Inspection on 17/11/06 for Hampden House

This inspection was carried out on 17th November 2006.

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

Hampden House 24/01/06

Hampden House 06/09/05

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

CARE HOMES FOR OLDER PEOPLE Hampden House 120 Duchy Road Harrogate North Yorkshire HG1 2HE Lead Inspector Anne Prankitt Key Unannounced Inspection 17 November 2006 09:15a 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 Hampden House DS0000064477.V321730.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. Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hampden House Address 120 Duchy Road Harrogate North Yorkshire HG1 2HE 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) 01423 566964 01423 562792 lynda.cooper@efhl.co.uk Elizabeth Finn Homes Ltd Mrs Lynda Cooper Care Home 66 Category(ies) of Old age, not falling within any other category registration, with number (66), Physical disability (66) of places Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the category PD must be: i) aged 60 years and over and ii) require nursing care 24th January 2006 Date of last inspection Brief Description of the Service: Hampden House is a purpose built care home, providing personal and nursing services to sixty-six service users. It was refurbished in 1996, with all rooms having en-suite facilities. Each floor is serviced by a lift. Further refurbishment of one wing of the home has just been completed. It is situated in a quiet residential area on the outskirts of Harrogate, has well kept, attractive garden grounds, and is a short walk from open green spaces. The home, which offers support and care for professional people and their families, is owned by the Elizabeth Finn Care, and run by Elizabeth Finn Homes Ltd. The registered manager confirmed on 17 November 2006 that the current weekly fees range from £555 to £785. Items not covered by the fee include hairdressing, newspapers and magazines. Information about the home is available in a brochure, which is provided to prospective service users before they are admitted, and a service users’ guide, which is available for them to see at any time. Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the site visit, the registered manager, Lynda Cooper, returned a completed questionnaire to the Commission. It provided information about the home, including who lived and worked there. The inspector has also kept a record about what has been happening at the home since the last inspection. Surveys were sent to health professionals and a random selection of residents. Five hours of planning took place before the site visit, which lasted for approximately eight and a half hours, and was conducted by one inspector. All of the information collected was used as part of the ‘key inspection’. The site visit was spent talking with the registered manager, residents and staff, and watching the general activity at the home. Some records were looked at, including some care plans, staff records, health and safety documents and financial records. The way that medication is managed was looked at, and the way that the registered manager assesses the quality of the service was discussed. The registered manager was available throughout the day. She was provided with feedback at the end of the visit. What the service does well: The home provides warm, comfortable and attractive surroundings for residents to live in. The care that residents need is written down in their care plan. Staff understand residents’ needs. Residents are satisfied with the care that they get. There is a good programme of activities available, and good effort is made to meet spiritual needs. Residents can be assured that they will be able to maintain contact with their families and friends, who will be welcomed at the home at any time. The registered manager takes complaints made to her seriously. Staff will make sure that they protect residents by reporting any concerns to her. Residents can be assured that there will be sufficient staff who are suitably trained to meet their needs. The registered manager listens to the views of residents and staff. She is liked by residents and staff. Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 6 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. Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 7 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 Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. Service users are given sufficient information so that they can make an informed choice, about whether they want to live at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Prospective service users are provided with a brochure, which tells them about the home before they are admitted. The service users’ guide is available to them after they are admitted, although the registered manager has decided that she will also provide a copy of the service users’ guide before the admission takes place. Staff complete a pre admission assessment for all prospective service users. It is detailed, and provides good information from which staff can develop a care plan. Two service users explained how they had met staff before they had Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 9 been admitted, and how they had enjoyed a period of respite before finally making their decision to make Hampden House their home. The registered manager confirmed that the home does not provide intermediate care. Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 10 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 and 10. Quality in this outcome area is good. Service users receive the care that they need by staff that they know. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Good information about service users’ care was available. Necessary risk assessments and care plans were in place. Care plans had been developed for specific care needs, and staff had taken time to ensure that they were personalised. For example, they had been completed where service users had problems with communication, or with their mental health. Care plan information was not all held together. There are computerised documents which are kept up to date electronically, and which include the daily records. Some records are also kept as hard copies. Staff are well acquainted with the system, which was complex on first sight. However, they did comment that a separate hand written report has to be completed when Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 11 agency staff work at the home, because they do not have access to the computerised system. The registered manager had already identified that the system needs to be streamlined, and will review them as part of her action plan for the home. Care assistants do not write in the care plans, but they do read them, and they have a handover meeting before each shift so that they have up to date information about service users. Service users’ care is reviewed when the home is concerned that they may no longer be able to meet their needs. The following points were discussed with the registered manager: • • • It would be good practice for staff to complete a nutritional assessment for all service users when they are admitted, so that they have a baseline assessment to refer to. There should be a risk assessment in place to alert staff where the past history of a service user suggests that they may need extra observation to ensure that they have taken their medication safely. Paper care plans are not kept locked away, although they are kept within the nurses’ stations. The registered manager had already identified this as an issue, and is currently looking into how the records can be made more secure. The home is split into three areas, which are then subdivided further into colour-coded areas. There are two areas which generally provide personal care only, although the registered manager said that, when a service user has a short term illness which results in them having nursing needs, they will try to accommodate these with the help of the community nursing team. This means that the service user can continue to be looked after by staff that they know in an environment that they are used to. The registered manager said that the home has a good relationship with the community health professionals. Comments from visiting professionals included: ‘We are very happy with the care provided’, ‘Very well run home. Staff very pleasant and caring. No concerns’. Staff work in specific areas, and service users know them. Comments from service users included: ‘The staff are very kind’, ‘Staff are very good’, ‘I like the staff’. All generally thought that they were treated with respect. One isolated comment made was that staff did not always knock on the door before they entered their room, and that they sometimes had to wait for them to come back when they had been helped into the bathroom. However, they concluded ‘It is not a bad place to live’. There are separate medication trolleys for different parts of the homes. The medication is administered by trained nurses other than on the ‘residential Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 12 wing’. Here it is handled by the Head of Care, or senior care staff, who have completed training in safe medication practice. Two trolleys and the main medication room were inspected. There is a system whereby all medication is checked into the home, and any surplus is disposed of safely. All of the records seen were kept up to date, and could be reconciled with the remaining medication. The storage systems were satisfactory, except that in one area of the home, some eardrops had not been locked away in the trolley after use. This was brought to the attention of the registered manager who said that she would remind staff of the need to keep medication locked away. Complaints since the last inspection included concerns about poor communication, a delay in care, a door banging at night, and communication prior to care consultation. There was evidence to show that the registered manager had investigated the concerns, and taken action where necessary. Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. Service users can be assured that they will be able to maintain important contacts with their families, and that their social needs will be considered. The registered manager is taking steps to make sure that service users’ choice is not compromised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is an activities organiser who works full time at the home. They are very enthusiastic. They have completed training to help them in their work. They provide group activities, which are advertised. They also spend time each day with individual service users who are unable to, or who may choose not to, leave their bedroom. There is a games room, a bar, which is open each lunchtime, and a hairdressing salon. There is a separate library, which is also used as a meeting place, to show films, and as a quiet room where church services are held. Representatives of Catholic, Methodist and Church of England denominations visit the home. This assists in meeting service users’ spiritual needs. Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 14 Service users agreed that the routine of the home allows them to go to bed when they choose to. From the comments made, it seemed that times at which they can rise were less flexible. Comments included: ‘Mornings are a bit hit and miss’, ‘Staff wake me up on a morning sometimes but I don’t mind’, ‘There is not much flexibility on rising’. The registered manager had already identified this as an issue, and said that staff have been provided with training in holistic care. She said more work was planned to improve the flexibility of the routine. However, one service user explained the lengths to which staff were going to fit in with their personal routine. This was greatly appreciated by them, as it allowed them to lie in each day, to have a late breakfast, and to take their main meal late in the evening. Both service users who returned their surveys said that staff listened and acted upon what they said. Service users’ rooms were very individualised. They are able to bring in their own furniture if they wish. They each have a pigeon hole into which their mail is delivered. Visitors are welcomed at the home at any time. Service users can see them in their own room, or in a communal area. The menu provides good choice. There was a vegetarian option available. The kitchen assistant asks service users each day what they would like to eat, and the timing of the main meal of the day is flexible over two sittings if needed. Fresh meat, vegetables and fruit are delivered to the home regularly. The cook confirmed that they are provided with good information from staff so that they know who is on special diets. They had already been informed about a risk assessment for two service users who had just been admitted. They currently cater for diabetic diets. They ensure that pureed food is served in separate portions so that it is looks more appetising. They said that the nursing staff liaise with the dietician, but that information that they need to know is filtered through to them so that they know who needs to have a fortified diet. Service users dine in different areas; depending upon how much help they need with their meals. The main dining area was beautifully set out ready for lunch. The separate area was being used for an exercise class, so had not yet been set up. Food is delivered to each floor in a hot trolley for those service users who wish to, or who need to, remain in their room to eat. Staff have access to the kitchen at any time so that they can prepare food for service users between meals. The cook also sets up supper dishes. Comments from service users about the food were varied. They included: ‘It’s not bad’, ‘It is sometimes variable’, one service user said that it is sometimes cold when it reaches the nursing wing. The registered manager took these comments seriously. She was already aware that there were some inconsistencies in the quality of the food provided, and intends to address them. Two complaints had been made since the last inspection about water not being delivered to a service user, and one about a poor tea. Records in the kitchen were kept up to date, and food was stored appropriately. Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. Service users can be assured that their concerns will be taken seriously, and that they will be protected by staff who understand their responsibilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no complaints made to the Commission for Social Care Inspection during the period since the last inspection. There were eight complaints made to the home. These are detailed in the relevant sections of this report. (Health and Personal Care, Management and Administration, Daily Life and Social Activities). There were clear records kept of how each of the complaints were dealt with. Service users spoken with, and those who returned their survey, though that their complaints would be listened to. Comments included: ‘I think that they would probably be sorted’, ‘I would complain to Lynda (the manager). She is very good’, ‘I know the official complaints procedure. It is posted in the main hallway’. Staff were very clear about what they would do if they suspected that a service user was being abused. They have received training in abuse awareness. They knew that they must not keep secrets if they suspected abuse. Their expectation was that the registered manager would report to the local authority. The registered manager confirmed that this is the policy of the home. Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 16 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 and 26. Quality in this outcome area is good. Service users live in pleasant surroundings, which are warm and comfortable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is set in lovely grounds. It is split into three areas, which are further subdivided into two. Since the last inspection, the blue wing has been refurbished to a high standard. This has allowed extra assisted bathing facilities to be provided. There are now eleven assisted facilities. There are kitchenette facilities available around the home so that service users and their relatives can make drinks at their leisure. There is a passenger lift, which enables access to each floor. There is an automatic door at the front of the building. The controls are situated at a low level. This assists wheelchair dependent service users in maintaining their independence. The home itself is Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 17 clean, warm and well decorated. There are a variety of communal areas for service users to enjoy, including a bar room with a grand piano, and a large airy hallway. Hoist equipment is available in each area, and each service user who needs to be moved with this equipment, is provided with their own sling. This reduces the risk from cross infection. Following a visit by the fire officer, the registered manager has provided confirmation that the fire exit signage has been changed as recommended. Appropriate equipment was available in the laundry, and staff have received training on infection control. This will help reduce the risk from cross infection. Staff were seen to wash their hands in the wash basins around the home. There was an outbreak of diarrhoea and vomiting earlier in the year at the home. The staff ensured that the necessary agencies were informed, and took appropriate steps to minimise the spread of infection. The registered manager now supplies a hand cleanser for visitors to use before they enter the building so that the risk from infection being brought into the home is minimised. Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is adequate. Service users are cared for by sufficient staff who undergo regular training to improve their care skills. However, any delay in checking the suitability of new staff means that service users cannot be fully certain that they are protected from unsuitable workers. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users agreed that there were sufficient staff available to meet their needs. On the day of the site visit, staff went about their duties quietly and unobtrusively. Service users did not appear to be rushed. Staff also thought that the staffing levels were satisfactory. The staff training plan supplied was not kept up to date, but staff spoken with confirmed that they receive statutory training on a regular basis. The registered manager plans to update the records so that she can be certain about who has had training, and when. Over half the care staff are qualified to at least NVQ Level 2. Staff complete a range of training to assist them in meeting the needs of service users. Training includes update in venapuncture, heart diseases, training from the Macmillan nurses, infection control, diabetes care, ‘no secrets’, medication training, dignity within the home and bed rail Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 19 training. Heads of Department are responsible for the supervision and appraisal of the staff who work on their unit. A newly recruited care staff member was spoken with. They were having a period of induction, and were supernumerary until the induction was completed. They were watching health and safety videos as part of this process. They had already received training in abuse awareness; they understood their responsibilities to report concerns, and knew that they must not keep secrets. They explained that they had been given a mentor who was helping them. Their recruitment checks had been returned before they started working at the home. Previous to the registered manager taking up post, newly recruited care staff were sometimes deployed before they had been properly vetted by the home. The applicant’s copy of the Criminal Record Bureau checks, which themselves had been applied for by previous employers, had been accepted by the home. The registered manager said that this practice would no longer be allowed. The administrator said that an enhanced check would now be obtained for the staff members concerned. One recently recruited staff member had commenced duties after a POVAFirst had been obtained, but before the CRB check had been returned. The registered manager explained that the circumstances were exceptional, as a number of staff had left, and replacements were needed to care for the service users. Assurance was given that the staff member was supervised until such time that a satisfactory Criminal Records Bureau check was returned. However, a recently recruited care staff member had commenced duties in similar circumstances, but only one written reference had been obtained at the point at which they were deployed. Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 20 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 and 38. Quality in this outcome area is good. The home is run by a manager who is keen to make further improvements to the quality of the home, by listening to service users and considering their views. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Lynda Cooper has been successful in becoming registered with the Commission for Social Care Inspection as registered manager. She said that she is well supported by her manager, who visits the home on a regular basis, and leaves a report on their findings. She is beginning to make changes where necessary Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 21 in the way the home is run, and has recently appointed a clinical care manager to help her. Staff find her supportive. She takes concerns brought to her attention seriously. She has recently investigated an issue brought to her attention about alleged racial discrimination. She holds regular staff meetings to ensure good communication between the staff teams. A weekly meeting is held to discuss pertinent issues in each area of the home. Staff comments included: ‘She is new fresh air – nice – new ideas’, ‘She is approachable’, ‘I have no problems with the manager’. One service user said: ‘She’s very good is this one’. The registered manager has organised for a number of quality assurance audits to take place at the home, including the medication system and kitchen area. The maintenance man carries out regular in house checks including the fire system, bed rails, and hot water accessible to service users. She explained that the audits are set against the National Minimum Standards. Surveys are sent to service users on a regular basis, and residents’ meetings are used as an opportunity to provide feedback about the results. The views of others who provide a service to the home are offered informally. It is the policy of the home that all service users will have Power of Attorney arrangements in place before they are admitted. The home has a standard residents’ account into which monies are pooled, and which is kept ‘topped up’ by each service user’s Power of Attorney. The account accrues interest. Because it is not possible to apportion the interest fairly, all Power of Attorneys have signed an agreement that the interest can be deposited into the residents’ amenities fund. Assurance was given by the registered manager that funding authorities, where applicable, are satisfied with this arrangement. A small float is kept so that service users can have access to their cash if they so wish, and a running total is kept of the money held on their behalf. These arrangements do not promote the independence of those who may wish to, or are able to, carry on managing their own finances, but the registered manager explained that the arrangement is part of the admission agreement. This means that service users will be aware of it before they are admitted to the home, and before they have made a decision whether the home will be suitable for them. The registered manager said that there were some annual services that had just been completed. She was waiting for certificates to be provided following tests on the Portable Appliances, and service of the fire equipment. The nurse call bells and fire fighting equipment was due to be serviced. Service for the gas boilers and appliances serviced had been overlooked. Since the inspection the registered provider has confirmed that arrangements have been made for this service to be completed. They have devised a system so that the contractors will visit automatically in the future. Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 22 The cleaner left a trolley with hazardous chemicals in an unlocked bathroom. The registered manager though that they had gone for their break. She agreed that the trolley should not have been left there, and said that she would remind the cleaner concerned that it must be locked away when not in use. The sluice rooms do not have a locking facility. However, they did not contain hazardous chemicals, and the hot water within is regulated. The registered manager did not think that service users were at risk from harm, but has decided that locks will be fitted to the doors so that any risk to service users is eliminated. Hampden House DS0000064477.V321730.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 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 X 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP9 OP29 Regulation 13 19 Requirement All medication must be kept locked away when not in use. The registered manager must make sure that all staff currently checked at the home have a completed Criminal Bureau Check at the correct level. In all future recruitment, two written references must be obtained before the staff member is allowed to provide care. 3 OP38 13 Hazardous cleaning materials must not be left unattended when not in use. 17/11/06 Timescale for action 17/11/06 17/11/06 Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations There should be a risk assessment in place where the past medical history of a service user suggests that they may need extra observation to ensure that they have taken their medication. It is recommended that a nutritional assessment be completed upon admission for each service user so that staff have a baseline to refer to when they review the care plan. It is recommended that the views of visiting professionals be formally sought and considered as part of the quality assurance work at the home. 2 OP8 3 OP33 Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Hampden House DS0000064477.V321730.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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