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Inspection on 07/06/07 for Enbridge House Care Home

Also see our care home review for Enbridge House Care Home for more information

This inspection was carried out on 7th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents said they liked living at the home and it has a relaxed atmosphere. The home is good at assessing if it can meet the needs of residents before they come to the home. Residents said that the activities provided by the home meet their needs. Staff said that they were supported and encouraged to obtain qualifications. One resident said they feel safe and comfortable at the home and their opinions are sought. Residents feel they have a good rapport with Mrs Plumb and said she runs the home in their best interests.

What has improved since the last inspection?

Eight out of the ten requirements made at the last visit have been met. The statement of purpose reflects the categories of care the home provide. Residents are aware of the service user guide and contracts. Residents said the activities have got more varied. Records of food provided at the home are maintained to monitor residents` diets. Staff have received training in first aid training and infection control and the frequency of fire training has been increased. The manager has received regular training and keeps evidence to demonstrate that updating is ongoing. The job description for the owner who works at times as acting manager and a carer were available for inspection with a training record. A quality assurance system demonstrates that the home has been audited and residents and others have been consulted via a survey. All care staff are trained in fire safety awareness twice a year by a competent person, a procedure is available for evacuating the home in the event of a fire and the fire protection system is fully operational. Fire doors which are kept open have appropriate closing mechanisms. Some areas of risk such as use of balconies and the fire escape have been assessed. The kitchen, upstairs hallway, 2 bedrooms and respite room have been re decorated.

What the care home could do better:

There has been progress in care planning procedures although further work is still needed to demonstrate that residents are consulted and included in reviews which reflect the outcomes of the service for residents. A requirement was made. More work is needed to improve the condition of the home which although is comfortable and nicely decorated in many areas, others are showing signs of wear and tear and need attention. A requirement was made. Staff recruitment has not taken place since the last inspection and so progress will be monitored at a future inspection. Training is still needed for staff in the area of mental health to enhance the understanding of the specific needs of people they are working with.

CARE HOMES FOR OLDER PEOPLE Enbridge House Care Home Church Road Woolton Hill Nr Newbury Hampshire RG20 9XQ Lead Inspector Tracey Horne Unannounced Inspection 7th June 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 Enbridge House Care Home DS0000012200.V338706.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. Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Enbridge House Care Home Address Church Road Woolton Hill Nr Newbury Hampshire RG20 9XQ 01635 254888 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) kblwork@tesco.net Mrs Mandy Ann Plumb Miss Karen Bolt-Lawrence Mrs Mandy Ann Plumb Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two named residents in the categories of MD(E) and DE(E) may be accommodated. 13th June 2006 Date of last inspection Brief Description of the Service: Enbridge House is registered to provide a service for 17 older persons. The home is situated in Woolton Hill village, near to Newbury and is a large property. Set in well-maintained grounds the home reflects the era of building, offering comfortable, tasteful surroundings to service users. Accommodation is offered over three floors and access is available via a central staircase or via a passenger lift. The accommodation consists of two shared double rooms and thirteen single rooms. One of the single rooms is offered for respite accommodation, the home having built up a regular clientele who visit the home for holiday periods. There is ample car parking space available to the front of the property. Mrs Plumb confirmed the fees are £580.00 per week. Information is available for residents and prospective service users in the front hall of the home. Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to assess how well the home is doing in meeting the key National Minimum Standards (NMS) and Regulations. The findings of this report are based on several different sources of evidence. These included: an unannounced visit to the home, which was carried out on the 7th June 2007 between 09.30 and 15.30, during which the inspector (Mrs Tracey Horne) had the opportunity to see residents in the communal areas and in their bedrooms, view records and procedures and talk to Mrs Plumb. Observations were made regarding the interaction between residents and staff and the care provided. The people living in the home prefer to be referred to as residents, therefore the rest of this report will reflect this. Mrs Plumb did not return the Annual Quality Assurance Assessment (AQAA) prior to this visit, therefore the Commission for Social Care Inspection (CSCI) did not receive the information needed to send out surveys to residents, relatives or staff. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the CSCI What the service does well: What has improved since the last inspection? Eight out of the ten requirements made at the last visit have been met. The statement of purpose reflects the categories of care the home provide. Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 6 Residents are aware of the service user guide and contracts. Residents said the activities have got more varied. Records of food provided at the home are maintained to monitor residents’ diets. Staff have received training in first aid training and infection control and the frequency of fire training has been increased. The manager has received regular training and keeps evidence to demonstrate that updating is ongoing. The job description for the owner who works at times as acting manager and a carer were available for inspection with a training record. A quality assurance system demonstrates that the home has been audited and residents and others have been consulted via a survey. All care staff are trained in fire safety awareness twice a year by a competent person, a procedure is available for evacuating the home in the event of a fire and the fire protection system is fully operational. Fire doors which are kept open have appropriate closing mechanisms. Some areas of risk such as use of balconies and the fire escape have been assessed. The kitchen, upstairs hallway, 2 bedrooms and respite room have been re decorated. What they could do better: There has been progress in care planning procedures although further work is still needed to demonstrate that residents are consulted and included in reviews which reflect the outcomes of the service for residents. A requirement was made. More work is needed to improve the condition of the home which although is comfortable and nicely decorated in many areas, others are showing signs of wear and tear and need attention. A requirement was made. Staff recruitment has not taken place since the last inspection and so progress will be monitored at a future inspection. Training is still needed for staff in the area of mental health to enhance the understanding of the specific needs of people they are working with. Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 7 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. Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives have the information needed to choose the home that will meet their needs and have their needs assessed prior to receiving care. EVIDENCE: Residents said that they had received information from the home, which enabled them to decide that they wanted to visit the home to view the facilities and environment. The inspector looked at one of the most recent pre admission assessment record. Mrs Plumb had visited the prospective resident to complete the home’s pre admission assessment before a place was offered at the home and said this usually occurs in the residents home or whilst they are in hospital and may coinsides with a care manager assessment. This was to ensure the home could meet their individual needs before the placement being offered. Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 10 Mrs Plumb said prospective residents and their families/ representatives are welcome to look around the home to see if the home would meet the individual’s needs. The pre admission assessments included a moving and handling assessment, medical history, allergies, history and risk of falls, equipment needed, personal care needs, personal preferences, medication and any anxieties etc. The resident’s contract states the fees that the home will charge them and the majority of contracts seen had been signed by the resident or their representative. The home provides single accommodation, for one person to receive respite care for a short period of time before they return to their home, or they are admitted into a permanent room if the resident wants to and is assessed as needing residential care. One relative said in their survey to the CSCI that their relative was receiving respite care at the home which worked very well for a few years, by the time their relative needed more care they were already familiar with their surroundings. Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Further improvement is needed to show that residents have been involved in reviewing their care. Medication practices in the home are managed well. Residents receive health and personal cares based on their individual needs and are treated with dignity and respect whilst their privacy is maintained. EVIDENCE: There was evidence of care plans being reviewed and staff said that they could be changed at any time if needed. However the review process does not show how resident’s views have been sought or whether they have been informed of any changes to their plan of care. This was made a requirement and was part of a requirement made at the last visit to the home. Two residents were aware of their care plans, one had been signed both residents said the staff know them well and provide the care and support they need. Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 12 The inspector looked at four residents’ care plans. The plans contained the information gathered during the pre admission assessment. Daily records did not always include information such as: what the resident had done during the day or how they were feeling/interaction etc, records stated ‘good appetite’ and ‘all care given’. Mrs Plumb acknowledged that records need to be more detailed but as staff and residents stated that the care and support given is as they wish, and staff stated that they have the information needed to provide the care and support to individual residents, this was not made a requirement on this occasion. Mrs Plumb confirmed that advice would be sought from the appropriate person, mainly by the resident’s general practitioner (GP) if staff have any concerns regarding residents health care needs. Records showed residents had accessed a chiropodist and GP. The medication procedure was observed and medication was stored securely in the home- this included controlled medication. It was well organised into individual sections for residents. Two staff spoken to confirmed that key holders only administered the medication and had been trained in medication practices. Records of administration were accurately recorded and a member of staff described the process of administering to each resident in turn. Records were also in place for controlled drugs and correct procedures, where sampled, had been followed. Records showed that staff who administer medication have attended a distance learning course in the safe handling of medicines. The inspector observed that staff were attentive, caring, respectful and they have a good understanding of each residents individual’s needs. Throughout the visit, staff were seen to knock on doors and wait before entering rooms and they spoke to residents in their preferred manner, as stated in their care plans, and were friendly but respectful. Staff said they are aware of the importance of dignity and respect, one staff stated, ‘I treat people as I wish to be treated’. Staff induction records showed that privacy and dignity and the provision of personal care are covered during the induction process, and the response from residents indicated that the carers treat them with dignity and respect and that they are trustworthy. Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to exercise control over their lives, participate in social activities, receive visits from friends and relatives as they wish and enjoy a choice of meals served in a relaxed atmosphere. EVIDENCE: Residents said they are able to exercise choice by participating in social activities if they wish, one resident stated that ‘the staff spend time with me, although I like my own company and this is respected.’ Resident’s preferences are identified during the assessment process, and this information is included in the individual’s care plan, therefore staff are aware of what residents like doing, but records do not always reflect this. Mrs Plumb said that one senior carer has additional responsibilities as the home’s activities coordinator to arrange various activities, during the inspection residents were chatting with staff, sitting ion the garden enjoying the sunshine and in the afternoon the majority of residents said they were enjoying a foot spa/massage by one of the carers. Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 14 The home celebrates residents birthdays with parties and an annual summer garden party is arranged where relatives are invited to attend. There is an open visiting policy, and this was evidenced by records of visitors to the home and confirmed by residents. The home employs one cook who confirmed everything she cooks and prepares is fresh, nothing is pre cooked. Fresh vegetables and fruit were available, and a supermarket delivered a weekly shop during this visit. Three Food items were taken out of the fridge to be disposed of as they were out of date. Mrs Plumb said that she would ensure stock is checked more frequently. The cook said that when she does not work, one carer is responsible for cooking, this is taken into consideration to ensure enough carers are available in the home. We observed refreshments being offered throughout the day for residents, this included fresh home made cake in the afternoon. Resident said they liked the food and could eat meals where they want and could ask for alternatives or more if needed. Enbridge House Care Home DS0000012200.V338706.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and staff are confident that their complaints will be listened to, taken seriously and acted upon. Staff have a good understanding of Adult Protection and residents are protected from potential abuse. EVIDENCE: Residents spoken with said that they were aware of the complaints procedure, even though they have not had to use it. They said they would go straight to Mrs Plumb if they had a concern or complaint and were confident that Mrs Plumb would take their concerns seriously. Residents confirmed that the staff are very good and listen to them no one has felt the need to complain, only compliment. Staff said they were aware of the home’s complaint procedure which includes the address for the Commission and that all complaints will be dealt within 28 days. The complaint log was available which included sufficient detail to monitor complaints successfully Mrs Plumb confirmed no complaints had been received since the last visit. Staff said they were aware of the correct procedures to follow if a disclosure of abuse was reported to them, and they had received formal training in abuse Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 16 awareness, certificates confirmed this. The home has procedures for staff to follow should abuse be suspected, including Hampshire County Council’s Protection of Vulnerable Adults and Whistle Blowing. Mrs Plumb confirmed that policies and procedures are reviewed and available for staff to access regarding complaints and protection, staff confirmed this. Enbridge House Care Home DS0000012200.V338706.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents experience a clean, hygienic and comfortable environment and pleasant gardens but further improvement is needed to provide residents with a well maintained home. EVIDENCE: Residents said the home is warm and comfortable. Some areas of the home had been re decorated, including two residents bedrooms. This was mentioned as a point of action during the last inspection and13th June 2006. The outside of the building appears shabby, paintwork was flaking and an over-flow pipe was leaking which has resulted in green marks on the wall by the main entrance. The entrance hall wall is shabby in places Mrs Plumb said this was because it is being prepared to be re decorated in June 2007. The hallway carpets are worn and stained and the downstairs toilet is being Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 18 replaced during June 2007 as it is in need of refurbishment. One toilet in the first floor bathroom had tape over it, Mrs Plumb said this was because it was not in use and will be replaced. There is no maintenance and re decoration plan despite this being a repeat a requirement at the last visit. A requirement has been made. Mrs Plumb said her father does the maintenance work and the home have recently employed another maintenance person to help. A maintenance record shows dates when faults were notified and when they were actioned and by whom. Staff said they have noticed improvements in the time it takes for jobs to be completed. Residents benefit from well-maintained and attractive gardens and said they often sit and admire them. Residents said they are able to bring their own furniture for their rooms, this was seen when visiting a bedroom. Some rooms have French windows leading to the garden. All bedrooms have either en-suite facilities or bathrooms close by. The shaft lift and the call bell system were reported to work regularly. Assisted bath seats are used and a mobile hoist is available. The home is cleaned five days a week residents said that it is always clean and smells nice. The home has an internal laundry that is well equipped. Infection control procedures were in place. Staff were observed to follow this guidance, equipment such as gloves and aprons were available and the home have a contract with a clinical waste company to ensure bins are emptied regularly. Enbridge House Care Home DS0000012200.V338706.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. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff receive regular training in most areas and are supported to obtain NVQ level 2 or above. Staff are skilled and in sufficient numbers to fill the aims of the home and meet the changing needs of residents. Recruitment practices ensure resident’s safety. EVIDENCE: Residents said there are always enough staff on duty who know how they like to be cared for, staff said that they felt there are enough staff on duty on each shift. It was evident through observation that staff had developed a good relationship between themselves and residents. Comment from residents included that staff were very kind and were helpful. As stated earlier in the report, no new staff have been employed by the home since the last visit, therefore it was not possible to establish whether the recruitment process is robust, this key standard will be reviewed at the next visit. Mrs Plumb confirmed that 30 of staff have achieved an NVQ 2 and above and a further 60 are working towards obtaining the award. Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 20 Staff said that they undertake training regularly in the necessary health and safety subjects such as fire safety, first aid, moving and handling, infection control and food hygiene. Other training courses attended by staff include abuse training and induction but no records were available to show staff had received specific training regarding mental health which would ensure staff were trained to meet individual’s specific needs. This issue was raised as part of a requirement at the last visit and was made a requirement. Mrs Plumb acknowledged this and confirmed training in this area would be arranged. Enbridge House Care Home DS0000012200.V338706.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. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Mrs Plumb is experienced but does not discharge her responsibilities to meet requirements. Management and administration needs to be improved but is based on openness and respect. An effective quality assurance system is in place. The home is not involved in monitoring or handling residents’ money. Residents’ health, safety and welfare are well promoted by the home with systems that ensure everyone is protected within the home. EVIDENCE: Mrs Plumb is a qualified and experience registered manager and maintains regular training updates via distanced learning courses. Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 22 Staff said there are clear lines of accountability within the home. Also the management approach of the home creates an open, positive and inclusive atmosphere. As mentioned earlier in the report Mrs Plumb has not made sufficient improvements to meet previous requirements. The staff felt they were included in the day-to-day decision making within the home, stating that changes and or issues are discussed and actions agreed at regular staff meetings that are minuted. As mentioned in this report and in the last two inspection reports, Mrs Plumb has identified areas planned for improvement within the home but there is no annual development plan to outline plans for the home for residents, relatives and staff to see or to monitor progress made. Residents said they are asked their views and opinions of the home regularly and the home have recently introduced surveys for residents and their relatives. The findings of the most recent were not available, as they had only just been circulated. Mrs Plumb said resident’s family or financial appointees safeguard resident’s money, rather than the home, two residents confirmed this. No unsafe practices were observed during the inspection. Certificates were available for required checks of systems and equipment. Risk assessments where necessary have been completed. Staff have received training in health and safety, first aid, fire safety, care of substances hazardous to health and moving and handling. The fire drill records showed that all staff had attended two fire drills in the last year as well as fire training every six months. Mrs Plumb explained the recording system for fire safety maintenance, training, evacuation and visual checks. The visual checks of all fire safety equipment has been recorded and undertaken at appropriate intervals and weekly fire alarm tests are carried out to ensure the safety of the residents. Regular risk assessments are undertaken and recorded to ensure that the safety within the home room by room. The home has a satisfactory reference file for the Control of Substances Hazardous to Health (COSHH) information leaflets for each chemical being used in the home. The home has a policy, procedures and information on health and safety. There is an ongoing system in place that ensures that all appliances are serviced, records and certificates seen indicated that the systems such as the electrics and specialist equipment including the passenger lift received regular servicing and maintenance. The employer’s insurance liability certificate was displayed and current. Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 23 Enbridge House Care Home DS0000012200.V338706.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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Enbridge House Care Home DS0000012200.V338706.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 15.2 (c,d) Requirement The registered manager must ensure care plans are revised with the resident or their representative. This is part of a previous requirement from the last inspection timescale 13/09/06 not met. The registered manager must ensure that a programme of redecoration and maintenance is planned and acted upon. This is an amended requirement from the inspection of 1/11/05 and a repeat from the last inspection timescale 13/08/06 not met. The registered manager must ensure that arrangements are made for staff to receive suitable training in working with residents’ who have a mental disorder. This is part of a previous requirement from the last inspection timescale 13/08/06 not met. Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 26 Timescale for action 26/07/07 2. OP19 23.2 (b,d). 26/07/07 3. OP30 18.1 (c.i) 26/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Enbridge House Care Home DS0000012200.V338706.R01.S.doc Version 5.2 Page 28 - 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!