Inspection on 14/09/05 for Eastbury House

This inspection was carried out on 14th September 2005.

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

The inspector 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

Eastbury House 12/08/08

Eastbury House 30/07/07

Eastbury House 07/02/07

Eastbury House 31/07/06

Eastbury House 06/01/06

Eastbury House 11/01/05

Eastbury House 01/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Eastbury House Long Street Sherborne Dorset DT9 3BZ Lead Inspector Rosie Brown Unannounced 14 September 2005 10:30 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 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. Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Eastbury House Address Long Street, Sherborne, Dorset, DT9 3BZ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01935 812132 01935 814164 Eastbury House (Sherborne) Ltd Miss Deborah Jayne Morgan PC Care Home only 19 Category(ies) of OP - 19 registration, with number of places Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11 January 2005 Brief Description of the Service: Eastbury House is situated close to the centre of Sherborne within level walking distance of the town amenities. The home is registered to provide care and accommodation to a maximum of 19 people over the age of 65 and offers long and short-term places. Parts of the building date back to the 17th century, in particular the hallway and main staircase, the dining room and lounge: all retaining many of the original features such as oak wood panelling, stonework and leaded lights. The old stable outbuildings in the side courtyard have been converted to provide bed-sitting room accommodation in two separate units. Miss Morgan is the registered manager of the home which is registered to as a limited company. Mrs Appleyard the previously registered owner of the home and is now registered as the responsible person on behalf of the limited company: she continues her involvement with the home and works closely with Miss Morgan. The accommodation for service users is arranged over the ground and first floor of the home. Due to the age of the building and extensions to the house made many years ago there are a number of internal stairs and steps and changes of level. There are two stairlifts fitted to back staircases that provide access to some but not all of the ten first floor bedrooms. Nine rooms are situated on the ground floor with two ground floor bed/sittingrooms rooms available in a building close to, but separate from the main house. Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 14th September 2005 and was undertaken by inspector Rosie Brown: it was the first of two statutory unannounced inspections planned to take place this year. The inspection commenced at approximately 10.30am and concluded by 4pm. This was the first time the inspector had visited this home and a favourable impression was gained. There 19 residents accommodated in the home and six members of staff on duty. The inspector assessed x of the National Minimum Standards and the requirements and recommendations set out in the report of the previous inspection. The communal areas and the majority of bedrooms were viewed: residents’ care records, staff recruitment records and certain policies and procedures were also examined. The inspector used observation skills to assess certain findings and also spoke with the manager, the deputy manager, five service users and two members of staff. Following the inspection, comment cards supplied by the Commission were returned. These included 11 cards from service users, 10 from relatives/visitors, 3 from GP’s and one from a care professional; the views expressed within them have also been used to inform this inspection report. What the service does well: The majority of residents accommodated in the home remain independent with many going out with family and friends on the day of the inspection. It was evident that a number of residents continue to have regular contact within the local Community and that group and individual social care is promoted and enjoyed. One comment card from a care professional states, ‘excellent care, lovely family atmosphere and residents treated as individuals’ while one GP commented, ‘always a well run home, all residents are happy with the care they receive and it seems to be a well managed home with an excellent record’. Care plans are in place and note the actions required by staff to meet identified needs. Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 Page 6 The home provides a good quality home made food to residents in the dining room and in their rooms. Service users manage their own financial affairs or are assisted by relatives or friends. The home is attractively decorated and comfortably furnished and a homely atmosphere is created. Many resident’s rooms are highly personalised with service user’s possessions and furniture. The gardens and grounds are well tended, providing pleasant views from a number of bedrooms and communal areas. What has improved since the last inspection? What they could do better: The home’s statement of purpose and guide must accurately reflect that access to some bedrooms in the home is difficult and not suitable to wheelchair users or people with mobility problems. It must also make reference to the central heating radiators that are not guarded and the hot water supply to wash basins, which is not controlled. Care plans must be in place prior to a service user’s admission into the home and be based upon comprehensive pre-admission assessment information. Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 Page 7 All care plans must evidence monthly review and include information concerning social care provision and the wishes of each service user regarding their care when dying and upon death. Care plans and associated riskassessments were not signed by the service user or representative to demonstrate their involvement in the decisions made concerning care needs. When accidents are reviewed the action taken to prevent recurrence must routinely be included into the resident’s care plan. Central heating radiators are not guarded and the hot water supply to washbasins in bedrooms and bathrooms is not governed to ensure it is supplied a safe temperature: there are no precautionary warning notices in place near to wash basins. COSHH products must be stored safely. The home’s call system would benefit from upgrading as planned and when this occurs a call point/board must be fitted in the staff sleep or the handset identify the source of the call. A risk assessment concerning the fact that wakeful night staff leaves the main house to check on residents living in the courtyard apartments must be drawn up: night staff arrangements should be subject to regular review. This report contains 10 requirements and 4 good practice recommendations. 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. Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 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 standard(s) 1, 3 and 6 The home has a statement of purpose and guide but this does not accurately describe access to some bedroom accommodation, which may be difficult due to steps or stairs and uneven floor levels. Therefore an informed choice about living in the home cannot be made by prospective service users’ who are physically frail. Pre admission assessment information obtained is not comprehensive enough to enable the drawing up of an accurate care plan prior to admission and this means that some service users’ care needs may not be initially met by the home. The home does not provide intermediate care. EVIDENCE: The home’s statement of purpose and guide is readily available to service users and relatives in the lounge and has been updated since the previous inspection. Information is contained in a large file and includes a great deal of relevant information about the home and other details required by legislation, including residents’ views about life in the home and a copy of the latest Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 Page 10 inspection report. However, it does not clearly describe access to certain bedrooms, which may be difficult for physically challenged service users or wheelchair users. Some bedrooms can be easily accessed by stair lift or are at ground floor level while others are only accessed via a series of steps or stairs. In addition, the contacts details of the Commission contained within the complaints procedure and in the sample terms and conditions contract are incorrect and must be updated to Commission for Social Care Commission (CSCI). The RI usually undertakes the pre-admission information and makes the decision about whether the home can meet the prospective service user’s care needs or not. The information examined for one recently accommodated service was not comprehensive enough to enable a care plan to be drawn up prior to admission. A requirement was made at the last inspection for action to be taken to ensure that proper pre assessments are carried out before residents enter the home. In addition, a letter from the home confirming that the prospective service users’ needs will/can be met, is not provided. Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10 and 11 Individual care plans and care related risk-assessments must be in place for all service users and need further development to ensure that they routinely refer to all health care needs. Initial care plans are not drawn up prior to admission to demonstrate how the home will meet identified needs. Care professionals are contacted for advice and guidance in relation to service users health care when considered necessary. Service users confirmed that their privacy and independence is promoted by the home. Care plans do not routinely include information about residents’ wishes regarding their care when dying or upon death. EVIDENCE: Three care files were examined, two contained up to date care plans while one did not. One plan showed evidence of regular monthly review and updating of care needs at times of significant change, a decline in health and return from hospital treatment. Care related risk-assessments are also in place, particularly regarding falls and their prevention. Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 Page 12 One recently admitted service user’s care plan did not have a risk-assessment in place concerning how staff help with the care of a Stoma site and colostomy bag and the prevention of infection. In addition, staff training related to Stoma care and has not been provided. Records noted that the District Nurse does regularly visit the person concerned. The care plan for one service user did not include social care and their regular church attendance, although daily records noted this to be the case. Of the care plans sampled only one had details of the undertaker to be called in the event of death and none contain the service users’ wishes concerning their care when dying. Although one comment card from a relative stated, ‘staff were particularly helpful and sympathetic to our family and my Uncle (also resident in the home) when my Aunt died’. Care records noted that health care professionals are contacted for advice and guidance and that specialist equipment is accessed through the community care services when necessary. Two comments cards received from GP’s confirmed this to be the case. The home uses an accident record book that complies with Data Protection and the deputy manager not only reviews each accident in turn but also carries out an audit to establish any patterns of occurrence. The care plans must routinely reflect the change in care provision undertaken following a fall. During the inspection a number of positive comments were received about the care provided to service users, including the following: ‘Top class’ ‘Couldn’t get better’ In addition, comments cards received from relatives make the following statements: ‘My mother is very frail……but, I always find her looking smart, smelling clean with her hair, nails etc attended to. She is looked after with great kindness and tenderness. I always find her smiling’. ‘My uncle enjoys an excellent quality of life…’. Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 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 standard(s) 13 and 15 Service users confirmed that the home promotes service user contact with family, friends and the local community. The service users are provided with nutritious good quality food, which is either served in the beautiful wooden panelled dining room at individual tables, the home’s kitchen or in their room. EVIDENCE: The home keeps a visits book in the hallway and this evidenced that a steady flow of visitors come and go from the home each day. The daily care records for three service users noted that they receive visitors while one partially sighted service user said they attend the local ‘blind club’. While another identified that they attend the local church service. On the day of the inspection two service users went out to lunch with family members while two visitors had lunch in the home with the service user they were visiting. The record of food supplied to service users is recorded into a diary on a daily basis. The cook uses a varied seasonal menu and also includes service users’ favourite dishes. Food is usually home baked and there are always two main Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 Page 14 course options at lunchtime. Breakfast requirements are noted individually as are tea- time requests. The manager said that local food suppliers are used where possible; all vegetables except peas are cooked from fresh as is meat and fish. Fresh fruit is available at all times in the dining room. Snacks and drinks are also provided at regular intervals throughout the day and in the evenings and on request at other times. Food supplies were seen to be plentiful. One resident said, ‘ the food here is really good and home made, my daughter is having lunch here with me today, there’s no charge’. The inspector saw one resident who is currently very frail being fed soup and noted that another is assisted by staff in the home’s kitchen. Staff also eat with service users who take their lunch in the home’s kitchen. Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17 and 18 The complaints procedure is supplied to service users and they were confident that their concerns would be taken seriously and acted upon. Residents’ legal rights are protected because the home does not become involved with financial or legal matters: this is clearly stated in the home’s statement of purpose and guide. The home has a policy concerned with adult protection to ensure that allegations of abuse would be properly responded to thereby protecting service users in the home, but all staff have yet to be trained in this subject. EVIDENCE: There is a complaints procedure, which complies with the National Minimum Standards. As stated earlier the leaflet contained in the statement of purpose must be updated to provide the correct title of the Commission: CSCI. During the visit two service users confirmed that they fell confident about raising a complaint and feel certain the matter would be remedied promptly. Service users or their representatives manage their personal finances; the home does not have involvement with service users money. Service users are provided with bills concerning any sundry expenses and the majority of transactions are undertaken through the bank, family or representatives. The home has a policy and procedure concerned with the protection of vulnerable adults and holds a copy of the local ‘No Secrets’ guidance for staff Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 Page 16 to follow should such a situation arise. In addition, a copy of the POVA guidance issue y the Department of Health in July 2004 concerning POVAFirst checks and supervision of staff that commence working in the home prior to a satisfactory CRB check being received. The ‘No Secrets’ document and the POVA guidance should be kept in the home’s policy and procedures file. The manger and senior staff have undertaken training in the recognition of abuse and local ‘No Secrets’ procedures but all staff must be provided with training in this subject. Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 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 standard(s) 19, 25 and 26 Residents live in a well-maintained home that has retained original features, the communal facilities are comfortably furnished and pleasantly decorated and the majority of bedrooms are highly personalised. The hot water supply to wash basins is not governed and the central heating radiators are not protected. Risk-assessments concerned with individuals safety and their vulnerability to scalding and burns have been drawn up but remedial actions have not been taken; this means that vulnerable people are at risk. Residents confirmed that the home is always clean with no unpleasant odours and no apparent hygiene problems. EVIDENCE: The home has two separate lounges and a separate dining room on the ground floor: these rooms and the hallway contain many of the original features of the 17th century house. New carpets were being laid on the stairs and corridors during the inspection. Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 Page 18 All bedrooms are at least 10 square metres and several are generously sized. The home has one double room that is currently used as a single. With four exceptions, bedrooms have en suite facilities of a toilet and wash hand basin; all rooms have a wash hand basin. Approved door locks have yet to be fitted to all bedroom doors but the manager said these would be made available on request. Due to the age and layout of the building the home is not suitable for people with severely restricted mobility or who use a wheelchair: some doorways and corridors are narrow and there are steps up to the front door. The two apartments in the rear courtyard have level access and are large enough to accommodate a person with some physical disability. The first floor is accessed via the main staircase with various changes of level with steps throughout the home. Stair-lifts provide access to some rooms on the first floor. The home has four communal bathrooms. A portable bath seat is available and one ground floor bathroom has an installed mobility aid. One ground floor bathroom has a ‘hip bath’ that is currently used by two service users: ‘hip baths’ are not recommended for use by the Commission. There are six communal toilets. Three bedrooms have en-suite bath/shower rooms and four have en-suite toilet and wash hand basins. One toilet near to the dining room does not have a call facility fitted and an unprotected hot towel rail was noted in one first floor bathroom. The hot water to wash basins is not controlled. Risk-assessments are drawn up but safety actions must be taken where identified, e.g. hot water warning notices posted and temperature control valves fitted. Individual risk assessments are in place concerning hot surface temperatures as central heating radiators are not guarded. However, an action plan regarding the protecting of radiators must be supplied to the Commission so that service users who are prone to falling in their room are safe from harm. A call system is fitted throughout the home and the manager explained that consideration is being given to upgrading this facility. When the system is renewed the registered persons must ensure that a call-board or handset must be permanently available in the staff sleeping room so that the source of a call can be easily identified. Hazardous cleaning products were not locked safely away as required by legislation. The home has a secluded mature garden with garden furniture where residents can sit and relax. Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The home is appropriately staffed each day by management, care and domestic workers to ensure that service users needs are met at all times. The home’s staff recruitment procedures have improved since the previous inspection to ensure the protection of residents living in the home but this has yet to be properly implemented. EVIDENCE: A copy of the staff rota was given to the inspector. This demonstrates that three care staff are on duty each day with the manager or deputy manager; Mrs Appleyard also continues to work in the home in a management capacity. Each night there are two care staff on duty with one sleeping in on call. Given the current needs of the service user group this seems appropriate. However, a risk-assessment must be drawn up regarding the need for the wakeful night staff going out of the main building to check the two service users accommodated in the courtyard, e.g. when and how frequently this is necessary and whether there should be two wakeful staff on duty for safety reasons. The staff rota should detail the hours worked by staff, their full names and the management arrangements, e.g. when manager, deputy or Mrs Appleyard are working and who is the designated first aid person on duty for each shift. Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 Page 20 The recruitment records for two new members of staff were examined and these detailed that all the majority of necessary checks and information was obtained before these persons commenced working in the home. Records showed that a kitchen assistant commenced working in the home in February 2005 and their CRB disclosure was not satisfactorily returned until March. Some time was spent considering the implications of the POVA (Protection of Vulnerable Adults) guidance issued in July 2004 by the Department of Health and the supervision of new staff that commence working in the home before their CRB check is returned. The induction of new staff meets NTO specifications. However, all staff must be supplied with training regarding the protection of vulnerable adults and local ‘No Secrets’ guidance: the manager explained that a training programme has been identified. Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35 and 38 The manager is appropriately qualified and experienced. Residents commented about her kindness and how easy she is to approach for assistance when necessary. The RI, Mrs Appleyard and the deputy manager cover in her absence to ensure that service users are properly cared for. The home does not become involved with service users financial affairs but also ensures that any necessary arrangements are made through family or representatives. The home is well managed and residents spoken with confirmed they are satisfied with the care they receive. Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 Page 22 EVIDENCE: The manager holds an HNC in Care Management and an NVQ level 4 qualification in Care, she is also an NVQ assessor. Care staff are supplied with induction training and mandatory training that meets NTO specifications and the manager is developing the training provision in the home to incorporate other subjects. Records of accidents and incidents that occur are kept, as required and information concerning untoward occurrences is sent to the Commission when necessary. The home has a policy and procedures guide for staff reference with regard to expected practices within the home, although Hazardous cleaning products are not currently stored in accordance to the Control of Substances Hazardous to Health (COSHH) Regulations. The home supplied documentary evidence to demonstrate that specialist equipment and gas and electrical installations are regularly serviced. Precautions are taken to prevent the risks of Legionella developing in the home’s water supply. The home’s call system should be improved as planned and a programme of covering or guarding radiators in the home must be commenced where radiators are exposed. This will ensure that service users who are likely to inadvertently hold onto them or fall against them are safe from harm. Likewise the hot water supply to washbasins must be governed and supplied at a safe temperature to prevent scalding. Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x 2 2 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 3 x x x 3 x x 2 Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 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. 1. Standard OP1 Regulation 4&5 Requirement The homes statement of purpose and guide including all details for compliance with NMS Standard 1 must be produced.(previous timescale of 1/4/05 not met in full). The home must be able to demonstarte that comprehensive assessments of need are undertaken prior to all admissions: to include all points listed in NMS Standard 3.3. (previous timescale of 12/2/05 not met in full). Care plans and associated riskassessments must be in place for each service user prior to admission. The regsistered person must also confirm in writing before admission that the home can meet each prospective service users assessed needs. Care plans must routinely include more detail regarding each service users wishes/needs for their care when dying and in the event of death. All staff must be supplied with training related to the local No Secrets recognition of abuse and adult protection. Timescale for action 31/10/05 2. OP3 14 (1) (a) 31/10/05 3. OP7 14 (1) (d) & 15 (1) 31/10/05 4. OP11 15 31/10/05 5. OP18 18 (1) 31/12/05 Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 Page 25 6. OP19 23 7. OP25 13 (4) 8. OP26 13 (4) 9. OP27 13 (4) 10. OP29 19 Locks of approved style must be fitted to all bedrooms doors. (previous timescale not met in full). A programme of fitting fail-safe hot water temperature control valves to washbasins and protecting of central heating radiator surfaces must be commenced: starting with those rooms where possible risks are identified, eg the hot towel rail in the communal bathroom on the first floor.. Hazardous cleaning products must be safely stored in accordance with the COSHH Regulations. A risk-assesment concerning the fact that the wakeful night staff leaves the main house to check two service users in the coutryard apartments must be drawn up and regualrly reviewed. A policy and procedure should be drawn up and implemented with regard to the recruitment and employment of new staff in advance of CRB disclosure and the supervision arrangements to be put in place. (changed from a recommendation in the previous report). 31/12/05 31/10/05 31/10/05 31/10/05 31/10/05 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. Refer to Standard OP7 OP7 & 8 Good Practice Recommendations When accidents are reviewed the action taken to prevent recurrence should be routinely included into the residents care plan. All documents should be signed by the writer.( repeated D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 Page 26 Eastbury House 3. 4. OP29 OP29 from previous report). The staff rota should cetail the complete name of each staff member, the hours they work and note the management arramgements for each day. The staff training programme should be developed to include topics relevant to service users care needs, eg the prevention ofinfection and stoma care. Eastbury House D55 S48854 Eastbury House V243552 140905 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection Unit 4, New Fields Business Park Stinsford Road Poole BH17 0NF 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. 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