CARE HOME ADULTS 18-65
Evaglades Residential Care Home 394 Marine Road East Morecambe LA4 5AN Lead Inspector
Mrs Jennifer Dunkeld Unannounced Inspection 10th July 2007 10:00 DS0000045535.V338530.R01.S.doc Version 5.2 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 DS0000045535.V338530.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 Adults 18-65. 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. DS0000045535.V338530.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Evaglades Residential Care Home Address 394 Marine Road East Morecambe LA4 5AN 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) 01524 418151 Mrs Sheila Mavis Mecklenburgh Miss Mandy Rowlands Care Home 8 Category(ies) of Learning disability (8) registration, with number of places DS0000045535.V338530.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home must at all times employ a suitably qualified and experienced manager who is registered with the NCSC. 26th October 2006 Date of last inspection Brief Description of the Service: Evaglades is a three storey building situated on the promenade, and overlooking the bay, in Morecambe. There is no outside space at the back of the home, but there are seats at the front of the home, where residents can sit in the better weather and watch the world go by. Large windows at the front of the home display the views along the coastline. It has been adapted to meet the safety requirements of a care home, and only the lower two floors are for residents. There is no lift in the home, so residents need to have fairly good mobility. All except one of the rooms are single, and they all have ensuite. There is sufficient communal space, with the lounge/dining area at the front of the home. There is easy car parking space in the road outside the home. Staffing is provided over 24 hours, every day of the year. Information about the service the home provides is available as a guide, which tries to cover everything a resident needs to know about daily life in the home. Commission for Social Care Inspection reports are readily available from the manager to anyone who asks to see them. As at 10th July 2007, the fee scale ranges from £563 to £811.50 a week, with additional charges for holidays, extra toiletries, magazines, transport and some activities. DS0000045535.V338530.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The first day of this site visit was unannounced, in that the residents, staff manager and owners were not aware that it was to take place. The site visit was part of the key inspection of the home. A key inspection takes place over a period of time, and involves gathering and analysing written information, as well as visiting the home. The second day of this inspection was announced in order to have one of the owners present for the visit. The total length of the 2 visits was 5.5 hours. Before the visit took place, the manager was asked to complete an AQAA (Annual Quality Assurance Assessment) and a response to surveys was requested from residents, any relatives, and visiting professionals. During the site visit 3 of the residents plan of care were viewed as part of the ‘case tracking process’ this is a method whereby the inspector focuses on a small group of residents. All records relating to these individuals are examined, along with the rooms they occupy in the home. Residents are invited to discuss their experiences of the home with the inspector; this is not to the exclusion of the other residents who contributed in many ways. Care plans were viewed for the 3 people taking part in the case tracking process. The care plan is a document outlining the needs of the individual resident and how these are to be met. Staff records were looked to ensure the necessary information, alongside required written records such as the administration of medication. The manager, residents and care staff were spoken with, to gain information about the service people receive. A tour of the home was made, viewing the lounge/dining room, bedrooms and bathrooms. Everyone was friendly and cooperative during the visit. What the service does well:
The home provides a relaxed, homely atmosphere within a small group of residents, with staff who have some training and experience.
DS0000045535.V338530.R01.S.doc Version 5.2 Page 6 The residents said that they could do what they want, and were seen to be given the opportunity to make decisions and act on them. One resident decided to go for a short walk before she joined everyone else in the main lounge. Staff work caringly alongside residents, to make the residents feel this is their home. The manager ensures the residents are happy with any new staff before the decision is made to employ them. Meals are home-cooked, varied, with well-balanced choices. The manager updates and revises the systems in the home, to make sure sufficient, clear information is held, and that it fully complies with the standards and regulations. She is aware also of the need to clearly identify the diverse needs of the residents, in order to be able to give them the right care. The staff spoke to the residents with a caring manner and tried to make sure they are content in life. What has improved since the last inspection? What they could do better:
The advice and requirement made during the last inspection with regard to formalising staff supervision, has still to be acted upon. The manager is aware of the need to ensure this is introduced as soon as possible. The manager tries to make sure that medication is administered correctly. However on the first day of this inspection the record of the administration of medication had not been signed for one person, to confirm medication had been given that morning. The medication record had been signed for 2 other people for later in the day as though already administered. It is important to maintain clear and correct records of medication and to ensure records are signed at the time medication is administered. No current record of the resident’s money that is held by the home was available. The record seen was 10 months out of date and did not give clear information as to expenditure. This was the reason for the visit on the second
DS0000045535.V338530.R01.S.doc Version 5.2 Page 7 day to further look in depth at how resident’s finances are managed. The people who live at Evaglades lack the capacity to manage their own finances and need support in managing their personal money. From closely studying the sparse information available, it was apparent that some residents were not in receipt of the all the state benefits they may be entitled to. On the first day of this inspection information was given to the service provider’s husband, in the absence of the provider, (who was away on holiday) as to how the residents personal financial records should be maintained. By the second day of the inspection he had set up the record and provided cash boxes for each resident. The manager stated that she does not handle any finances and never has, as finances are managed and maintained by Mr and Mrs Mecklenburg (service provider and husband) The residents should be able to access their money at all times. The current system according to the staff and manager, has on occasions led to people not being able to go out as no money was available. Currently the home purchases the residents clothing. Person centred care, would support residents in choosing/purchasing their own items of clothing. A record of all such purchases should be maintained along with receipts, as outlined during the inspection. Whilst some consideration has been given to the resident’s daily lifestyle, such as attending college course, this is an area that needs expanding upon to ensure the residents have a fulfilling lifestyle appropriate to their age. Activities need to form part of the care plan and be individual according to the preferences of the person themselves. Some people may wish to try new experiences and need suggestions as to what is available to them. The home is furnished to a reasonable standard, however some of the furniture is looking tired for example the comfortable dining chairs look in need of freshening up. A slope leading from one of the bedrooms had a rippled carpet. Mr Mecklenburg explained that he had arranged for someone to visit the home and stretch the carpet to remove the ripple. The meals served at lunchtime on the first day of the visit looked appetising, however their were no condiments on the table for people to add to their meal and none were offered to the residents by the staff. Napkins were not available and in general the meal service had an institutionalised appearance. The availability of a more homely table covering, condiments and napkins, would give a better appearance to compliment the appetising food offered. DS0000045535.V338530.R01.S.doc Version 5.2 Page 8 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. DS0000045535.V338530.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000045535.V338530.R01.S.doc Version 5.2 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No one moves into the home before having their needs assessed and being assured that these will be met. EVIDENCE: There is detailed information available about the home for all residents, or possible residents, which has been developed over time into a very clear and easy to read description of the services provided, and who provides them. Individual records are kept for each resident, and although there have been no new residents for the last three years, the manager was able to discuss the way anyone new would be initially invited to visit the home and meet the residents. A social work assessment would be used to help the manager decide whether the home was the right place for the new person, that the staff were able to give the right care, and that the present residents were compatible with them. Assessments were seen for the long-term residents in this home, and care plans were available.
DS0000045535.V338530.R01.S.doc Version 5.2 Page 11 Staff spoken with were aware of the care needs of all of the people in this small friendly home. The staff comments included, ‘the residents are just like part of our family as we have known them a long time’ and ‘It’s great going on holiday with them as they have such a good time’ DS0000045535.V338530.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The residents could further benefit from living at Evaglades if they were enabled to make more choices. EVIDENCE: The care planning system is structured, with each individual’s plan telling staff how to look after them, giving information that includes areas covering their physical and mental health needs, dietary needs, and a personal profile. The information creates a mental picture of each person. Reviews and updates of the care plans take place. Some residents spoken to were aware that they had their own ‘papers’ (care plans) but due to the level of understanding, others did not. DS0000045535.V338530.R01.S.doc Version 5.2 Page 13 The manager and staff constantly talk to the residents, who clearly feel free to say or signal if they want something, then staff check straight away if there is anything they can do to help. A resident spoken to said: ‘I like to go out for a walk’ and I am going in a minute or two before we have lunch.’ One resident likes to reminisce about life before living with Mr and Mrs Mecklenburgh and proudly showed a book bought all about the Royal Albert Hospital, where he had lived for 50 years from being a young boy. The manager said that the residents were gently guided to help them make their own decisions. This could be further developed if finances were available at the time people wish to go out for various reasons such as a meal out or new activities. Enabling people to choose and purchase their own clothes could improve their feeling of fulfilment. Risk assessments are carried out on resident’s activities, for example some like to go out on their own for short walks. The manager guides the residents, and discreetly monitors the activity to make sure they are safe. The Assistant manager when completing the AQAA (Annual Quality Assurance Assessment) recognised the benefits that could be gained from the staff having training in ‘Person Centred Planning’. This could enhance the current care plans and give the staff greater job satisfaction. DS0000045535.V338530.R01.S.doc Version 5.2 Page 14 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The residents could benefit from a more fulfilling lifestyle, where they are enabled to take part in age appropriate activities. EVIDENCE: The AQAA completed by the Assistant manager reflected the following: ‘two of our residents go to the local college two days a week. we have a craft afternoon every two weeks. we encouage family involvement where possible, one of the residents telephones her sister every other Sunday and is also assisted to write letters. We also provide games and a communal TV where they can join in if they want.
DS0000045535.V338530.R01.S.doc Version 5.2 Page 15 Some of our residents like to help with the cleaning, setting the tables and washing the dishes. One of them likes to go for a walk by herself around the block and sit outside to look at the sea.’ The residents spoke of the holidays they have. The staff confirmed that they go on 2 holidays every year, to Pontins. They said the residents really enjoy themselves when on holiday. When staff were asked what would the residents who go to college do during the 6 weeks the college is closed, they said we have a planned a trip out for one day and would look at what else they might like to do in locality, such as walk in Happy Mount park. The meals served at lunchtime on the first day of the visit looked appetising, however there were no condiments on the table for people to add to their meal and none were offered to the residents by the staff. Napkins were not available and in general the meal environment had an institutionalised appearance. The availability of a more homely table covering, condiments and napkins, would give a better appearance to compliment the appetising food offered. The menus reflected a balanced diet was offered. Menus were based on the known likes of the residents. DS0000045535.V338530.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who live at Evaglades would benefit from having the administration of their medication accurately recorded. EVIDENCE: This small home is run as a family home, with a small staff group for the low numbers of residents. This means that both staff and residents know each other well, and so changing needs are easily noted by staff. Residents come and go to their rooms as they wish, some choosing to stay there for a while to watch television or play records. There were records on each of the residents’ files of contact with, for example, GP’s, Community Psychiatric Nurses, and hospital appointments. A ‘Health Records’ booklet was used for each person, which includes all of his or her health information in an easy to read and understand style, and would be taken by the resident to any appointment with a health professional. This
DS0000045535.V338530.R01.S.doc Version 5.2 Page 17 records the visit, and what the result of that visit was. Staff complete these with the residents, and the manager said they like to take time to make sure the resident is sure the information is right. None of the present residents are in charge of their own medication, and any new residents would have a risk assessment before it was decided whether it was safe for them to do so. Staff helping with the administration of medication had attended a medication awareness course. The manager tries to make sure that medication is administered correctly. However on the first day of this inspection the record of the administration of medication had not been signed for 1 resident, to confirm medication had been given that morning. The medication record had been signed for another 2 people for later in the day as though already had their evening medication. It is important to maintain clear and correct records of medication and to ensure records are signed at the time medication is administered. DS0000045535.V338530.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. The residents lack capacity and as such could be vulnerable. EVIDENCE: There is a complaints procedure in place, with a complaints book to record any complaints, which may come to the manager’s attention. No complaints have been received by either the home or the Commission for Social Care Inspection. One resident said, “I tell Mandy (the manager) if I don’t like something.” Another said, “Alan (service providers husband) makes sure I am alright”. Both residents showed a lot of confidence that they were safe with the people who were looking after them. Staff spoken to knew about the Safe Guarding Adults procedure, and what to do if they had any concerns. They said they would always act if they thought a resident was at risk. Also if it was a member of staff causing concern they would inform the manager. All staff are enabled to attend abuse awareness training.
DS0000045535.V338530.R01.S.doc Version 5.2 Page 19 As discussed with Mr Mecklenburg: Each resident should have their benefits paid into their own bank accounts with a standing order to the home for their contribution to the fees (cost of living at the home.) The balance can then be drawn as the person chooses, with assistance to save towards larger expenditure such as holidays. Weekly sums drawn for the day-to-day expenses should be entered into a temporary savings account book in the home. The service provider’s husband was advised of the correct method of accurately recording financial transactions. Each resident should have his or her money securely stored by the management. The money should be able to be accessed by the senior person on duty as and when required by the resident. By the second day of this inspection Mr Mecklenburgh had begun to put the advice into practice. Some people do need help to manage their money and support should be given in a person centred and individual way so that the resident can be supported to access their money and decide how to spend it. DS0000045535.V338530.R01.S.doc Version 5.2 Page 20 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The residents could further benefit from living in a home that is maintained to meet their needs. EVIDENCE: The home is fairly well maintained, and the décor is kept to a good standard. The manager confirmed that the upkeep of decoration is the same as in any family home, and all of the rooms viewed were clean, tidy and attractive and comfortable. Double-glazing has been fitted in all of the bedroom windows. One of the residents showed their room, with photographs and pictures they had made proudly displayed on their wall. Personal belongings were evident all over the room, making it very individual and homely. “I like to sit in my room sometimes if I want to be quiet. I can watch my television in here as well,” said the resident. However the picture on the TV was of a poor quality and
DS0000045535.V338530.R01.S.doc Version 5.2 Page 21 when pointed out, Mr Mecklenburg said he would have a look at it and endeavour to get a better picture. Local shops and entertainments are within easy walking distance from the home, and some residents enjoy a walk along the promenade where the home is situated, overlooking the lovely view of the coastline. Fire and environmental health checks have been carried out. The laundry is away from where food is prepared and eaten, and is kept well in order by the staff, who were aware of how to prevent possible infection. The removal of the ripple in the carpet outside one bedroom could prevent a possible fall/trip occurring. Mr Mecklenburgh has confirmed this is being addressed. The dining room chairs are in need of shampooing to remove stains/marks. The residents spoke contentedly about their home. DS0000045535.V338530.R01.S.doc Version 5.2 Page 22 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff files showed that the necessary recruitment checks had been carried out to ensure the protection of residents. References and Criminal Records Bureau checks were available, and notes of the interview were made. All staff receive induction training, and the manager uses a training book for staff, which names all of the areas to be addressed during the induction, such as communication, personal care, and continence. The subjects are covered by the new staff and signed when completed. The manager monitors the training of the small numbers of staff. Learning Disability Award Framework (LDAF) courses have been attended. First aid, food hygiene, moving and handling and fire marshal have also been attended. Just under 50 of the care staff hold at least the NVQ Level 2 award. A further 2 staff commence the training in September, when successfully completed the
DS0000045535.V338530.R01.S.doc Version 5.2 Page 23 home will have 60 of the staff with this qualification, which is above the requirement of 50 by April 2008 The formalisation of staff supervision would give staff the opportunity to raise any concerns and have their training needs addressed. The staff spoken with throughout this inspection had a good understanding of their role and spoke in a professional and positive manner about the people they care for. DS0000045535.V338530.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39, 41 and 42. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Poor financial management leaves the residents vulnerable. EVIDENCE: The residents have lived with the service provider and her husband for a large number of years and they talk contentedly about Alan and Sheila (service provider and husband), in many ways the home functions as one family. The registered manager has always encouraged the residents to tell her whenever they feel unhappy about something, or if they would like something done differently in the home. The residents were all relaxed and appeared content in their home.
DS0000045535.V338530.R01.S.doc Version 5.2 Page 25 The residents are always included in discussions about the running of the home, for example the recruitment of new staff, and they would be involved in the admission of a new resident. “The new staff came to meet us first,” commented a resident. The annual holidays are a joint decision based on known previously enjoyed holidays. The manager knows she needs to monitor the service delivery, and has tried to involve visiting health professionals. The present residents do not have a lot of family involvement and lack capacity to communicate in writing, so it is difficult to set up formal quality monitoring systems. However, the manager has set up a system of daily diaries for each individual, which are a good record of events and choices in the residents’ lives. Any regular patterns can be noted and changes to the service made if necessary. The manager is constantly looking at ways to improve and develop the service, so that it complies as well as it can with the standards and regulations. The Assistant manager identified in the AQAA the possible benefits of the staff having training in Person Centred Planning. All accidents are recorded on file. Appropriate fire precautions are taken with a fire alarm system, extinguishers and a fire blanket, all which are checked regularly. The manager and one senior staff have attended a fire marshal course, and all staff are instructed on what to do in case of fire, with a monthly fire drill. The service provider has failed to have a good system for recording residents income and expenditure. As outlined under the Complaints, Concerns and Protection section of this report: ‘Each resident should have their benefits paid into their own bank accounts with a standing order to the home for their contribution to the fees(cost of living at the home.) The balance can then be drawn as the person chooses, with assistance to save towards larger expenditure such as holidays. Weekly sums drawn for the day-to-day expenses should be entered into a temporary savings account book in the home. The service provider’s husband was advised of the correct method of accurately recording financial transactions. DS0000045535.V338530.R01.S.doc Version 5.2 Page 26 Each resident should have his or her money securely stored by the management. The money should be able to be accessed by the senior person on duty as and when required by the resident. Some people do need help to manage their money, but this support should not override their right to access their money and decide how to spend it.’ DS0000045535.V338530.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 2 X 3 1 1 3 X DS0000045535.V338530.R01.S.doc Version 5.2 Page 28 NO 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 YA7 Regulation 16(2)(L) Requirement The service provider must ensure the residents (or persons acting on their behalf) have access to their money. The service provider must ensure staff supervision sessions are formalised The service provider must ensure the residents have greater access to engage in local community activities The service provider must ensure the residents state benefits are paid into their own bank accounts Timescale for action 14/08/07 2 3 YA36 YA13 18(2) 16(2)(m) 31/08/07 31/08/07 4 YA23 20(1)(a) 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The service provider should enable staff to attend training on Person Centred Planning, which would enhance the standard of the Care planning.
DS0000045535.V338530.R01.S.doc Version 5.2 Page 29 2 YA17 The service provider should enable the residents to enjoy their meals in a pleasant surrounding with the necessary table wear, including condiments. DS0000045535.V338530.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 DS0000045535.V338530.R01.S.doc Version 5.2 Page 31 - 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!
