Inspection on 15/04/09 for Eastwood House

This inspection was carried out on 15th April 2009.

CQC found this care home to be providing an Adequate 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

Eastwood House 06/05/08

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Eastwood House Doncaster Road Rotherham South Yorkshire S65 2BL Lead Inspector Valerie Hoyle Key Unannounced Inspection 15th April 2009 08:30 DS0000070909.V374972.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastwood House Address Doncaster Road Rotherham South Yorkshire S65 2BL 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) 01709 363 093 01709 837 788 eastwoodhouse@hotmail.com Nightingale Premier Care Homes Ltd Manager post vacant Care Home 37 Category(ies) of Dementia (37), Old age, not falling within any registration, with number other category (37) of places Eastwood House DS0000070909.V374972.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; Dementia - Code DE. The maximum number of service users who can be accommodated is: 37 6th May 2008 2. Date of last inspection Brief Description of the Service: Eastwood House is a large converted and extended Victorian house situated close to the centre of Rotherham. It is set back from the main road into Rotherham and it close to the local park. The home is situated near to bus routes. It is a care home, registered to provide care and accommodation for 25 older people and a twelve bedded unit for people who have dementia. The home offers single room accommodation, all of the rooms benefiting from ensuite facilities with the exception of two rooms on the first floor. There is a lift, which give access to the first floor. There are a variety of communal areas and two dining rooms. The dementia unit is on the first floor. The facilities are: two lounges, dining room, snack kitchen toilets and bathrooms. There is a secure garden for these People who use the service. The home is maintained to a high standard. There are attractive gardens to the front, rear and side of the property and outdoor seating and patio areas. The gardens are well stocked with various plants, shrubs along with tubs and hanging baskets. The walkways around the home are designed to enable the residents to access all parts of the garden Fees for Dementia Care are £411 and residential £366 as at 15th April 2009 and additional charges are made for hairdressing from £5:50, Chiropody from £18:00, Optical, Dental services, specialised toiletries and magazines, dry cleaning etc at cost. Service User Guides and Statement of Purpose is available on request from the manager, and the last inspection report (dated 6th May 2008) is available on request. Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 5 Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 stars. This means that the people who use this service experience adequate quality outcomes. This unannounced inspection of this service took place over 7.5 hours starting at 08:30 finishing at 16:00; this included a partial inspection of the home. Five people who use the service, four staff and a visiting district nurse were spoken to during the visit; their views were included throughout the report. Information from five surveys from people who use the service is also contained in this report. Two relatives were spoken to during the inspection to assess their views on the service. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. Occupancy at this home follows current trends, with 34 of the 37 beds occupied on the day of the inspection. Four peoples care plans were looked at. Policies relating to medication, complaints, protection of vulnerable adults and handling of people’s monies were looked at. Six staff recruitment and training records were examined to assess how people were protected. Procedures and risk assessments relating to health and safety were looked at and discussed with the manager. The manager is Sarah Mckenzie; she has worked at the home for a considerable length of time and was appointed as manager in January 2009. She is working towards the NVQ Level 4 in management and intends to register for the Registered Managers Award when she has completed the NVQ qualification. The AQAA was sent to the home in March 2009, this was returned to us on time, which demonstrates responsiveness and cooperation. An annual quality assurance assessment is a self-assessment and a dataset that is filled in once a year by all providers whatever their quality rating. It is one of the main ways that we will get information from providers about how they are meeting outcomes for people using their service. The AQAA also provides us with statistical information about the individual service and trends and patterns in social care. Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 7 The inspector would like to thank everyone who agreed to being interviewed as part of the inspection process, and the friendliness of staff. What the service does well: The home continues to provide a good standard of environment for people and relatives confirmed that the home was mostly kept clean and tidy. Activities were well organised and people made positive comments about living at the home. People were busy making birthday cards for a person who was about to celebrate their 100th birthday. The activity coordinator was enthusiastic and engaged with people to keep them involved in the activity. People said they enjoyed the variety of activities offered at the home. Visitors to the home said “staff always makes me feel welcome; one person said a number of relatives had lived at the home which indicated that they were happy with the care provided”. Relatives confirmed they were confident in the manager’s ability to deal with any concerns they may have. There is a stable staff team who have shown commitment to their own learning, they were commended for their NVQ achievements. What has improved since the last inspection? What they could do better: The information provided to new people and their representative should be kept up to date, including information about how to make a complaint which should include the timescales. A review of the way complaints are recorded is required which should include details of outcomes and letters to support any action taken. A complaints leaflet would improve how people can raise concerns anonymously. Care plans could contain more detail to ensure staff have information to confirm people’s involvement in activities, including their likes and interests. Arrangements must be in place to make sure that sufficient medicines are always available in the home for people to take when needed. Hand written Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 8 MAR chart entries should be sufficiently clear and detailed to be sure that all staff can follow the directions and changes correctly. Medication record keeping should be improved so that all medicines entering the home can be fully accounted for. Procedures to safeguard people who use the service had been obtained, although staff still required formal training in the protection of vulnerable adults. The recruitment procedures do not sufficiently protect people who use the service. Some essential employment checks had not been obtained before staff commenced work at the home. The induction package was dated and it does not meet the ‘Skills for Care’ standards. Refresher training in most areas was out of date. The manager must prioritise the training to ensure staff have the right skills to meet the needs of people who use the service. Mental Capacity Act and Deprivation of Liberty policies and procedures should be developed and training in those policies should be introduced. The registered providers provide support to the manager, although they have not completed the monthly audit as required by regulation 26 of the Care Homes Regulations 2001. The manager should submit an application to be registered with the Care Quality Commission. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 9 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 Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were assessed before moving into the home to ensure their needs can be met. Information provided was adequate, although it could be improved to make it more user friendly. EVIDENCE: All new people receive a full needs assessment before admission; this was carried out by the manager who had the required skills and competencies. The service was efficient in obtaining a summary of assessments undertaken by the placing authority, and insists on receiving a copy of the care plan before admission. Two assessments were looked at and they focused on the needs of people who use the service. Before agreeing admission the manager and staff Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 11 carefully considers the needs assessment for each individual prospective person and the capacity of the home to meet their needs. Surveys received confirmed people received sufficient information before moving into the home, and people said staff helped them to settle into the home. One relative said they had visited the home three times before moving her relative into the home. She said staff was consistently friendly and they were able to answer all her questions. The Statement of Purpose had been updated, although the complaints procedure still contains old information and was not clear about how to raise concerns. The information was not user friendly and could be improved further using pictures and written using easy word. Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans generally provided adequate information to protect people who use the service. Medication policies and procedures were generally well managed; however some improvements would make administering medication safer. EVIDENCE: Care plans had been developed since the last inspection to ensure people’s nutritional needs were met. There was evidence that assessments identify if people were at risk although the risk assessments were quite brief. Moving and handling assessments had been completed; although peoples care plans looked at indicated that their mobility did not require the use of equipment. Care plans looked at were mostly reviewed monthly and there were daily records which confirmed people’s needs had been met. Social and leisure care plans did not identify the activities that people liked to be involved in. Two of the four care plans looked at did not have a social and leisure care plan, which was discussed with the manager. Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 13 Surveys received from people who use the service indicated that they were happy with the care provided; however some people said they sometimes had to wait to receive their support. Others said staff listen to what they have to say, but would like more time to talk to staff who always seemed busy. Relatives said staff was mostly available when needed, although more care was needed to ensure their relatives hearing aid was maintained. Peoples healthcare needs were met and there was evidence to confirm regular visits from healthcare professionals. The staff had regular contact with the district nursing services, they offer advice and support. A visiting district nurse said staff had got better at informing nursing services when problems arise. The nurse said staff generally assisted the nurse, which had improved communication and ensure continuity of treatment. A recent referral to safeguarding adults regarding skin care had been investigated by social services staff. The outcome of the investigation confirmed staff had acted appropriately. Care plans looked at confirmed Waterlow assessments (assessments to ensure people skin remains healthy) had been undertaken, and regimes to prevent pressure sores were in place. Medication procedures were generally well managed, although some improvement was required to ensure medication was recorded when received. Several MAR (Medication Administration Records) did not state who have received the medication or the date it had been received or commenced. The quantity of medication brought forward from one monthly cycle to another was not always recorded on the new MAR chart. This means it is difficult to produce a complete record of medication within the home and to check if medication is being given correctly. Eye drops were not always administered as described on the label. MAR charts showed long periods when the eye drops had been refused. Some of the eye drops did not have the date they had been commenced. Eye drops must not be used past the recommended 28 days after opening. A number of records showed that movicol had been refused; this means that people were not receiving medication as prescribed. There are procedures in place for ordering, receiving, administering and disposing of medicines but these documents do not always follow current best practice. The Royal Pharmaceutical Society of Great Britain and CQC professional advice documents on handling medicines in social care are not available in the home. Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to socialise with family and friends and mealtimes were well managed. EVIDENCE: People were able to join in activities, which were provided by the recently appointed activity coordinator. People were observed making birthday cards for a person who was celebrating her 100th Birthday later in the week. The coordinator said people had enjoyed an Easter bonnet party and spring fayre. Entertainment from outside was brought into the home on a regular basis, and funds were raised to pay for that. The activity coordinator also spends time on the unit for people with dementia. The lounge showed pictures and crafts which had been made by people who use the service. Posters show future events including residents meetings and a newsletter. People were able to purchase newspapers at their own cost and the hairdresser visits weekly. Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 15 Visitors said that staff always made them feel welcome, and they could visit anytime. People said they enjoyed family and friends visiting, one person said they looked forward to trips to their relative who lived locally. People were able to make choices about where and how they spend there time. Many people said they liked to spend time in their bedrooms watching TV and listening to music. They said they had brought in lots of their belongings, which helped them feel at home. Mealtimes were well managed and the food nicely presented. People said they enjoyed all of the meals provided, as the cooks were very good. Staff were available to give assistance where needed and meals provided to people in their rooms were nicely presented. Visitors were provided with drinks and they said they were able to join their relative for a meal if they wanted to. Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns, and have access to a complaints procedure. However policies and procedures need to be reviewed. Safeguarding procedures were followed. EVIDENCE: The information contained in the Annual Quality Assurance Assessment confirmed that two complaints had been made in the last twelve months. The complaints were discussed with the manager who confirmed that procedures were followed, and action was taken to resolve the complaints. The complaints records were looked at. The form used was unclear; it was difficult to identify who the complainant was. There was no letters or investigation records to confirm outcomes from complaints. A complaints leaflet could be developed that is easily available to improve the way people and their representatives can raise concerns. This would help people who want to raise concerns anonymously. Complaints procedures should be updated to identify the stages to be followed, following a complaint being made. Surveys confirmed that people were aware of the complaints procedure and who to speak to if they had a concern. The home had there own Safeguarding Adults and Whistleblowing policy, which would be followed if any incidents of abuse was raised. The procedure was Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 17 brief and it was unclear on the steps to follow to report incidents of abuse. The home had obtained the local authorities safeguarding adult’s procedures. These procedures should be followed if any incidents occur in the future. The AQAA confirmed that there had been one safeguarding referrals. Safeguarding meetings and investigation had been concluded and the outcome of the investigation confirmed the staff had acted appropriately. The manager has delivered some internal training to staff and holds discussions with staff to talk over issues and how to recognise different forms of abuse. Staff still requires formal training in the protection of vulnerable adults. Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service were provided with a clean, comfortable environment. There was sufficient staff to maintain good hygiene standards. EVIDENCE: Eastwood House is a long established residential home, which has had extensions, added. The home meets the requirements of the Disability Act and the layout is suitable to meet the needs of the all the people who use the service. In April 2006 an application was approved to have a dementia unit upstairs. The unit has two lounges, dining room and snack kitchen and has an enclosed garden for the use of these people. At Eastwood House all bedrooms are single occupancy and there was evidence that many of the people had personalised their bedrooms. Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 19 There is a selection of communal areas throughout the home. There is a redecorating programme in place for all areas of the home. The downstairs dining area had been redecorated and there are plans for new carpets to be laid in that area. There is a choice of bathing facilities for example, assisted baths and shower room with a number of toilets placed around the home. The home provides a hoist to assist people with moving and handling needs. The home has purchased an additional hoist for the first floor of the home as required at the last inspection. The grounds are well kept with patio areas at side and rear of the home, which are used for people who receive care on the residential unit with a separate area for the people in the dementia unit. The home was clean and fresh and people said the home was generally clean and tidy, relatives said sometimes she felt that her mum’s room had not been dusted and the sink was sometimes not cleaned. Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff had the skills and knowledge to fulfil their roles within the home, although some refresher training was needed. There was a stable staff group. Recruitment policies were generally followed however some key records were missing. EVIDENCE: Staff rotas were looked at to ensure the right levels was maintained. A senior carer has responsibility for organising the shift and staff was deployed to work specifically on the two units. The rotas only showed the first name of the member of staff and it did not show their designation or the actual hours worked. Recruitments and selection files were looked at to determine if the right staff were employed to work with vulnerable adults. Of the six files looked at references were missing from three files. Three of the files did not have a CRB (Criminal Record Bureau) Check although they did contain a POVA (Protection of Vulnerable Adults) check. Only one file had proof of identity and there was no evidence to confirm gaps in employment had been checked. The files were generally untidy and disorganised, which was discussed with the manager. Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 21 Induction and training records were looked at. The induction programme was dated and fails to meet the ‘Skills for Care’ standards. The manager said staff completes the induction and then staff are provided with a mentor until the person is deemed competent. Refresher training was required in most of the mandatory areas. The manager was aware of the need to provide the training and has identified an organisation to provide the training. Most staff have attended an internal safeguarding adults training, although formal training is still required. Mental Capacity Act and Deprivation of Liberty policies and procedures should be developed and training in those policies should be introduced. The home continues to support staff to undertake national vocational qualifications (NVQ). The numbers of staff trained to level 2 NVQ in care exceeded the minimum 50 required by The National Care Standards Act 2000 Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were protected by sound management practises, and their views were actively sought to improve the service. The financial interests of people were safeguarded, and good health and safety procedures ensured they are protected. EVIDENCE: The manager was appointed in January 2009. She has worked at the home for a good number of years and has commenced NVQ level 4 in management. The organisation should take the appropriate action to apply for the registration of the manager with Care Quality Commission. Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 23 There was evidence that the home actively seeks the views of people who use the service. There was a satisfaction survey and they also have meetings to enable people to discuss problems and give there views on how they want the home to be run. A representative of the organisation must visit the home monthly and undertake a quality audit (Regulation 26). The report must be made available for inspection. People who use the service were able to manage their own finances, although some prefer the manager to assist with dealing with their personal monies. Records were looked at and they were an accurate reflection of the accounts held on people’s behalf. Accident records were looked at. Appropriate action had been taken to risk assess when falls had occurred. The manager should purchase new accident recording documents to ensure it is used in accordance with Data Protection Act 1998. Maintenance and service records examined were up to date and current to the services provided. The home has the required Health and Safety policies and procedures and displays the relevant notices. Fire safety procedures were in place and service records were looked at and were current, ensuring the safety of people who use the service. Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X 3 X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 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 Peoples care needs must clearly state their leisure and social care needs. This will ensure people’s emotional needs can be met. Arrangements must be made to ensure that accurate records are kept of all medicines received, administered and leaving the home or disposed of. This helps to confirm that medication is being given as prescribed and facilitates accurate checking of stock levels. This will ensure people receive their medication as prescribed. A new CRB must be obtained for all new staff employed at the home. Two written references must also be obtained to ensure the right staff are employed. Proof of identity (passport and birth certificate) must be included in the employment checks and gaps in employment history must be checked and recorded. Timescale for action 01/07/09 2. OP9 13 01/07/09 3. OP29 19 01/07/09 Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 26 4. OP30 18 All staff including the manager must attend formal safeguarding adults training. Staff must receive training to ensure they have the skills and competencies to meet the needs of people who use the service. Induction training must meet the ‘Skills for Care’ standards. To ensure staff have the right introduction to the home. Monthly quality audits must be undertaken, as required by regulation 26 of the Care Homes Regulations 2001. 01/08/09 5. OP30 18 01/08/09 6. OP31 26 01/06/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The Statement of Purpose and Service User Guide should be updated to ensure it includes how to raise concerns and it should be user friendly using pictures and written using easy word. Professional guidance documents on handling medicines in social care should be available for staff to use in support of the existing medication policy and procedures. Handwritten entries on MAR charts should be accurately recorded and detailed. This makes sure that the correct information is recorded so that all staff understands and follows the changes correctly. Medication procedures should be reviewed to ensure they reflect the Royal Pharmaceutical Society of Great Britain and CSCI professional advice documents on handling medicines in social care The date when eye drops commenced must be written on the box to ensure they are not used past the manufactures DS0000070909.V374972.R01.S.doc Version 5.2 Page 27 2. 3. OP9 OP9 4. OP9 5. OP9 Eastwood House 6. OP16 7. OP29 8. OP30 9. 10. OP30 OP31 recommended 28 days. The complaints procedure should be updated to include the stages that would be followed if a complaint was made. Complaints records must include investigation records and letters to confirm outcomes of complaints. Leaflets should be easily accessible to ensure people can raise concerns without being identified. The manager should check the date on the CRB as good practise suggests that a new CRB check should be carried out every three years, to ensure the information is up to date. Staff rotas should include the full name of the staff member and their designation. The rotas should also show the actual times worked on the rota so that the inspector can make a judgement on the staffing levels. Mental Capacity Act and Deprivation of Liberty policies and procedures should be developed and training in those policies should be introduced. The manager should submit an application to the Care Quality Commission to be the registered manager. Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 28 Care Quality Commission Yorkshire and Humberside Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Eastwood House DS0000070909.V374972.R01.S.doc Version 5.2 Page 29 - 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!