Inspection on 22/08/07 for Eboracum

This inspection was carried out on 22nd August 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eboracum 30/08/06

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Eboracum 177 Park Grove Barnsley South Yorkshire S70 1QY Lead Inspector Christine Rolt Key Unannounced Inspection 22nd August 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Eboracum DS0000065058.V346708.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. Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eboracum Address 177 Park Grove Barnsley South Yorkshire S70 1QY 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) 01226 203903 F/P01226 203903 eboracumhouse@tiscali.co.uk Mr Stephen John Oldale Miss Susan Jane Leigh Miss Joanne Featherstone Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2006 Brief Description of the Service: Eboracum House is a stone built residence with a purpose built extension on two levels providing personal care for 18 elderly people. It is situated in a residential area of Barnsley, on a main bus route, close to the M1 junction 37, local bus routes and shops. It stands in its own grounds with mature trees and shrubs. There is a car park to the side of the building. The home has a lounge, a conservatory and a dining room. There are 18 single bedrooms, some of which are on the ground floor. Two bedrooms have en suite facilities. The home has a passenger lift and is equipped with handrails and other adaptations to assist people living in the home. The fees were £334.50 to £350.00. Items and services not included in the fees were chiropody, hairdressing, toiletries, private taxis and newspapers. The manager supplied this information during the site visit on 22nd August 2007. Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection and comprised information already received from or about the home and a site visit. The site visit was from 9.30 am to 6.15 pm nd on 22 August 2007. The majority of people living at the home were seen throughout the day. Three people living at the home were tracked throughout the inspection. Questionnaires were sent to four people, seven relatives and two health care professionals. Completed questionnaires were received from 3 people living at the home, six relatives and one health care professional. During the site visit a visitor was asked for their comments about the service provided and two members of staff were interviewed. Care practices were observed, a sample of records was examined, a partial inspection of the building was carried out and service provision was discussed with the manager. The inspector wishes to thank the manager, members of staff, people living at the home, relatives and the health care professional for their assistance and co-operation. What the service does well: What has improved since the last inspection? Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 6 People living at the home had individual files that contained all their relevant information. Reviews of care plans were carried out in consultation with the people living at the home and their representatives. Relatives made positive comments about this and considered that any concerns could also be raised at these meetings. The availability of staff had improved. Members of staff who recorded information in care plans now completed this task in one of the communal rooms instead of using the staff office, which was some distance away. This ensured that there were always members of staff available. Staff had undertaken adult protection training, which gave them the knowledge to define abuse and how to report it. 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. Eboracum DS0000065058.V346708.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 Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. 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. Prospective residents and their relatives had the information they needed to make an informed choice. Assessments were carried out to ensure that the home could meet people’s needs. This home does not provide intermediate care. EVIDENCE: The majority of relatives considered that they had received sufficient information to make a decision about the home. The manager said that all people living at the home had copies of the Service User Guide in their bedrooms and there was also a copy in the entrance hall together with the Statement of Purpose and the Complaints Procedure. These were in a folder but were not immediately visible. The manager was advised to display these Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 9 more prominently to ensure that visitors had access to them. advised to display a copy of the latest inspection report. She was also People living at the home were assessed prior to admission to the home and copies of the assessments were seen on their files. They contained a good range of information of their individual needs and wishes. There was no information on files to show that the home had confirmed in writing that they were able to meet each person’s needs. Eboracum DS0000065058.V346708.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. Residents were treated with respect, and their day-to-day care needs were generally reflected in their care plans but could be enhanced. Medication procedures were generally sufficient to ensure that residents were protected. This judgement has taken account of the overall outcomes for the people. However specific areas, identified in the evidence, need prompt attention and action by the manager. EVIDENCE: Relatives considered that people’s care and health needs were met and they were kept informed. Comments were, “Mum is always dressed nicely and always looks clean and tidy”, “Mum is given all the help she needs getting up in the morning and getting ready for bed”, “Because mum is registered blind, the staff help her with meals, getting dressed etc.”, “Mum is kept in clean clothing suitably attired for each session”, and “The home always gets in touch Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 11 if mum has had a fall. They took her to hospital once to have her checked over and have an X-ray”. The files for three people who live at the home were checked. These contained a range of information. Visits by health professionals were recorded and provided good information of the reasons and outcomes of their visits. This information was cross-referenced to the daily records. The manager was advised to include health professional’s names and not just their titles to provide clarity. The care plans provided information of how care needs were to be met, but could be enhanced by utilising specific information supplied in their assessments. This would ensure a person centred approach. Daily records provided good information of how physical, health and emotional needs were met but there was no information of how people spent their days or how their social needs were met. Care planning was discussed with the manager. Files contained Nutritional Assessments but there was no code to determine when people were at risk. The manager was advised to obtain and use the Malnutrition Universal Screening Tool (MUST) as a better method of determining whether people were at risk. She obtained a copy during the site visit and said that she would read it and then ensure it was incorporated into care plans. People were weighed monthly but on two of the three files seen, there were statements “Weight unobtainable”. The manager explained that these people were unable to weight bear therefore could not be weighed on the current stand on scales. She said that that arrangements were in place for the home to share sit on scales with two other homes but that the registered providers were aware of the situation and sit on scales were to be purchased for the home. There were no risk assessments for people who had their beds against the bedroom wall. The need to ensure the safety of people who require help and the people who help them to get in and out of bed was discussed with the manager. The home had a Policy and Procedure for Accidents. The document was not user-friendly and the manager was advised to ensure that staff were aware of procedures for dealing with accidents, particularly head injuries. Accident forms were available on people’s files but daily records did not consistently provide information that people were monitored following an accident or fall. This issue was raised at the previous inspection. To ensure that health needs are met, records must be kept of how the person was monitored to determine whether any injury was sustained that was no apparent at the time of the accident. This was discussed with the manager Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 12 who said that she would implement a 72-hour monitoring sheet for people who had accidents or falls. Care plans were reviewed monthly and there was information on files that people living at the home and their relatives were included. This was verified in a comment from a relative “…also review each month with manager Miss J. Featherstone” The home used a monitored dose system (MDS) for medication. The medication for three people was checked against the Medication Administration Records (MAR) sheets and these tallied. Loose medication (i.e. not in the MDS) was checked at random and this tallied with the records. The medication trolley was clean and tidy. The dispensing pharmacist did not provide details of the medication within the cassettes therefore staff could not check this against the MAR sheet. The MAR sheets were pre-printed by the pharmacist and these showed the monthly total of medication supplied on each week’s sheet, which gave a false impression of the medication available, thus complicating stock control. The manager was told to discuss these issues with the dispensing pharmacist. Staff were using their own codes instead of the given codes to identify where medication had not been given. Since the last site visit, the home had purchase a small plastic refrigerator for the storage of medication that required refrigeration. The suitability of this refrigerator was discussed; it was questionable whether the refrigerator could maintain a steady temperature. At the time of this site visit, the refrigerator temperature was not being monitored. The home did not have any controlled medication. The manager produced loose sheets to show how controlled medication would be recorded. These were not suitable and the manager was advised to obtain a bound book with numbered pages in preparation for any person who was prescribed controlled medication. Medication issues were discussed with the manager and she was advised to obtain a copy of the Royal Pharmaceutical Society guide to medication in care homes. Residents’ privacy and dignity were respected and relatives confirmed this. One relative considered that there were not enough staff to take people to the toilet. “No one ever comes whilst we’re there asking if anyone needs the toilet”. This was discussed with the manager who said that people were taken to the toilet if they requested to go, if seen wandering about and it was thought that they might need the toilet, and also at set times. She said that they did not go round asking people if they wanted to go to the toilet because staff needed to respect people’s dignity and privacy. Toilet doors were clearly signed but to assist people who may have some confusion it was suggested Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 13 that symbols also be placed on the door and the door colour changed to make it more easily identifiable. The manager agreed to consider this. Eboracum DS0000065058.V346708.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. 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. The lifestyle within the home did not always match people’s expectations and preferences but this was being addressed. Personal choice and control were promoted. Meals were good quality with variety and choice. EVIDENCE: The lack of activities raised the most comments from relatives. A programme of activities was displayed on the wall, but according to relatives, this was not adhered to. On the day of the site visit there were sufficient staff on duty and there were also three students. Some people were participating in table activities. There was a computer for people’s use and one person said that she enjoyed using the computer, and staff had showed her how to correspond via e-mails and e-cards with her relatives who lived abroad. The manager said that three people used the computer – two used it to keep in contact with their families and one person used it for clothes shopping. Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 15 Relatives considered that more activities should be provided. Their comments were “I think more activities to keep the residents’ minds more active would be beneficial”, “Activities carried out not just written on wall. I know they can’t do much but a little personal encouragement would make a difference”, “Encourage more activity and means of stimulating minds”, There is a board showing planned activities but when visiting never seem to see any of these taking place” and “It would be nice if there was an activities organiser to help the residents join in more. Also it would be nice if they had older songs playing on tape or CD I’m sure the residents would sing along to these as they remember all the older songs” and “There is no motivation whatsoever. Compared to our sister’s residential home there where she is activities are always done. It seems to me there are not enough staff to talk to them or do anything with them. They just sit about all day long”. The manager was asked how she ensured that all the people living in the home were motivated and stimulated as there was no information on people’s care plans (See Section Health and Personal Care above). She said that group and individual outings were arranged. She was aware that some people could not participate in some activities, so to meet their needs, she and staff were receiving training on activities. An adviser was visiting the home to show staff how to stimulate and motivate people with dementia. The home had two pet cats and one of the people living in the home said that she took responsibility for feeding them. Relatives said that they were made welcome in the home. Information on people’s preferences and wishes were recorded in their plans of care. A relative commented, “The residents are allowed to get up when they want and have breakfast when they want”. A member of staff confirmed that staff worked around the routines of people living at the home. There were no menus displayed to inform people of the meals on offer. The manager said that people living at the home could have anything they wanted to eat. Because mealtimes are the highlights of the day, the manager was advised to display a menu. A resident commented on the good quality and choice of meals and relatives’ comments were also positive; “The food is very good as it is all made freshly”, “Nice substantial meals”, “Beautiful Sunday dinner”, “Nice cakes at teatime and variety of sandwiches” and “Varied meals plentiful amount of food”. A relative’s comment about staff help at mealtimes was “At meal times the meal seems to be put in front of mum and left for her to manage as best she can. She finds some things difficult to cut up” but two other comments from relatives were“ The staff help her with meals” and “Also she has help at mealtimes if anything needs cutting up etc.” Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 16 A relative was concerned about the availability of fresh fruit “A little fresh fruit peeled and sliced and handed round they don’t seem to have any treats between meals. Mum does as we see to it”. This was discussed with the manager who said that the home frequently provided slices of fresh fruit mid morning and mid afternoon. Fruit was also available at mealtimes and there was also fruit in a bowl in the dining room. The manager said that they tended not to put a lot of fruit in the bowl because the heat made it deteriorate quickly but the main reason was hygiene issues in that some people picked it up, took a bite and then put it back in the bowl. The manager also added that fruit was available at any time. The home had the Silver Award for catering dated 14th December 2005 displayed. Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 17 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. People using this service were protected from abuse. They and their relatives and friends were confident that their complaints would be dealt with appropriately. EVIDENCE: The home had a complaints procedure. This was in a folder in the main entrance. The manager was advised to display this more prominently to ensure that visitors were aware of the complaints process. The procedure was checked and needed slight amendment. The home had an adult protection policy and procedure and also a local procedure with contact numbers to ensure that staff left in charge of the home were aware of the procedure to follow. All staff had undertaken adult protection training and the manager had also undertaken Training for Trainers to enable her to teach adult protection training. There were no allegations of abuse and no complaints. Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 18 Relatives knew how to make a complaint. One relative said, “The manager and staff are very approachable”. When relatives were asked if the home had responded appropriately to concerns, the majority considered that they did or would if the need arose. One relative commented, “No concerns raised up to this time, but I’m sure they would respond appropriately”. One relative considered that staff needed to be reminded and commented, “Every issue needs persistent reminding”. The provision of a person centred approach to care planning (see Health and Personal Care section) would alleviate some of the issues raised by this relative. Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 19 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 was pleasant, hygienic, well maintained and generally safe. EVIDENCE: Relatives comments about the home were all positive “Clean and presentable accommodation”, “There is a homely atmosphere as the home is quite small”, “The home itself is always clean and mum’s bedroom always looks tidy” and “Clean, tidy, no odours”. A new carpet had been fitted in the entrance hall and up the stairs. All rooms were pleasantly decorated. Furnishings and furniture were in good condition. Bedrooms were well decorated, clean, and with good quality carpets and furnishings. People had personalised their rooms and some had their own Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 20 furniture. Bathroom, shower room and toilets were clean. There were no offensive odours. Aids and adaptations were in place and since the last inspection, handrails had been fitted in the garden to promote people’s independence. The gardens were neat and tidy. In some of the bedrooms, the beds were against the wall. The manager said that some of these people needed assistance to get in and out of bed. No risk assessments had been carried out to determine if there were any risks to the person or the staff. (See also section Health and Personal Care). The call system pull cords in lounges were accessible to people living in the home. One relative considered that “The home is mostly run very well some attention could be paid to make sure the toilet rolls are replaced in the toilets. Sometimes when I have taken mum to the toilet there hasn’t been any toilet roll”. This was discussed with the manager who said that she was aware of the problem and that toilet rolls were constantly being replaced because people living at the home were taking them back to their rooms or placing them in their handbags. The manager agreed to continue to look at measures to prevent this happening. Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 21 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. Staffing levels met people’s needs. People were supported and protected by the homes recruitment procedures and staff’s skills and competence. EVIDENCE: At the time of this site visit there were sufficient staff on duty. However, there were three students, which seemed excessive for staff to be able to supervise properly and also deal with people’s needs. The manager was asked to consider reducing the level of students on each shift to ensure that staff were not supervising students at the expense of meeting people’s needs. The manager said that this was already being considered and one of the students was to move to evening shifts. Relatives considered that the staff always or usually met people’s needs and that they had the skills and experience to do so. Comments were “The staff know all the residents very well” and “Care staff seem to go on relevant courses”. Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 22 Since the last site visit, staff were using one of the communal rooms instead of the staff office to write up the daily records. This ensured that there were always sufficient members of staff in the immediate vicinity. Two staff spoken to during the site visit had worked at the home for 12 years and 23 years respectively. Both said that they enjoyed their jobs and confirmed that opportunities for training were good. Details of staff training was available and showed that staff undertook skills training to meet people’s needs. The manager said that staff had undertaken training in meeting the needs of people with dementia and the latest training to be undertaken was Equality and Diversity. Four staff had already undertaken this and all other staff would follow. The recruitment files for two members of staff were checked. Both contained the relevant information. However, dates of employment and information on some records indicated that new employees were being supervised on the premises prior to receipt on POVAFirst checks. The need to ensure that POVAFirst disclosures are in place before new employees start working under supervision was stressed to the manager. The manager said that staff received individual supervision and files verified this. Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 23 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 home is run and managed in the best interests of people living at the home. Their health, safety and welfare are promoted and their financial interests are safeguarded. EVIDENCE: The registered manager had worked at this home for several years and was known to the people living in the home and their relatives. She had completed NVQ Level 4 and had almost completed the Managers Award. She ensured that she was up to date with current practices. Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 24 The home continued to hold the Investors in People Award. Written reports of visits to the home by the registered provider were available and these were checked during the site visit. The home had a good quality assurance system that included environmental checks, audits of systems within the home, residents and relatives meetings, staff meetings, individual staff supervisions, questionnaires and observations of staff practices to ensure competency. Money held on behalf of people who lived at the home was checked against written records. These tallied. Receipts were available for purchases made on behalf of people living at the home and these were numbered for ease of reference and attached to the records. Audits were carried out. Money was stored safely. The manager confirmed that receipts were issued for money received on behalf of people living at the home. When money was handed over to people living at the home, signatures were obtained where possible. Mandatory health and safety training was ongoing and information of each member of staff’s level of training was recorded. Certificates were available to verify that systems and equipment within the home had been serviced and maintained within the required timescales. Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 25 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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 4 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 26 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 OP3 2 OP7 12 Standard Regulation 14 Requirement Prospective residents must be informed in writing that the home can meet their needs. Utilise specific information supplied in assessments to ensure a person centred approach. Daily records need to include information of how social needs are being met. Where beds are placed against walls, assess the risks to the safety of people living at the home and staff who assist them in and out of bed Provision must be made for weighing all people to ensure that health needs are met. Information on how people ’ health needs are monitored following a fall or accident must be recorded. (Timescale of 24/11/06 not met) The pharmacist must be consulted about: • written details of medications supplied in cassettes for checking against Medication DS0000065058.V346708.R01.S.doc Timescale for action 17/10/07 14/11/07 3 4 OP7 OP7 12 13 17/10/07 19/09/07 5 6 OP8 OP8 12 13 19/09/07 19/09/07 7 OP9 13 19/09/07 Eboracum Version 5.2 Page 27 8 OP9 13 9 OP9 13 10 11 OP9 OP12 13 16 12 13 OP16 OP29 22 13 Administration Records (MAR). • the quantities of medication recorded on the MAR sheets, which do not give a true description of the medication supplied. Staff must use the codes on the Medication Administration Record to ensure consistency and prevent errors The refrigerator used for the storage of medication must be fit for purpose and maintain a steady temperature. The temperature must be monitored and recorded to ensure that it is within the required scale. Controlled drugs must be recorded in a bound book with numbered pages. Consult people about individual and group leisure activities and ensure that activities are suited to their needs and preferences. Amend the complaints procedure to include timescales. POVAFirst disclosures must be available before new employees work under supervision. 19/09/07 19/09/07 19/09/07 17/10/07 19/09/07 19/09/07 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 Consider displaying the Statement of Purpose, Service User Guide and a copy of the most recent inspection report in a more prominent position to ensure visitors are aware of these documents. The provision of a more user friendly Accident Policy and DS0000065058.V346708.R01.S.doc Version 5.2 Page 28 2 Eboracum OP8 3 4 5 6 OP10 OP15 OP16 OP27 Procedure would ensure that staff were aware of the procedure to follow, particularly when head injuries were sustained. To promote independence for people with some confusion, consider changing the colour of lavatory doors and adding signage. The provision of a menu would ensure that people were aware of the meals on offer. The complaints procedure should be displayed more prominently. Consider a better distribution of students to ensure that people’s needs are not compromised Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Eboracum DS0000065058.V346708.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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