recording of medication administered to residents. The inspector examined all medication records on the day of the random inspection and was satisfied that the issues identified by the registered providers and the acting manager had been rectified; the acting manager had made accurate records of any discrepancies found and how these had been corrected. On the day of this site visit the inspector observed the administration of medication by a senior carer; this was carried out in a satisfactory manner. There is evidence that all staff that administer medication have undertaken accredited training, and there are sample signatures held with medication records to enable signatures to be checked for authenticity. Medication administration records include a laminated photograph of each resident; this helps new staff to identify residents correctly and offers an additional safety measure into medication procedures. Eastbourne Villa DS0000019664.V358292.R01.S.doc Version 5.2 Page 12 Controlled drugs are stored separately and securely. The controlled drugs book records medication received, administered and the balance remaining, and all entries have double signatures. These records were checked against actual drugs held and were found to be accurate. The inspector noted that a record is kept of the results of anti-coagulant drug tests; this is good practice. The medication trolley is stored securely, i.e. it is fastened to the wall in the dining room and is kept locked at all times. The acting manager was advised that security would be improved if alternative storage arrangements could be found for the trolley, and was advised that the home should ensure that medication is stored at the correct temperature. The acting manager agreed to look into this and some suggestions of where the trolley could be relocated were discussed. Following the day of the site visit, the acting manager contacted us to inform us that they have obtained a thermometer to store in the medication cabinet as an additional safety measure. The AQAA form submitted by the registered persons stated, ‘We strive to preserve and maintain a service user’s dignity, individuality and privacy’ - the SOFI inspection confirmed this. One resident said in a survey, ‘Always someone there to help me. This comforts me, to know I have the care and support and that everyone is friends, and we are safe’. Eastbourne Villa DS0000019664.V358292.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to maintain their chosen lifestyle and to continue with their hobbies and interests. Visitors to the home are always made welcome. Residents say that meal provision at the home is good. EVIDENCE: The inspector observed that residents are encouraged to live their chosen lifestyle. On the day of the site visit residents were sitting in various areas of the home, including their own room. There is a TV in one of the lounges and there is a quiet room and a conservatory where residents can sit if they prefer to be quiet; the quiet room has a large goldfish bowl of fish and some residents prefer to sit quietly watching the fish. The inspector observed that bedrooms are a reflection of a person’s chosen lifestyle and their hobbies and interests. Care staff told the inspector that they understand their role as key worker, and ensure that they spend one to one time with residents and do their shopping if they are unable to do it themselves. Eastbourne Villa DS0000019664.V358292.R01.S.doc Version 5.2 Page 14 Care plans include a social history that includes details of friends and relatives and information about their previous lifestyle and interests. There is an activities diary included on the new database and this records any activities undertaken by residents. The weekly key worker notes include information on ‘Communication and social stimulation’ – this records any visitors to the home, any visits out of the home and activities undertaken for individual residents. A member of staff recorded in a survey, ‘We have just had a fund raiser for Christmas entertainers and all the residents got involved to some degree’. Quality assurance records evidence that regular entertainment is organised for residents in addition to day-to-day activities. Residents were seen to take part in various activities on the day of this site visit, including reading, watching the TV and using an age-appropriate colouring book. Residents were also seen to undertake small tasks around the home such as feeding the birds, setting the table for lunch and folding napkins. Relatives seen on the day of this site visit told the inspector that they are always made welcome at the home. One relative commented in a survey, ‘Friendly staff – liaise with me appropriately. Mum is very happy there’. One resident has had a cordless telephone installed in their bedroom and takes the handset into the lounge so that they can easily keep in touch with relatives and friends. The home has a policy on the use of advocacy and the acting manager told the inspector about a specific situation where an advocate had been used to support a resident; this had been arranged by the home. The inspector recommends that information be obtained about advocacy services so that it can be displayed and easily accessed easily by people. On the day of this site visit the inspector observed that there was a menu on display. In addition to this, the staff member who was preparing meals spoke to each resident to discuss the meal options and assist them to make a decision about lunch. The dining room is pleasant and bright and staff were seen to assist residents appropriately to eat and drink. Residents told the inspector that the food provided by the home is good and that they are able to have an alternative to the meal on offer if they request this. One service user said, ‘there is a clear menu board so we know what to expect’ and another said, ‘The hot meals are well cooked’. Staff are aware of service users’ likes and dislikes and prepare a different meal for residents when it is known that they will not like the meal on offer. On the day of this site visit, one resident requested a salad instead of the main meal on offer, and diabetic and liquidised meals were provided. The inspector observed that there are ample drinks provided throughout the day. Eastbourne Villa DS0000019664.V358292.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 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and others know how to use the complaints procedure and residents said that staff listen to them. Residents are protected from the potential to be abused by the training and skills of the staff group. EVIDENCE: There are appropriate complaints policies and procedures in place, and the complaints procedure is displayed in the complaints folder that is kept in the reception area of the home, along with the complaints log. The acting manager told the inspector that the policy and procedure is also included in the statement of purpose and service user’s guide. There have been no complaints made to the home or to the CSCI since the last key inspection. Three of the four residents that completed a survey said that they knew how to make complaint, three of the four relatives said that they knew how to make a complaint and all staff said that they knew what to do if a resident or relative had any concerns; one member of staff gave a very full explanation of the procedure in place at the home. One resident said in a survey, ‘Staff always listen to me and are helpful’. There are appropriate policies and procedures in place regarding the protection of residents from all forms of abuse. The acting manager has attended an update on the specific safeguarding adults training designed for managers, and Eastbourne Villa DS0000019664.V358292.R01.S.doc Version 5.2 Page 16 most staff have undertaken this training; there are plans in place for the remaining staff to do so. All of the staff currently working in the home have achieved NVQ Level 2 in Care and they have undertaken work on this topic as part of this award. There have been no recorded allegations or incidents of abuse at the home since the last key inspection. Eastbourne Villa DS0000019664.V358292.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 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is clean, well maintained, well furnished and decorated and provides very comfortable surroundings for residents. EVIDENCE: The home (along with other homes in the East Riding of Yorkshire) has received some specific funding from the local authority to make improvements to the environment. At Eastbourne Villa this money has been used to redecorate and refurnish the communal areas of the home. New carpets have been purchased for both of the lounge areas and the dining room, and vertical blinds have been purchased for most areas of the ground floor and the bedrooms at the front of the property. This has resulted in the home being decorated and furnished to a high standard and it now provides a lighter and brighter atmosphere for residents. Eastbourne Villa DS0000019664.V358292.R01.S.doc Version 5.2 Page 18 There is no maintenance plan that records future plans for maintenance and replacement of equipment, but it is evident that the home is well maintained and that equipment is replaced as necessary. The acting manager told the inspector that five bedrooms have been redecorated, that the tumble dryer and the washing machine have been replaced and that all windows have been fitted with window guards. Laundry facilities at the home are satisfactory and the inspector observed good hygiene practices being used by staff on the day of the site visit. There was a strong odour in one of the bedrooms; this was discussed with the acting manager who assured the inspector that action was being taken to alleviate this problem. Eastbourne Villa DS0000019664.V358292.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 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care staff are recruited in a safe way and receive induction and on-going training to ensure that they are qualified and skilled to care for the residents living at the home. EVIDENCE: There is a staff rota in place that records the role of each member of staff. There is currently no cook employed at the home; care staff are covering catering duties but the risk of cross infection is minimised by one member of care staff being allocated to this role on a daily basis and undertaking catering duties instead of caring duties. The number of care staff on duty has been maintained. All care staff (apart from one member of staff who is on long-term sick leave) have completed NVQ Level 2 in Care training. This has resulted in a welltrained staff group who are equipped to care for the residents accommodated at the home. The inspector examined the recruitment and selection records for a new member of staff. These evidenced that the person completed an application Eastbourne Villa DS0000019664.V358292.R01.S.doc Version 5.2 Page 20 form that included details of their employment history, their previous experience and their training achievements. All safety checks were in place prior to this person commencing work at the home. There is evidence that this employee did the Skills for Care common induction standards training when they were first in post, and that they have attended various training courses since starting work at the home, including safeguarding adults, continence care, moving and handling, fire safety, bedrail guidance and infection control. A member of staff recorded in a survey, ‘I received a twelve week induction and received support from my duty manager and other team members’. There is also evidence that new staff are required to sign a document to confirm that they have read relevant policies and procedures, including whistle blowing, safeguarding adults, confidentiality and data protection. The acting manager recorded in the AQAA form that she needs to produce a new training and development plan for the home. There is a copy of an old training plan in use and individual staff records of training achievements and needs are comprehensive. These records evidence that twelve staff did First Aid training in August 2007, five staff did Mental Capacity Act training in November 2007, ten staff did fire training in November 2007 and eleven staff did bed rail training in August 2007. The manager was reminded that dates should be recorded on the training and development plan so that the need for ‘refresher’ training can be identified. The acting manager told the inspector that distance learning packs have been ordered that cover such topics as health and safety, infection control, dementia care, drug administration, food hygiene and safeguarding adults. They intend to use these packs to offer refresher training to staff. Eastbourne Villa DS0000019664.V358292.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 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health, welfare and safety of residents and others are protected by the systems in place at the home, and by staff training programmes. EVIDENCE: The acting manager has completed NVQ Level 4 in Care and has started the Registered Manager’s Award. The acting manager told the inspector that she has undertaken in-house training along with the rest of the staff group to ensure that her own knowledge is kept up to date. She has submitted an application to the CSCI registration team to become the registered manager of the home. A member of staff said in a survey, ‘the home has improved since the duty manager took over’ and another said, ‘communication between staff and management is very good’. Eastbourne Villa DS0000019664.V358292.R01.S.doc Version 5.2 Page 22 The home has a quality assurance system in place and they have achieved the Investors in People award and QDS (the local authority’s quality scheme) parts 1 and 2. Residents meetings take place; the most recent meeting took place in November 2007 and minutes evidence that eleven residents attended. Residents discuss various issues, including forthcoming activities and entertainment. Staff meetings also take place every twelve weeks. The results of quality surveys are displayed in the quality folder that is displayed in the entrance hall of the home. The acting manager was advised that the results of quality surveys should be used to inform the annual development plan for the following year, and she agreed to action this. An annual report is completed for QDS purposes and the acting manager was advised that a copy of this should be submitted to the CSCI. The records for monies held on behalf of residents were seen by the inspector and were found to be satisfactory; they include information about monies received, monies spent and a running total. Records were cross-checked with actual monies held and these were found to be accurate. Receipts are obtained for any purchases made for residents and for monies received from relatives and friends. The acting manager told the inspector that residents now have access to their monies at all times and explained how this system works. The inspector examined health and safety documentation held at the home. A very thorough fire safety audit is undertaken every week by the acting manager; this is good practice. Weekly fire tests take place and three-monthly fire drills; staff and visitors are involved in these as well as residents. There are appropriate risk assessments in place to ensure safe working practices, and risk assessments for bed rails and fire safety are audited by the manager on a regular basis. All other health and safety documentation was seen to be in order, such as service certificates and maintenance certificates. Records held at the home evidence that staff undertake induction training and refresher training on health and safety topics. Accidents are recorded appropriately and the CSCI are now informed of any accidents to residents that require medical intervention. Eastbourne Villa DS0000019664.V358292.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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Eastbourne Villa DS0000019664.V358292.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. 2. 3. 4. 5. Refer to Standard OP8 OP9 OP14 OP30 OP33 Good Practice Recommendations There should be regular safety checks on bed rails to ensure that they are safe for use; these checks should be recorded. Alternative arrangements should be sought for the storage of medication to enhance security. Information about available advocacy services should be displayed in the home to give residents and others easy access to this information. Dates should be recorded on the training and development plan so that the need for ‘refresher’ training can be identified. A copy of the Annual Service Review that is completed for QDS purposes should be used to inform the annual development plan for the following year. A copy of the Annual Service Review should be sent to the CSCI. Eastbourne Villa DS0000019664.V358292.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Eastbourne Villa DS0000019664.V358292.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. 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!