Inspection on 13/08/07 for Ennis House

This inspection was carried out on 13th August 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.

Other inspections for this house

Ennis House 23/11/09

Ennis House 24/05/06

Ennis House 01/12/05

Ennis House 18/04/05

Ennis House 05/11/04

Ennis House 14/04/04

Ennis House 28/05/03

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Ennis House 59-61 Enys Road Eastbourne East Sussex BN21 2DN Lead Inspector Lucy Green Key Unannounced Inspection 10:35 13 & 16th August 2007 th 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 Ennis House DS0000021096.V340430.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. Ennis House DS0000021096.V340430.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ennis House Address 59-61 Enys Road Eastbourne East Sussex BN21 2DN 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) 01323 720719 01323 722604 ennishouse@baldry59.freeserve.co.uk Mr Michael Baldry Mr Michael Baldry Care Home 40 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (40), Old age, not falling within any of places other category (40) Ennis House DS0000021096.V340430.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is forty (40). Service users must be older people aged sixty-five (65) years and over on admission. A maximum of twenty service users at any one time may be aged between fifty (50) and sixty-four (64) years. This includes one named service user aged forty-nine (49) years on admission. Service users with a primary diagnosis of past or present mental illness only to be accommodated. 24th May 2006 4. Date of last inspection Brief Description of the Service: Ennis House is registered to provide long-term residential care for up to forty older people with either a past or present mental disorder. This service does not provide intermediate care. The home is a large property, which has been created by adapting and linking three terraced houses. The home is situated in a residential area of Eastbourne, close to the town centre. Resident accommodation is provided in single rooms, many of which have ensuite facilities. Communal space is provided by a number of lounges and a dining room. The home has one designated smoking room and sufficient toilets and bathrooms. A passenger lift provides partial access to the upstairs of the home. Two spacious gardens are situated to the rear of the property. Information provided by the Provider on 16 June 2007 details that the current range of fees at Ennis House are between £378.87 and £425.11. Additional charges are payable for hairdressing, chiropody and newspapers. More detailed information about the services provided at Ennis House can be found in the home’s Statement of Purpose and Service User Guide - copies of these documents can be obtained directly from the Provider. Latest CSCI inspection reports are on available on request at the home. Ennis House DS0000021096.V340430.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report reflects a key inspection based on the collation of information received since the last inspection and a site visit which lasted for a total of eight hours. The inspection was conducted across two days, with the first visit being unannounced. The Registered Manager was not available on the first day of inspection and therefore the Inspector arranged to return a few days later to look at some documentation and meet with the Registered Manager. During the site visit, the Inspector conducted a partial tour of the premises on both days and undertook an examination of some medication, care and staffing records. The Inspector met with twenty-three of the thirty-three residents accommodated at the time of the inspection and had individual conversations with thirteen of them. Five staff, including, the Head of Care, two senior carers, a carer and a new staff member were interviewed as part of the process and two other staff members also spoken with during the course of the first visit. Comment cards were sent to the home to distribute amongst relatives and visitors. At the time of this report, none had been returned to the CSCI. What the service does well: Ennis House is a family owned and run home that provides a high quality service to the people it accommodates, within a relaxed and friendly environment. The home has an experienced team of staff who enjoy their work and have a good understanding of the needs of the people living at the home. Residents spoke highly of the support received by staff and positive relationships between staff and residents were observed. Choice is given paramount importance at Ennis House and staff consult with residents about all aspects of their daily lives as a matter of routine. The provision of meals enables residents to have food and drink at times which suit them. As such, breakfast is served across a period of several hours to enable accommodate the differing times that people get up. Residents benefit from a choice of freshly prepared meals each day. Residents have the opportunity to spend their time as they choose. The home encourages and supports people to be as independent as possible and to maintain contact with family, friends and the wider community. Ennis House DS0000021096.V340430.R01.S.doc Version 5.2 Page 6 The home has to manage a lot of resident medication and there are robust systems in place to ensure that this is managed well. 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. Ennis House DS0000021096.V340430.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 Ennis House DS0000021096.V340430.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): 3&6 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents are protected by an assessment process that ensures their needs are identified and confirmed they can be met before they move into the home. Ennis House does not provide intermediate care. EVIDENCE: Information submitted by the Provider in the Annual Quality Assurance Assessment detailed that there have been five people admitted to Ennis House in the last twelve months. The Inspector viewed the pre-admission assessments information in place for two of these people. There was documentary evidence that a representative from the home had conducted a thorough assessment on each individual prior to both these residents moving into the home. The home had also obtained copies of the Ennis House DS0000021096.V340430.R01.S.doc Version 5.2 Page 9 latest Care Management Assessment and Integrated Care Programme Approach for these individuals. A review of the subsequent care plans in place for these two individuals provided evidence that the information gathered at the assessment stage is then subsequently used to develop a plan of care. Prospective residents are encouraged to visit the home prior to admission to assess the suitability of the placement. There was evidence in care plans and from speaking with the individuals, that the people recently admitted to Ennis House had visited the home prior to moving in. In both cases the home had confirmed in writing to the individual and their Care Manager when the trial period had expired and that the home could meet the individual’s needs for a permanent stay. There is no provision for intermediate care at Ennis House and therefore Standard 6 is not applicable. Ennis House DS0000021096.V340430.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 quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ health and personal care needs are met in a respectful and private way. Residents are protected by the systems in place to manage medication. EVIDENCE: A sample of four care plans were viewed and it is pleasing to report that the progress noted in this area at the last inspection has continued. Each resident has a plan of care that provides detailed information about their health and welfare needs, with evidence of multi-disciplinary input. The overview of care needs which provides the reader with instant key information about the type of support each resident requires makes the care plans easy to use. Discussion with staff re-iterated this point and one staff member commented that they believed the care plans to be “the best they have ever been”. Care plans contain risk assessments for a range of areas and it is generally possible to track the level of risk and the controls in place to minimise the risk. Ennis House DS0000021096.V340430.R01.S.doc Version 5.2 Page 11 The home is however reminded to ensure that adequate risk assessments are in place for all activities and issues where a potential risk is posed, including for those residents who access the community independently. The home must ensure that the judgements they make instinctively are robustly recorded. As the home had demonstrated a commitment to developing these documents by demonstrating improvement in this area between the two inspection days, a requirement has not been made and a review of this area will take place at the next inspection. There was evidence that care plans and associated documentation have been reviewed on a monthly basis and any changes made recorded. It was however identified that there was a period of several months where routine reviews were not conducted on all care plans. Such reviews had commenced again in August and therefore the documentation was up to date at the time of the inspection. A Senior Carer informed the Inspector openly that there had been some slippage with the review process and this was also reflected in the Provider’s Annual Quality Assurance Assessment. As the home has selfaudited this issue and implemented improvement, this is not reflected as a requirement of this inspection. It is however an expectation that monthly reviews are conducted and will be assessed again at the next inspection. Staff practices observed throughout the inspection days again demonstrated that they have a good understanding of the residents and their needs. Discussion with staff produced evidence that they have an excellent knowledge about the people they support. Residents are encouraged to be as independent as possible and it was entirely obvious that staff provide support in the way preferred by each individual. It was clear from observation, talking to residents and staff and from the written material in place, that care and support is provided in a sensitive, dignified and respectful way. Many of the residents hold keys to their bedrooms and these were found to be in use at the time of the site visits. Throughout the both inspection days, staff were noticed knocking on residents’ doors and seeking permission before entering their private space. Residents are fully supported with their health care needs and care plans contain a record of any visits or contact with professionals external to the home. There was evidence of current involvement from General Practitioners, District Nurses, Dentists, Chiropodists, Optician and the Community Mental Health Team. Records demonstrated that residents are regularly weighed and dietician input is sought where necessary. Three residents were identified at the time of the inspection as currently experiencing complex healthcare issues. Both the care plans and support provided by staff to these residents reflected that the necessary steps were being taken by the home to maintain their well-being. Ennis House DS0000021096.V340430.R01.S.doc Version 5.2 Page 12 Medication systems were inspected by way of a review of the Medication Administration Records (MAR sheets) and examination of the storage of medication. The supplying pharmacy undertakes routine checks of medication and it was evident that any recommendations from these visits have been actioned. The home has a good system in place for managing the large amount of medication that has to be administered each day. Records were clear and it was possible to track changes of medication. A Senior Carer confirmed that only senior staff who have been appropriately trained and supervised handle medication. It was identified that a few residents administer some (or all) of their own medication. It was evident from discussions with staff that appropriate discussions and assessments had taken place to ensure that these individuals were competent to manage their medication and these are now recorded in the care plan Ennis House DS0000021096.V340430.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported to lead their lives how they choose. Residents benefit from an inclusive environment where there are opportunities to participate in activities if they wish to. Choice and flexibility are given paramount importance at mealtimes. EVIDENCE: The daily running of the home was observed on both days to allow residents the freedom of choice about when they get up and go to bed. During the inspection it was noticed that residents choose where and how to spend their time. Conversations with residents highlighted that they have each developed their own individual routines and wherever possible, staff facilitate this. Residents are encouraged and supported to maintain contact with their family and friends. Residents told the Inspector about the friendships that have developed within the home and how they can choose who to spend their time with. The home operates an open door policy and residents are able to spend Ennis House DS0000021096.V340430.R01.S.doc Version 5.2 Page 14 time with their guests in their rooms or in one of the lounges. The visitors’ book evidenced that there are lots of regular visitors to Ennis House. One individual has responsibility for the co-ordination of activities in the home and has produced a social profile for each resident which provides a synopsis of information about the social likes and dislikes of each resident. Whilst, the number of residents choosing to participate in group activities has reduced, the home still offers this opportunity four afternoons each week. The activity timetable provides a range of activities including skittles, bingo, puzzles, arts and crafts and card games. Evaluation sheets are in place for each day and therefore it was possible to track the activities that had taken place, who had participated and how successful each event was. Individual conversation with the residents about the activities highlighted that some people really valued the opportunities to participate in planned social events, whilst others preferred to follow their own interests. Some residents are able to go out independently, for others support is required. For residents who love to go out all the time, the Head of Care reported that the home does their best to facilitate this by putting on extra staff to support residents out for coffee, lunch or to the shops. One resident is supported to regularly go out on Friday evenings to watch tribute acts at Eastbourne bandstand. In addition to the in-house activities, the home also has monthly visits from the Music In Care Homes group and church singers. Residents are supported to attend church as when they choose. The home also has a licensed vehicle and which is planned to be used for more group trips outside the home. The provision of meals continues to be of high quality. Meals are prepared according to a four-week rotating menu, with residents, staff and management confirming that an alternative is always available. There was evidence that the menu is frequently reviewed and changed to provide a wide variety of meals. On the day of the first day of inspection, the Inspector noted that there were at least two residents had a lunchtime meal that was alternative to the menu. Care plans and observation provided evidence that the kitchen is open all day and residents can have snacks and drinks at any time. Breakfast is served over several hours to accommodate the different times people choose to get up. There is always the option of a cooked breakfast and on the day of inspection one resident informed the Inspector that they had had cereal and eggs on toast for breakfast that morning. The serving of the lunchtime meal was observed on the fist inspection day, with the main meal being savoury mince, vegetables and mash potato. Dessert was jam roll and custard. Two residents chose to have a different lunch, with one having an omelette and another scrambled eggs on toast. Ennis House DS0000021096.V340430.R01.S.doc Version 5.2 Page 15 Residents are able to choose where to take their meals, but for many this is seen as a social time. The dining room is arranged into small groups and lots of positive interaction was noticed at this time. The food seen was appetising and nicely presented and all residents spoken with spoke highly of the food provided at Ennis House. One resident told the Inspector; “the food is even better than before”. Ennis House DS0000021096.V340430.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from an open culture where they are able to express their views and feel valued and protected from harm. EVIDENCE: Ennis House has a complaints policy which is accessible to both residents and visitors to the home. Information provided by the home highlights that they have investigated two complaint in the last twelve months, which were noth appropriately handled by the Provider. The CSCI has not received any complaints about the provision of service at Ennis House in the last twelve months. The residents spoken with all confirmed that they knew how to complain and stated that if they had any concerns they would go straight to either the Provider or the Head of Care. The staff interviewed were knowledgeable about the vulnerability of residents and the systems in place to protect them. The Head of Care and a Senior Carer have completed a training in the protection of vulnerable adults and all the other staff are booked onto this training which is due to take place in November 2007. Ennis House DS0000021096.V340430.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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from an environment which provides choice of space and privacy, however, a number of maintenance issues impact on both safety and homeliness. EVIDENCE: Ennis House is a large property, which in addition to single bedroom accommodation, offers a range of communal areas. The home is divided into two areas; one of which provides level access by way of a passenger lift. The other part of the building is accessed by stairs and therefore the residents accommodated in this part of the house must be fully ambulant. Ennis House DS0000021096.V340430.R01.S.doc Version 5.2 Page 18 During a tour of the building, the Inspector again highlighted a number of maintenance issues which require attention. For example, the carpet and lino in a number of areas is frayed, which not only looks worn, but also poses a potential trip hazard. Some parts of the home are used as a general storage areas and for reasons of health and safety and general homeliness, should be cleared. Two bedrooms were found to be malodorous, although discussion with the Head of Care identified that these were due to complex situations that were being managed. Some bedrooms and parts of the home showed signs of wear and tear and were found to be in need of general re-decoration. A maintenance programme is in place and many of the issues raised by the Inspector are included on this schedule. The general requirement made at the last inspection that the Manager review the priority of work being done to ensure all areas of the home are maintained to a safe standard is therefore carried forward. The home has successfully implemented the new legislation in respect of smoking, by providing one designated smoking lounge. This new system was reported by all to be working well, with residents smoking either in this area or outside the home. Ennis House DS0000021096.V340430.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. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from being supported by an experienced and committed team of staff and are protected by the recruitment systems in place. EVIDENCE: On both inspection days, there were sufficient staff to support the needs of residents as detailed in the care plans. A review of current and past rotas indicated that staffing levels provide a minimum of five care staff across the waking day (8am-8pm). More often than not however, the morning is covered with either six or seven care staff to accommodate appointments and support residents outside the home. The Registered Manager works in a supernumerary capacity. At night, the home is staffed by two waking staff and one person sleeping in. In addition to care staff the home employs adequate numbers of cooking and domestic staff. Staff spoken with all confirmed that staffing levels were adequate at this time. The residents who spoke with the Inspector again commented how nice staff were. One resident expressed: “the staff are really great” and another told the Inspector: “there are good people to look after me”. The interaction between residents and staff was observed to be positive. Ennis House DS0000021096.V340430.R01.S.doc Version 5.2 Page 20 It was identified that whilst new staff undergo an induction programme, this is not currently in line with Skills for Care. The Head of Care demonstrated the areas that are covered on induction and reported that all staff have either completed or are booked onto an appropriate induction and foundation programme. It is however reflected as a requirement in this report, that all new staff complete the full induction programme within the timescales laid down by the National Training Organisation. Staff training is ongoing, seven staff (43 ) have now completed and four staff (25 ) are working towards National Vocational Qualifications (NVQ). The home has a training matrix in place and planned updates include manual handling and the Protection of Vulnerable Adults. The Head of Care stated other core training was up to date. It was a requirement of the last inspection that specific training in supporting people with mental health needs and managing challenging behaviour be provided for staff. The Head of Care reported that they have been unable to find a provider of this training. Discussion with staff highlighted that they still believe this training will be useful and therefore the requirement is re-affirmed. The recruitment files for four care staff were inspected and the required information was in place for each individual, including satisfactory checks with the Criminal Records Bureau, two written references, completed application form and full employment history. Ennis House DS0000021096.V340430.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, 36 & 38 Quality in this outcome area is good. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from living in a home that is well managed and run for their best interests. The home must develop formal systems for quality assurance in order to continuously improve service delivery. EVIDENCE: The management team at Ennis House, ensure that the home is run in the best interests of the people who live at the home. The Registered Owner/Manager has been in post for many years and has a wealth of experience in this field. That being said, he does not have either the care or management qualifications required by the National Minimum Standards. The Head of Care is working towards NVQ 4 in Care and Management and a Senior Carer holds the Ennis House DS0000021096.V340430.R01.S.doc Version 5.2 Page 22 Registered Managers’ Award and NVQ Level 4. The management team therefore collectively have the required skills and qualifications. It is therefore judged that at this time, that the outcome for the people living at Ennis House is that they are living in a well managed home. Ennis House is an open and inclusive environment where people feel valued and listened to. That being said however, the home must develop more formal systems for monitoring quality assurance. The home has achieved Investors in people status and has a policy on quality monitoring which needs to be fully implemented. It was discussed with the management team that the home needs to develop its own formal systems of self-audit and gaining feedback, in order that the home can continuously improve. As part of this process, regular recorded supervision sessions should be happening on a one-to-one basis for staff and regular staff meetings should also occur. Residents’ finances are safeguarded by a system that ensures all transactions are logged and receipts maintained. The information submitted to the Commission by way of the Annual Quality Assurance Assessment indicates that the home has a number of systems in place to ensure the health and safety of the home is monitored and maintained. The Inspector did not therefore look at records pertaining to the maintenance of equipment and routine testing. Ennis House DS0000021096.V340430.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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 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 3 X 2 X 3 2 X 3 Ennis House DS0000021096.V340430.R01.S.doc Version 5.2 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP30 Regulation 18(1)(c) (i) Requirement The Registered Person must ensure that staff receive training in managing challenging behaviour and supporting people with mental health needs. (Previous timescales of 01/05/06 and 01/09/06 not met) 2. OP30 18(1)(c) The Registered person must ensure that all new staff undergo an induction programme that meets Skills for Care specifications, within the times set down by the National Training Organisation. A formal system of monitoring quality assurance to be put in place. (Previous timescale of 01/03/06 not met) This should include regular staff supervision and staff meetings. (Previous timescale of 01/09/06 not met) 3. OP19 23(1)(a) The process of redecoration and refurbishment must continue DS0000021096.V340430.R01.S.doc Timescale for action 01/12/07 01/10/07 2. OP33 24 01/11/07 01/11/07 Ennis House Version 5.2 Page 25 giving priority to areas of health and safety. 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 OP36 Good Practice Recommendations It is recommended that a record is maintained of staff supervision sessions. Ennis House DS0000021096.V340430.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Ennis House DS0000021096.V340430.R01.S.doc Version 5.2 Page 27 - 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!