Inspection on 12/08/08 for Fallowfield

This inspection was carried out on 12th August 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fallowfield 20/09/06

Fallowfield 16/11/05

Fallowfield 22/04/05

Fallowfield 26/01/05

Fallowfield 20/08/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Fallowfield 14 Great Preston Road Ryde Isle Of Wight PO33 1DR Lead Inspector Mick Gough Unannounced Inspection 12th August 2008 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 Fallowfield DS0000012490.V369558.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. Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Fallowfield Address 14 Great Preston Road Ryde Isle Of Wight PO33 1DR 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) 01983 611531 01983 611531 fallowfields@btconnect.com Mr Keith John Betteley Mrs Jennifer Ann Betteley Carol Ann Montague Care Home 21 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (21), of places Physical disability over 65 years of age (9) Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users in the Dementia category must be over the age of 55 years on admission. 20th September 2006 Date of last inspection Brief Description of the Service: Fallowfield is registered to provide residential care to twenty-one older people, including eight people with dementia. The home was formerly a Victorian residence, converted to provide accommodation on the ground and first floors with access to the upper floor via a passenger lift or stair lift. Set in a pleasant residential area of Ryde there is a garden and seating area for the residents at the front and to the rear of the building. The current owners took over the home five years ago and have made many improvements to the homes environment. The home also provides respite day care and respite residential care when there is a room available. Fees at the home range from £376.67 to £461.51 per week but this depends on the type and level of support required. Full details of current fess are available from the home. Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience Good quality outcomes. This report details the evaluation of the quality of the service provided at Fallowfield and takes into account the accumulated evidence of the activity at the home since the last inspection, which was carried out in September 2006. The inspection took into account; the previous key inspection report and the last annual service review which was carried out in September 2007 when comment cards were sent out to staff and residents at the home. Included in the inspection was an unannounced site visit to the home, which took place on the 12 August 2008. Evidence for this report was obtained from reading and inspecting records, touring the home and from observing the interaction between staff and users of the service. It was possible to meet and talk to 9 of the residents, however it was not always possible to obtain their views on how the home was meeting their needs due to their dementia. We did speak with 2 visitors to the home, 3 members of staff and the homes manager who assisted the inspector throughout the visit. The home is registered to provide support for 21 residents and at the time of the inspection there were 21 people living at the home. What the service does well: Care plans provided good information for staff on the support that was required and they informed staff how residents wanted this support to be given. Staff at the home treat residents with dignity and respect and residents’ have access to a full range of healthcare support. The residents are supported to participate in appropriate activities and are encouraged and supported to be involved as much as possible. The home has a dedicated and stable staff team and staff have been supported to obtain recognised qualifications and over 90 of the care staff employed by the home has either achieved or is working towards National Vocational Qualifications. They are committed to their role and work well together as a team. Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There was 1 requirement made as a result of this visit and other points, which need to be addressed to help improve the service provided for residents are contained within the main body of the report. General observations were: Recording of monthly reviews in care plans could be improved to provide more evidence that care has been delivered effectively and to evidence that residents are involved in the review process. The home keeps some controlled drugs and these are currently kept in a locked box inside a locked cabinet, however the law concerning the storage of controlled drugs has recently changed and the home must ensure that if any controlled drugs are to be held at the home, they must be stored in a proper Controlled Drugs Cupboard In brief, the requirements for CD storage are: • Metal cupboard of specified gauge • Specified double locking mechanism • Fixed to a solid wall or a wall that has a steel plate mounted behind it • Fixed with either Rawl or Rag bolts Suppliers of CD cabinets can confirm that a cupboard meets the legal requirements. We recommend that care homes request formal confirmation when purchasing a CD cabinet. The manager told us that the home has a mobility vehicle but she said that this has not been used to its full potential this year and the home recognised that arranging more trips out for residents was an area where the home could improve. Currently the home does not record what activities take place and there is no record of who takes part. We discussed this with the manager who told us Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 7 that she would obtain a separate activities book where any activities that take place will be recorded together with details of who takes part. 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. Fallowfield DS0000012490.V369558.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 Fallowfield DS0000012490.V369558.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. Prospective users of the service can be confident that their needs would be fully assessed before they move into the home. EVIDENCE: All residents have there needs assessed before they move into the home. The homes manager said that she obtains social service assessment before going out to visit potential new residents prior to them moving into the home. She carries out a needs assessment; this is done using an assessment form, which includes information on; mobility, communication, emotional support, personal care needs, recreational needs, medical history, sight, hearing, continence, religious & cultural needs, dietary needs, family involvement, and any particular needs. 3 residents files looked at showed that needs assessments were in place and the homes completed AQAA also stated that assessments take place before anyone moves into the home. Any potential new residents and their relatives are encouraged to visit the home before moving in. Intermediate care is not provided by the home. Fallowfield DS0000012490.V369558.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of residents are set out in an individual plan of care and residents and have access to all relevant health care professionals and their health care needs are met. The administration of medication is satisfactory, however the storage of any controlled drugs needs to be improved. Residents at the home are treated with dignity and respect and their personal care is given in private. EVIDENCE: Care plans were seen for 3 residents and these contained information on; medication, mobility, continence, communication, general health issues, personal care needs and there were risk assessments in place. Care plans were made up in a folder and each section had good information for staff. One residents plan stated “needs support with bathing” and the care plan gave good information for staff on what support was required and how the resident would like the support to be give. Another care plan stated that “the resident needed emotional support” and the plan explained the reasons why support was required and gave staff good information on how to provide the correct type of support. All care plans had moving and handling assessments and Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 11 these provided good information for staff. Daily recording in care plans was clear and gave information on what support had been given and how the resident had been throughout the day. Reviews for each resident are carried out at monthly intervals by the residents key worker, however this recording did not always provide written evidence that care has been delivered effectively or if resident had been involved in the review. This was discussed with the homes manager who understands the need for reviews and recording to provide information on care delivery. Each care plan had evidence that risks assessments had been carried out and these gave information for staff on the risk, what control measures were in place to minimise the risk and also any additional control measures that may be required, these gave staff good information on how identified risks could be minimised. Residents at the home are registered with 4 local GP surgeries but have a number of different GP’s, the manager stated that there was a good relationship with the GP’s who visit the home when required. Resident may keep their own GP if they wish. The manager stated that dental checks and treatment could be problematic but she had registered residents with a local dentist who was willing to provide home visits if required. Some residents have their own dentist in the local area. A local optician provides eye care to those residents who do not have their own optician and he is able to provide home visits. The home has a visiting chiropodist who calls every 6 – 8 weeks. There is a central district nurse service who call at the home when required and the home can contact the district nurse service without having to go through the GP. Access to other healthcare professionals is through GP referral. The home uses a monitored dose system from a local chemist and they provide Medication Administration Record Sheets (MARS) with the photograph of the individual resident on, they also put the photograph of the resident on each dosset package to clearly identify each individual. The home has a policy and procedure for receipt, recording, storage, disposal and administration of medication. We looked at medication administration records and these were all up to date with no gaps seen in the records. The home keeps some controlled drugs and these are currently kept in a locked box inside a locked cabinet, however the law concerning the storage of controlled drugs has recently changed and the home must ensure that if any controlled drugs are to be held at the home, they must be stored in a proper Controlled Drugs Cupboard In brief, the requirements for CD storage are: • Metal cupboard of specified gauge • Specified double locking mechanism • Fixed to a solid wall or a wall that has a steel plate mounted behind it • Fixed with either Rawl or Rag bolts Suppliers of CD cabinets can confirm that a cupboard meets the legal requirements. We recommend that care homes request formal confirmation when purchasing a CD cabinet. Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 12 We spoke to 9 residents, however it was not always possible to get their views about the home due to their dementia, however when looking at surveys returned to the home, comments from health care professionals, staff and relatives were positive about the care provided at the home. We had the opportunity to speak with 2 visitors to the home who told us that staff were very caring, helpful, and friendly and stated that there relatives were always treated with dignity and respect. Observations made on the day of the visit confirmed that residents and staff get on well together and staff were observed interacting with residents and were seen to treat them with dignity and respect and staff used their preferred form of address when talking to them. Fallowfield DS0000012490.V369558.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. The home provides a range of activities for residents, which meets their expectations and the recreational interests are provided for. Residents are able to maintain contact with family and friends and visitors are welcome at any time. Residents are supported to exercise choice and control over their lives and are provided with a wholesome and balanced diet in pleasant surroundings at a time convenient to them. EVIDENCE: The home provides a range of activities for residents and these include: mobility games, jigsaws, quiz’s, board games, skittles, bingo, sing-a- longs, manicure, hairdressing and on the day of the visit there was a film show organised for residents and this takes place monthly. The home does not have a dedicated activities co-ordinator and activities are organised by staff. Those residents spoken to said they enjoyed some of the activities at the home, while others told us that they preferred not to be involved. A list of weekly activities is displayed on the notice board at the home. The manager told us that the home has a mobility vehicle but she said that this has not been used to its full potential and the homes completed AQAA said that arranging more trips out for residents was an area where the home could improve. Currently the home does not record what activities take place and there is no record of who takes Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 14 part. We discussed this with the manager who told us that she would obtain a separate activities book where any activities that take place will be recorded together with details of who takes part. The home has a visiting policy and there are no restrictions on visitors, we saw from the visiting book in the hallway at the home that were a regular stream of visitors to the home and visitors responses to the homes questionnaire indicated that visitors were made welcome and staff were very friendly. We spoke to two visitors who told us that they are always made welcome and never had any problems when visiting the home. Residents spoken to confirmed that they are able to make informed choices and were able to control their own lives as much as possible. We observed staff and residents interacting and they appeared to get on well together and both residents and staff spoken to confirmed this. We observed residents being consulted throughout the day from the choice of music playing to what they wanted to drink. Staff spoken to said that they always ask residents what they want and would always respect their wishes and views. Staff were observed speaking to residents appropriately using their preferred form of address, also knocking on residents doors before entering. Residents are encouraged to bring some of their own possessions into the home and those rooms seen had been personalised. The home operates a 3-week rolling menu, which is changed regularly and resident’s likes and dislikes are taken into consideration. A record of food eaten by residents is kept. In the morning’s residents have a choice of cereals or toast, lunch is the main meal of the day and on the day of the inspection the lunchtime meal was cottage pie and fresh vegetables. The evening meal is arranged for 1600 – 1630 and is a hot snack type meal, the manager told us that she would like to have this later but residents wanted their meal at this time. Supper is provided between 1800 – 2000 for those residents who want it and this ranges from cheese and biscuits, sandwiches or just coffee and biscuits. Residents are able to have drinks throughout the day and night and staff are able to make snacks for residents at any time. The home employs 2 cooks who work 0730 – 1400 seven days per week. The cooks cover these hours between them and cook the main meal of the day and bake cakes for residents. Care staff provides breakfast, tea and supper. Residents spoken with said the food was good and we observed lunch being taken in the dining room and meals were well presented and staff provided appropriate support. Staff consult resident the day before to tell them what the main meal is and will provide an alternative if the main choice is not to their liking, on the day of the visit one resident had chicken for lunch as he did not want the cottage pie. Meals are served in the dining room at the home, which was bright and airy, although residents can eat elsewhere if they wish. Records of food consumed in the home are kept and the cook had made a cake for one of the residents who was celebrating a birthday on the day of the visit. Fallowfield DS0000012490.V369558.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. The home has a complaints procedure in place, which includes all required information. The homes policies and procedures help to protect residents from any form of abuse. EVIDENCE: The AQAA returned by the homes manager prior to the inspection indicated that there had been no complaints made to the home in the past 12 months. Residents spoken to were not all aware that the home had a complaints procedure but were clear that they would address any complaint they may have to a staff member and staff told us that they would report any complaints to the manager. A recent survey to relatives indicated that they were not all aware of the homes complaints procedure and the manager told us that she will be writing to all relatives and enclosing a copy of the complaints procedures. Each resident has a copy of the complaints procedure in their room The home has a policy and procedure for dealing with any complaints and this contained all of the required information including timescales. Staff members spoken to were also aware of the complaints procedure. Staff at the home receive training on adult protection as part of their induction and annual updates are provided for staff. Members of staff who were spoken to were aware of their responsibilities in this area and said that they would report any concerns to the manger. The home has a whistle blowing policy and also a copy of the Hampshire Adult Protection procedure and the manager was aware of her responsibilities in this area. Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, clean and homely environment that is maintained to a satisfactory level and was pleasant and hygienic with no offensive odours, however certain areas of the home would benefit from refurbishment. EVIDENCE: A tour of the building was undertaken and all areas of the home were clean and tidy and in a reasonable state of repair. All bedrooms seen were well equipped with all the required furniture and fittings and residents rooms had been personalised. It was noted that some rooms would benefit from redecoration and refurbishment and the manager told us that it was the intention to carry out refurbishment as rooms became empty. The home is laid out over three floors with a passenger lift and also stair lifts to provide easy access for residents. There are bathrooms and WC.s on both the upper and ground floors and the majority of resident’s rooms are on the upper floor. The basement of the home houses the Kitchen and laundry and is not accessible to residents due to steep stairs and this area is sections off by a Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 17 stair gate to prevent falls. On the ground floor there is a large lounge area with music system and a TV and the home has had a large conservatory built, which is attached to the lounge and this provides a bright airy quiet area for residents to sit and relax. Residents spoken to said the addition of the conservatory has made a big difference to the communal space available. There is also a dining room, office and small kitchen on the ground floor. The home has a laundry in the basement, which is equipped with a sluice machine, industrial washing machine and tumble drier and there was appropriate protective clothing available. The home does not have dedicated laundry staff and carers undertake the laundry throughout the day. Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 18 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. The home has sufficient staff on duty to ensure residents receive the support they require. Staff were found to be well motivated and competent to do their jobs and residents are protected by the homes recruitment procedures. The home provides training for staff to enable them to carry out their roles effectively. EVIDENCE: On the day of the visit the inspector looked at the staffing levels for the day of the visit and this showed that there are 3 staff members on duty between 0730 & 1700, 2 staff are on duty 1700 – 2100 and 2 awake staff members on duty between 2100 and 0800. An on call member of staff who is available if required also backs up staff. These numbers are in addition to the homes manager who works Monday to Friday 0800 – 1700 and there is also a cook who work between 0730 – 1400 each day and a cleaner who works 0800 – 1400 five days per week. Staffing numbers were discussed with the manager and she stated that she felt that, staffing levels were sufficient, however staffing numbers would be kept under review. All residents spoken to said that they felt that staffing levels were adequate comments received included “the staff are very good” “ I have no complaints about the staff, they are very helpful” and “I am well looked after”. Staff spoken to also said that they felt that staffing levels were sufficient. Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 19 The home employs a total of 12 care staff and 10 of the 12 staff hold a minimum of NVQ level 2, with 1 staff member due to start NVQ shortly. The manager stated that the home would support staff to obtain National Vocational Qualifications. Recruitment records were seen for 2 members of staff and these contained all of the required information including, references x 2, proof of identity, POVA and CRB checks. Staff training records were looked at and the manager showed us training files which showed that training is provided in; first aid, food hygiene, moving and handling, fire, infection control and adult protection, medication, H & S, dementia care and challenging behaviour. It was recommended at the last visit that the manager makes up a training matrix so that any training was easily identified and she is currently working on this. A suitable induction programme is in place for any new staff and this is provided by “Skills for Care” and staff are expected to complete the induction booklet in their first 6 months at the home. There is an “in house” induction, which gives details of policies and procedures and the manager has made up questionnaires for staff to complete and these provide evidence that staff receive a good induction. Staff spoken to confirmed that they received a thorough induction and that they are provided with appropriate training in order to carry out their care tasks. Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by a person fit to be in charge and able to discharge her responsibilities fully. The home has a quality assurance system in place to seek the views of residents, relatives and other professionals to measure the effectiveness of the service. Staff are supervised as part of the normal management process and systems are in place for the safekeeping of residents personal spending money. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The manager has been in post for over 6 years and has NVQ4 in both management and care, she operates an open door policy and is able to manage the service effectively, she told us that she undertakes regular training to update her skills. Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 21 The home has an effective quality assurance system in place and questionnaires are sent out to residents, relatives, staff, heath care professionals and other interested parties, responses to questionnaires are kept in a folder at the home and we were able to view these and they showed that people were generally happy with the service provided. The manager told us that she holds regular staff meetings and minutes of these meetings are kept. Currently the home does not hold residents or relatives meetings and the manager told us she would look at arranging these in the future, to see how the home is meeting people’s expectations. The home does not manage any resident’s money, they do however keep some personal spending money for residents, a clear record is kept of all transactions and this provides a clear audit trail. We checked the balance for one residents and this were accurate and up to date. There is an in date fire risk assessment for the building and regular health and safety monitoring takes place. The fire logbook was inspected and all appropriate testing and checks have been recorded. Appropriate certificates were in date for gas safety, fire alarms systems and equipment, private electrical equipment, stair lifts and hoists. The homes passenger lift is currently not working and we were informed that work on the installation of a new lift is due to commence shortly. Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 22 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13(2) Requirement The home must ensure that any controlled drugs are stored in a controlled drugs cabinet that meets the legal requirements as laid down in the Misuse of Drugs (Safe Custody) Regulations 1973. Timescale for action 03/10/08 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 Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone 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 Fallowfield DS0000012490.V369558.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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