Inspection on 30/11/07 for Greta Cottage

This inspection was carried out on 30th November 2007.

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

Greta Cottage 25/11/08

Greta Cottage 29/08/06

Greta Cottage 22/02/06

Greta Cottage 25/07/05

Greta Cottage 08/11/04

Greta Cottage 27/08/04

Greta Cottage 06/01/04

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

CARE HOMES FOR OLDER PEOPLE Greta Cottage Greta Street Saltburn-by-Sea TS12 1LS Lead Inspector Katherine Acheson Key Unannounced Inspection 30th November 2007 and 3rd January 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Greta Cottage DS0000000087.V355301.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. Greta Cottage DS0000000087.V355301.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greta Cottage Address Greta Street Saltburn-by-Sea TS12 1LS 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) 01287 622498 01287 626400 Greta Cottage Limited Mrs Heather Yvonne Russi Care Home 29 Category(ies) of Dementia (3), Old age, not falling within any registration, with number other category (29) of places Greta Cottage DS0000000087.V355301.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 29 2. Dementia - Code DE, maximum number of places 3 The maximum number of service users who can be accommodated is: 29 29th August 2006 Date of last inspection Brief Description of the Service: Greta Cottage is a converted Victorian House in a residential area of Saltburn. The home is registered to provide personal care for up to twenty-nine older people. Within the twenty-nine registered beds the home can accommodate a maximum number of three residents with dementia. There are twenty-seven single bedrooms and one double bedroom. Some of the bedrooms have en-suite facilities comprising of a toilet and hand washbasin. Bedrooms in the home environment meet with size requirements of National Minimum Standards. On the ground floor of the home there are three lounge areas and a conservatory. One of the lounge areas is also used as a dining room. A passenger lift enables residents to access the first floor. There is an enclosed garden area for resident use. Greta Cottage is managed by the provider and supported by a team of staff. On the date of this inspection the cost of care at Greta Cottage was £430 to £440 per week. Greta Cottage DS0000000087.V355301.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means that people who use this service experience excellent quality outcomes. This unannounced key inspection was carried out on 30th November 2007 and 3rd January 2008 and lasted for seven hours in total. On the first day of the inspection the Inspector arrived unannounced. The Manager of the home was aware of the second day of the inspection. The reason for the inspection was to see how good a job the home does in meeting the National Minimum Standards set by the government for Care Homes. Five residents, one relative and the cook were spoken to during the inspection. General discussions also took place with care staff. A lengthy discussion also took place with the Manager. Numerous records including care plans, menus, quality assurance, complaints and staff recruitment and training records were examined. The Inspector walked around the home with the Manager. Before the inspection ten surveys for residents and ten surveys for relatives were sent to the home for the Manager to distribute accordingly. Surveys requested feedback on the service and staff provided. Nine resident and three relative surveys were returned to the Commission for Social Care Inspection. Comments received can be read within the report. The Manager had completed an Annual Quality Assurance Assessment (AQAA) before to the inspection. The AQAA is the Registered Persons own selfassessment of the service and care that is provided. Information contained within the AQAA is reflected within the report and is also used to support the judgements. The details of any issues identified at this inspection requiring action are to be found at the back of this report. What the service does well: The home provides an excellent standard of care to residents. The care that residents receive is based upon their individual needs. Care staff working at the home are trained, competent and have an extensive knowledge of the people they are caring for. Greta Cottage DS0000000087.V355301.R01.S.doc Version 5.2 Page 6 Since last inspection the home has had an extension. The home can now accommodate a maximum number of twenty-nine older people, three of which can be older people with dementia. At the time of the inspection the home was fully occupied and did have residents with dementia. The Manager and staff working at the home were able to demonstrate throughout the inspection process how they managed to care effectively for two different client groups. One relative spoke of “The relief of finding something like this for mum”. This relative went onto say, “Every member of staff is really good. They are totally welcoming and the home has a lovely atmosphere” It was evident throughout the inspection process that residents are at the heart of the service. Residents are supported and encouraged to maintain independence make choices and enjoy life. Activities take place on a regular basis and as such residents lives are fulfilled. The home has a warm welcoming and friendly atmosphere. One resident spoken to during the visits said, “It feels like Heaven”. A survey received stated, “The home takes care with respect in a way I can only wonder at. When I say goodbye I can relax in the knowledge that care provided is of a high standard. The homes recruitment process is robust and staff are well trained What has improved since the last inspection? What they could do better: No requirements have been identified as the result of this inspection. The Manager advised that she and staff working at the home are continually looking at ways to improve Greta Cottage to ensure that residents are well cared for and live life to the full. Medication storage could be improved upon. Although stored securely, this is within resident areas and as such detracts from the homely feel. Staff at the home should record the temperature of the medication fridge to ensure that it is within normal limits and as such ensure that medication requiring cool storage is stored at the correct temperature. Greta Cottage DS0000000087.V355301.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. Greta Cottage DS0000000087.V355301.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 Greta Cottage DS0000000087.V355301.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): Standards assessed 3 and 6. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Assessments of prospective residents are carried out to ensure that the home can meet their needs. EVIDENCE: The Manager said that before going into the home residents are assessed by a Social Worker. Staff at the home then carry out their own pre-admission assessment either visiting the person in their own home or at hospital to ensure that the needs of the resident can be met at Greta Cottage. If residents are self-funding then an assessment is usually only carried out by experienced staff working at the home. The Manager advised of a recent assessment she had carried out on a resident. This assessment process consisted of a visit to the resident to introduce her and the home and assess the resident’s needs. This assessment process also Greta Cottage DS0000000087.V355301.R01.S.doc Version 5.2 Page 10 involved relatives. The Manager said that all residents and relatives are encouraged to visit the home before admission and if the resident/family likes the home and it is felt that needs can be met they can reserve a room. Before admission residents/relatives are encouraged to personalise the room so that it feels more like home. One relative spoken to during the visit said, “We visited the home unannounced, they were totally welcoming. We knew that this was the place” The Manager advised that since the registration changes at the home in November 2007, staff at the home ensure that detailed assessments are carried out. The home has had an extension, which has meant an increase from nineteen to twenty nine residents. As well as an increase in resident numbers the home can accommodate a maximum of three residents with dementia within the twenty-nine beds registered for older people. The Manager said that it was even more essential to carry out a detailed assessment to ensure that residents are compatible. Surveys, received by the Commission for Social Care Inspection, and residents who spoke with us confirmed residents had enough information about the home before they moved in. One survey stated, “We had a look round and stayed for the day. We enjoyed being at Greta Cottage” The home does not provide intermediate care and as such standard 6 does not apply. Greta Cottage DS0000000087.V355301.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): Standards assessed 7, 8, 9 and 10. People who use this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides an excellent standard of care, residents living at the home are happy and care received is based on their individual needs. Procedures are in place to ensure good management of medication to ensure safety of residents. EVIDENCE: Two plans of care were looked at during this visit both of which contained detailed information about the resident and the help they needed. Likes, dislikes and personal preferences were recorded. Care plans showed clear evidence of choice. Care plans were evaluated on a monthly basis. Resident’s files included healthcare visits and appointments. The records showed the regularity of visits for treatment from: doctors and district nurses, opticians, dentists and other healthcare specialists. Greta Cottage DS0000000087.V355301.R01.S.doc Version 5.2 Page 12 One plan of care was that of a resident who had been admitted to the home following the change to the homes registration in November 2007 and who had dementia. This plan of care was extremely informative. Relatives had been directly involved in the care planning stage advising the home of important information which included life history, family, work, likes, dislikes and care needs. This information is particularly important when caring for someone with dementia. During the visit the Inspector was able to speak to the relative of this resident who advised, “This is an absolutely brilliant place, the relief of finding somewhere like this. On the day mum came into the home they cooked for all the family to help mum settle in”. The Manager and relative spoken to said that since admission the resident had improved. The relative said, “We think that health is improving she has started to eat and she has lost her worried face”. The Manager advised that resident’s bedroom doors have their name or a picture on it so that bedrooms can be quickly identified. She said that for those residents with dementia photographs of themselves when they were younger have been put on their bedroom door as people with dementia recognise themselves when they were younger and as such can help them to recognise their bedroom. Residents spoken to confirmed that their dignity and privacy was respected. During the inspection staff were observed to knock on residents doors before going in. It was evident following general discussion with staff and indirect observation that staff working at the home know the residents they are caring for very well. For the majority of the inspection the Inspector was sat in view of residents and as such could get a good feel of day to day life in the home. Staff were courteous, residents were content and happy. Residents were directly involved in daily life. One resident spent sometime in the domestic kitchen with the cook washing and tidying up after breakfast. This resident when spoken to said. “ I was a cook in a restaurant. I like to go in the kitchen on a morning and wash and tidy up”. Residents spoken to during the inspection and comment cards received stated, “We are all pally in here I get on with all of the residents” “I think it is great, the staff are lovely and nothing is too much trouble” “I have come a long way since I came in here, I couldn’t find better” “ The staff are always helpful and there when I need someone to talk to” Greta Cottage DS0000000087.V355301.R01.S.doc Version 5.2 Page 13 “When mum first came here I was concerned for her well being. I had taken care of her with help for thirteen years. I had no need to worry they treated her as an individual” During the inspection arrangements for receiving, storing, administering, recording and disposing of resident’s medication were observed and examined. The home has a medication policy, however this was not looked at during the visit. The Manager said that this had been reviewed and updated since last inspection. The Manager said that those staff who administer medication to residents have received appropriate training and also have their competency checked on a regular basis. Medication systems were looked at during the visit. The ordering and returning of unused medication was good and records were well written. Medicines are stored within drug trolleys within resident areas that are fixed to the wall to ensure safety, however this did not give a homely feel. The Manager spoke of creating a room in which to store medication and that she was to consult with the Fire Authority in respect of this. The home has a designated locked fridge in which to store medicines requiring cool storage. Staff at the home should take and record the temperature of the fridge on a daily basis to ensure medicines requiring cool storage are stored at the correct temperature. Greta Cottage DS0000000087.V355301.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): Standards assessed 12, 13, 14 and 15. People who use this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Appropriate and enjoyable activities do take place at the home and residents are able to exercise choice and control. Visitors are encouraged and made to feel welcome at anytime. Food provided is enjoyed by residents and provides residents with a wholesome balanced diet. EVIDENCE: The home employs an Activity Co-ordinator to plan, arrange and take part in resident activities. The Activity Co-ordinator works six hours a week over three days. At other times care staff organize activities. Activities taking place include bingo, dominoes, quizzes, word search, cards, and arts and crafts. Each morning those residents who want to take part in armchair exercises. On the second day of the inspection residents were seen to be enjoying exercises. One resident spoken to during the inspection laughed and said, “I join in the morning exercises, on my birthday I am going to do Knees Up Mother Brown” Greta Cottage DS0000000087.V355301.R01.S.doc Version 5.2 Page 15 The Manager said that The Music Man visits the home once a month and sings and entertains residents. Again on a monthly basis the home has open house in which relatives and friends enjoy an open buffet and wine. Residents spoke of a busy Christmas time, making cards, decorations and having fun at the homes Christmas party. One resident spoken to during the visit said, “I’ve had the best Christmas ever, we all got a big carrier of presents off the Manager”. Another resident spoken to said, “There are nice ladies and gents in here I am interested in them all. One resident in here I give the morning paper to and they give me the evening gazette” Staff at the home talked about planning a regular clothes/fashion show, which they hoped to involve residents and their families. This would enable clothes to be modelled and if residents wanted to, make a purchase. The Fisherman’s Choir are booked to entertain residents in the home in February. The Manager said that the majority of residents are registered on Ring and ride which is a service that caters for people who are unable to use public transport. Some residents regularly use the service to visit family and go shopping. Residents are supported and enabled to go out independently. One resident visits the local club independently. All surveys received in respect of the home said that staff arranges activities that residents can take part in. Comments made included, “I enjoy the activities on a morning and afternoon”, another said, “I like a good knees up and sing song”. The home supports residents to practice their religion, a representative from the Roman Catholic Church visits on a regular basis to give some residents communion. A representative from the local Church of England Church also visits once a month and carries out a short service. Visits from relatives and friends are welcome at any time. The home included in the extension a room for relatives, which could be used for overnight stay if the need arose or if family were travelling any distance. The Manager advised that this has proved to be a huge success. Residents interviewed spoke of flexibility in routine and freedom of choice. One resident said, “I like to go to bed about 11:30pm and get up about 7:00am. I have had a couple of late nights recently, we have had a snowball or a shandy and enjoyed a sing song and listened to music” Food provided by the home is enjoyed by residents. There is a four-week menu plan in which residents are offered choice. The dining room is pleasant. The lunchtime of residents was observed. Mealtime was relaxing with residents enjoying the food provided. The lunchtime menu on the second day of the inspection was mince, dumplings, mashed potato and mixed vegetables, pudding was peaches and cream. Greta Cottage DS0000000087.V355301.R01.S.doc Version 5.2 Page 16 Residents spoken to during the inspection and comment cards received stated, “The meals are very good and freshly cooked” “I get help with my diabetes diet. The meals are pretty good” “There is always lots of choice, the meals are nice” “The cook is marvellous she will ask you what you fancy. She will do you anything” “The food is lovely the mince and dumplings were nice today. I love the salmon and meat sandwiches. There is always plenty of food and plenty of sweet stuff” Greta Cottage DS0000000087.V355301.R01.S.doc Version 5.2 Page 17 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): Standards assessed 16 and 18. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and relatives are able to express their concerns. Staff are aware of procedures to follow if abuse is suspected which helps to protect residents. EVIDENCE: The home has a complaint procedure, which informs residents/relatives of their right to complain to any commissioning authorities such as Social Services. The home keeps a record of complaints. There have not been any complaints made in the last twelve months. Residents, relatives and comment cards received stated that they were able to approach the staff to raise any concern that they may have. One comment card received stated, “ I haven’t needed to make a complaint” another said, “They do a good job I am happy here”. The home has an adult protection policy that details action that staff should take if abuse is suspected. The Manager said that staff receive adult protection training on induction and then on a regular basis thereafter. Staff spoken to during the inspection were able to inform of procedures to follow if abuse is suspected. Greta Cottage DS0000000087.V355301.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): Standards assessed 19 and 26. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of the environment within this home is good providing the people who live there with and attractive, homely and comfortable place to live. EVIDENCE: Greta Cottage provides a homely, comfortable place for residents to live. Since last inspection the home has had an extension and now accommodates a maximum number of twenty-nine people. There are twenty-seven single bedrooms and one double bedroom. Some of the bedrooms have en-suite facilities comprising of a toilet and hand washbasin. Bedrooms in the home environment meet with size requirements of National Minimum Standards. On the ground floor of the home there are three lounge areas and a conservatory. One of the lounge areas is also used as a dining room. A Greta Cottage DS0000000087.V355301.R01.S.doc Version 5.2 Page 19 passenger lift has been installed which enables residents to access the first floor of the home. The Inspector walked around the home with the Manager. The atmosphere was warm, friendly and welcoming. Communal lounges are spacious and light with comfortable furnishings. At the time of the inspection decoration was taking place in the corridors and residents bedrooms. Some bedrooms were having new carpet fitted. The home has an enclosed garden area for resident to enjoy. On the day of the inspection the home was found to be clean and odour free. Comments made by residents included, “It’s lovely and clean” and “ten out of ten for the cleaning” Laundry facilities are in place and staff are aware of procedures to follow to prevent the spread of infection. Greta Cottage DS0000000087.V355301.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): Standards assessed 27, 28, 29 and 30. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff at the home are experienced to meet the needs of residents. The homes recruitment procedure is robust which helps to ensure resident protection. EVIDENCE: At the time of the inspection there were twenty-nine residents living at the home, two of which were in hospital. The homes duty rota showed that there were three care assistants on duty from 8:00 until 5:00pm one of which is a senior care assistant, one care staff member comes on duty at 3:00pm until 8:00pm and two care staff come on duty 5:00pm until 10:00pm again one of which is a senior care assistant. In addition to the staffing numbers detailed the Manager of the home said that she works from 8:00am until 5:00pm, often later, at least five days a week. Residents/relatives spoken to during the inspection and surveys received stated that they thought there was enough staff on duty. One survey stated, “I can always press my buzzer or ask and someone will come to help me”. Greta Cottage DS0000000087.V355301.R01.S.doc Version 5.2 Page 21 The Manager said that 70 of care staff working at the home has achieved a minimum qualification of NVQ level 2 in Care with other staff working towards achieving the qualification. Two staff files were looked at during the inspection both of which contained a certificate confirming that they had undertaken an induction programme. The Manager said that this induction meets with the required standards as set by Skills for Care. The homes recruitment procedure is robust. The files of two newly appointed staff were looked at during the visit. Evidence was available to confirm that appropriate Criminal Record Bureau checks are carried out before staff start working at the home. Files examined contained all of the required information including, proof of identity and two references. Certificates were available on staff files looked at to confirm that they had received recent training in fire, moving and handling, emergency aid and safe handling of medication. Residents/relatives and surveys received spoke highly of the Manager and all staff working at the home. Comments made included, “The staff are well trained, they work with you and they are approachable”, another said, “The Manager, she is a brick, the staff are wonderful I could not find better” Greta Cottage DS0000000087.V355301.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): Standards assessed 31, 33, 35 and 38. People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well run with the health and safety of residents being promoted. Quality assurance systems are in place to ensure that the home is run in the best interest of residents. EVIDENCE: The Owner/Manager of the home has many years of experience of working with older people in a social care environment. The Manager has completed a NVQ level 4 in management and care. The AQAA, which was completed by the Manager, advised that Greta Cottage is run in an open and transparent way. Policies and procedures are adhered to Greta Cottage DS0000000087.V355301.R01.S.doc Version 5.2 Page 23 everything is updated an example being insurance, business plans, certificates and accounting. The Manager of the home complies with relevant legislation. Surveys are sent out to residents on a yearly basis to see if they are happy with the home and care that is provided. The results are published and made available. The home looks after small amounts of money belonging to some residents. Appropriate records of transactions are kept. A sample of health and safety records were examined and were found to be in order. Records were examined to confirm that fire alarms, emergency lighting and fire extinguishers had been serviced within the last year. Water temperatures in resident’s bathrooms are taken on a weekly basis to ensure that they are within normal limits. The Manager said that regular checks of the fire alarm system are also carried Greta Cottage DS0000000087.V355301.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 X X 3 Greta Cottage DS0000000087.V355301.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 Refer to Standard OP9 Good Practice Recommendations Staff at the home should take and record the temperature of the medication fridge on a daily basis to ensure medicines requiring cool storage are stored at the correct temperature Greta Cottage DS0000000087.V355301.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Greta Cottage DS0000000087.V355301.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!