Inspection on 15/08/07 for Five Stacks Residential Home

This inspection was carried out on 15th August 2007.

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

Five Stacks Residential Home 20/09/06

Five Stacks Residential Home 07/02/06

Five Stacks Residential Home 06/07/05

Five Stacks Residential Home 21/03/05

Five Stacks Residential Home 25/06/04

Similar services:

Claremont House

Firstlings

Fen Road

Dial House Nursing Home

Croxley House

Eversley Nursing Home

Cresta Lodge

Chilton Meadows Residential & Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Five Stacks Residential Home 209 Point Clear Road St Osyth Clacton on Sea Essex CO16 8JD Lead Inspector Sara Naylor-Wild Key Unannounced Inspection 15th August 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 Five Stacks Residential Home DS0000017941.V349126.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. Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Five Stacks Residential Home Address 209 Point Clear Road St Osyth Clacton on Sea Essex CO16 8JD 01255 820417 01255 820417 fivestacks@tinyworld.co.uk 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) Mr John Sidney Donhou Mrs Diane Howard Care Home 17 Category(ies) of Dementia - over 65 years of age (17) registration, with number of places Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 17 persons) The registered person shall ensure that a continuing programme of development is provided for managers and staff in relation to dementia care and good practice, equivalent to the recommendations of the Alzheimer’s Society The registered person shall keep under review the provision of additional communal living space to meet the assessed needs of service users The registered person shall ensure that staff provision is increased to meet the needs of planned admissions of service users 3rd October 2002 3. 4. Date of last inspection Brief Description of the Service: Five Stacks Rest Home is a former family dwelling house that has been extended and improved to form the present accommodation. The detached house is located within a residential area. The accommodation is within both single and twin occupied bedrooms on the ground and first floor. There is a passenger lift available. The communal space is ample, there being a main lounge area and a kitchen/dining room. The decoration, furniture and fittings were of a high standard and the whole house represents a comfortable living environment. The front of the property has been laid to hard standing but is enclosed by attractive trees and shrubs. The rear garden is large and features an enclosed swimming pool and sun terrace with extensive lawns. The garden is also enclosed with attractive trees and shrubs The home changed registered category of care to Older People Dementia Care in 2004. There were conditions attached to the registration that required the home to continue to review and develop the accommodation and staff training in dementia care. Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report includes the unannounced inspection site visits on 15th August 2007 and 17th August 2007. The evidence contained in this report was gathered from discussion with managers, staff and relatives visiting the home, observation of residents interaction, questionnaires completed by residents relatives and professionals visiting the home and information contained in the Annual Quality Assurance Assessment (AQAA) provided to the Commission for Social Care Inspection (CSCI). Ms Diane Howard, the Registered Manager and the other members of the management team, Joanne and Samantha, assisted the inspector at the site visit. Feedback on findings was given to them during the visit with the opportunity for discussion or clarification. The inspector would like to thank the Ms Howard, the management and staff team, residents, relatives and visiting professionals for their help throughout the inspection process. What the service does well: This is primarily a family based service with the proprietor in daily contact and both his daughters working in the management team. The ethos of the service has always been to provide a standard that the proprietor and his family would be proud to use themselves. This ethic has been added to over recent years by the developments in meeting the Care Homes Regulations 2001 and the service has as a whole always strived to improve its position from previous years The coalition between the management team has strengthened the service delivery and allowed members to develop their strengths and skills. The attitude and approach of the staff towards service users living at the home is not only kind but also respectful. They carry out their duties in a calm and relaxed manner that permeates the whole home. There is a strong emphasis on person centred care in the organisation of the staffs working day, with priority being given to spending time with service users particularly in social activities. The premises are maintained to a high standard and provide accommodation that supports residents’ needs. Activities form an integral part of the daily routine of the home and provide residents with diversion and occupation. Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 6 The number of staff who holds a recognised qualification has been steadily increasing and supports the quality of care support provided at the home. What has improved since the last inspection? What they could do better: The information provided in the AQAA should be considered to ensure it provides the most comprehensive details to assist the Commission in understanding how the registered persons understand the service strengths and weaknesses and where they will address these. The continued development of the quality of care planning documentation would be beneficial to the service. The way in which the quality assurance programme provides anonymity and gains insight into the residents’ viewpoints. Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 7 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. Five Stacks Residential Home DS0000017941.V349126.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 Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are informed about the service and can be confident the service understands how best to support them at admission. EVIDENCE: The statement of purpose has not been altered since the last inspection and there have not been any changes in the service or the way it operates that would prompt this. The management team were advised to keep this document under review and ensure that it continues to represent the way in which the service operates. The relative of a resident spoken with during the inspection was clear that they had received information about the home prior to their family member’s admission via a service users guide and had been able to visit the home on several occasions as part of the admission process. Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 10 The format of the initial needs assessment for prospective residents is made up of commentary boxes against all the outcome groups in daily living such as mobility, continence and social needs. The completed versions seen on residents’ files contained indications of the overall level of need of the individual, so for example they stated that a resident required assistance with their personal care. This would assist the service to understand what areas of support were required. As a point of quality development the documents did not always provide details of how this is manifested. This would assist staff to understand to what extent individuals were they able to meet their own needs and how much they would requires intervention from others. The greater the information contained in the document the more able the service is to understand if any equipment or additional resources and skills were required and therefore prepare a more successful admission for the prospective resident. This was discussed with the manager and management team and areas of good practice were identified in other elements of the document The service does not offer intermediate care. Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that staff understand how to support them consistently. EVIDENCE: The files of the same residents were read to consider how the service uses care planning to support residents. The files are headed by a full-page description of the residents past and present life and gives an overview of their strengths and needs. The actual care-planning documents contained reference to each of the daily living tasks and these were set out with needs, goals and action identified. The entries provide an outline of the individuals’ needs and how staff should support these. The descriptions in some plans were not person centred and tended to concentrate on a list of the problems first and an end statement that was more positive in reference to the individuals’ abilities. Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 12 The inspector was shown a separate sheet that had been devised from a piece of quality assurance work in relation to meal times. These contained a good level of person centred descriptions of individual residents abilities at mealtimes and how staff should offer support. These were held in the kitchen as reference for staff serving meals however the management team were advised to ensure this document was included in the care planning for residents and to consider how the descriptive style of these documents could be used as a basis for reviewing other areas of their care plan. In all cases the care plans were reviewed regularly and updated information was added although in some cases the actual care plan instructions had been superseded by entries indicating that no change was required. The manager was advised to review this practice of recording. Residents’ records relating to health care visits and instructions in meeting health care needs were included in the care planning document and where appropriate record of issues such as fluid intake and weight were monitored. The administration of residents’ medication was observed at this inspection visit. The service operates a monitored dosage system (MDS) for permanent residents. The pharmacist makes this up and has accompanying computer generated records of the prescription instructions for each drug the resident takes. Residents who are staying on a respite arrangement would not be included in this system and therefore staff complete handwritten records at the individuals admission. These contain the name of medication, their strength and the dosage to be taken. Both sets of records were up to date and maintained appropriately. The observation of staff giving out medication demonstrated a competent adherence to the current pharmaceutical guidance. Staff who are responsible for dispensing medications have all undertaken a competency based medication course. The service has a written procedure for staff to follow in relation to the care of residents who are dying. The compliments book pays tribute to the way in which they have attended to this and contains the following:” my relative was always treated with respect and individual care and attention. Thanks as well for the attention given to relatives in the last hours of the residents’ life when staff supported them with nutrition needs and emotional needs.” Five Stacks Residential Home DS0000017941.V349126.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 good. This judgement has been made using available evidence including a visit to this service. Residents can expect the service to provide opportunities for stimulation and occupation that suits their abilities and preferences. EVIDENCE: The service continues to demonstrate a commitment to offering residents opportunities for fulfilment and occupation. The notice boards in the home advertise a weekly activities planner. This planner is used as a basis for the staff to undertake activities although flexibility is used so for example on the day of the inspection visit the planned quiz was not working due to the residents attention on that day, this was changed to a sing along and continued. The service had appointed an Activities coordinator since the last inspection with a lead in coordinating and collating ideas for activities and documenting how successfully residents respond to activities on offer as well as gaining insight into their past interests. Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 14 These records will assist the home in understanding how successfully the provision has been delivered and support the planning of future activity initiatives such as the development of an allotment area in the gardens in a response to a resident’s horticultural background. The team have developed some innovative thinking in providing activities such as the use of current IT memory games and old style games such as a beetle drive. Verbal feedback from relatives provided to the inspector and in quality assurance responses demonstrates that relatives see the way in which the service occupies and stimulates residents is seen as a key part of their success in caring for residents. Relatives were seen visiting frequently during the inspection of the home. Those spoken with were confident about the way in which their involvement was welcomed by the home and saw their role as a partnership with the staff group in supporting the resident. The meals are all home cooked and a printed menu is available for residents who can access this to chose their meals. The staff also employs a use of visual prompting in helping residents to choose meals by presenting plated meals for residents to make a choice from. The service recently conducted a quality service audit with residents that concentrated on mealtimes. They carried out a trial in which residents were encouraged to help themselves to the vegetables for each meal from serving bowls placed at their table. The way in which residents responded to this and how this affected their intake of vegetables from their normal diet was recorded over a period. At the end of the trial the staff had identified to what extent the opportunity for choice was helpful to residents and to what level they should support them in making the choices. This was a good piece of person centred work that has given the staff insight into the individual as well as providing opportunities for dignity and respect at meal times. Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that their views will be listened to and acted upon. EVIDENCE: The services complaints policy had not been changed and continues to meet the National Minimum Standard (NMS). Staff were aware of the complaint procedures to be followed if a concern was brought to their attention. The relatives spoken with at this inspection visit were aware of the policy and procedures and were confident that the service would resolve issues they brought up. There is a log maintained of all complaints and compliments received in the home. No complaints have been recorded in the previous 12 months. There is further work to do in ensuring that those residents with cognitive impairments are able to make their views known, and this was discussed with the manager as a point of development for a service that offers a specialist support to people with dementia. Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 16 However other initiatives have been made in ensuring that anyone living, working or visiting the home can make their views known. This has been through the placing of a communications book in each residents bedroom, and the instructions on the front of the book invites people to make their observations and views known by completing the book, which is read by the senior care staff at the end of each day. A relative spoken with said they used the book and had found this to be a useful medium for raising minor issues and passing on compliments. The home has a Safeguarding adults policy and the staff have all been trained in recognising and reporting signs of abuse. Five Stacks Residential Home DS0000017941.V349126.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, 20, 21, 22, 23, 24, 25 & 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents benefit from an environment that is suited to their needs. EVIDENCE: The environment is maintained to a high standard, with updating of décor and furnishings as required. The manager was aware of the ongoing maintenance plan although there was not a written document. The new wing of three bedrooms and communal space was now fully occupied and residents were observed using the quiet area provided throughout the inspection. Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 18 The décor in the home is low key and pale, although some use of colour has been made in identifying toilet and bathroom doors for residents with cognitive impairments. There are also photos placed on doors to help residents identify the use or occupier of the room. The use of colours and signage are recommended good practice in supporting independence in dementia The home continues to benefit from a large garden and service users were using the facility on the day of inspection. The proprietor and management team outlined the planned landscaping of the back garden to provide a solid footpath around the whole garden with seating areas spread out along its path. This had been raised by relatives of the residents in a quality assurance feedback and formed part of the services improvement plans for the coming year. This it was hoped would provide a stable footing for residents and encourage them to utilise the garden more. Residents’ bedrooms were decorated in a personal way with their won furnishings and decorative items if they wished. Five Stacks Residential Home DS0000017941.V349126.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident that the staff that have sufficient skills to support them. EVIDENCE: The staff rota on the day of the inspection visit denoted 3 care staff plus housekeepers, cooks and administrative staff. These numbers were reached following a calculation of the staffing ratios using the residential forum. This tool compares the assessed dependency of the residents living at the home and the numbers of staffing hours required to meet these. From observation on the day of the inspection visit, there seemed to by sufficient numbers of staff to provide an unhurried and calm approach to supporting residents. A sample of Staff files was examined during the course of the inspection visit and these contained appropriate levels of documents to demonstrate the service operates a robust recruitment procedure. The cross-referencing of the documents and information provided by candidates would assist the home in protecting service users from unsuitable candidates to work in a care setting. Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 20 The staff training programme was ongoing and a matrix of training staff currently hold was available in the staff room. This provides both staff and managers with an at a glance understanding of when qualifications have become outdated and where staff have gaps in their skills and development. The training plan provided staff with courses to give them skills in health and safety issues such as fire safety training, food handling and moving and handling. In addition there were dementia courses and NVQ qualification courses undertaken. The development of individual training profiles that use information gathered from supervision and residents needs assessments would further enhance the skills base of the service. The AQAA the service provided to the Commission indicated that 10 of the current 15 care staff held an NVQ level 2 or above, with two other staff taking the course. This exceeds the NMS of 50 of staff holding a recognised qualification. Five Stacks Residential Home DS0000017941.V349126.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, 32, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives can be confident in the operation of the service and the leadership provided by the management team. EVIDENCE: The management tasks have been reviewed and shared between the Management team made up of the registered manager and the two administrators. This arrangement not only makes better use of the time available to the manager, but also utilises the skills and strengths shared in this team. Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 22 One of the administrators for example had implemented the quality assurance programme and carried out the mealtime audit, while another was instrumental in developing the culture and ethos in the home. This provided opportunity for the manager to concentrate on skills and development of the staff team through supervision and training. There is continuing evolvement planned with the senior care staff taking a lead in areas of the homes development. The service holds monies on behalf of some residents and the records for these were checked at this visit. They demonstrated a robust system of auditing and provided evidence of both income and expenditure with associated receipts. Some items of value were also held on behalf of residents such as jewellery and keys. These were not documented and the manager was advised to do this and ensure they were kept separately from the monies. The service has a quality assurance system in place and has conducted an audit by issuing questionnaires to relatives, health professionals and staff. All the responses were held on file, people had taken trouble to complete them with a lot of detail and provided the service with very positive feedback. Comments include: Staff: very good communication between staff and management with a happy working atmosphere, happy with training on offer and always new courses to do, if we need something new management gets it within a few days. 10/10 management is very friendly, a comment made about the roles of senior carers when there is more than one on a shift and they are in a carer role. Another states that seniors spend too much time in the office and that communication is poor between management and senior to carers although carers and cooks and cleaners communicate well. Another states a bath hoist could be used for some residents. Professionals: cooperation from staff is first class, fives stacks is a well-run clean home where the service user are well cared for and happy. Overall we feel this is a caring and well-run residential home. All staff are very helpful and the highest quality of service is given to residents. Staff were helpful polite and welcoming it has been a real pleasure working with the staff and resident at five stacks we look forward to having more involvement in the future Next of Kin: you treat each person as a human being and attend to their needs mental and physically as well as a patient your place is treated as a hotel not a home. I cannot see where you can improve either in care or kindness. You are very good at spotting a need and giving spontaneous one to one Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 23 attention. You create a pleasant and welcoming atmosphere I am always without exception made so welcome lots of smiles. I cannot think of anything that I would wish to see more of. An atmosphere of care and compassion permeates the home, which reflects considerable credit on management and staff. We like the way mealtimes are organised good home cooking and a very nice dining room to socialise when eating perhaps more outings would benefit the whole group Other comments included suggestions about the use of the garden and outings. The questionnaires were all named by the person completing the form, and although the service had provided the option of remaining anonymous this does not fully conform to the accepted understanding of the purpose of a quality assurance system. Quality assurance systems are intended to gain information anonymously in order to understand the difference between expected and actual performance of the services processes to identify opportunities for improvement. It is not the aim to deal with individual issues that should utilise the complaints processes. Discussions took place with the member of the management team responsible for this area of development at the visit. The services Quality assurance policy states that an annual development plan for quality improvement will be drawn up as part of the business plan and based upon feedback from service users, staff, relatives plan will be costed and focus upon specific measurable standards and will include named staff as responsible for each objective. It also states that results of surveys will be confidential but the results will be published and distributed to all residents. Following the inspection the Commission was provided with the services audit and action plan in response to the questionnaires. This provided a general outcome for each area and the efforts the service will make to continue improvement. How this fits into the actual business plan was not clear in the document and is an area of development for the service. In addition to this work each residents room also contains a comments book with an invitation to residents and relatives to use this for suggestions or comments on the way the home looks and feels. This is checked on a daily basis by senior staff. A relative spoken with said they had found this a very useful method of communication and used it regularly. Residents were consulted via the coffee mornings and one to one discussions were appropriate, and records were maintained of these and added to the quality records held. As a service with a specialist category of care for Dementia there needs to be an ongoing consideration of how the residents Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 24 with cognitive impairments are able to contribute to the quality assurance information. All staff were offered one to one supervision and records relating to their discussion are kept on their file. Issues in relation to conduct and development are covered in these sessions and this was demonstrated in the sample of documents seen at the inspection. The records relating to health and safety of equipment and systems operating in the home were examined and those including fire safety, annual maintenance of lifts and moving and handling equipment and electrical safety were in date. The service has conducted an intensive piece of work in relation to fire safety in which they have accounted for each residents escape plan in the event of a fire. This includes the times taken to reach both internal and external evacuation sites and the way in which this should be supported. The information forms part of the service Fire Safety risk assessment and provides a very comprehensive understanding to staff in an emergency situation. Five Stacks Residential Home DS0000017941.V349126.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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 X 3 Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 Refer to Standard OP7 Good Practice Recommendations Residents strengths and abilities in each are of daily living should form the basis from which care plans are written, this will support staff in both maintaining the respect for the individual and ensuring that they support the resident in a way that provides opportunities for independence. Quality monitoring should not identify the individual but gather information about the services performance against the objectives contained in the Statement of purpose. 2. OP33 Five Stacks Residential Home DS0000017941.V349126.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Five Stacks Residential Home DS0000017941.V349126.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. 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