Inspection on 30/04/07 for Emberbrook Care Home

This inspection was carried out on 30th April 2007.

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

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The Shelley

Thorndene

Springfield House

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St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

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

CARE HOMES FOR OLDER PEOPLE Emberbrook Care Home 16 Raphael Drive Thames Ditton Surrey KT7 0BL Lead Inspector Lisa Johnson Unannounced Inspection 09:30 25th April 2007 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 Emberbrook Care Home DS0000068324.V333122.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. Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Emberbrook Care Home Address 16 Raphael Drive Thames Ditton Surrey KT7 0BL 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) 020 8398 3300 020 8398 3302 Four Seasons (No 10) Limited Rosalyn Wells Care Home 68 Category(ies) of Dementia (44), Dementia - over 65 years of age registration, with number (2), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (30), Old age, not falling within any other category (14), Physical disability (50), Physical disability over 65 years of age (2), Sensory Impairment over 65 years of age (4) Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 10 beds may be used for intensive rehabilitation for those aged 40 years and upwards 31st October 2006 Date of last inspection Brief Description of the Service: Emberbrook Care Centre is a purpose built care home providing nursing care predominately for older people and is operated by Four Seasons Health Care. The Centre has two units specialising in dementia care and a limited number of places in other units for service users from the age of 40 years. Service provision affords permanent and respite placements. The Centre is a two-storey, detached building located in a small, exclusive residential development adjacent to a medical centre. There are local shops and amenities nearby in Thames Ditton village. Living accommodation at the centre is arranged in four wings. Each has all single en–suite bedrooms, kitchenettes, sitting rooms, separate dining rooms and assisted bathing and toilet facilities. All areas are wheelchair accessible. The dementia care units are located on the first floor accessible by two passenger lifts. They share a suitably equipped sensory room. Each living unit has its own dedicated staff group and senior sister or charge nurse responsible for directing and supervising care delivery. Emberbrook Care Centre has a welcoming reception area, hairdressing and office facilities and car park. There is a small enclosed garden with a furnished patio, aviary and water feature. The weekly fees range from £550-£860. Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The visit was unannounced and took place over six and half hours, commencing at 9.30am and finishing at 4.00pm. Mrs L Johnson and Mrs M Williamson, Regulation Inspectors, carried out the visit. Ms R Wells, Registered Manager, represented the service. Since the previous visit an application to register the company, Four Seasons Health Care, with the Commission for Social Care Inspection has been completed. The inspectors spoke to six people who live in the service to gain their views on the care provided. Some of the people living in the service have communication difficulties, therefore their direct views about their care could not be obtained. Observations of interactions and service user responses have been recorded in this report. The inspectors also spoke with four relatives. Nine comment cards were received from people using the service and eight relative comment cards were received. These comments are reflected in this report. A full tour of the premises took place. Information was examined which was provided by the manager with the pre-inspection questionnaire. Staff training records and policies and procedures were sampled. The inspector spoke to four members of staff. The inspector would like to thank the people living in the home, relatives and staff for their time, assistance and hospitality during this visit. What the service does well: The home provided a warm and welcoming feel and, since the previous visit, the home has undertaken a programme of refurbishment with the home now providing a high standard of accommodation, which is well maintained, comfortable and clean. Comments received from residents and their relatives included, “The refurbishment is excellent”, “The dining room is attractive“ and “The bedrooms and communal areas are always clean”. The home has completed good care plans which are regularly reviewed, updated and are carried out in consultation with people using the service and/or their representatives. Comments stated, “The staff always welcome my input”. “The sister in one unit is excellent at consulting me about changes in condition, treatment and wellbeing”. Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 6 Comments received from relatives indicate that they are made to feel welcome when they visit the service. “I find the home friendly”, “Relatives and friends are made welcome”. A number of positive comments were received about the care provided in the home - “The care service treat people as individuals who are respected at all times”, “The staff are respectful and kind”, “The nursing and personal care is good”, “Staff are very attentative to my relative and always respond to any concerns or requests”. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Emberbrook Care Home DS0000068324.V333122.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 Emberbrook Care Home DS0000068324.V333122.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 & 6 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that pre-admission assessments are completed prior to admission to the home. The home does not support people for intermediate care. EVIDENCE: The home has a brochure, which is formulated in large print, a Statement of Purpose and service user guide, which clearly describes the services that the home is able to provide. The manager stated that these are provided to prospective people moving in to the home and their representatives. Pre-admission assessments were sampled for six people and these were observed to be detailed and comprehensive. The cultural and diversity needs of residents are considered as part of this assessment. Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 9 Comment cards received from both people using the service and their representatives confirm that information was provided prior to admission to the home. One comment received stated, “Staff were keen to have as much information about my relative’s background, for example their interests before moving in.” Emberbrook Care Home DS0000068324.V333122.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 & 10 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Each person is provided with an individual care plan, which details the individual’s health, personal, emotional and social needs. The health care needs of people are met and they are treated with respect, and their right to privacy is respected. Improvement is needed to ensure that people are protected by the home’s medication policy and procedures. EVIDENCE: During this visit four residents’ care plans were sampled. Plans were based on full needs assessments including personal, health, wellbeing, mental health and social, including cultural and diversity needs, religious preferences and communication. All plans had clear objectives and goals, which had been completed in consultation with people living in the service and/or their representatives, with all plans being signed by them to confirm their agreement. Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 11 Each care plan showed evidence of monthly reviews, with clear records maintained of the current needs and instructions of care to be given. Staff spoken with had a good awareness of the care plans. Comments stated, ”The staff always welcome my input and the sister in charge of the wing is excellent at consulting me about changes in condition, treatment and wellbeing”. Care plans identified the likes and dislikes of individuals. It was evident that risk assessments were completed including waterlow scores, moving and handling assessments, including falls, and nutritional assessments were completed with monthly weight charts being maintained. Care plans sampled indicated that people using the service are supported by health care professionals including a local GP, community psychiatric nurses, physiotherapists who are employed by the service and who were seen consulting with people during this visit, with records being maintained for all healthcare appointments and consultations. One person had been referred to a dietician. Comment cards received from people living in the service and seven relatives stated that the home provides medical support. Comments received included, “The health and personal care is good”, “My relative is visited regularly by the chiropodist and dental service”, and “The staff react quickly to medical problems”. People living in the home have their own bedrooms and during this visit staff were observed to maintain the privacy of people by keeping the doors shut when carrying out personal care and knocking on doors before entering. Staff were observed to be interacting with people in the dementia care in a respectful manner and providing observation. One relative commented, ”I see members of staff sitting and talking to my relative”. Other comments received included, “The home treats people as individuals who are respected at all times”, and “The care service helps people live in a dignified way”. Six out of eight relative comment cards received said that the home usually meets the cultural and diverse needs of their relatives. The medication administration policies and practices were examined. Appropriate storage and controlled drug records were well maintained. A policy and procedure was in place including self-medication, and clear audit trails were in place. However, during a tour of one unit the medication for one individual was seen on their table in their bedroom, which had not been administered. It was required that the staff must adhere to the home’s policy and procedure for the administration and recording of medicines, ensuring the health, safety and welfare of people living in the service. This matter was brought to the attention of the managers of the service, who responded appropriately and promptly. Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 12 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 & 15 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that people living in the home have access to a range of recreational and leisure activities and maintain links with their family/friends and the local community. Choices and individual preferences are respected and people receive well-presented and balanced meals. EVIDENCE: The home has now appointed an activities coordinator and a part time assistant. On arrival at the home, a group of people and staff were leaving to go on a trip to Kew Gardens. A weekly programme of activities was in place, which was displayed in each unit. Activities include reminiscence, sensory awareness, sherry mornings, sing a longs, quizzes, film night and bingo. The home had also held a St George’s day party that had been well received. Breakfast clubs are held daily on each unit and staff spoken with said that they also carry out activities in the afternoons when the activities organiser is working in another unit. Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 13 Comments received included, “My relative is included in outings, singing and music”, “The activities have increased which residents enjoy”, ”There has been a marked improvement with activities”. Another relative spoken with said that activities have improved since the appointment of the activities coordinator. Two comments received stated, “The activities are generally good, but would like more stimulating activities such as lectures films and trips out and more trips to the garden would be good.” The manager is advised to respond to these matters. It was evident that people in the home maintain contact with their family and friends and during this visit a number of relatives were visiting the home. There are no visiting time restrictions. Comments received from relatives included, “I find the home friendly”, and “Relatives and friends are made welcome.” Each unit provides a small sitting room, which is available for relatives and friends to use. People moving into the home are able to bring their own furniture into the home if they so wish, and the inspectors were informed that when a bedroom becomes vacant people have the opportunity to choose their preferred colour scheme. Menus are planned by the chef in consultation with people taking into consideration their preferences and dislikes. The chef stated that all diets can be accommodated and choices are made available. Seven out of nine service comment cards received from people living in the home say that they enjoy their meals and comments included, “The food always smells good and appetizing”, and “The dining room is attractive and afternoon tea is served with an assortment of cakes.” Two comments received stated that there was room for improvement, “Food presentation and choice could be better”, and another comment indicated that an individual is provided with fruit, which they are unable to manage without assistance. The manager is advised to review this matter. During this visit the lunchtime meal was varied, nutritious and well presented. Special attention was provided to the meals that were pureed, to enhance their presentation. The home has obtained a Hearts of Gold award for nutrition. Since the previous visit the home has obtained new dining tables, which were accessible for service users using wheelchairs. Tables were nicely presented with crockery and serviettes. In the dementia care units staff were observed to be sitting and interacting with people and providing appropriate support. Food is delivered in hot trolleys to the units and meals that are provided to people who are in their bedrooms were attractively presented on trays. Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 14 It was observed that condiments were not provided in the dementia care units and it was recommended that this matter is attended to, to ensure that these items are made available should people wish to have these with their meals. Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home and their representatives have access to an effective complaints procedure and their views are listened to and acted upon. Policies and procedures are in place, which protect them from abuse EVIDENCE: The home provides a complaints procedure, which is provided with the service user guide. Since the previous visit the Commission has received two complaints, one of which was appropriately investigated by the manager, and the responsible individual investigated the second matter. The manager maintains records for any complaints or concerns received. Evidence was sampled and it was observed that clear records were documented which included evidence of and outcomes of investigations carried out. Seven out of nine comment cards received from people using the service say that they are aware of the procedure, and eight relative comment cards are or usually aware of the procedure and who they can talk to. Four relatives spoken to during this visit stated that they were happy with the care provided by the home. Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 16 One person living in the home said, “It’s nice here”, and another individual said, “I am happy here and the staff look after us well”. Other comments received from relatives included, “Since the new company has taken over I have not had to make a complaint”, “Staff are very attentive to my relative and always positively respond to any concerns or requests”, “The staff are cheerful and ever helpful and I feel free to take up anything with the manager or sister at the time.” Since the previous visit three matters have been referred under the local authority multi-agency safeguarding adults from abuse procedures and one matter is currently ongoing. The home has a copy of the updated local authority policies and procedures and the company has their own procedure. The inspector was informed that all senior staff have attended the local authority training and three staff spoken with have received appropriate training and were aware of their responsibilities should they ever witness abuse. Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. People using the service live in a well-maintained, clean, comfortable, homely and safe environment. EVIDENCE: Since the previous visit the company has carried out a refurbishment programme. During a tour of the home it was observed that it has been redecorated and furnished to a high standard. The environment was bright and cheerful. Dining rooms were bright and airy, which has been complimented by new furniture. Comments received included, “The refurbishment is excellent”. Some minor maintenance issues were identified including a broken kitchen cupboard, which the company is going to action. One relative described the maintenance person as ‘always cheerful and obliging to requests’. Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 18 There is a large garden to the rear of the home, which is well maintained and provided with furniture and also has an aviary. All areas of the home are accessible and a lift is provided to access the second floor. Seven out of ten comment cards received from people living in the home say that the home is clean and fresh. During this visit the home was seen to be clean and hygienic. Separate laundry facilities were in place, which were maintained to a good standard. The laundry staff were aware of infection control procedures and training records indicated that training in infection control takes place. Comments received included, “The home is clean and attractive”, and “The bedrooms and communal areas are always clean”. However, one comment received stated that décor, furniture and some cleanliness in one room needed improvement. Some bedrooms were viewed during this visit and were adequately maintained. The home has been presented with a gold food standards award from the Council for Kitchen Hygiene and a recent environmental health visit has been conducted, which was satisfactory. Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty were adequate to meet the needs of people living in the home who are protected by the home’s recruitment policies and procedures and were in the safe hands of the staff who were competent and trained to do their jobs. EVIDENCE: The pre- inspection information provided by the manager suggests that adequate numbers of staff are employed to meet the needs of individuals in the home. During this visit the dementia care units were each led by a qualified nurse and three carers. The home also employs two deputy managers, catering, ancillary and administrative and maintenance staff. Eight out of nine comment cards received from people living in the home said staff are available when they need them. One comment received indicated that there had been an occasion when assistance was requested and this had been delayed. During this visit several call bells were activated and staff were observed to answer these in a responsive and timely fashion. Since the previous visit some care staff have been completing National Vocational Qualifications and the manager is advised that this programme continues to ensure that fifty percent of staff have gained National Vocational Qualifications (Level 2) or above. Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 20 It was evident that staff undertake training and development and a number of nursing staff have attended training and take lead roles in updating others. One member of staff said that she had completed training in tissue viability and two other members of staff spoken with lead on moving and handling and continence. Weekly training sessions are provided, one of which was taking place during this visit. All staff working in the dementia care units have completed dementia awareness training. Three members of staff spoken with stated that they had completed mandatory training including first aid, infection control, moving and handling, safeguarding adults and medication administration. This was confirmed by examination of training records on staff files. One comment received from a relative stated, “The staff are experienced and have the right skills, and new staff receive training”, and “I am satisfied with the current staff and work practices.” Another comment received indicated that the spoken English of some members of staff from abroad was not good. This matter was discussed with the manager who said that staff are supported to attend English communication classes. All new staff receive induction on commencement of employment, based on the Skills for Care common induction. Records for these were observed on one staff member’s file sampled. The home has an equal opportunities policy in place and staff recruitment files were sampled which were maintained in good order and contained all of the required information including police checks. Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered manager is able to demonstrate that she has the appropriate qualifications and experience. The home is run in the best interests of people living in the home and their financial interests are protected. The health, welfare and safety of residents is protected. EVIDENCE: The registered manager is a registered nurse and holds a BSc degree and is near to completing the Registered Managers Award. People using the service and relatives commented that, “The matron is approachable”, “The matron’s door is always open”, and “We are pleased with the current manager.” Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 22 Staff spoken with said that they felt supported by the management structure and one person said the manager is ‘hands on’. Staff also stated that regular meetings are conducted. The home has a quality-monitoring programme in place, which includes carrying out annual surveys for people using the service and for relatives. These surveys are to be issued shortly and the manager said that the outcomes would be made available on the company’s web site. The company is carrying out other quality assurance audits, including care planning and pressure area care. Pre-inspection information indicates that there is a range of policies and procedures in place. Monthly quality visits are conducted with copies of reports maintained in the home. Since the previous visit staff now receive regular formal supervision, which was confirmed by staff and from files sampled. Relevant insurances relating to the home were available. The home maintains some monies on behalf of people and these records were sampled for five individuals. Receipts and records were maintained of any expenditure. The home’s fire records were sampled and it was evident that regular fire alarms and fire drills are recorded. During a tour on the dementia care unit it was observed that fire extinguishers were stored in lockable clear fronted cupboards to ensure the safety of individuals living there. However, the keys for these cupboards were placed in the cupboards to ensure quick accessibility should this equipment be required. The service conducts regular water temperature checks and records were examined. Accident records were appropriately maintained. Pre-inspection information provided indicates that all regular servicing and maintenance of equipment is regularly conducted. Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement Staff must adhere to the home’s policy and procedure for the administration and recording of medicines ensuring the health, safety and welfare of people living in the service Timescale for action 25/04/07 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 2 Refer to Standard OP15 OP30 Good Practice Recommendations It is recommended that people living in the service be provided with condiments to have with their meals. Fifty percent of care staff should achieve a National Vocational Qualification (Level 2) Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Emberbrook Care Home DS0000068324.V333122.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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