Inspection on 06/09/07 for George Hythe House

This inspection was carried out on 6th 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 Hythe House 02/09/09

George Hythe House 03/05/06

George Hythe House 30/01/06

George Hythe House 13/12/05

George Hythe House 19/04/05

George Hythe House 06/10/04

George Hythe House 22/04/04

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

CARE HOMES FOR OLDER PEOPLE George Hythe House 1 Croft Road Beaumont Leys Leicester Leicestershire LE4 1HA Lead Inspector Diane Butler Key Unannounced Inspection 6th September 2007 09:15 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 Hythe House DS0000006386.V341496.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 Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service George Hythe House Address 1 Croft Road Beaumont Leys Leicester Leicestershire LE4 1HA 0116 2350944 0116 2366560 queensroad@lqha.co.uk/ georgehythehouse@lqha.co.uk www.leicesterquakerhousing.com Leicester Quaker Housing Association 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) Mrs Jeannette Evelyn Ewens Care Home 41 Category(ies) of Dementia - over 65 years of age (31), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (31), Old age, not falling within any other category (41), Physical disability over 65 years of age (41) George Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person to be admitted in categories MD(E) or DE(E) when 31 persons in total of these categories/combined categories are already accommodated. 3rd May 2006 Date of last inspection Brief Description of the Service: George Hythe House provides a service for 41 older people, some of whom have mental health needs, dementia and/or physical disabilities. The home was purpose built in 1993 and is owned and managed by the Leicester Quaker Housing Association. The accommodation is on two floors, which are served by a shaft lift. There are 41 single rooms, all of which have en-suite facilities. There is a large communal lounge on the ground floor and a smaller lounge on the first floor. The latter is used primarily as the focus for activity sessions. The home is divided into four wings, each having its own dining room and kitchen. One of the wings is dedicated to caring for people with dementia. There are attractive garden areas for residents and visitors to enjoy and ample parking is available at the front of the home. The wing dedicated to dementia care has its own secure garden for the residents to enjoy. Current fee levels at the home range from £327.00 to £567.00 per week. Details of all charges, including what is not covered in the fee above, can be found in the Information booklet and fee sheet which is given to all prospective and current residents. Inspection reports are available at the home, or can be accessed via the CSCI website: www.csci.org.uk. Further information about the home is available from the Registered Manager. George Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit, which took place over a seven and a half hour period on Wednesday 5th September 2007. The registered manager was on duty at the time of the inspection. When undertaking key inspections the Commission for Social Care Inspection (CSCI) focuses upon outcomes for residents and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting four residents and tracking the care they received through looking at their records, speaking with them when possible and discussion with staff on duty at the time of the visit. A further six residents and two relatives were spoken with during the site visit. A period of time was also spent observing both residents and staff to get a flavour of what life is like living at George Hythe House. Further planning for the site visit included checking the service history and last Inspection report and looking through the AQAA document (Annual Quality Assurance Assessment), which was submitted to the Commission for Social Care Inspection prior to the visit. Questionnaires were also sent to a selection of residents and their relatives to gain their views of the home. Comments received include: “I am very happy with the treatment my husband receives at the home. The carers are very kind and caring, the food is good and wholesome”. “I am looked after very well and the staff are very caring”. “As my relative suffers dementia and is not always easy to deal with, I feel the carers understand their feelings and treat them with kindness, respect and not confrontation. This works most times and when I visit usually every other day, without warning, their attitude and kindness is always the same”. What the service does well: George Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 6 George Hythe House provides residents with a safe and secure place to live. Resident’s needs are thoroughly assessed before moving into the home to ensure that their needs can be met. Choices are offered on a daily basis including when to get up and go to bed and what to eat and where and when to eat it. Privacy and dignity is maintained at all times and all residents spoken with confirmed that they were well cared for and their care and support needs were met. The registered manager is both supportive and approachable and families and friends are strongly encouraged to visit the residents living in the home. All new staff complete a period of induction and a staff handbook, which includes relevant policies and procedures, is given to all staff employed. A good programme of in-house activities is offered which includes musical evenings, craft sessions and indoor games. Outings and trips are also arranged. What has improved since the last inspection? What they could do better: Review all documentation to ensure all is fully completed, signed where applicable and relevant. Staff need to have up to date information to enable them to meet the residents needs. Provide regular planned activities both within the main area of the home and the dementia care wing when the activities organiser is away. Residents clearly benefit from the activities offered and miss them when they are not provided. Ensure that at all times there are sufficient numbers of staff on duty to meet the needs of the residents living in the home. George Hythe House DS0000006386.V341496.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 Hythe House DS0000006386.V341496.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 Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents needs are fully assessed prior to them moving into the home. EVIDENCE: A resident information booklet is in place. This document, which contains information about the home, is given to all prospective residents. Information contained in this document includes the philosophy and aims of George Hythe House, the routines and facilities offered and details of the complaints procedure should a resident have a concern about anything. Details of the current charges for living at the home are also given. A relative spoken with during the visit confirmed that they had received this information. George Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 10 The registered manager stated that all prospective residents are visited either in their own home or in hospital to carry out a needs assessment and to discuss what the home has to offer. Prospective residents and/or their relatives are also invited to look around the home, this enables them to get a flavour of life in the home and see what facilities the home offers. All residents spoken with stated that someone from the home had visited them before they moved into the home and that someone had been able to visit to make sure it was the right place for them. Comments received included: “Xxxx( team leader) and someone else visited me in the hospital”. “My daughter looked around and someone came to the hospital to see me”. “My daughter went round to about fifteen different homes and said that this one was the best”. On checking the files belonging to the four residents case tracked it was noted that all included a copy of the initial assessment. At the time of the visit George Hythe House was not providing intermediate care. George Hythe House DS0000006386.V341496.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are currently looked after well in respect of their health and personal care needs. EVIDENCE: On checking the files belonging to the four residents case tracked it was noted that three of the four had a care plan in place. The forth file, which belonged to a resident who had moved in four days previously had yet to be completed, this was acknowledged by the registered manager and actions were already being taken to find out why this had not been completed. It was acknowledged that a needs assessment was in place, which highlighted what help the resident needed and this would be used until the care plan was developed. The registered manager stated that the care plans were reviewed on a monthly basis by the resident’s key carer. George Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 12 On checking the files it was noted that the three care plans in place had been reviewed though one had not been reviewed since June. The registered manager stated that this would be reviewed straight the way. Risk assessments were in place for all the residents case tracked. These included assessments on moving and handling, slips trips and falls and pressure sores. On checking the file belonging to a resident who takes warfarin, (a medication which helps thin the blood) it was noted that a risk assessment had not been completed. The registered manager stated that this would be completed immediately. It was noted that not all documents had been signed or dated and not all had been fully completed. It was recommended that a review of all the documentation be carried out to ensure that all relevant paperwork is completed appropriately. The registered manager acknowledged this and stated that this would be carried out. On checking the daily records belonging to the service users case tracked it was evident that health care professionals were being involved in their care. These included the local GP’s, Dentist, Optician, chiropodist and the Community Psychiatric Nurse. One resident spoken with stated “I am on antibiotics, xxxx (the team leader) called the doctor yesterday for me”. A second resident explained that the dentist was visiting her the day following the visit. The medication records belonging to the residents case tracked were checked and were found to be in order however, it was noted that on two occasions medication had not been signed for as given. The registered manager acknowledged this and stated that this would be looked into. The inspector was informed that the registered manager audits the medication records every month to check for any mistakes in recording etc, (this was evident whilst checking the records), if issue arise a meeting is held with the staff member responsible and appropriate actions are taken to address the issue. All staff responsible for the administration of medication have completed safe handling of medicines training. All residents spoken with stated that their current care needs were being met and that they were treated with respect and cared for in a dignified manner. Comments received included: “Its very nice, we are looked after very well”. “The staff are very polite”. “The staff are treating me very well”. George Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 13 “I am very satisfied thank you”. “If you’ve got to be somewhere this is a nice place to be”. Interaction between residents and staff was extremely positive on the day of the visit with staff members speaking to residents and visitors in a respectful, friendly and supportive manner. George Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to make choices on a daily basis. EVIDENCE: Choices are offered on a daily basis including whether to stay in bed or get up, what and when to eat and whether or not to join in the activities provided. Comments received included: “I ring the bell when im awake and they come and help me up”. “You can eat in your own room if you want to”. “You can get up and go to bed when you want to”. George Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 15 A dedicated activities organiser is employed to provide activities and one to one sessions, however at the time of the visit this person was on long term sick. The registered manager explained that whilst without the activities organiser staff were providing activities whenever possible though this was not structured or formalised. All residents confirmed that activities are offered though currently not as often as they would like and during the visit no activity was offered. One resident explained, “We have activities every day when xxxx(the activities organiser) is here, though not so much whilst shes away”. Another resident stated, “I attend activities when shes here, they are providing a few activities whilst shes away, were going for a pub meal on Friday” Within the dedicated dementia wing activities are provided by the care workers though this is again on an informal basis. Through discussion with the residents case tracked it was evident that outings and trips are organised on a regular basis and all spoken with were looking forward to the pub meal arranged for the Friday following the visit. All residents spoken with stated that the food served in the home was very good. Choices are offered at every mealtime and drinks and snacks are available throughout the day. The cook meets with all residents on arrival at the home to find out their personal likes and dislikes and whether they have any special dietry needs. This information is then included in the residents care plan documentation. Family and friends are encouraged to visit. All residents spoken with stated that their relatives and visitors could visit at any time and relatives spoken with during the visit confirmed that they were made welcome and were able to visit whenever they wished. Comments received included: “The foods good, you get a choice, they come round with the menu”. “The food is very nice, most times any how”. “The food is very nice, I am putting on weight, im going to have to leave the puddings alone”. “I have no worries at all about living here and my daughter can come at anytime”. “Visitors can come at any time and they are always made welcome”. George Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: A complaints procedure is in place. A copy of this can be found on the notice board situated in the reception area of the home and details are also included in the Information booklet, which is given to all residents living at the home. All residents spoken with were aware of whom to talk to if they were concerned about anything and all were confident that any issues raised would be dealt with appropriately. One resident explained, “If you’ve got a problem we have a key worker and we just tell them or the manager, she’s very good”. A second resident stated, “I would talk to Jeanette [the manager] if I had to complain, she’s nice”. Information received prior to the visit stated that two complaints had been received since the last inspection in May last year. This was confirmed on speaking with the registered manager. These complaints, which included issues around a resident’s medication, care planning and accessibility of the residents call bell were appropriately investigated and where necessary, actions were taken to ensure that these issues do not arise again. George Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 17 The registered manager is aware of the procedures to follow with regard to the protection of the residents in her care and staff members spoken with were aware of the actions to take should they suspect any form of abuse. Abuse awareness training has been provided since the last inspection and a whistle blowing policy is in place. George Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 18 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): 19,20,21,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a clean and comfortable place to live. EVIDENCE: The areas of the home seen on this occasion were well maintained and suited to the residents needs. Decoration is of a good standard and furnishings in the communal areas are domestic in character and in good condition. The accommodation is provided within four wings, each wing offers a kitchen/dining area, which can accommodate up to ten residents and assisted bathing facilities are also provided. There is a large lounge on the ground floor and a smaller lounge on the first floor. At the time of the visit the main lounge on the ground floor was in the George Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 19 process of being redecorated, once decoration is completed this room will provide a comfortable and pleasant area to sit. All rooms are single with ensuite facilities and each room is served by the homes call bell system. The rooms belonging to three of the resident’s case tracked were seen. These were clean, appropriately furnished and included the residents personal belongings. All residents spoken with were satisfied with the accommodation provided. One resident explained, “I have my own room, bathroom and fridge!” All areas of the home seen on this occasion were clean and fresh. There are attractive garden areas for residents and visitors to enjoy and ample parking is available at the front of the home. George Hythe House DS0000006386.V341496.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are appropriately trained and competent to do their jobs. EVIDENCE: There were sufficient numbers of staff on duty on the day of the visit to meet the current needs of the residents. Residents spoken with felt that on the whole there were enough staff on duty to meet their individual needs, though one resident did state that occasionally, because of staff sickness and holidays, they felt that another member of staff would have helped. The inspector was informed, “They do what they can but it can be a bit thin on the ground sometimes, weekends are the worst”. The majority of staff members spoken with on this occasion felt that there were currently enough staff on duty to enable them to care properly for the service users without feeling rushed, though it was mentioned that occasionally they could do with more staff. A discussion took place with the registered manager with regards to regularly monitoring the needs of the residents to ensure that sufficient numbers of staff are on duty. George Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 21 All residents spoken with confirmed that their current care needs were being met and on speaking with four members of staff on duty during the visit it was evident that they were well aware of the individual needs of the four residents case tracked. One resident stated, “There very good, if your not feeling very well there in and out of your room all day long to check that you are alright”. Three staff files were checked and were found to include all the necessary checks including references and a CRB (Criminal Records Bureau) check. The registered manager explained that all new staff complete a period of induction and a staff handbook, which includes relevant policies and procedures, is given to all staff employed. This was confirmed on speaking with members of the staff team. A number of training courses have been provided since the last inspection including: Dementia Awareness Abuse Awareness Safe Handling of Medicines Activities Training Day Moving and Handling Infection control Challenging Behaviour, Communication and Person Centred Care. Twenty six care workers have either completed or are currently completing their NVQ level 2 (National Vocational Qualification) and two team leaders are completing their NVQ level 3. One domestic worker has completed their NVQ 2 in housekeeping and one member of the kitchen staff have completed their NVQ 2 in cooking. George Hythe House DS0000006386.V341496.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): 31,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and the health and welfare of the residents are promoted and protected. EVIDENCE: The registered manager has many years experience in care and has completed her NVQ level 4 and Registered Managers Award. Evidence was also seen during the visit of her completing a number of training courses to update her knowledge and skills. All residents spoken with during the visit stated that the registered manager was approachable and would have no hesitation to talk to her should they need George Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 23 to. One resident spoken with stated, “We’ve got a good manager and staff as well”. A second resident stated, “The manager is approachable, she’s nice”. Care workers spoken with felt supported by the management team and all spoken with stated that there was always someone available to talk to should they need to discuss any issue or concern. One staff member stated: “Nothing is too much trouble for the management or care staff, there is always someone there if you need them”. Another staff member explained, “ Any issues are always dealt with, never ignored, you can’t fault them” [Management team]. One of the resident’s case tracked is assisted with their finances. On checking the paperwork held at the home it was noted that appropriate records and receipts are held to ensure that their finances are safeguarded. The registered manager explained that staff support meetings are provided for the staff working at the home. This was confirmed on speaking to care workers on duty at the time of the visit. Residents and staff are consulted with regard to how the home is run. The inspector was informed that rather than having one large residents meeting, smaller resident meetings are held on each wing and the registered manager also meets residents on a one to one basis to find out if they are satisfied with the care and support they receive. One resident explained, “We have resident meetings, though not very often”. Staff meetings are held on a monthly basis and quality assurance questionnaires are completed enabling the manager to gain the views of the residents (and their relatives) in her care. Minutes of staff meetings and completed questionnaires were seen. The registered manager explained that relative meetings are also held four times a year enabling them to meet with each other and the staff working at the home. Evidence of these meetings taking place was seen. Training in Health and safety is provided to all staff during their induction period and training in fire safety, infection control and moving and handling are provided on a regular basis. George Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 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 X 3 X 3 3 X 3 George Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 25 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 OP12 OP33 Good Practice Recommendations The registered provider should ensure that a review of all documentation associated with the care of the residents is carried out. The registered provider should ensure that a formal programme of activities is recorded and offered whilst the activities organiser is away. The registered provider should ensure that systems are in place for the residents to be consulted on how the home is run on a regular basis and record such systems. George Hythe House DS0000006386.V341496.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Hythe House DS0000006386.V341496.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. 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!