Inspection on 25/07/08 for Firth House

This inspection was carried out on 25th July 2008.

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

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

Other inspections for this house

Firth House 04/09/07

Firth House 25/09/06

Firth House 10/02/06

Firth House 18/05/05

Firth House 14/12/04

Firth House 08/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Firth House 18 Firth Mews Millgate Selby North Yorkshire YO8 3FZ Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 25th July 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Firth House DS0000007957.V368824.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. Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Firth House Address 18 Firth Mews Millgate Selby North Yorkshire YO8 3FZ 01757 213546 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) margaret.millin@anchor.org.uk www.anchor.org.uk Anchor Trust Margaret Meek Millin Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP, maximum number of places: 40 The maximum number of service users who can be accommodated is: 40 4th September 2007 2. Date of last inspection Brief Description of the Service: Firth House provides personal care and accommodation for up to 40 older people. The home is a purpose built two-storey property set in its own gardens near to the town centre of Selby. There is parking to the front of the home. The home is divided into four small living units. Two on the ground floor and two on the first floor. Each unit has it’s own dining room, with a small kitchen area attached. One large lounge on the ground floor is provided. All people who use the service have a single en-suite room. The home is situated in a quiet residential area and is in walking distance of shops and community facilities. A copy of the latest Commission for Social Care Inspection (CSCI) report is available on the notice board near the entrance to the home. The weekly fees on the date of the inspection are £530. There are additional fees for the services of a hairdresser and a chiropodist. Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. The Commission for Social Care (CSCI) inspects care homes to make sure the home is operating for the benefit and well being of the people who live there. More information about the inspection process can be found on our website www.csci.org.uk The last key inspection was carried out in September 2007. This inspection took place on 25 July 2008. Before this unannounced visit we reviewed the information we had about the home and the manager completed an annual quality assurance assessment (AQAA). We used this information to help us decide what we should do during our inspection visit. Surveys were sent out to people who live at the home, staff and health care professionals. Thirteen surveys were returned. Comments from the surveys have been included in the report. One inspector was at the home for one day from 9.30am to 4.30pm. During the visit we looked around the home and talked to people who live at the home, a visitor and people who work there. We observed staff caring for people in the communal rooms and looked at care plans, risk assessments, daily records, menus and staff records. Feedback was given to the deputy manager at the end of the visit. What the service does well: The service provides a very high standard of care. We talked to people who live at the home. They are very happy with the care they receive. One person said, “We are looked after extremely well.” Another person said, “If it was rubbish I wouldn’t be here.” A relative also told us the home provides good care. They said, “It’s a family atmosphere.” “I can’t fault it.” The staff are proud to work at the home and the high standard of care they provide. One person said, “We look after people really well.” Another staff member said, “Staff spend time with people, have a chat and make sure they are happy.” Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 6 Healthcare professionals were very complimentary about the home and said it meets people’s healthcare needs. One person said, “It’s clean, efficiently run and very caring- has a very high reputation amongst the GPs.” Another person said, “I have seen the staff care extremely well for their clients.” People who live at the home have a varied and fulfilling lifestyle. They can choose from a range of activities both in the home and the community. Meals are very good. One person said, “The food is always fantastic.” The home is well managed and the high standard of care is strongly influenced by the management team. People live in an attractive, homely, clean and safe environment. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Firth House DS0000007957.V368824.R01.S.doc Version 5.2 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 Firth House DS0000007957.V368824.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 does not apply) People who use the service experience good quality outcomes in this area. People’s needs are properly assessed before they move into the home and they are assured their needs will be met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: We talked to two people who had recently moved into the home. One person said they looked around the home with their family before they made the decision to move in. Another person said they stayed at the home for two weeks before they decided. They were both very happy living at the home. One person said, ‘It’s very, very nice here.’ We talked to one relative. They thought the admission process was good and said they had been provided with ‘a lot of information’ about the home. They said, “Everybody came to have a look around and we had lunch. My mum was given the option of staying over and we could have stayed in the guest room.” Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 9 We talked to a team leader who has completed several pre admission assessments. She said they always gather enough information about each person before they move in, and encourage people to visit the home. We looked at three people’s assessment records. They all had pre admission assessments and assessments that were completed within 24 hours of the person moving into the home. The assessments contained information about the type of support they required. Surveys from people who live at the home said they received enough information to help them decide if they wanted to move in. One person said, “The written information was clear and concise but the most important aspect was visiting the home to gain an overall impression. Firth House came out ‘head and shoulders’ above the other nine visited.” Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience excellent quality outcomes in this area. People who live at the home are treated with dignity and respect, and their individual needs are recognised and well met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: We talked to people who live at the home. They are very happy with the care they receive. One person said, “We are looked after extremely well.” Another person said, “If it was rubbish I wouldn’t be here.” A relative also told us the home provides good care. They said, “It’s a family atmosphere.” “I can’t fault it.” We asked the staff what the home does well and they all said provide good care. One person said, “We look after people really well.” Another staff Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 11 member said, “Staff spend time with people, have a chat and make sure they are happy.” Staff also talked about privacy and dignity and gave us good examples of how they do this. On the morning of the inspection, a male and female staff had exchanged units where they were working for a short period of time to make sure one person had their preferred gender to support them with personal care. Much of the day was spent talking to people and observing the care being given to people. This included how staff interact with people at the home. Everything was done at a relaxed pace. Staff treated people with warmth and respect and they were kind and courteous. The general appearance of people who live at the home was good, they were dressed appropriately and attention had obviously been given to their personal care. For example, people’s hair had been brushed and their glasses, shoes and clothing were clean. Staff had good knowledge about the people who live at the home. They understood people’s current needs and knew about their past. They were able to talk about people’s family members. The care that staff described for each person was the same as the care that was written in the care plans. For example one staff member talked about how they support one person when they misplace personal items and this was observed during the day. This was also recorded in their care plan. Another staff member talked about a morning routine for one person, which was also recorded in their care plan. We looked at four people’s care plans and assessments. These were well organised. Information in the care plans was very good and gave sufficient information about potential risks and how individual needs should be met. One risk assessment did not contain enough information, although action taken by staff minimised the risk of harm. One person smokes in their room, and staff stay with the person during the night when they smoke. This was not properly assessed or written in the assessment or care plan. The deputy manager and a team leader acknowledged more information should be recorded and started to address this at the inspection. Some staff who complete the care plans said they were time consuming and take up valuable ‘caring time’. One person said, “I do feel like an admin worker come part time care assistant.” The deputy manager said the plans are still fairly new, and they are working with the team to look at how they can complete them more efficiently. Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 12 In the AQAA the manager gave us many examples of what the home does well. This included, “Working together with external professions to identify health needs and ensure health requirements are met.” and “ Staff training on specific areas of health care takes place according to the individuals needs documented in the service user plan.” People told us the home was good at meeting healthcare needs. One person talked about health problems and said, “Staff were straight on the ball, the district nurse was called.” We looked at information that showed us people’s health and welfare is properly monitored. Reviews identify any changes in needs and any significant events. Weight and blood pressure is monitored and healthcare appointments are clearly recorded. We received two healthcare surveys. They were very complimentary about the home and said it meets people’s healthcare needs. One person said, “It’s clean, efficiently run and very caring- has a very high reputation amongst the GPs.” Another person said, “I have seen the staff care extremely well for their clients.” We looked at medication systems. Medication is well organised and good systems are in place to make sure the right medication has been administered. The records were completed correctly. Two people self medicate. Care plans and assessments identify how this is carefully monitored. Good individual storage facilities are provided. This is good practice and promotes independence. When we looked around the home we noticed a medication cabinet for storing ointments and creams was left unlocked. The team leader noted this and immediately addressed it with the staff member. Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience excellent quality outcomes in this area. People enjoy living at the home and feel well cared for. Everyone works hard to make sure people have a stimulating and varied lifestyle. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: In the AQAA the manager told us that people who live at the home have a good and varied lifestyle and gave examples of how they do this. She said, Anchor’s aim is to ‘Improve the lives of older people and focus on the person centred care is a high priority’. During the visit we were able to confirm the home are successfully achieving this. People who live at the home said they are very happy with the level of activities. One person said, “There are events on a regular basis.” Another person said, “We look on the list to find out what is on; there is always lots to do.” Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 14 On the day of the inspection, people were taking part in small group activities. Some were chatting, others were playing dominoes, and others were playing croquet. One person told us they had gone into Selby the day before with a carer. Others told us they had been on an outing to Bridlington a few days earlier. One person who is partially sighted talked about receiving help with activities from an organisation specifically for people with ‘low vision’. Information about the organisation was displayed in communal areas. We asked people what has improved since the last inspection. Several people said the ‘Hospitality Manager’. This is a new appointment and the hospitality manager is responsible for organising group activities and outings, and spending time chatting to people. One person who lives at the home said, “She comes to see us, she is lovely.” A staff member said, “People are offered more variety and enjoy more variety.” The appointment has improved the lifestyle for people living at the home. People said relatives are made to feel welcome and they can visit at any time. One person who lives at the home said, “My son visits whenever he wants and everyone is always pleased to see him.” People who live at the home told us they make decisions about what they do. Two people talked about meeting as a small group after lunch for a general chat. People said they decide when to go to bed and when to get up. One person said, “I usually come through for my breakfast about 9.30.” A night staff told us some people choose to stay in communal areas until midnight, others choose to go to their rooms much earlier. She said, “We respect people’s choice and always try to make sure we offer what people want.” We observed the lunch period, which was very well organised. There was a pleasant and relaxed atmosphere. People said they enjoyed the food. One person said, ‘it was lovely’. Another person said, “The food is always fantastic.” Serviettes and condiments were on each table. Food was served in tureens and people were encouraged to serve themselves. People were offered a range of drinks and had specialist equipment to help them eat. Staff talked to people throughout the meal and offered help when they needed assistance. We looked at the menus which were varied and nutritious. One person said, “I need a special diet. The cook knows and always makes sure I get the right food.” Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. People who live at the home are safeguarded. People are confident that they will be listened to and that appropriate action will be taken when necessary. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: People who live at the home said they know who to speak to if they are not happy and how to make a complaint. One person said, “The carers are always available to talk to and pass on any concerns.” Another person said, “Small complaints have been dealt with effectively by the staff. There have been no major issues of concern.” Since the last inspection the home has not received any complaints that have been taken through the formal complaints channel. The home records all complaints/concerns, which includes comments of dissatisfaction from people who live at the home or their relatives. This is good practice and helps monitor levels of satisfaction and the quality of the service. Staff have received training on safeguarding adults. They were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. They were also able to describe the different types of abuse. Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 16 Staff said they would report any concerns to the management team and they were confident they would deal with them promptly and appropriately. Since the previous key inspection visit there has been no safeguarding referrals. Firth House DS0000007957.V368824.R01.S.doc 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 & 26 People who use the service experience excellent quality outcomes in this area. People live in an attractive, homely, clean and safe environment. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home is furnished and decorated to a very high standard. It is separated into four units. Each unit has its own dining area and kitchen. This means that people who live at the home can enjoy some independence by using the smaller domestic style kitchens and the small dining areas which lend themselves to the social occasion of meal times. Some people have drink-making facilities in their room. People said they could make drinks in their room or the small kitchens whenever they liked. Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 18 The home was very clean and well organised. One person who lives at the home said, “It’s always lovely and clean.” Staff said the home is always cleaned to a very high standard. People who live at the home are encourged to personalise their rooms and to bring familiar pieces of furniture in with them. All the bedrooms have an ensuite toilet and sink. There is a large communal lounge for people who live at the home to socialise in. It is well set out with chairs arranged in small clusters to encourage conversation and small group activity. There are patio doors which lead out on to a well kept, attractive garden and patio area. There is good access for anyone with mobility problems. And there is plenty of garden furniture and shelter from the sun. Several people were sat in the garden. One person said, “It is lovely sitting in such a nice garden.” There are a number of bathrooms in the home, providing a choice of bath or shower. The baths and equipment in the bathrooms can help people who have mobility problems. Each bathroom has a jacuzzi bath. The décor, fixtures and fittings in these rooms is very attractive and homely looking. We checked water tempertures around the home. These were satisfactory although the hot water very slightly exceeded the recommended temperature to one bath. We looked at the weekly temperature checks and this had not been previously noted. The team manager who is responsible for health and safety agreed to monitor this. On the day of the visit the weather was very hot, which was a possible cause for the increase in water temperature. Clinical waste is properly managed and staff wear protective clothing when attending to the personal care needs of people who live at the home. Staff have received training in infection control. People who live at the home spoke highly of the laundry service at the home. In the AQAA the manager said they had made a lot of improvements in the last 12 months. She said they had: • • • • • Refurbished communal areas including decoration and carpets Fitted a new fire detection system Fitted new lighting and electrical switches Plumbed in water coolers in all dining areas Built a new summerhouse and pathway around the building. Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 19 Firth House DS0000007957.V368824.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 People who use the service experience good quality outcomes in this area. People who live at the home are supported by a skilled and caring staff team. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Surveys and discussions with people who live at the home were very positive and it was clear they were happy with the staff. We received the following comments: • • • • • • The staff are all lovely Staff are all very nice They are very good to us Staff are all lovely, they will do anything for us Staff listen and act on what they say (Survey information). Staff are always available when you need them (Survey information). Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 21 Staff said staffing levels are good and they can spend quality time with people who live at the home. They also said they have time to take people out and sit and chat. There are usually four care staff on the morning shift and four on the afternoon shift, with a team leader or senior team leader. The manager or deputy is also available throughout the day during the week and on occasions at the weekend. At night there are three staff on duty or two staff with a senior staff member on call. In addition to this, there are housekeeping and domestic staff, catering staff, an administrator and a handyman for the home. We received six staff surveys. They all told us they receive training which is relevant to their role and helps them to understand and meet the individual needs of the people who live at the home. They told us they regularly meet with the manager to discuss how they are working. The surveys were positive and it was evident people enjoy working at the home although three people did say the amount of paperwork had an impact on their work. A member of staff that has recently started working at the home talked about the recruitment and induction process. They confirmed that they attended an interview, and had to wait for a criminal records check and satisfactory references before they could start work. They also discussed the induction process which they said was very good. All staff surveys said their employer carried out checks, such as their CRB and references, before they started work. We looked at staff files for three people that had recently started working at the home. All the information that is required as part of the recruitment process was available. We talked to staff about training and looked at the training records. Staff said training was ‘very good’ and the management team and Anchor encourage staff to ‘do as much training as they can’. Training records confirmed staff have completed a good range of training courses, including back care, rights and responsibilities, health and safety, service user plan training, dining with dignity and introduction to dementia. Fifteen out of thirty nine staff have completed their NVQ (National Vocational Qualification) level 2 in care or above. Other staff are also working towards this. Four senior staff have qualified as NVQ assessors which will give staff more opportunities for doing the NVQ. We identified that food hygiene training records were not up to date. It was not clear which staff had completed the training but it was evident some had not. The deputy manager said they would organise some food hygiene training and make sure all staff have completed the training. Firth House DS0000007957.V368824.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, 32, 33, 35 & 38 People who use the service experience excellent quality outcomes in this area. The home is very well managed. The high standard of care that is provided in the home is strongly influenced by the management team. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home has an experienced and qualified registered manager who has completed the Registered Managers Award. People told us the home is well managed. One person who lives at the home said, “Everything is very organised.” A staff member said, “The management is good, it’s a good home because we all have the same approach to our work.” Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 23 Another staff member said, “We always check things out with the management, they are very good and patient.” Staff also said they receive good support from Anchor. We looked at personal allowance records. All financial transactions were recorded and receipts were obtained for any purchases made. In the AQAA the manager said, “Getting the views of the people who use our service is really important to us.” They told us they have monthly ‘residents and relative’ meetings and send out surveys every six months. They said they have made some changes because they have listened to people, which includes a more structured activity programme and a summerhouse and a pathway allowing people who live at the home to have full access to the garden areas. They received twenty-three service user surveys and fifteen relative surveys in June 2008. This information was still being analysed at the time of our visit. ‘Resident and relative’ meetings are held once a month. At least once a month a representative from the organisation should visit the home to make sure it is being properly managed. We looked at the reports from the visits and these confirmed the home is being monitored. However, the visits have not been carried out as often as they should be. Reports were only available for May 2007, November 2007, June 2008 and July 2008. The deputy manager said the visits are now taking place on a regular basis because a new area manager is in post. We looked at incident/accident records. Details of events were well documented. One person told us they had recently fallen. We checked the accident record and this was recorded. The person who recorded the event had also identified how they could prevent the same from happening again. The manager tells us about important events that happen at the home. Since the last inspection we have received regulation notifications when significant events have occurred. No concerns around safe working practices were seen on the day of the inspection. In the AQAA the manager said equipment has been serviced or tested as recommended by the manufacturer or regulatory body. We checked when fire equipment was serviced and this corresponded with what had been written in the AQAA. Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 24 Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 X X 3 Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 OP7 OP9 OP30 Good Practice Recommendations Risk assessments for people who smoke in their rooms should reflect the action taken. This will make sure everyone understands how risks are minimised. Cabinets that house medical ointments, creams and external applications should be kept locked. This will help make sure people are safe. All staff should receive safe handling of food training and this should be recorded. This will make sure food that is served is safe to eat. Firth House DS0000007957.V368824.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Firth House DS0000007957.V368824.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!