Inspection on 09/01/06 for Far End

This inspection was carried out on 9th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Far End 27/07/09

Far End 03/08/07

Far End 05/01/06

Far End 19/07/05

Far End 21/02/05

Far End 16/08/04

Far End 24/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Far End Far End Sandhurst Lodge Wokingham Road Crowthorne Berks RG45 7QD Lead Inspector Jill Chapman Announced Inspection 9th January 2007 13:30 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 Far End DS0000011254.V324950.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. Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Far End Address Far End Sandhurst Lodge Wokingham Road Crowthorne Berks RG45 7QD 01344 772739 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) tddundas@totalise.co.uk Ms Patricia Trezise-Dundas Ms Dorinda Trezise-Dundas Ms Patricia Trezise-Dundas Care Home 3 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (3) of places Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2006 Brief Description of the Service: Far End provides care and accommodation for up to 3 people who are aged over 65 years of age and is situated in a peaceful location close to the village of Crowthorne. The home is adjoining a large Victorian property with 14 acres of surrounding land owned by the proprietors. The extensive grounds are well maintained consisting of lawns with shrubs and trees. The proprietors live on the ground floor of the home and share with the service users a large lounge/diner/kitchen. Service users have their own rooms on the first floor, where there is a toilet, bathroom with toilet and additional small kitchen area on the first floor. In addition there are many pets in the home including several dogs and cats. Service users can bring into the home their own pets. The current fees for the home are £397.00 per week. Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was a short notice announced ‘Key Inspection’. The inspector arrived at the service at 13.30 and was in the service for three and three quarter hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The inspector had discussions with the proprietor manager, a member of staff and three service users. Survey feedback was recived from one service user, a relative, a Doctor, Care Manager and a Nurse. Staff and service user records were sampled and a tour of service users accomodation was carried out. The inspector thought that the home generally provides good quality care for the service users however there is one outstanding requirement from the last visit and some requirements from this inspection to ensure their welfare and safety. What the service does well: There was positive feedback from service users, a relative and other professionals who have contact with the home. They were happy with the care given in the home. Service users and others are given information about what the home has to offer. Service users are only admitted if the home can meet their needs. Service users are happy with the service and they said that their care and health needs are met. There are no specific cutural or religious needs at present but the proprietor confirmed that these could be met if needed. Service users enjoy a stimulating lifestyle and have regular access to the local conmmunity. They are helped to keep in contact with their families and friends. Service users are supported to maintain independence and choice. Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 6 Service users are satisfied with meals provided and they benefit from choice and flexibilty at mealtimes. Service users and their relatives know that any complaints will be dealt with appropriately. The proprietors and staff have been trained to know how to protect service users from potential abuse. The layout of the home meets the needs of the current service users and they are satisfied with their accmodation. Service users benefit from well maintained, homely and clean accomodation. Service users receive staff support relevant to their needs. Staff are given induction and training to meet service users needs. Relevant recruitment checks are carried out to make sure staff are suitable to work with vulnerable service users. The home is managed by a qualified and experienced proprietor/manager. Regular health and safety checks and servicing of equipment helps keep service users safe. What has improved since the last inspection? What they could do better: The Statement of Purpose and Service Users Guide need further information about the service added to help service users and others know what is on offer. Service users’ diaries could be further developed to show the good day to day care practice that is carried out in the home. Individual risk assessments for service users should be developed to make sure that potential risks are identified and reduced. Some improvements are needed to the storage of medication and in showing that staff are fully trained to give medication correctly. Menus need more detail and the balance between processed and freshly prepared meals provided needs to be kept under review to ensure a healthy diet is maintained. Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 7 Volunteers should be made aware of the Vulnerable Adults procedure to help them be aware of how to protect service users. Due to the layout of the home and lack of designated communal space for service users and service users’ accomodation being on the first floor, the home would not be suitable for service users who wander or who have challenging behaviour. More detail about the accomodation available to service users needs to be included in the Statement of Purpose and Service Users Guide. There is an outstanding requirement that the home needs to develop a formal way of seeking the views of service users and others involved in their care, to help develop the service. Written confirmation is needed from the Fire safety officer to make sure the alternative escape route and the use of stair and bedroom gates are safe for service users in the event of a fire. 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. Far End DS0000011254.V324950.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 Far End DS0000011254.V324950.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): 1, 2 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and others are given information about what the home has to offer. The Statement of Purpose and Service Users Guide needs further information about the service added. Service users are only admitted if the home can meet their needs. The home does not provide intermediate care. EVIDENCE: There is a statement of Purpose/Service Users Guide which gives most of the required information about the home. This has been updated to include recent staff changes and the new adress for the CSCI office. Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 10 The current registration covers one service user who has developed dementia. The layout of the home would not be suitable for all potential service users who have dementia. The proprietor/manager confirmed that should this bed become vacant the home would only admit service users with a diagnosis of dementia if they could meet their needs. This should be clarified in the Statement of Purpose and Service Users Guide. The Proprietor confirmed that the Statement of Purpose and Service Users Guide could be provided in large print and other formats to meet diverse needs. A previous requirement to ensure that service users have a comprehensive asssessment of needs has been met. There have been two new admissions since the last inspection. The service users’ files show that they have received a full assessment of need carried out by both the placing authority and the home. Standard 6 does not apply to this home. Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are happy with the service and their care and health needs are met. Care plans have been further developed and are reviewed regularily. Daily diaries could be further developed to show the good day to day care practice that is carried out in the home. There are no specific cutural or religious needs at present but the proprietor confirmed that these could be met if needed. Individual risk assessments for service users should be developed. The arrangements for medication are mostly satisfactory but some improvements to the storage of medication and in showing that staff are fully trained, are needed. Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 12 EVIDENCE: A previous requirement to ensure that all service users have an individual plan of care has been met. The assessment document includes individual care plans and these show how care needs can be met. There is evidence of frequent review. In discussion with service users, it was clear that their health and care needs are met and that they are satisfied with the care they receive. Individual diaries are kept for service users and these record significant events and medical appointments. These records could be further developed to show the good day to day care practice that is carried out in the home. There should be daily entries to show personal care given, service user’s mood, any health issues, food taken, outings, activities and visits/visitors. There are no specific cutural or religeous needs at present but the proprietor confirmed that these could be met if needed. There are currently no individual risk assessments in place for service users and these should be developed. These need to be in place to cover potential risks from bathing (to include the risks of drowning or scalding), mobility, falling and any risks associated with dementia. The proprietor said that home is well supported by the local doctor and that he is quick to respond to any concerns about service users’ health. There was positive feedback from a questionnaire sent to the doctor about how the home responds to service users’ health issues. Records are kept of health appointments and there was evidence that the home helps service users to acces the services of health professionals or resources. For example flu injections from the District Nurse, Chiropodist, Dentist and the Memory Clinic. The proprietor said that service users are weighed every three months and more regularly if there are concerns. There is a medication policy in place and staff are trained to give medication during their induction. There is no detailed written record of the medication training given to staff and this shoul be carried out. The proprietor and staff should also access accredited medication training to fully meet the standard. The home uses a monitored dosage system and some medication is stored in a locked cabinet. Others are kept in the kitchen which, although locked when staff are not in the room, is a multipurpose room where cleaning products and food are also stored. All medication should be stored in a locked cupboard to ensure safety and to prevent the possible risk of cross contamination. There are suitable arrangements in place for returning unused medication and a stock control system is in place for medication which is only needed occasionally. A homely remedies policy has been agreed with the GP. Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 13 Service users confirmed that staff treat them with respect and protect their privacy. There are locks on bedroom and bathroom/toilet doors, which although the current service users choose not to use them, can be opened by staff in an emergency. Service users confirmed that staff knock before entering their bedsitting rooms. The Statement of Purpose highlights service users rights to privacy. One service user has her own phone line and staff can arrange for the others to make private calls in the kitchenette. Service users confirmed that personal care is carried out privately and that they see health professionals or visitors in their bedsitting rooms. Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 14 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. Service users enjoy a stimulating lifestyle and have regular access to the local conmmunity. They are helped to keep in contact with their families and friends. There is evidence that service users are supported to maintain independence and choice. They benefit from choice and flexibilty at mealtimes. Service users are satisfied with meals provided but the menus need more detail. The balance between processed and freshly prepared meals provided needs to be kept under review to ensure a healthy diet is maintained. EVIDENCE: In discussion with service users and staff it is clear that they can make choices in their daily routines. Staff help them to get up in time for day centre but on other days the morning routine can be more relaxed. They are able to choose what time they go to bed and what days they would like a bath. They are able to choose whether to invite other service users into their rooms or not. One service user does not like the home’s pets coming in to her room and has a gate to keep them at bay. The three service users attend a local Day Centre four day a week. They said they enjoy the opportunity to socialise with Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 15 others. One service user goes to a swimming group on a Sunday and goes to an Alzheimers Club. The service users also enjoy local outings and pantomimes. One service user said she likes to help in the garden and another reads books from the local library. The good access to local community resources provides service users with socialisation and a stimulating lifestyle. Service users said they are encouraged to keep in contact with their families and friends. Some go out at weekends to visit them and visitors are welcome in the home. There is evidence that service users are supported to maintain independence and choice. The arrangements for providing service users’ meals were seen. There is no designated service users dining room and most meals are taken in their bedsitting rooms. Each service user has a supply of biscuits and fresh fruit in their room. Service users confirmed that they have a choice at breakfast, their main meal and their evening meal. Main meals are taken at day centre four days a week and some go to lunch at relatives at the weekend. Main meals provided by the home are mostly processed frozen meals which are cooked by microwave in the homes kitchenette. There is no cooker in the kitchenette to enable fresh meals to be prepared but on occasions the meals are prepared in the proprietor’s kitchen. The proprietor said that the current system provides more individual choice for service users. Menus do not show the main meals taken at day centre so it was difficult to judge whether the service users are getting a good balance of freshly prepared food as well as processed food. The menus do not show which vegetables are served each day and whether they are fresh or frozen. The home grows some of their own vegetables and service users said they enjoy these. Menus could be futher developed to show this detail. The proprietor said she would liaise with the Day Centre to know what meals the service users receive there. The current service users are happy with the arrangements for meals. Should the service users needs change or day centre attendance decrease, then the provision of main meals would need to be reveiwed to make sure the home is providing a balanced and nutritous diet. The kitchenette is a multipurpose room and appeared rather cluttered at the time of the inspection. Advice was given to keep the area clearer to help maintain health and safety and food hygiene. Both the proprietor and staff member have up to date food hygiene certificates and a Food Hygiene Inspection in June 2006 was positive. Far End DS0000011254.V324950.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives know that any complaints will be dealt with appropriately. The propreitor and staff have been trained to know how to protect service users from potential abuse. Volunteers should be made aware of the Vulnerable Adults procedure to help them be aware of how to protect service users from potential abuse. EVIDENCE: CSCI has received no information from service users or their relatives about complaints made against the service. There have been no complaints received by the home since the last inspection. Service users and their relatives know who to talk to if they have a concern and all of the service users are satisfied with the service. It was clear from discussion with service users that any minor problems are resolved easily. Service users confirmed that they get on well with the staff and proprietors. The proprietors and staff have had Protection of Vulnerable Adults training and there is a Whistle Blowing policy in place. A staff member described what she would do if she had concerns about the safety of service users. It is recommended that the volunteers are made familiar with the Vulnerable Adults procedure. Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 17 Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 18 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, 20, 23, 24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The layout of the home meets the needs of the current service users and they are satisfied with their accmodation. More detail about the accommodation available to service users needs to be included in the Statement of Purpose and Service Users Guide. Due to the lack of designated service users communal dining and lounge space and the service users accomodation being on the first floor, the home would not be suitable for service users who wander or who have challenging behaviour. Service users benefit from well maintained, homely and clean accomodation. EVIDENCE: The service users’ accommodation is on the first floor and this comprises of three individual bed sitting rooms, a bath, shower, two toilets and a Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 19 kitchenette for the preparation of service users’ meals. There are stair lifts for service users who are unable to climb the stairs. The premises are well maintained by a handyman employed by the owners. All three bedrooms were seen and these are comfortably furnished and homely. They are personalised with service users’ belongings. Each bedsitting room has a wardrobe, wash hand basin, small dining table and chair, easy chair and small settee and side tables. Service users have their own TVs and have room to entertain visitors. Service users all said they liked having their own bed sitting room. There is no designated communal lounge or dining space for service users. This should be made clear in the Statement of Purpose and Service Users guide. The proprietor/manager said that service users are made welcome in the proprietors ground floor accomodation but this is not made clear in the Statement of Purpose and Service Users Guide. The current service users said they are happy with their accomodation. Due to the layout of service users’ accomodation and the home would not be suitable for service users who wander or who exibit challenging behaviour and this should be made clear in the Statement of Purpose and Service Users Guide. There is a large communal garden. One service user said she likes to help in the garden and the proprietor said that they all like to help feed the birds in the aviary. The proprietors have built a gazebo where service users can sit or take meals in the summer. A requirement to develop a management system including risk assessment for the control of infection from animal waste and other hazards in the communal areas has been met. The proprietor said that risk assessments for the premises have been carried out and it was seen that washable flooring has been laid in two bedrooms and the hallway. It was noted that the standard of cleanliness in service users’ accomodation was good. It is part of the paid staff members role to carry out routine cleaning. The home deals with some incontinence but currently does not need a sluice system. It is recommended that should service users’ needs change or when the washing machine needs replacement , consideration should be given to purchasing a machine with a sluice facility. Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 20 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. Service users receive staff support relevant to their needs. Staff are given induction and training to meet service users’ needs. Relevant recruitment checks are carried out to make sure staff are suitable to work with vulnerable service users. EVIDENCE: A staff rota is kept and shows the hours that the home is staffed. The proprietor/manager covers most of the hours. One staff is employed for 19 hours per week, from 2-6.30pm Tuesday and Thursday and from 8.30am2.30pm on Saturday, with an additional flexible four hours per week. The current service users do not have waking night staff needs, the proprietor sleeps in at night and is on call if service users need assistance. There are two volunteers, both well known to the proprietors, who also work in the home when needed. When the proprietors are on holiday the home is staffed by the staff member and two volunteers . The staff member does not currently have National Vocational Qualification level 2 but this is under discussion at present. The home has a recruitment procedure and this includes following up references and carrying out crimminal records checks and th Protection of Vulnerable Adults list. The proprietor/manager said that references were not Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 21 followed up for the appointment of the current staff because she was previously a volunteer in the home for several years. A Criminal Records Bureau check had previously been carried out when she was recruited as a volunteer. Advice was given to check with the Bureau to see if a futher CRB check and POVA check are needed. Records show that staff are given a a statement of their terms and conditions and annual appraisals are carried out. The employed staff member is experienced in housekeeping and pastoral care in another care setting. She is confident in her role in the home and is valued by the proprietor and service users. It was seen that there is a good relationship between service users and the employed staff. She has had induction and appropriate training relevant to her role. These include Food Hygiene, Fire safety, First aid, Health and Safety and Dementia. Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is managed by a qualified and experienced proprietor/manager. Regular health and safety checks and servicing of equipment helps keep service users safe. There is an outstanding requirement that the home needs to develop a formal way of seeking the views of service users and others involved in their care to help develop the service. Written confirmation is needed from the Fire safety officer to make sure the alternative escape route and the use of stair and bedroom gates are safe for service users in the event of a fire. Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 23 EVIDENCE: The home is managed by one of the owner/proprietors Ms P Trezise-Dundas. She has NVQ in Management and Care and has many years experience of running care homes. There is evidence that both proprietors regularily update their training or take training to meet the specific needs of the service users. It was clear from observation and from speaking with service users that service users’ views are sought on a day to day basis. A requirement to develop a formal quality assurance system has not yet been carried out and will be raised again. The home does not currently look after any service users’ monies. One service user looks after her own and the other two have relatives who deal with their affairs. The pre inspection checklist shows that regular maintenance and servicing of equipment takes place. Records sampled show that regular safety checks are carried out for example, fridge freezer temperature, food temperatures, hot water temperatures and fire safety checks. Written confirmation should be sought from the Fire Safety Officer, that he has agreed the alternative means of escape via a service user’s bedroom window and the use of two gates, one for the stairs and one to a service user’s bedroom. Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 2 X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP33 Regulation 24 Requirement To maintain a system for reviewing the quality of care offered by the home. Outstanding timescale 01/05/06 To update the Statement of Purpose and Service Users Guide with information highlighted in the report. Risk assessments for individual service users should be developed. A detailed written record of the medication training given to staff should be in place and the the proprietor/manager and staff should access accredited medication training. All medication should be stored in a locked cupboard to ensure safety and to prevent the possible risk of cross contamination. Menus need more detail to evidence a balanced and nutritious diet. Written confirmation is needed from the Fire safety officer to make sure the alternative DS0000011254.V324950.R01.S.doc Timescale for action 09/04/07 2 OP1 4&5 09/04/07 3 4 OP7 OP9 13 (4)c 18 (1) c 09/03/07 09/04/07 5 OP9 13(2) 09/03/07 6 7 OP15 OP38 17(2) Schedule 4 .13 23(4) b.c. 09/03/07 09/04/07 Far End Version 5.2 Page 26 escape route and the use of stair and bedroom gates are safe for service users in the event of a fire. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP15 OP18 OP26 Good Practice Recommendations The balance between processed and freshly prepared meals provided needs to be kept under review to ensure a healthy diet is maintained. It is recommended that the volunteers are made familiar with the Vulnerable Adults procedure. It is recommended that should service users needs change or when the washing machine needs replacement , consideration should be given to purchasing a machine with a sluice facility. Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Far End DS0000011254.V324950.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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