Inspection on 20/12/06 for Grove House

This inspection was carried out on 20th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Grove House 22/05/06

Grove House 01/02/06

Grove House 16/06/05

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

CARE HOMES FOR OLDER PEOPLE Emmanuel Christian Care Home Grove House 1 Palm Grove Claughton Prenton Wirral CH43 1TE Lead Inspector Jeanette Fielding Unannounced Inspection 20th December 2006 09:00 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 Emmanuel Christian Care Home DS0000063096.V319609.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. Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Emmanuel Christian Care Home Address Grove House 1 Palm Grove Claughton Prenton Wirral CH43 1TE 0151 652 1021 0151 652 2629 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) Four Seasons (Emmanuel Christian Care Home) Ltd Mrs Siobhan Dean Care Home 63 Category(ies) of Dementia (23), Old age, not falling within any registration, with number other category (23) of places Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may from time to time admit persons from the ages sixty years to sixty five years of age. 17 Intermediate Care beds aged 50 years and over Date of last inspection 22nd May 2006 Brief Description of the Service: Grove House is part of the Emmanuel Care Centre located in a residential area in Birkenhead, Wirral. The home is owned by Four Seasons (Emmanuel Care Home) Ltd. The home is registered to provide nursing care, either long term or transitional, for up to 46 persons and intermediate care for up to 17 persons. All service users are accommodated in single bedrooms, each having en-suite facilities. A number of lounges and seating areas are provided to enable service users to choose where they spend their day. Service users accommodated for intermediate care have a greater input from Occupational and Physiotherapists to provide them with the skills to enable them to return home following hospitalisation and are accommodated at the home for a period of up to six weeks. The ground floor provides for 17 persons requiring Intermediate Care. The first floor provides nursing care for 23 persons who have dementia, and the second floor provides for 23 elderly persons who require general nursing care. Fees are £540 per week for nursing care and £550 per week for EMI care. Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted by Mrs Jeanette Fielding and Mr Les Smith and was completed in one day. The inspection commenced at 09:00 hrs and continued until 19:00 hrs. Records relating to the care required by and afforded to service users were inspected and the views of service users and visitors to the home were sought. Some records were found to be poorly maintained. A tour of the premises was undertaken to ensure that facilities were in place and that a good standard of cleanliness was maintained. Staff were observed when they were working in the communal areas with service users. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 6 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 Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 7 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 adequate. This judgement has been made using available evidence including a visit to this service. The homes Statement of Purpose and Service User Guide do not provide sufficient information to enable prospective service users to be clear about the services the home offers and thereby make an informed decision regarding their choice of care home. EVIDENCE: The home has a Statement of Purpose and Service User Guide, which are held in the foyer of the home and accessible to all visitors. Copies are available to all prospective service users and visitors to the home. This document requires to be reviewed and amended to reflect changes in the service. The home now accommodates service users for long term care but the Statement of Purpose and Service User Guide only give information regarding transitional or short term care. It is essential that all prospective Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 8 service users be given full and accurate information regarding the service available to enable an informed choice to be made regarding their future care. One section of the Service User Guide appeared to be a pro-forma which had not been completed to give details of this specific home. A sample of twelve service users care files were inspected and were for service users who were accommodated for both long term and intermediate care. Two service users had transferred from a nearby home but there was no evidence that a full assessment had been undertaken on them prior to admission. The records from the previous home were held on the file, although some of the information recorded was not currently relevant as the service user’s needs had changed since they were admitted from the previous home. Three pre admission assessments had not been fully completed. A new pre admission form had been used for recent admissions to the home. This document relies on a numerical score being given to identify needs together with specific details on the service users’ care needs. Two were found not to contain the specific details and did not therefore provide sufficient information to enable a plan of care to be adequately prepared. The other preadmission assessments were found to be detailed and informative and resulted in the care needs being identified. Little information is recorded regarding the mental health condition and requirements of those service users accommodated due to their dementia. A more detailed history of that dementia, how it was displayed, the time that the service user had suffered and any previous interventions would give staff sufficient information to enable them to plan the care. Requirements in respect of pre-admission assessments have been made at previous inspections. It is imperative that this matter is addressed as a priority. The care files for those service users accommodated for intermediate care were much improved. The assessment gives full details of the service users needs and identifies an achievable outcome for the service user to enable them to return home with sufficient skills to assist them to live independently. Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 9 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 poor. This judgement has been made using available evidence including a visit to this service. The nurses have failed to follow the procedure for handling medications which has the potential for placing service users at risk and harm. EVIDENCE: A plan of care is prepared for each individual service user. Two service users who had transferred from another care home had not had new plans prepared. The plans provided by the previous home were in use. Whilst it is good practice for one home to give full information regarding a service user, to another home to which the service user transfers, it is required that each home maintains all documents regarding service users in their care. No original documents are to be transferred from one home to another. Second Floor. General Nursing Care Unit. One service user has a diagnosis of diabetes. Blood sugar tests are taken on four occasions each day but the plan of care does not identify the reason for Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 10 this high level of testing. No nutritional assessment had been made, which is necessary due to the diabetes, or the need for a specific diet to be given. One service user had been transferred from the EMI unit to the general nursing unit. No assessment or reason for the transfer was documented in the care file. No mental health assessment or care plan had been completed to provide information to staff on how to provide care for the dementia that the service user continued to suffer. The daily report makes reference to redness which would indicate the potential for pressure sore development. No skin integrity plan had been prepared to address this problem in the early stages, thereby preventing pressure sores developing. It was noted that some of the care plans had been completed by the night staff. It would be difficult for night staff to complete these plans as they are not able to assess, review or monitor the service users adequately as many of the service users are sleeping when these staff are on duty. Night staff should be responsible for care plans relating to when they are on duty i.e. sleep patterns, night medications or wandering during the night. Night staff could certainly build on some of the information held in the plans, but can not take responsibility for preparing plans when they are not able to fully assess the service users specific needs in relation to that plan. First Floor. EMI Unit. Some photographs of service users were not held on the service users’ files. The inspectors were advised that the camera for this purpose was not available. In view of the high number of agency staff employed at the home, it is essential that photographs be held to aid identification. The use of bed rails for service users was being reassessed by the home at the time of the inspection. No agreement or consent for the use of bed rails was in place for two service users. One care file was found to contain care plans that had been discontinued following review. The practice of holding outdated plans on current files is to be discontinued. Staff are at risk of not providing the relevant level of care to service users due to outdated information held in the files and may put service users at risk. Mental health assessments and plans did not contain sufficient information to enable staff to provide the appropriate level of support. One file makes reference to a service user occasionally becoming aggressive but no information is recorded for staff with regard to the appropriate action to take at this time to support or diffuse a situation. Some care plans were found to be undated or unsigned. It is essential that all plans are dated and signed by the person completing the plan. Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 11 Ground Floor. Intermediate Care Unit. The care files on this floor were generally very good. Assessments had been made and plans put in place. The service users on this floor were accommodated for intermediate care and records are held of interventions by physiotherapists and occupational therapists who work closely with the service users to enable them to return home with sufficient skills following hospitalisation. Daily reports completed by nurses give full details of the actual care given to service users. There was a lack of photographs on the care files to ensure identification of service users. The turnover of service users in this unit is quite high and so it is essential that photographs be held on the files. The home has failed to produce adequate care plans and to maintain care files appropriately over a number of inspections. This situation cannot continue and all care files should be reviewed and updated as necessary. Service users on all floors were spoken to on the day of the inspection and confirmed that their privacy and dignity were respected by the staff, however, the toiletries and socks stored in a bathroom cupboard would indicate that some items are for communal use which compromises dignity. Medications. It was found that nurses had failed to follow the policy and procedure for the recording of medications to some degree on all units. Second Floor. Co-Codamol is prescribed for one service user and the instructions on the MAR sheet and the medication pack states one or two tablets. No record is held of whether one or two tablets have been administered to the service user and so it is not possible to audit the medication. Handwritten entries on the Medication Administration Record (MAR) sheets had not been countersigned by another member of staff to ensure that the entries were accurate. Two medications had been administered to service users but no signature of the nurse administering the medication was found on the MAR sheet. Creams and Inhalers had not been signed for by the nurses. One service user requires medication, Warfarin, to be administered at a specific and varied dose on the advice of the doctor following regular blood Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 12 tests. The nurses had not accurately recorded the date for the next blood test. Failure to continue with the current medication programme has the potential for serious consequences if the blood test is not undertaken on the appropriate date. A supply of Forticreme, a dietary supplement, was stored in the medication room. The storage information on the packaging states that this product should be stored in a cool place. The temperature in this room was 27 degrees, which is in excess of the appropriate storage recommendation. First Floor. Some medications received into the home had not been signed for in the appropriate record book. Handwritten entries on the MAR sheets had not been countersigned. One medication, where two tablets were required to be administered by the nurse, had been duly signed, however, it was found that one tablet remained in the blister pack. The storage cupboard was found to contain 1200mls of Immodium Syrup that had been received into the home one week prior to the inspection. Inspection of the MAR sheet for the service user for whom this had been prescribed had been marked with a letter ‘M’ to indicate that the medication was not available. The records relating to the receipt of this medication into the home was not accurately recorded. Ground Floor. Some MAR sheets did not contain photographs of the service users. It is essential that photographs be placed on the service users’ individual medication records to ensure accuracy of administration. The inspectors were advised that the camera was not currently in working condition. Handwritten entries were found on MAR sheets, some of which had not been signed by the nurse making the entry. A high number of discrepancies were identified at the last inspection and requirements made that the policy and procedures be followed. It is evident that the nurses have continually failed to follow the homes policy and procedures. New unit managers have been appointed on each of the units and should check and audit the medications on a frequent basis to ensure accuracy of entries and appropriate storage and take appropriate action as necessary. All medications storage areas were clean. Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 13 Emmanuel Christian Care Home DS0000063096.V319609.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. Dietary needs of service users are catered for with a balanced and varied selection of food available to meet service users tastes and preferences. EVIDENCE: The inspectors were advised that routines within the home are flexible to suit the service users preferences. Those service users accommodated for Intermediate care have a more structured day to work around the routines of the occupational and physiotherapy professionals. Visiting is available at any time and relatives and friends are encouraged to visit. Service users choose where they meet with their visitors and may use their own bedroom or one of the communal areas. At the time of the inspection, a group of entertainers were in the home singing Christmas Carols. Service users were encouraged to participate and it was evident from observation that service users really enjoyed the event. A programme of social stimulation and activities are provided for service users who may choose whether or not they participate. Details of forthcoming Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 15 activities are displayed on the notice board in each area of the home. Ministers of Religion visit the home on a regular basis and provide services on request. The home offers a four-week rotating menu that offers a selection of meals at each mealtime. Service users are encouraged to take their meal in the attractive dining rooms to promote social interaction, but can be served their meal in the privacy of their bedroom if they wish. The menus provide evidence that a varied and balanced diet is offered to all service users. Special diets can be provided on the advice or recommendation of the GP or dietician. Staff were observed to assist some service users with their meals discretely in the dining room. In the dining room on the ground floor, the tablemats were found to be extremely dirty and required to be cleaned. Some cups, and some cutlery, were found to be stained and require attention. Meals are prepared in the main kitchen and are served individually from heated trolleys by the care staff. Emmanuel Christian Care Home DS0000063096.V319609.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. Staff have a good knowledge and understanding of Adult Protection issues to protect service users from abuse. EVIDENCE: The home has produced a comprehensive complaints procedure which is detailed in the service user guide and is also displayed on notice boards within the home. The procedure gives service users and visitors to the home full information on how to make a complaint and to whom the complaint should be directed. No complaints have been received by CSCI since the last inspection. A programme of training in the protection of vulnerable adults has commenced with 25 staff having completed the training. Additional training sessions have been planned to ensure that all staff are given the opportunity to attend. Discussion with staff provided evidence that all were aware of the different types of abuse that could occur and of the action to be taken in the event of it being suspected. Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The continued inappropriate storage of toiletries places service users at risk. The quality of the building and facilities within the home are good and provide service users with a bright and pleasant environment in which to live. EVIDENCE: Grove House is a purpose built care home located within the Emmanuel Care Home Centre. It is located close to shops, parks and is accessible by public transport. Car parking areas are provided. The home is on three floors with all areas being accessible by a passenger lift. All service users are provided with a single bedroom, each having en-suite facilities. All en-suite facilities are provided with a shower. Additional toilets Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 18 are provided together with additional shower and bathrooms. Bedrooms are decorated and furnished to a high standard. A selection of communal areas is provided. One of the shower rooms, on all floors was found to be used for storage as individual showers are provided within the en-suite facilities. Incontinence pads were seen to be stored in the sluice on the first floor. These are to be stored in the bedroom of the service user for whom they are prescribed. Soiled incontinence pads had been placed in the bin, in the first floor sluice, but had been placed between the disposal bag and the bin resulting in an offensive odour. In the bathroom on the first floor, the EMI unit, toiletries were seen to be stored in an unlocked cupboard. Appropriate arrangements are to be put in place to store these items securely. In the bathroom on the second floor, assorted toiletries, including razors, soap and toothbrushes were stored in a cupboard. These items were not labelled with the service users’ names. An assortment of socks and tights were also held in this cupboard. Service users personal items are to be held in their individual bedrooms or en-suite facilities and appropriate security measures put in place as appropriate. The hot water in this bathroom was found to be excessively hot and presents as a scalding risk to service users. The wallpaper was found to be peeling away from the wall in the ground floor shower room and requires attention. Bedrooms are furnished and decorated to a good standard and it is evident that staff and relatives have personalised the rooms to reflect service users individual choices and lifestyles. The home was found to be decorated tastefully in preparation for Christmas. The home was generally clean however, attention needs to be given to the tablemats, cups and cutlery on the ground floor. Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is unable to provide evidence to indicate that all staff are competent and thereby ensure that service users are protected. EVIDENCE: The home employs qualified nurses and care assistants to provide for the service users needs. Agency staff are employed to cover vacant posts, annual leave and sickness where regular staff cannot meet these additional hours. A sample of staff files were inspected. Some files were found not to contain the full information necessary. Job descriptions were not on the files and some files did not contain evidence of induction training. Training has recently been given to nurses on the administration of medication. The failure of the nurses to provide safe administration of medications has identified the need for additional training to be given in this area, however, training does not ensure competency and so the competency in handling medications should also be undertaken and a record of this held on the staff files. The home has a robust recruitment policy and procedure, although one file inspected was found only to contain one reference. This would indicate that Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 20 the procedure has not been followed. Failure to follow the recruitment procedure has the potential for placing service users at risk. Recent training for staff includes The Protection of Vulnerable Adults, Anaphylaxis, Venepuncture and Customer Care. Records are held of staff supervision which is now given on a regular basis. Discussions were held with staff during the inspection. All staff spoken to were fully aware of their role and responsibility. The inspectors were concerned, when asking a member of the care staff for the code for accessing the sluice, that she did not know it and had to look up the number, indicating that she was not aware of how to access this area without referring to a book. It is expected that all staff be fully informed of how to access all areas to which they are to use. Unit managers have recently been appointed to take responsibility for individual units. Their role is to ensure that all documentation is accurate, informative and up to date and that service users are afforded the appropriate level of care and support. Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Safety certificates were again not available for inspection to provide evidence that staff and service users are protected. EVIDENCE: The manager is a qualified nurse and an experienced manager. She has achieved an NVQ level 4 in management and could evidence details of ongoing training. She has an open door policy and is available to service users and families each day. Staff meetings are held on a regular basis and minutes of these meetings are held. Regular meetings have also been held for service users and their Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 22 families to update them on changes on the management and to provide a forum to discuss relevant issues. The home does not deal with any of the service users finances. Tests have been made on the fire detection equipment, however, it was identified that some of the emergency lighting units had been out of action for many weeks. The manager advised the inspectors that she had contacted the company’s estates manager to arrange for these to be repaired or replaced but no action had been taken. Contact was made by the inspectors with the estates manager to discuss the serious concerns. Arrangements were put in place for the lighting units to be replaced. Advice was sought from Merseyside Fire Authority to ensure that adequate lighting was available to ensure the protection of service users in the event of a fire. An immediate requirement was made for the home to provide adequate lighting and a request made for the home to advise CSCI when the work had been completed. Emmanuel Christian Care Home DS0000063096.V319609.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 2 X 1 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4&5 Requirement The registered person must ensure that the Statement of Purpose and the Service User Guide be reviewed and updated to reflect changes within the home. The registered person must ensure that the pre-admission assessments contain all necessary information to ensure that the specific needs of the service users can be met. This remains outstanding from previous inspections. The registered person must ensure a plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. This remains outstanding from previous inspections. The registered person ensures that the staff follow the homes’ DS0000063096.V319609.R01.S.doc Timescale for action 28/02/07 2 OP3 14 31/01/07 3 OP7 15 28/02/07 4 OP9 13(2) 21/12/06 Emmanuel Christian Care Home Version 5.2 Page 25 policy and procedure for the administration and recording of medications. This remains outstanding from the last inspection. 5 OP15 23(2)(d) The registered person must ensure that all placemats, cutlery and crockery are to be maintained in a clean, stain free condition. 21/12/06 6 OP10 OP19 13(4) The registered person must 21/12/06 ensure the safety of service users through appropriate storage of toiletries. This remains outstanding from the last inspection. The registered person must ensure that clinical waste is disposed of appropriately to ensure that offensive odours do not occur. 21/12/06 7 OP26 23(2)(d) 8 OP29 18 The registered must ensure that 21/12/06 staff are recruited in line with the homes’ policy and procedure. The registered person must ensure that all fire detection and emergency lighting units are maintained in a working condition. 06/01/07 9 OP38 23(4)(c) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 26 Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Emmanuel Christian Care Home DS0000063096.V319609.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!