Inspection on 20/02/06 for Firbank

This inspection was carried out on 20th February 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 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

Firbank 11/07/06

Firbank 17/07/05

Firbank 19/01/05

Firbank 25/05/04

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Firbank 8 Crescent Road Shanklin Isle Of Wight PO37 6DH Lead Inspector Janet Ktomi Unannounced Inspection 20th February 2006 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 Firbank DS0000012491.V250507.R01.S.doc Version 5.0 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. Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Firbank Address 8 Crescent Road Shanklin Isle Of Wight PO37 6DH 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 862522 01983 863490 Georgia Rose Residential Care Limited T/A Firbank Mrs Margaret Jones Care Home 26 Category(ies) of Dementia - over 65 years of age (2), Learning registration, with number disability over 65 years of age (2), Old age, not of places falling within any other category (26), Physical disability over 65 years of age (7) Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th July 2005 Brief Description of the Service: Firbank is a registered residential home providing care and accommodation for up to 26 people over the age of sixty-five years with a range of physical, social and emotional needs. The home is situated in a quiet tree-lined avenue in Shanklin close to local amenities, shops and public transport. Accommodation is provided on three separate floors all of which may be accessed by a passenger lift. The home has installed hand and grab rails at various points around the building to assist service users with mobility difficulties. Externally there is a patio area and extensive sea views from some bedrooms and the communal lounges. The home is owned by Georgia Rose Residential Care Limited and managed by Mrs Margaret Jones. Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second unannounced inspection of this inspection year. Core standards not assessed during the first inspection were assessed along with additional core and non-core standards. The inspection was undertaken on a weekday afternoon and lasted three and a half hours. A tour of the building was undertaken and discussions were held with service users, visitors, deputy manager and the care staff on duty. All of the people living within the home were met during the inspection and those able gave their views about the service. All the service users stated that they enjoyed living at the home and liked the staff. Care and other records and documentation identified in the report were viewed. The manager was not present during the unannounced inspection, the inspector telephoned her following the inspection to clarify points identified in the inspection and report. What the service does well: What has improved since the last inspection? The home has continued its programme of planned maintenance and refurbishment, replacing a number of bedroom carpets and all radiators are now covered. A new walk-in bath has replaced the Parker bath. The home continues to provide the same high standard of service. Service users continue to be very happy living at the home. Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4, The home fully assesses potential service users prior to admission to ensure that their needs may be met. Standard 6 is not applicable, as the service does not provide intermediate care. EVIDENCE: The care plan containing the pre-admission assessment of the most recent admission to the home was viewed during the unannounced inspection. Preadmission assessments for other service users were also seen within their care plans. The manager or deputy manager carry out pre-admission assessments on prospective service users using a specific tool which covers all the relevant areas required in the assessment of prospective service users. Initial assessments are often carried out in the service user’s home or the hospital. Information was also seen from relevant professionals such as care managers, GPs, District Nurses or the hospital to ensure a full and accurate assessment is completed. Service users spoken with during the assessment stated that they felt all their needs were being met at the home. Staff spoken with confirmed that they Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 9 have training as required to meet service users’ general and specific needs. A variety of training certificates are displayed on the walls of the home’s hallways. During the inspection there was a discussion with the deputy manager. This indicated that she and the manager were clear about the extent of needs the home could support and action that should be taken should these needs increase following admission resulting in the home no longer being able to adequately meet a person’s needs. Firbank DS0000012491.V250507.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 and 10 The home meets service users’ health, personal and social care needs whilst ensuring dignity and privacy are upheld. Medication is appropriately managed within the home however the home must ensure that Medication Administration Records are fully completed. EVIDENCE: The home has a policy and procedure for the administration of medications, with medication found to be stored in an appropriate locked facility. Records are kept in regard to all medications received into the home and administered by suitably trained senior care staff. The inspector saw the arrangements for controlled medication, the storage and recording of which was found to be appropriate, although none was in use at the time of the unannounced inspection. The home has a new medication trolley specifically suited to the pre-dispensed system used in the home. When not in use this is stored in a locked cupboard. The home has a fridge for the safe storage of medications with maximum/minimum thermometer and temperatures recorded twice weekly. This will ensure that medications that must be kept at cool temperatures are stored appropriately. Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 11 The inspector viewed the medication administration records for all service users. It was noted that on a number of records there were spaces where prescribed medications had not been signed as being administered. A blank box does not inform other care or medical staff if a medication has been given and not signed for or not given and why. Medication Administration Records have a code sheet detailing the reason why a particular medication may not have been administered and this must be used whenever a medication is not administered. Gaps must not be left in medication administration records. The home has five bedrooms registered as twin rooms. At the time of the unannounced inspection all were being used as single rooms. Previous discussions with the manager indicate that rooms would only be used as shared if service users specifically requested this such as a married couple who wished to continue to share a bedroom. Service users spoken with during the inspection confirmed that all personal care is provided in private. Service users stated that they felt the quality of personal care provided was good with choice as to when and how care would be provided. During a tour of the building, staff were noted to knock on service users’ bedroom doors and addressed service users in a friendly polite manner. Service users stated that they liked the staff, who all treated them with respect and that their dignity was protected. Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. The home meets service users’ social and leisure activities in a flexible and varied manner. Contact with family and friends is encouraged and supported and a varied, nutritious diet is provided which meets individual needs. Service users are provided with opportunities to make choices and to have control over their lives. EVIDENCE: During a tour of the building the inspector was able to see a number of certificates and awards received by individual service users for activities (spelling bee, darts, quizzes etc.) they had taken part in. The inspector was able to see a list of planned activities for the coming weeks displayed on the hall wall. Service users stated that external outings were also organised and photographs of outings were seen displayed on the hall wall. Within care plans and pre-admission assessment there is information detailing service users’ leisure interests, spiritual and social activities. Service users spoken with stated that they enjoyed the organised activities and were able to follow individual leisure activities such as reading, painting and knitting. Discussions with care staff indicated that they are able to join in the activities such as bingo and that supporting and encouraging service users during their leisure activities is seen as part of their role as care staff. Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 13 The home’s visiting policy is displayed on the entrance hall wall and states that visiting is possible at all reasonable times. Should residents request that specific people do not visit then staff would support their decision. Visitors are requested to sign a visitor’’ book on arrival and leaving the home. The home has two lounges, one of which is not often used and could be available should service users wish to receive visitors in private other than in their own bedrooms. The inspector was able to meet one visitor during the inspection who confirmed that he was able to visit whenever he wished and that he was made welcome. Service users are encouraged to bring personal items including furniture to the home and the inspector noted evidence of personalisation within all rooms. Wherever possible service users are encouraged to maintain control and management of their own financial affairs. Discussions with service users showed that they felt able to make decisions and choices over day to day issues such as meals, times for getting up/going to bed, having personal care needs met and how and where within the home they spend their time. The standard relating to meals was fully assessed during the previous unannounced inspection. During this inspection residents and visitors spoken with were again positive about the food they receive at the home. Residents reported that they have a choice at all meals that may be taken wherever they wish, within their own rooms, the dining room or one of the lounges. The inspector was able to see the evening meal lists care staff had completed with service users as to their choice for their evening meal. Lunchtime menus seen provided a choice of different main meals. Service users confirmed that they have access to snacks and hot and cold drinks in between meals and these were seen within the lounges around the home including a bottled water cooler in the main lounge. All staff involved in meal preparation have completed a food hygiene course, certificates being seen on the walls around the home. Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Service users or their representatives are able to complain if they are unhappy with the service provided at the home. Staff are aware of adult protection issues and would respond appropriately if they had concerns in relation to adult protection. The home must ensure that POVA and enhanced CRB checks are undertaken for all staff employed in the home. EVIDENCE: Residents spoken with during the inspection all seemed clear that they would discuss any concerns or complaints with the manager or one of the deputy managers. Service users spoken with stated they had no concerns or complaints at the time of the inspection. The home’s complaints policy, including reference to the Commission for Social Care Inspection, was seen on the entrance hall wall. Care staff were aware of the action they should take should a service user or visitor wish to make a complaint. The home has an adult protection policy which links to the Isle of Wight Adult Protection policy. The home has appropriate policies for whistle blowing and gifts to staff. Discussions with the deputy manager and staff showed that they had an understanding of adult protection issues and were clear about their responsibilities and actions that should be taken if abuse is suspected. The home always has a senior member of staff available on call when not in the home, the on-call list being seen during the inspection. Discussion with staff confirmed that they had received training about adult protection during both induction and NVQ courses and were aware of the actions they should take if Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 15 they suspect abuse of a service user may have occurred. The home encourages service users or their representatives to manage individual service users’ personal finances. The arrangements in respect of small amounts of personal cash held for residents were viewed and found to be appropriate in both storage arrangements and record keeping. Whilst reviewing staff files it was not possible to identify POVA First and Enhanced CRBs undertaken by the home on the two must recently appointed members of care staff. CRBs were present for other care staff. Telephone discussions with the manager following the inspection confirmed that she was unaware of POVA First checks and had accepted CRBs held by the care staff. These checks must be undertaken, and a clear POVA First check received prior to care staff commencing employment in the home. The manager stated that she had a copy of the Care Standard Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004 amended regulations in respect of staff employment and these must be fully adhered too. Firbank DS0000012491.V250507.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25 and 26. The home is warm, clean and well maintained providing appropriate accommodation, both private and communal, to meet service users’ needs. EVIDENCE: During the inspection a full tour of the building was undertaken with all communal areas and a number of service users’ bedrooms seen. The home provides accommodation for service users on three floors, all of which are accessible by a passenger lift. One room is not served by the lift and occupied by a fully mobile service user. The home has an ongoing maintenance and redecoration programme. Since the previous inspection a number of bedroom carpets have been replaced and parts of the home redecorated. All radiators have now been covered. Externally some of the trees and shrubbery have been trimmed increasing the light to some bedrooms. In the warmer months the front of the home has an attractive range of bedding plants and hanging baskets with seating available for service users. Handrails are provided around the home to assist service users who may have mobility needs. Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 17 The home provides a dining room and two lounges, one on the ground floor and one on the first floor. Both lounges provide fine sea views. The ground floor lounge opens out onto a rear patio with another pleasant outside area to sit at the front of the home. All the communal spaces are accessible to all service users via the passenger lift. Furniture within the shared areas was found to be in good repair and fit for purpose. A water cooler is provided in the main lounge for use by residents or their visitors and staff. All service users are accommodated in single bedrooms although shared rooms could be available in the larger bedrooms if specifically requested. All service users’ bedrooms were fully furnished with suitable bed, wash hand basin or ensuite facilities, call bell system, television, easy chair, table, drawers and hanging space. Bedrooms were carpeted and nicely decorated. As previously stated a number of bedroom carpets have been replaced. Most service users’ rooms contained personal items such as small pieces of furniture and photographs creating a homely feeling. Service users spoken with were happy with their personal accommodation. Bedrooms all have individually controllable central heating and are naturally ventilated by windows. All bedrooms were found to be clean and free from offensive odours at the time of the unannounced inspection. Since the previous inspection the home has replaced the Parker bath with a walk-in bath. An additional bathroom is provided on the top floor and WCs located close to the lounges and dining room. Two rooms have en-suite facilities. The home employs domestic staff and on the day of the unannounced inspection the home was found to be clean, tidy and free from offensive odours. All WCs and communal bathing facilities were noted to have a supply of paper towels and liquid soap with guidelines available for staff around infection control and the use of chemical cleaners. Care staff informed the inspector that supplies of plastic gloves, aprons and paper towels are freely available. The care staff confirmed that they have received training in infection control with certificates seen on the hall walls. The home has a laundry with industrial machines capable of washing to required temperatures. A separate washing machine capable of washing to 90ºc is used for soiled laundry. Firbank DS0000012491.V250507.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The home employs sufficient care and ancillary staff to meet service users’ needs and ensures that care staff are appropriately trained and supervised to do their jobs. The home must ensure that POVA and CRB checks are completed on all new care staff. The home should obtain copies of the General Social Care Council code of conduct and supply these to all care staff. EVIDENCE: The home employs five care staff and the deputy manager responsible for care during the morning, three care including senior during the afternoon/evening and two care overnight. In addition to the care staff employed the home also employs catering, domestic, maintenance, gardening and administrative support staff. Service users and visitors spoken with during the inspection reported that staff are very prompt in answering call bells and that they felt care staff had sufficient time to meet their needs. Staffing rotas were seen during the inspection and correlated to staff in the home at the time of the unannounced inspection. Additional shifts resulting from staff holidays or sickness are covered by the home’s own staff. Care staff stated that there were adequate numbers of staff employed at the home to meet service users’ needs and that everybody worked together as a team. Care staff confirmed that there are lots of training opportunities with a large number of certificates displayed on the hall walls around the home. Thirteen of the home’s twenty-four care staff have at least NVQ level 2 (a number having Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 19 level 3 qualifications) equating to just above 50 . Additional care staff are undertaking NVQ training. Service users all described the care staff as being helpful, pleasant and kind. Observations of the interactions between care staff and service users during the inspection indicated that care staff treat service users with dignity and respect. The staff files were viewed to confirm the home’s recruitment procedures. The files of the two newest members of staff, one appointed in September 2005 and the other in January 2006 were examined. Both files contained completed application forms and two written references. There was no evidence of Criminal Record checks including POVA list checks. The inspector telephoned the manager following the inspection and discussed the recruitment files. The manager confirmed that she had a copy of the Care Standard Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004 that state the need for the POVA list to be checked prior to the commencement of employment. This can only be done via the CRB check with the umbrella organisation used by the service being able to complete an email check approximately 72 hours after the CRB has received the completed form. The manager was unaware of the POVA First check and agreed to contact the umbrella organisation they contract with to ensure that these checks are completed. The home must comply with the Care Standard Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004 in respect of the POVA list and staff supervision pending the full CRB being returned. There was evidence in staff files seen of terms and conditions of employment. The home did not have a copy of the General Social Care Council code of conduct and care staff have not received copies of the code. The home should obtain copies of the GSCC code of conduct and provide these to care staff. Firbank DS0000012491.V250507.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38. The manager is experienced and qualified with the management arrangements within the home appropriate to ensure that service users’ needs continue to be met in a homely atmosphere in which service users felt valued and well cared for. Service users’ opinions are sought weekly during resident meetings. The arrangements for residents’ personal finances are appropriate. The fire equipment/detection book detailing the weekly checks indicated that these had not been regularly undertaken. It is required that these are carried out and that the book is fully completed. EVIDENCE: The registered manager, Mrs Margaret Jones, has owned or managed Firbank for over twenty years. The manager has NVQ level 4 in care and the Registered Manager’s Award. The manager is an NVQ assessor and supports NVQ training in the home. The manager confirmed that she undertakes Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 21 compulsory update and training relevant to service users’ needs. The manager has a job description and there are clear lines of accountability within the home, with the deputy manager and senior staff supporting with the on-call arrangements. Staff described the home as being a happy place to work and that support is always available from the management team. Staff felt that they could make suggestions about changes within the home. Service users stated that the home was a nice place to live, that they felt safe, happy and that they would recommend the home to a friend. The home is regularly visited by a representative of the company with reports being made available to the Commission and the manager. Care staff confirmed that there are regular staff meetings. The home has the Investors in People award that reflects its commitment to staff development and training. Service users’ meetings are held every Monday, the minutes of which were seen during the inspection. These meetings allow the service users to be informed of anything that is to happen in the home such as new admissions or staff changes. The meetings also allow service users to make comments and suggestions about activities and meals. Residents and visitors spoken with during the inspection all stated that they were able to discuss any concerns with the manager with whom they had frequent contact and were confident that she would resolve any concerns. The home was full at the time of the unannounced inspection with care staff confirming that this was generally the case. Appropriate insurance certificates were seen displayed on the hall wall. The home would appear to be financially viable. Where possible service users are encouraged to continue to manage their own financial affairs, when this is not possible their representatives take over this responsibility. The home will arrange for shopping for individual service users to purchase personal items. The records of a randomly selected service user’s personal allowances were checked and found to be full and accurate. The administrator explained that statements of personal allowance expenditure are sent to service users’ representatives when service users do not themselves manage their own personal allowances, a sample being seen during the inspection. Secure facilities are available for service users within bedrooms if they request this. The administrator, manager and care staff confirmed that care staff receive both formal and informal supervision, with records of formal supervision and annual appraisals being held by the home, samples of which were seen during the inspection. Regular staff meetings are held during which staff are provided with information about changes within the home and issues affecting service users’ care are discussed. Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 22 During the unannounced inspection a variety of records was inspected. These included duty rotas, pre-admission assessments, care plans, risk assessments, care records, staffing rotas, accident records, medication administration records, menus and food records, fire and emergency lighting equipment records. As previously stated the Medication Administration Records were found to contain a number of gaps with no indication as to whether prescribed medication had been administered or not. The home must ensure that Medication Administration Records are fully recorded at the time of administration. The fire equipment/detection book was examined and the inspector noted that the weekly checks had not been regularly undertaken. It is required that these are carried out and that the book is fully completed. As previously stated the home did not have all the information as required in Schedule 2. This being in respect of the POVA and CRB checks. The home must ensure that all Schedule 2 information as specified in the Care Standard Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004 is held for all staff working in the home. Staff stated that they receive training in manual handling, first aid, health and safety, fire awareness and food hygiene. Certificates confirming this were seen on the hall walls. Safety notices were seen appropriately positioned around the home and infection control equipment was available for care staff. Covers are fitted to all radiators. The home keeps all chemical cleaning items in a cupboard that was locked at the time of the unannounced inspection. Appropriate measures to ensure the security of the premises were in place. A certificate from an external company who service and check the fire equipment was seen on the office wall having been issued in September 2005. Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 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 2 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 2 3 Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP9OP37 Regulation 13 (2) Requirement Medication Administration Records must be fully completed. The correct code must be used on all occasions when a medication is not administered as prescribed. Timescale for action 01/03/06 2. OP18OP29 OP37 19 (1)(b) 19 (4)(b) 3. OP37 The Care Standard Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004 must be fully complied with. Care staff must not commence employment until a clear POVA first check has been received. 23(4)(c)v) Ensure weekly tests of fire detection/management equipment are carried out and recorded in the official record book. 01/03/06 01/03/06 Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 25 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 OP29 Good Practice Recommendations The home should obtain copies of the General Social care Code of Conduct and supply care staff with copies of the code. Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA National Enquiry Line: 0845 015 0120 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 Firbank DS0000012491.V250507.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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