Inspection on 07/11/07 for Firs Hall

This inspection was carried out on 7th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Firs Hall 04/11/08

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

CARE HOMES FOR OLDER PEOPLE Firs Hall Firs Avenue Failsworth Manchester M35 0BL Lead Inspector Mrs Fiona Bryan Unannounced Inspection 7th November 2007 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 Firs Hall DS0000069971.V354087.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. Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Firs Hall Address Firs Avenue Failsworth Manchester M35 0BL 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) 0161 683 5154 0161 688 7324 Firs Hall Care Home Limited Manager post vacant Care Home 31 Category(ies) of Dementia (12), Old age, not falling within any registration, with number other category (0) of places Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - code PC, to people of the following gender:Either; whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP; Dementia - Code DE (maximum number of places: 12). The maximum number of people who can be accommodated is: 31 Not applicable Date of last inspection Brief Description of the Service: Firs Hall is a large, detached, residential care home accommodating up to 31 older people. The home is located on the Oldham/Manchester border and is accessible for local amenities and bus routes. Accommodation comprises 21 single rooms, 12 with en-suite toilets, and five double bedrooms, one with an en-suite toilet. Other facilities include two lounge/dining areas. The home has recently come under new management and is now owned by a limited company, Firs Hall Care Home Limited. The responsible individual is Mr J Heifetz and there is no registered manager at the present time. The weekly fees range from £334.00 to £351.00, which does not include the following: hairdressing; newspapers; toiletries; dry cleaning; prescription fees; transport/taxi fares; private health care services; clothing; continence products; trips out; private telephone and satellite TV installations and rentals, and ‘the tuck shop’. A service user guide and statement of purpose are available on request and are displayed in the reception area of the home. Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection, which included a site visit, took place on Wednesday, 7th November 2007. The home was not told beforehand of the inspection visit. All key inspection standards were assessed at the site visit and information was taken from various sources, which included observing care practices and talking with people who live at the home, the acting manager and other members of the staff team. The acting manager also completed a form called an Annual Quality Assurance Assessment (AQAA), which asks them to tell us what they think they do well, what they have improved upon and what they need to do better. Three people were looked at in detail, looking at their experience of the home from their admission to the present day. A partial tour of the building was conducted and a selection of staff and care records was examined, including care plans, medication records, employment records and staff duty rotas. This was the first inspection for the service, which has been classed as a new service, as a new provider, Firs Hall Care Home Limited, has bought it. There is currently no registered manager; two senior carers have taken on the role as acting manager and perform that role for half a week each. We were assisted at this inspection by one of the acting managers and the area manager for the company. What the service does well: The take-over of the new company seemed to have been accomplished smoothly and with minimal impact on the residents. Residents said that they felt there had been no significant changes since the new owner took over and certainly none for the worse. Residents said that staff understood their care needs and treated them kindly and with respect. Routines seemed to be flexible and residents were free to move around the home, sit in their own rooms or spend time in one of the lounges and said their visitors were made welcome. Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 6 From information provided before the inspection it was reported that 61 of the care staff had successfully completed NVQ training. Residents and staff said there were usually enough staff on duty to meet the needs of the residents. On the day of the site visit the home was clean and tidy, although in need of quite extensive refurbishment and redecoration. What has improved since the last inspection? What they could do better: A number of areas were identified as needing improvement, which the area manager fully acknowledged and was committed to addressing as soon as possible. Staff have been asked to start using different paperwork to record care plans and risk assessments and are in the process of updating this information. Further work is needed to ensure that all the necessary information is available for staff about the care each person needs. Further consideration is needed as to how residents’ social care needs are met. There was little evidence of any opportunities for social stimulation and staff need to discuss with the residents what their interests are and use this information to plan events that suit their abilities and expectations. Menus and mealtimes need to be reviewed to ensure that residents are provided with different choices and enjoy their meals in a social and congenial setting. Although there is a complaints procedure, most residents did not seem to know how to make a complaint if they needed to. A start has been made on obtaining residents’ views about how the home is run but this needs to be further developed. As previously stated the home needs a lot of refurbishment and some new equipment and accessories are required, such as trolleys, privacy screens, bedding, towels, quilts and pillows. The area manager has said that she will do an inventory to determine what is needed and prioritise purchases. Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 7 Some records that are needed for the efficient running of the home, such as staff training records and records of weekly health and safety checks of the building and equipment, need to be created or brought up to date. The area manager has been visiting the home on a frequent basis but needs to provide us with a monthly report so we can monitor what improvements have been made in the light of this report. 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. Firs Hall DS0000069971.V354087.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 Firs Hall DS0000069971.V354087.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 and 3. Standard 6 is not applicable. Quality in this outcome area is adequate. Information is provided to prospective residents so they can choose a home that will meet their needs. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A service user guide was displayed in the reception area of the home and was also provided in each resident’s room. The guide contained all the necessary information to inform prospective residents about the services the home could offer, although it did need slightly amending as some information was incorrect, for example, the guide stated that the home had a “memorabilia room” but this was no longer the case and the previous acting manager had left and her details were still in the guide. Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 10 Work had started on producing a staff profile, which was also displayed in reception. It was planned that the profile would contain photographs of all the staff, together with descriptions of their job titles and qualifications. Since the new owner took over the home no new residents have been admitted so it was not possible to determine if pre-admission assessments of prospective new residents were undertaken before a decision was made as to whether the home could meet their needs. However, it was reported that this was the normal procedure. Staff were in the process of changing the documentation over from records used by the previous owner to records that the new company wished to use. Three residents were case tracked and some old assessment information was available in their files; however, these were not fully completed and need further work to ensure all the necessary baseline information is up to date and relevant. Firs Hall DS0000069971.V354087.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 and 10 Quality in this outcome area is adequate. Care plans do not always address all the residents’ needs, which leads to a risk that some needs may not be met. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Three residents were case tracked. In general, there were satisfactory details about residents’ preferred routines and abilities in respect of personal care needs. However, shortfalls in information were evident in areas such as mental health and social care needs. People’s specific needs also were not always fully addressed, for example, in relation to their spiritual needs; this meant that residents’ more diverse needs were not always fully explored and staff may not have had the information to understand and meet them. Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 12 Risk assessments had been undertaken to assess the risk to residents in relation to falls, moving and handling, nutrition and pressure ulcers. All had been reviewed monthly. Other risk assessments for specific issues relating to individual residents, such as smoking, were not always in place. Records showed that residents had seen the dentist and optician. Residents spoken to said the podiatrist had not visited them and one resident was diabetic, so this was particularly important for them. The acting manager said there had been problems in accessing a podiatrist for residents but she was hopeful this had now been resolved and said residents would be seen by the podiatrist in the near future. Several residents had been given the flu vaccination. Residents generally looked fairly clean and tidy, although it was noted that one resident was unshaven and had dirty teeth. This resident remained like this throughout the day and later his jumper was not changed, although it was stained with food. This resident’s care plan did indicate that he needed help with his hygiene needs and staff need to be prompt in attending to these areas. Residents said that staff understood what help they needed and what their preferred routines were and stated that staff were kind and helpful. A key worker system is usually in operation but it was reported that it needed updating. Examination of the medicines records for residents showed that medicines were generally managed satisfactorily. At times, staff were entering “F” on the medicine administration records to indicate that the medicine had not been administered; when they do this, staff should write on the chart what the reason for non-administration is. Controlled medicines were held for one person and the storage and recording of these were satisfactory. The refrigerator used for the storage of medicines was kept in the office and was unlocked. This fridge should be kept locked at all times. Firs Hall DS0000069971.V354087.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 and 15 Quality in this outcome area is adequate. More person-centred care planning is needed to ensure that people’s social, cultural and recreational expectations can be met. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Residents said they could get up and go to bed as they chose. Some residents spent most of the day in one of the two lounges, whilst others preferred to spend some time in their own rooms. An activities organiser is not employed at the home. Residents were quite vague about how they spent their time. Some residents said they liked to read and that there were plenty of books available and the mobile library visited the home. It was reported that “an old time” a singer was invited to come and entertain them. One of the residents enjoyed playing the organ and had played for other residents. Some residents said they used to go out but hadn’t done so for some time. Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 14 Generally, residents said there was not much going on in the home but most said that the arrangements in place suited them and that they were quite content to sit and chat to each other or read. At 10am most residents in one of the lounges were asleep and although the television was on, no-one was watching it. One resident said he was very bored and staff need to consider how they can meet his social care needs. Staff felt that more social stimulation was required for the residents. One relative who returned a questionnaire distributed by the home commented, “staff are very caring and do a brilliant job but a bit more entertainment for residents would be welcome”. Further development of the key worker role and better highlighting and explanation to people living at the home about who their key worker is and the role they have could help staff to further identify people’s more diverse needs and meet them according to people’s individual strengths and abilities. The day’s menu was displayed on white boards in the dining areas. These showed that residents had the choice of cereals and cheese, jam or marmalade on toast with fresh orange juice for breakfast. Lunch was stated as being either braised steak and onion or fish fingers with mashed potato and mixed vegetables or baked beans. However, by the time the meal was served, the menu had been amended, as the braised steak was not cooked so the chef had decided to serve it at teatime instead. Therefore, residents had no choice at lunch and all were served fish fingers, chips and beans. Tea was the steak or jacket potatoes; the jelly stated as the dessert on the menu had not set, so the carers had to put together a quick dessert of ice cream and fruit. Lunch was served at 12.15pm. Some residents sat at the dining tables, whilst others remained in the lounge and ate from bedside tables. The tables in the dining room were quite bare and basically presented. Tablecloths and crockery had been arranged but no extras, such as condiments, place mats or napkins. All the residents seen were able to eat independently; however, staff could have shown more finesse in serving the meals and made the mealtime more of a social occasion by chatting more with the residents and using the opportunity to encourage residents to socialise. One carer was observed serving two residents their meal without saying anything to them and afterwards one resident was overheard saying to the other “I didn’t say throw it at me”! The plates that the meal was served on were small and some residents were seen trying to keep the food on their plates. When the area manager was asked about this, she said that some of the residents had small appetites so small plates were used. However, the plates looked overflowing and the food not very attractively presented so larger plates could have been used, even if residents wanted small portions. Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 15 A member of staff was observed asking the residents if they wanted salt and vinegar, which she then sprinkled on to the meal for them (no pepper or sauce was offered). Most residents appeared capable of putting their own salt and vinegar on their meal. Residents were generally complimentary about the food provided. One resident said that there was not usually a choice but they thought that if they wanted an alternative, they would be able to have it. Another resident said the food was “lovely”. The area manager said that the menus would be reviewed and revised in the near future. Firs Hall DS0000069971.V354087.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 and 18 Quality in this outcome area is adequate. Further training in safeguarding adults is needed and residents and their representatives need further information about the complaints procedure. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The complaints policy is displayed in a file in the reception area and also in residents’ rooms. A complaints box is also kept in reception. However, some residents were not sure who they would need to speak to if they had a complaint. Several relatives who returned questionnaires distributed by the home said they didn’t know how to make a complaint. The new company has not received any complaints since they took over the home but a procedure is in place to record any complaints that are made. It was reported that some staff have received training in safeguarding adults but other staff still need to attend this training. The safeguarding procedure was displayed the dining room. contact details for Oldham Social Services and the CSCI. Firs Hall DS0000069971.V354087.R01.S.doc This included Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26 Quality in this outcome area is adequate. Residents live in a clean and tidy home but further redecoration and refurbishment is required. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A tour of the home was conducted. The reception area was an impressive room with a sweeping staircase and period features. The décor here was in keeping with the building, creating a very homely and individual feel with old artefacts such as a gramophone, wireless, clock, candlesticks and coalscuttle on display. Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 18 Two large lounge/dining rooms were provided with room to seat approximately 12 residents in each. One lounge in particular was airy and bright with an open plan archway through to the dining area. Although the communal areas were decorated to a reasonable standard and new carpets had been laid in the hallways and lounges, many of the residents’ bedrooms were in need of refurbishment and redecoration. Furniture throughout the home was shabby and worn, wallpaper was coming off the walls in places and the bed linen, towels, quilts and pillows were thin and threadbare. Individual rooms needed attention, for example, there was no lampshade on the bedside lamp in one room. The area manager did say that she was planning to do a full inventory of the home and devise an action plan, which would prioritise the work to be done. Residents said they liked their rooms and they were satisfied with the cleaning and laundry services. One resident said her room was nice and big. Some equipment is needed, such as a trolley for the housekeeper as she is currently using a resident’s wheelchair to transport her cleaning products around the home. The owner is also asked to consider purchasing new vacuum cleaners, as several do not work and the domestic staff reported having difficulty operating others. It was also reported that there was insufficient crockery and cutlery provided. The area manager and the chef both said that new crockery and cutlery had been purchased but stocks seemed to quickly go down again. It was noted that a lot of staff notices were displayed around the home, both in communal rooms and in residents’ rooms. These notices were for the information of staff, for example, advising them that their wage slips were ready for collection or asking them to ensure that they picked up residents’ clothing if it fell off the coat hangers. These notices detract from the homely feel of the home and should be removed. An extra privacy screen is needed in one of the double rooms, as the one in place did not provide suitable privacy for residents when they were using the washbasin. Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. Staffing levels were sufficient to meet the needs of the number of residents living at the home but further staff training and improved recruitment procedures are needed to protect the residents. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Residents and staff said that staffing levels within the home were sufficient to meet residents’ needs. At the time of the site visit, the acting manager was on duty with a senior carer and two carers plus the housekeeper (who was also responsible for the laundry) and the cook. Additionally, one person from the Job Centre was working at the home on a four-week placement for work experience, with a view to being recruited on a permanent basis. It was reported and staff duty rotas showed that usually three care staff were on duty from 8am until 10pm with the person-in-charge on duty until 5pm. Two carers are on duty at night. Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 20 Information supplied by the acting manager prior to the site visit reported that 61 of care staff at the home had successfully completed NVQ training to level 2 or above. Five staff have registered to commence this training. Two staff personnel files were examined. The references that had been obtained in both cases were insufficient, as they either did not specify what the referee’s relationship with the applicant was or they were pre-written testimonials that had not been verified for authenticity. One file only contained one reference. No training records were available for inspection. The area manager said she had asked staff to produce certificates of all the training they had attended and was intending to develop a training plan once she had established what training everyone had received. Staff said that they had received no training to date since the new company took over the home. New staff need to attend induction training that meets Skills For Care specifications. Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. Although there is currently no manager, the company is ensuring that staff are supported and are taking steps to seek the views of residents in how to develop the home. This judgement has been made using available evidence, including a visit to this service. Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 22 EVIDENCE: There is currently no manager in position at the home. Interim arrangements have been put in place, whereby two of the senior carers are acting as “in charge” for half a week each, whilst they are continuing to fulfil their normal duties for the other half of the week. Residents did not feel that there had been any detrimental changes that had significantly affected them since the new owner took over. The acting manager said she felt well supported by the area manager who regularly visits the home and who is always available by phone. There have been no residents’ meetings since the new owner took over but relatives’ questionnaires were sent out in October 2007 and the responses had been noted. One relative had said that she wanted a meeting to discuss some issues and this had been arranged for the day following the site visit. Comments from some of the relatives’ questionnaires included “I believe my aunt is in good hands” and “Most of the staff have made mum feel very happy and comfortable. They have also made me feel very welcome and I thank them for all the care and love they show mum”. There had been one staff meeting when the new owners first took over, however some of the requests made by staff had still not been actioned. This had left some staff feeling that their views were not being listened to and morale in the home seemed to be quite poor. The area manager said that a system for auditing care practices, such as care planning and management of medicines, was being put in place and acknowledged that although she was visiting frequently, no Regulation 26 reports had yet been written to formally record what had been looked at or what decisions had been made about the progress of the home. Small amounts of money were held for people living at the home to purchase small items; systems were in place to ensure the safe handling and storage of service users’ monies. From information provided by the owner it was evident that the fire alarm system, emergency lighting system, nurse call system and fire extinguishers had all been serviced and inspected appropriately. However, records showed that routine checks of the building and equipment that should be carried out by staff at the home on a weekly basis had not been carried out since July 2007. Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 23 A recent food hygiene inspection resulted in six requirements being made. Several had been addressed but some were still outstanding. These should be complied with. Staff had asked for a new sling for the hoist at the staff meeting and this had still not been provided. Necessary equipment needed for safe moving and handling of residents must be obtained as a matter of priority. The area manager said she would arrange delivery of the sling as soon as possible. A record had been maintained of accidents occurring in the home. Staff now need to put a system in place to audit these records to highlight any risks that may be minimised. Firs Hall DS0000069971.V354087.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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 X X X 2 X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 OP29 Regulation 19 Requirement Timescale for action 15/12/07 2 OP30 18 3 OP38 13 New staff must not be employed unless at least two references have been received, one of which is from the person’s last employer, and the authenticity of the references have been confirmed. This will ensure that only suitable staff are employed to work at the home. All staff must have up to date 31/12/07 training appropriate to the work they are to perform to ensure staff operate in a safe manner. Arrangements must be made to 15/12/07 ensure that equipment identified as necessary for the safe moving and handling of residents is obtained in a timely manner. Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 26 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 4 5 Refer to Standard OP1 OP7 OP8 OP9 OP12 Good Practice Recommendations The statement of purpose and service user guide should be reviewed to ensure that all the information provided is accurate. Care plans should be more detailed in the areas on mental, emotional and social care needs to ensure all residents’ needs are met. Staff should be prompt in identifying and dealing with residents’ personal care needs. The refrigerator used to store medicines should be kept locked at all times. The key worker system should be developed to increase the opportunities to meet the social needs of people living at the home. Residents should be consulted about what activities and social events they would like to participate in. Menus should be reviewed and amended to include a choice at each mealtime. Consideration should be given to offering a cooked breakfast to residents at least twice a week. Mealtimes should be promoted as a social occasion and meals attractively presented to stimulate residents’ appetites. Further work should be done to ensure that residents and their representatives are aware of the complaints procedure and feel confident to use it. The registered person should ensure that all staff attend training in safeguarding adults. A programme of refurbishment and redecoration should be developed. Worn bedding, towels, quilts and pillows should be replaced. An additional privacy screen should be identified in the double room identified during the inspection to ensure both residents’ privacy is maintained. A staff training record should be developed to clearly record the training staff have had and highlight when refresher training is due. All new staff should receive induction training that meets Skills for Care specifications. DS0000069971.V354087.R01.S.doc Version 5.2 Page 27 6 OP15 8 9 10 11 12 OP16 OP18 OP19 OP24 OP30 Firs Hall RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 13 14 15 16 Refer to Standard OP33 OP33 OP38 OP38 Good Practice Recommendations Residents’ meetings should be held to enable residents to give their views and suggestions about how the home is run. The area manager should start sending Regulation 26 reports to the CSCI. Weekly health and safety checks on the building and equipment should be made and recorded. Requirements made at the food hygiene inspection should be addressed. Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Area Office 11th Floor, West Point 501 Chester Road Old Trafford Manchester M16 9HU 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 Firs Hall DS0000069971.V354087.R01.S.doc Version 5.2 Page 29 - 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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