Inspection on 10/09/07 for George Basterfield House

This inspection was carried out on 10th September 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

George Basterfield House 12/06/06

George Basterfield House 09/01/06

George Basterfield House 29/06/05

George Basterfield House 11/11/04

George Basterfield House 19/05/04

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

CARE HOMES FOR OLDER PEOPLE George Basterfield House Risedale Road Barrow in Furness Cumbria LA13 9BZ Lead Inspector Marian Whittam Unannounced Inspection 10th September 2007 10:00 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 George Basterfield House DS0000035198.V344372.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. George Basterfield House DS0000035198.V344372.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service George Basterfield House Address Risedale Road Barrow in Furness Cumbria LA13 9BZ 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) 01229 894549 julie.lowery@cumbriacc.gov.uk www.cumbriacare.org.uk Cumbria Care Mrs Julie Bernadette Lowery Care Home 35 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (35) of places George Basterfield House DS0000035198.V344372.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home is registered for a maximum of 35 service users to include: - up to 35 service users in the category of OP (old age not falling within any other category) - up to 16 service users in the category of DE(E) (Dementia over 65 years of age) The staffing levels in the home must meet the Residential Forum Care Staffing Formula for Older Adults. When single rooms of less than 12 sqm usable floor space become available they must not be used to accommodate wheelchair users and where existing wheelchair users are in bedrooms of less than 12 sqm they must be given the opportunity to move to a larger room when one becomes available. 12th June 2006 3. 4. Date of last inspection Brief Description of the Service: George Basterfield House is a care home registered to provide care for 35 residents, including 16 with dementia. The home is in a residential area of Barrow in Furness, close to the local park, leisure centre, shops, post office, public houses and other amenities. The home is on a bus route and is about half a mile from the town centre. The home is on two floors and has a passenger lift for residents .All the bedrooms in the home are single occupancy and 3 have en suite facilities. The home is divided into individual units, Linden and Elmview are EMI units and Ashlea and Oakdale are for physically frail residents. Each unit has its own non smoking lounge, kitchen and dining area in addition to the large communal lounge on the ground floor and the ground floor lounge used by service users who wanted to smoke. The home has secure garden areas that residents may use. Information is available to prospective residents in the combined Statement of purpose and service users guide; this is available and displayed in the home and is available in different formats. A copy of the last inspection report is available. The fees charged by the home range from £363.00 to £422.00 per week as at the date of the inspection and an additional charge is made for personal toiletries, newspapers, magazines, also hairdressing, chiropody services and any personal travel expenses, according to information provided by the home. George Basterfield House DS0000035198.V344372.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit, that forms part of a key inspection, took place over seven hours. Time was spent looking around the home observing routines and staff interaction, talking with residents in the lounges and in their own bedrooms, speaking to the care staff, observing any activities in progress and looking at care plans. An assessment of medication handling was done through inspection of relevant documents, storage and meeting with the staff and residents. Policies and procedures, systems for recording complaints, financial records and personnel and training records were looked at in the afternoon as well as other records required by regulation. Before the visit information was also gathered on the service from records of previous visits, notifications and other regulatory activities including concerns and complaints raised with CSCI by people coming into contact with the service. Questionnaires about the service from residents, relatives, medical professionals and other agencies, provided by CSCI, were returned before the inspection took place. Issues raised in these were looked at during the visit. What the service does well: The home provides a comfortable and homely atmosphere and residents and people living there are able to bring in their own things from home such as pictures, ornaments and suitable items of furniture to make their rooms more homely and personal. Everyone coming to live in the home is assessed before they come to the home to see if their needs can be met. Residents spoke well of the staff and senior staff and generally liked the staff team and said they listened to what they had to say. The staff were observed to have a good rapport with residents and their approaches to residents were friendly and informal. Throughout the day the inspector saw that staff and residents got on well together and that residents individuality and choices were respected. There are robust recruitment procedures for staff and the thoroughness of pre employment checks helps to safeguard the welfare of people living in the home. The service has safe systems for administration of medicines. There are good protocols for the administration of “when required” medication so that they are given only when residents need them promoting their health and well being. George Basterfield House DS0000035198.V344372.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although overall medication handling is good care must be taken to make sure that all medicines received into the home, from whatever source, are always accurately recorded so all a person’s medicines can be accounted for. The manager recognises the value to residents of making care more personalised and for good practice should give consideration to making it clearer within personal plans how people living there are being involved in creating and developing their care plans. This would help planning care around personal perspectives on how people want to be supported and their independence maintained. Although efforts are being made to improve activities they need to be provided consistently and their availability not affected by staffing issues so people can rely on their individual recreational choices taking place. The manager should review their Protection of Vulnerable Adults (POVA) procedures to make sure they follow multi agency good practice guidance and local protocols to protect residents from abuse. The manager should also make sure that supervisors and staff deal sensitively and effectively with concerns raised with them to ensure relatives feel comfortable raising issues. Consideration should be given to better planning of staff levels to ensure staffing is organised to meet people’s clearly identified support needs rather than just around the number of staff on duty. George Basterfield House DS0000035198.V344372.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. George Basterfield House DS0000035198.V344372.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 George Basterfield House DS0000035198.V344372.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): NMS 1, 2, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an assessment procedure for people coming to live in the home and relevant information is provided to help people make an informed decision about coming to live there. EVIDENCE: The home has an up to date combined statement of purpose and service user guide, including resident views and the most recent inspection report, on display in the entrance hall. This document states the home’s aims, information on the environment and the level of service provision. Residents do not have their own personal copy given on admission; the document is kept on display and available from the office. Survey responses and conversations with people living in the home indicate that people feel they had enough George Basterfield House DS0000035198.V344372.R01.S.doc Version 5.2 Page 10 information about the home to help them choose before they came in. These documents are also available in different formats. Individual care plans show that before coming to live in the home the residents have there personal, health and social needs assessed. Assessments are done by social workers under care management arrangements and by the home manager or senior staff to try to ensure they are able to meet people’s individual needs. This information is used to develop individual care plans for people. Assessments are on going following admission and other agencies are involved in care and assessment. The home has an eight week introductory period followed by a full care review to make sure needs are being met and the home suits the resident. Residents are provided with terms and conditions of residency so they are aware of their rights and responsibilities George Basterfield House DS0000035198.V344372.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): NMS 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a care planning and assessment system in place that gives staff the information they need to meet resident’s individual health, personal, cultural and social care needs. EVIDENCE: All residents have an individual care plan, based on initial assessments and risk assessments, setting out assessed health, social and personal care needs and these are being reviewed and updated. The information provided covered areas such as a person’s mobility, diet, health needs, personal care and their social and religious preferences. Appropriate equipment to prevent pressure sores is in use, individual’s mental health is monitored and effective nutritional screening is being done and weights recorded. George Basterfield House DS0000035198.V344372.R01.S.doc Version 5.2 Page 12 Specific healthcare needs are being identified during the assessment. This information ensures the staff are aware of the level of care required to meet the different needs. Residents say they have been involved in gathering the information in their plans and some people living there make their preferences and views on the running of the home clear themselves. The care plans are clear and reflect people’s personal care needs but the information on the care needed is largely from the caregiver’s perspective rather than the person receiving the care. For good practice a more individualised approach to a person’s care would be to include the person’s own perspective, where possible, on how they want to be supported, cared for and their independence promoted. This was discussed with the manager who appreciates the need for more person centred planning and is looking at how that may be developed within existing resources. Staff spoken with were aware of residents personal care needs and individual preferences and showed a familiarity and understanding of these. Observation during the inspection, checking of records of care planning and conversations with residents suggests that they feel they are treated as individuals and their privacy respected. We looked at the medication procedures and found that the residents are protected by safe systems for handling and administering medication and keeps good records of medicines it administers to residents. Staff are being given training on medication administration and handling. Although there were some examples of good practice in recording there was an occasion when a medicine received into the home had not been checked and quantities recorded on receipt. Therefore there was not a complete audit trail of that medication to follow to account for its administration and the discrepancy in the amount in stock that was found. Medicines received, from whatever source, must be recorded so all a person’s medicines can be accounted for. There are protocols for the administration of “when required” medications so that they are given only when residents need them. We also checked the procedure for recording any controlled drugs that may be prescribed and found these to be correctly and safely maintained. Residents’ doctors often confirmed changes to medication in writing so that staff had clear instructions and this helps reduce the risk of errors. George Basterfield House DS0000035198.V344372.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): NMS 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service have a choice of food and opportunities for recreation are generally being provided for them as resources allow. EVIDENCE: The home encourages relatives and friends to visit and residents say there are no restrictions on when people can visit them. Care plans have information about people’s preferred social and religious activities and some useful personal profiles. This is valuable information that could be used more effectively in promoting an individuals perspective on opportunities for recreation particularly for those who have difficulty communicating their thoughts and feelings. The manager is aware of the need to provide recreational opportunities tailored to an individuals preference and capabilities as well as group activities. The manager and staff are continuing to develop their activities programme within the resources they have. The manager has organised the rotas to try to give time for an extra carer to do more one to one activities. A record is kept of the individual activities people take part in. George Basterfield House DS0000035198.V344372.R01.S.doc Version 5.2 Page 14 People have until recently been able to do individual activities such as baking, painting and shopping and the residents doing this confirmed how much they had enjoyed it. Some residents and relatives survey responses and comments indicated that activities sometimes did not happen when the home was short staffed. The activities record showed that individual activities had not been taking place as previously during recent staff holidays and sickness when staff had been stretched. There is a need to maintain consistency when offering individual recreation and leisure opportunities that is not affected by staffing issues. This inconsistency undermines the good work that the staff and manager have been doing to give more choice on recreation. The home has been successful in encouraging wider community links with local schools and residents as well as local churches. More trips out are being organised although some residents commented that it was disappointing that when staff “went to the trouble of organising something people don’t turn up to go”. Another resident said that “staff try to encourage involvement between the residents with bingo and things but unfortunately a lot of them can’t be bothered joining in”. There is a four weekly menu in place and menus are available in large print on the units. Minutes of resident’s meeting show that food and activities are both discussed at their meetings and that ideas are passed back to the cook and suggestions are acted upon. At the meeting there was a request for bacon, eggs and waffles and this is now on the menu for tea. One resident said they always had a cooked breakfast when they wanted it, which they enjoyed. Although some surveys suggested a lack of variety in the food provided residents spoken with said there was always a choice and alternatives, for instance one person said they did not like beans on toast for tea and staff got them a salad instead. Information is available within the home on advocacy services and how to get help dealing with pension or financial problems. George Basterfield House DS0000035198.V344372.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): NMS 16, 17 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is an accessible complaints procedure and adult protection procedures are in place although not always fully followed to ensure resident’s best interests are promoted. EVIDENCE: Since the last inspection the home has referred one Safeguarding Adults incident and this is being investigated and addressed by the home manager with other relevant agencies. The home has recorded one complaint made to them, which they have investigated and recorded and the Commission for Social Care inspection (CSCI) has not received any other concerns. There are suitable procedures in place for dealing with complaints although some residents and relatives were not aware of it. The complaints policy and procedure is in the guide for the people using this service and there is also a copy on display. The service has internal policies and procedures for the Protection of Vulnerable Adults (POVA) and a copy of the Local Authority’s procedure was also seen to be available and information on whistle blowing. However the recent safeguarding issue has highlighted that the multi agency guidance and local protocols are not always fully followed with regard to POVA provisional George Basterfield House DS0000035198.V344372.R01.S.doc Version 5.2 Page 16 listing. Training is given on adult protection and preventing abuse to the care staff. Survey responses and comments from people living in the home indicated that some are not clear about how to make a complaint although people generally said they felt that staff listened to what they had to say. Although one person did say it often took along time to get things done when they were brought up. Some relatives surveys indicated that they were not always satisfied with the way their concerns were handled by senior staff and one felt that when they had raised a complaint felt “damned if you do” as staff ”went for me”. Clearly that response does not encourage people to raise matters. Surveys from local GPs indicate the home has always responded to any concerns raised by them. There is information on advocacy and two residents had used the services of an advocate to help them fill out their questionnaires. The home did not deal with any resident’s personal finances only small amounts of spending money for safekeeping and practices and procedures are in place to protect resident’s financial interests. An external financial audit by Cumbria care was taking place during the visit. Discussions with the auditors indicated all was in good order. George Basterfield House DS0000035198.V344372.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): NMS 19, 20, 21, 22, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a comfortable and homely living environment. The premises are reasonably well maintained and kept to a good standard of cleanliness. EVIDENCE: There is a programme of maintenance and improvement for the home although not all work planned for the last financial year went ahead and is being carried over to this year. This was evident most in the general appearance of the home such as damaged paintwork and wallpaper needing attention. The plan includes new carpets in 4 bedrooms and redecoration of the manager’s office and kitchen and 2 of the staircases. George Basterfield House DS0000035198.V344372.R01.S.doc Version 5.2 Page 18 The home does not have a dedicated maintenance person on site and the manager and staff do the required safety checks. Some relative’s survey responses indicated that minor maintenance could take a long time to get attended to. The grounds are tidy and one person living there said they had liked gardening so particularly enjoyed sitting outside when the weather was good and seeing the flowers. The dining and lounge areas on the units are clean, homely and well decorated and used for daily activities and some residents were sitting in them reading their papers, knitting and watching television. There are telephone facilities available for residents to use. All bedrooms are single rooms and vary in size and furnishings with some people bringing in their own possessions to make their rooms more personal and homely. There are separate toilets close by resident’s rooms and bathrooms with assisted bathing aids and some bedrooms have en suite toilets. There are suitable adaptations inside the home for wheelchair users and moving and handling equipment is in place to make people comfortable, safe and promote their independence. Call bells are in resident’s bedrooms, toilets, bathrooms and communal areas. There are infection control procedures in place in the home and staff were observed using protective aprons and gloves where needed. Training records indicate that staff are being given training on infection control and there is now a link worker for this There is a small laundry and sluice areas on each floor and care staff on the units are responsible for doing the laundry and taking it back to residents. The home was generally clean and tidy with no unpleasant smells. George Basterfield House DS0000035198.V344372.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): NMS 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are effective recruitment procedures being followed to safeguard residents and appropriately trained staff offering care to people living in the home. EVIDENCE: The inspector discussed the staffing arrangements with the manager in the light of the current staff shortages indicated on the rotas and commented on by staff and relatives. These are due, in the most part to staff sickness at a peak time for staff holidays. Existing staff are working covering to ensure levels of staff do not fall dangerously low but the manager has still had to use agency staff at times. During the visit an agency staff member who had not worked on that unit before was working alone on Linden unit where 6 people with dementia live. By moving staff around during the course of the day it was seen that the manager keeps staffing levels at an adequate level but this is not good for continuity of care or meeting individual needs. It was evident staff levels are not being arranged around meeting individual outcomes for people more to meet basic care needs and keep them safe. Surveys and comments from residents and relatives indicated that low staff levels continue to be a problem. One person said “the shortage of activities lets George Basterfield House DS0000035198.V344372.R01.S.doc Version 5.2 Page 20 the home down but I realise this doesn’t happen because of the shortage of staff”. A relative felt staff levels were often low at weekends and the rotas for the preceding weekend showed that levels were down. The supervisor had to work as a carer as well as do their own job to try to keep staff levels safe. A resident said, “unfortunately the home is very understaffed but what staff are there work very hard to help us.” Training is being well supported in the home and is being planned and organised to make sure mandatory training is up to date and individual training needs prioritised. NVQ training courses are well established with 50 of staff achieving level 2 or 3 and several staff are still doing the course. All staff have individual professional development files recording their training and development. There are clear recruitment and selection procedures being followed and overseen by the manager. Application forms are completed, references taken up and interviews arranged. Records show that new staff are appointed and begin work only after all the required legal checks have been completed and that they have a period of induction training. George Basterfield House DS0000035198.V344372.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): NMS 31, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service live in a home that is well managed and run in their best interests. EVIDENCE: The home has an experienced manager in post who is registered with the Commission for Social Care Inspection and has completed the Registered Managers Award although she is still awaiting verification of completion. The manager is clear about her role and responsibilities and the ways in which the service can continue to develop and improve for people living there given the budgets she works within. George Basterfield House DS0000035198.V344372.R01.S.doc Version 5.2 Page 22 There are records of residents meetings taking place in the home, the topics residents wish to discuss and minutes of the meetings. The home is doing satisfaction surveys for residents and families to get feedback. Regular staff meetings allow staff the chance to raise issues for discussion, there are internal reviews of policies and procedures and staff appraisals and supervision are being done. There is a development plan for the home within the overall organisational plan setting targets and objectives. Staff spoken with found that the manager was approachable and supported them in their roles and training. The standard of record keeping and organisation of information is generally satisfactory. Policies and procedures are in place to protect resident’s financial interests and to safeguard spending money given to the home for safekeeping. Financial records and practices were being assessed and audited by Cumbria Care’s own auditors on the day of the visit and these systems were found to be in good order by the auditors. There are health and safety procedures in place to promote the interests and safety of residents and records of fire and other mandatory training, fire drills, equipment, electrical testing and gas service testing and the servicing of equipment and appliances under service agreements. The home’s fire risk assessments have been reviewed in line with changes in fire regulations. George Basterfield House DS0000035198.V344372.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 3 X X 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 George Basterfield House DS0000035198.V344372.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement All medicines received into the home, from whatever source, must be accurately recorded so all a person’s medicines can be accounted for. Timescale for action 30/09/07 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 Consideration should be given to making it clear within personal plans how people living there are being actively involved in creating and developing their care plans and their personal perspectives on how they want to be supported and their independence maintained. The registered persons should provide consistent leisure and recreational that are not affected by staffing issues so people can rely on individual recreational choices taking place. The manager should make sure that supervisors and staff deal sensitively and effectively with concerns raised with them to ensure complainants feel comfortable raising DS0000035198.V344372.R01.S.doc Version 5.2 Page 25 2. OP12 3. OP16 George Basterfield House 4. OP18 5. OP27 issues. The manager should review their Protection of Vulnerable Adults (POVA) procedures to make sure they follow multi agency good practice guidance and local protocols to protect residents. Consideration should be given to better planning to ensure staffing to meet clearly identified support needs rather than just staffing number requirements. George Basterfield House DS0000035198.V344372.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 George Basterfield House DS0000035198.V344372.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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