Inspection on 04/09/08 for Hannah Levy House Trust

This inspection was carried out on 4th September 2008.

CSCI found this care home to be providing an Adequate service.

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

Hannah Levy House Trust 25/06/07

Hannah Levy House Trust 24/11/06

Hannah Levy House Trust 24/02/06

Hannah Levy House Trust 02/11/05

Hannah Levy House Trust 09/03/05

Hannah Levy House Trust 31/08/04

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Hannah Levy House Trust 15 Poole Road Bournemouth Dorset BH2 5QR Lead Inspector John Hurley Unannounced Inspection 4th September 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hannah Levy House Trust DS0000003944.V371661.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. Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hannah Levy House Trust Address 15 Poole Road Bournemouth Dorset BH2 5QR 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) 01202 765361 01202 751007 hlhtrust@btconnect.com Hannah Levy House Trust Manager post vacant Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Hannah Levy House Trust DS0000003944.V371661.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 providing personal care onlyto service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category The maximum number of service users who can be accommodated is 34. 25th June 2007 Date of last inspection Brief Description of the Service: Hannah Levy House Trust has charitable status and has been set up to provide care, including personal care, to those members of the Jewish Faith who need such assistance. The home has a Board of Trustees that has regular contact with the home. Hannah Levy House Trust is situated half a mile from the centre of Westbourne, with its local shops, library and other amenities. The home is on a bus route providing easy access to Bournemouth town centre and the Travel Interchange. There is plenty of on site parking as well as parking on the roads surrounding the home. Hannah Levy House Trust is registered to accommodate a maximum of 35 older people and provides both permanent and respite care as well as day care. All rooms are for single occupancy although some are large enough to be used as doubles should this be requested by residents. Hannah Levy House Trust provides twenty-four hour personal care, all meals, laundry and domestic services. Residents are encouraged to participate in a wide range of activities, including outings to local places of interest. The fees for the home, as confirmed to the Commission for Social Care Inspection (CSCI) at the time of inspection, are set at £490 per week and include chiropody. Additional charges are made for hairdressing, dry cleaning, toiletries and newspapers. Hannah Levy House Trust DS0000003944.V371661.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 1 star. This means the people who use this service experience Adequate quality outcomes. This was the first unannounced key inspection of Hannah Levy House Trust care home for the inspection year 2008/9. The inspection process followed the Commission for Social Care Inspection Inspecting for Better Lives methodology. The unannounced inspection lasted eight hours. The views of the people who use the service and people important to them were sought by way of questionnaires and conversation during the inspection; where appropriate their comments are included in this report. The inspector toured the building, spoke with the management and staff on duty and spoke privately with people who use the service on both an individual and group basis. They also spoke with a number of visiting relatives and joined the resident group for lunch. The responsible individual and one other trustee met with the inspector at various times during the inspection. The home had just appointed a new manager that is currently going through the registration process. The inspector sampled the documentation relating to the individuals who reside at the home along with records relating to staff and other documents required by regulation. The Responsible Individual is Mrs Jessica Blooman OBE, one of the trustees, who has regular contact with the home. A newly appointed manager, is currently in post and in the process of seeking registration with the Commission. What the service does well: The people who use this service have good information about the home in order to make an informed decision about whether the service is right for them. They appear to have a relaxed lifestyle supported by staff that are knowledgeable with regards to their individual needs. The home provides a number of activities for those that can participate. People who use the service are encouraged to exercise choice over their daily routines. The food on offer is home cooked and of a good nutritious standard, people who use the service commented positively on both the quality and Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 6 quantity of the food on offer. The presentation of food and religious considerations appear to be adhered throughout. The home undertakes a range of quality audits to ensure that the standard of service provided is maintained and improved upon. People who live at the home and relatives spoken with were pleased with the care provided. The home has a very low turnover of staff thus offering good continuity to the people who use the service. What has improved since the last inspection? What they could do better: The management of the home needs to ensure that initial assessments of need are carried out including the reassessment of people returning from hospital. They also need to ensure that all care plans are reviewed and updated regularly. These reviews should also include an update of the current risk assessments. The administration of medication via the per required needs route needs to be better regulated to ensure the protection of all those who require assistance. The management of the home needs to ensure that they have a clear understanding of vulnerable adult procedures in order to ensure that people are protected at all times. It would benefit those who use the service if staff had regular managed supervision. It would also be helpful if the management of the home established if those whom they use for training are accredited to provide training. Hannah Levy House Trust DS0000003944.V371661.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. Hannah Levy House Trust DS0000003944.V371661.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 Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5,6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home ensures that prospective residents are provided with appropriate information regarding the home. People who use the service and their families are invited to visit the home and assess the services provided. Intermediate care is not a feature of the service EVIDENCE: The home has a Statement of Purpose and Service User Guide that provide details of the services and facilities provided at Hannah Levy Trust Home. These documents have been updated since the last inspection. The inspector looked at the arrangements made to carry out an initial assessment of need, which in the main should be completed prior to any individual moving into the home. Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 10 It was found that the initial assessment process whilst in general terms met the required standard had a number of omissions and ambiguous statements, which undermined the process. For example one person was assessed as “not having any falls lately” but did not inform the reader of the time scales referred too, one person had a comment stating that they had a history of depression but it was not recorded how this may have impacted on their life. During the inspection, residents confirmed that they or a relative had been given the opportunity to visit the home before making the decision to move there. The responsible individual informed the inspector that intermediate care is not a feature of this service. Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Care records do not provide sufficient detail to ensure that individuals’ personal needs are being fully and safely met. Significant incidents do not influence care plans. Staff treat residents with respect and dignity, promoting residents’ feelings of worth as valued members of the household. The home has systems in place for managing residents’ medicines but some aspects need improving to protect residents. EVIDENCE: Discussion with staff and people who use the service confirmed that staff are able to demonstrate a good knowledge of individual care needs. However care Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 12 plans have not been kept up to date to reflect this knowledge. The inspector noted that 7 out of 34 of the care plans had not been reviewed consistently over the preceding months. One persons documentation showed that the last time their care plan was reviewed was 2002. An existing client had recently returned from hospital following a fall. There was no evidence that their care needs had been reassessed to ensure that they could be met by the home. The existing care plan had not been updated to reflect any new circumstances, assistance or short term goals set. Similarly risk assessments had not been reviewed following significant incidents such as serious falls for example one person had caught their leg in a bed rail that resulted in injury but no further reference to this incident had been considered in their own documentation. The use of bed rails is not consistently risk assessed or reviewed. There was no evidence that the use of bedrails had been agreed through consultation process’s or risk assessment procedures. One person’s records state that they have dementia and can become “agitated”. There is no further explanation to this agitation or how this affects their life. Whilst in the general day to day recording there is evidence of visits by doctors and district nurses as the care plans have not been kept up to date it is uncertain as to how these visits have addressed individuals needs. The home has systems in place for managing medicines. Only senior staff deal with medication and they first have to undertake a course of related training. Medicines are stored securely. A Monitored Dosage System is in use. Through examination of the medication records it was established that the administration of medication could be more robust with the introduction of a clear rationale for the dispensing of medication via the Per Required Needs (PRN) route for example, one person was being give an tranquilizer when they became agitated but there was no explanation as to what was meant by agitation or what other strategies could be employed to assist the person such as a change of environment or gentle reassurance. Another area of concern relating to PRN medication related to the staff always asking individuals if they require any PRN medication, such as painkillers. The records viewed demonstrated that some individuals always accept any medication offered. Their associated care files did not demonstrate that any medication review had been considered or the effects of long term administration of medication discussed with the individuals doctor or other health care professional. These observations were discussed with the senior staff and management at the time. Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 13 The inspector was able to talk with many of the people who use the service some of which by choice spent some of their time in the privacy of the own rooms. These people expressed how much they appreciated that the care staff respected their privacy and dignity and that they were not made to do anything they did not wish to, such as attending activities or having meals in the dining room. They further confirmed that all personal care was provided in the privacy of their bedrooms or bathrooms. They further commented that they are always addressed in the way they have requested and that staff are always polite. It was clear from observation and the time spent with those who use the service that they feel comfortable and at ease with staff. Staff were seen throughout the inspection to be treating people with courtesy and kindness. Hannah Levy House Trust DS0000003944.V371661.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. The home is flexible in its approach to the provision of activities and meals, enabling residents to retain control over their lives wherever possible. The pace of life at the home appears to meet the expectations of the resident group allowing a relaxed way of living. EVIDENCE: The service operates in a manner that reflects all aspects of a traditional Jewish home. This meets the religious and cultural needs of the residents. The home has a small synagogue, where services are held each week on Shabbat. All the other festivals are celebrated and enjoyed in the home. All festivals are also celebrated within the home. The home has good links with the local congregation and has its own minibus to enable residents to make trips out to either local synagogues or to visit members of the Jewish community, clubs etc. Some people who use the service suggested that the trips out had not be so frequent of late. Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 15 Those who use the service are able to maintain contact with the local Jewish community, as well as with family and friends. Members of the local Jewish community continue to organise monthly birthday teas for residents throughout the year, celebrating all birthdays that fall within a given month with a special tea and presents. A few people are also physically able to participate in activities outside of the home, which are organised by the local synagogues. Relatives and friends are encouraged to visit as often as possible and no restrictions are placed upon them. This was confirmed in discussion with residents and staff and by viewing the Visitors Book People are encouraged to choose their own lifestyle within the home and make choices wherever possible. These include choosing when to get up or go to bed, what to wear, what to eat or drink and to come and go as they please. They are able to bring their own possessions into the home to personalise their bedrooms. Individuals confirm that their individual preferences and routines are respected. The inspector observed that many people have their own newspapers delivered and stay in touch with world affairs. Hannah Levy House Trust provides a kosher diet under strict supervision. Prospective residents are made aware of this prior to admission. The chef has considerable experience in kosher catering. All meals are usually taken in the dining room (in two sittings) or in the residents own bedroom. The lunchtime meal in the dining room took place in a relaxed, unhurried atmosphere with discreet staff assistance provided wherever necessary. Mealtimes can be flexible to fit in with care needs, appointments etc. The menu shows that residents enjoy a healthy, well-balanced diet, but some residents expressed concerns, particularly about the quality of the kosher bread provided. The inspector joined a small group of individuals for lunch and discussed the pace of life at the home. We were informed that although there was not a lot of a planned activity this suited them. A person informed the inspector that they were confident if they asked a member of staff if they could go out for a walk or to help them exercise then arrangements would be made. Hannah Levy House Trust DS0000003944.V371661.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. The people who use the service and people important to them consider that their views are listened too and comments made are acted upon. A recent incident at the home has not been dealt with appropriately and may have put people who live at the home at an undue risk EVIDENCE: The inspector was informed that no complaints have been made since the last inspection. The people who use the service and people important to them confirmed to the inspector that they felt confident that they could raise issues with the staff or management and these would be dealt with sensitively and promptly. The home has a comprehensive complaints policy that has recently been updated to now meet the National Minimum Standards. The manager informed the inspector that most of the staff had attended protection of vulnerable adults training. The staff the inspector spoke with impressed as people who would report concerns of a vulnerable adult nature. Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 17 One safeguarding incident that had recently been reported was briefly looked into at the time of the inspection. Close inspection of the records indicated that this safeguarding issue may have been handled in a more sensitive and timely fashion. The files of the people involved did not have any updated risk assessments and no information with regard to behaviour management was available to staff. Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at the home benefit from continued investment into the environment. There are sufficient communal areas and bathroom facilities to meet the needs of those who live there. More thought should be given to ensuring those individuals who have enduring mental health problems can remain as independent as possible. EVIDENCE: We toured the premises accompanied when we first entered the home inspecting a number of communal areas. They found that the home was Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 19 generally clean in all areas observed. It was noted that all toilet and bathrooms were found to be clean and hygienic. The home is centrally heated throughout and twenty-four of the thirty-five bedrooms are provided with en suite facilities. There is an attractive and accessible rear garden with garden furniture and a patio area for residents to enjoy. Bedrooms are situated on the ground, first and second floors. There is a dining room, large lounge and also a large conservatory all of which are well furnished and equipped. Aids and equipment are available for residents who may have disabilities, to help promote independence. There are passenger and stair lifts to aid access to all floors of the home as well as assisted baths, hoists etc. People informed the inspector that they are able to bring personal possessions with them into the home. The inspector looked at a sample of the bedrooms used by people who use the service and found that they had been personalised with pictures, furniture and photographs to reflect the individuals taste. It was noted that for most of the people who use the home it is freely accessible however there are some exceptions. Some of the corridors have handrails to assist people to mobilise independently around the home but these do not offer assistance down the whole length of the corridor. Another issue, which requires thought, is orientation cues for those people who are or have developed a dementia type illness allowing them to move around as easily as possible. Hannah Levy House Trust continues to employ a housekeeper and dedicated laundry and domestic staff. The home is clean and there are no unpleasant odours, making life within the home more pleasurable. The well-equipped laundry is sited on the ground floor. Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28.29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs enough staff to meet the needs of residents and to ensure their safety and comfort and maintenance of the good condition of the premises. Recruitment practices ensure the protection of residents from potentially unsuitable staff. More needs to be done to ensure that agency workers are fit to carryout the role that they undertake to ensure the protection of those who use the service. EVIDENCE: Staffing levels are provided in accordance with the assessed needs of residents to ensure that at all times sufficient staff are available to properly meet their needs. All staff spoken with during the inspection were enthusiastic about their work and felt that they provided a good standard of care to residents and are properly supported by the management and training provision. Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 21 The records of a sample of staff members were examined and found to contain all essential information including written references, interview assessment, health details and evidence of identity. Criminal Records Bureau (CRB) disclosures are obtained for all staff in advance of employment. The home has an induction programme that they have developed. It would be helpful if the homes induction programme was updated to ensure it met with the Skills for Care recommendations and requirements. It was noted that the home has continued to provide regular training for its staff via an external training provider. Again it would be helpful if the homes management verified the trainer’s accreditation to provide such training. The designated manager confirmed that they use agency staff from time to time. They understood that they had a responsibility to ensure that agency staff have been robustly vetted prior to commencing work but could not show the inspector any documents to confirm that this had happened. Through discussion with the staff group and by observing the people who use the service it is reasonably clear that the staff team have a natural empathy for the people who live at the home. There were many good examples observed of staff interacting positively with the people who use the service for example sitting down and talking with an individual who had become distressed or filling in records whilst sitting with a client. Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home could be improved for the benefit of those who live and work there. Opportunities for developing the staff team and in turn improving the outcomes for those who use the service are being lost. EVIDENCE: At the time of the inspection there was a designated manager in post. They have applied for registration with the Commission but this had yet to be Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 23 granted. The responsible individual was sharing some of the responsibility of running the home. Through the examination of the documentation at the home it is clear that some areas need to be improved and management systems put in place. Assessments and care plans need to be systematically reviewed to demonstrate how the changing needs of individuals are met. Risk assessments need to be regularly updated and management systems put in place to ensure all incidents are evaluated and action taken to ensure the well being of those who live at the home. Examples relating to the management of medication and safeguarding adults are discussed in the appropriate sections of this report. Whilst the home has continued to carry out quality assurance assessments where they consult people who use the service to ensure that their expectations are met. What the management do not do is look at other areas to evidence degrees of satisfaction such as individual’s documentation, for example for the person who has dementia the use of a questionnaire may be of very limited use but their daily records and personal plans may demonstrate areas of achievement or the need for improvement. Whilst observing the first dinner sitting it was clear that the staff had an established routine but what was less clear was how this routine was managed or for whose benefit as all individuals who attended this sitting required assistance. Two individuals were assisted to eat by one staff, which reinforced a task centred approach. Staff spoken with confirmed that this was always the case. The individuals care records that were sampled did not evidence that they had been consulted about when they choose to eat and with whom. This approach may serve to reinforce the disability and could be seen as discriminatory if not properly approached and documented. It would therefore be helpful if the management ensured that people are properly consulted about their personal preferences and the outcome of these discussions used as part of their care plan review. The provider has commented that the reason for this approach is to maintain the dignity of those who may need assistance at meal times. They further informed us that this approach is discussed with relatives at the time of admission. The inspector looked at the staff files to establish the frequency of formal staff supervision and found this was erratic. There was no structure to the frequency or content of supervision. Supervisors had yet to receive training with regards to supervision but had been provided with reading materials on this subject. Therefore opportunities for developing the staff team and in turn improving the outcomes for those who use the service are being lost. During a tour of the building a number of records relating to the care needs of the people who use the service were in public places. All information of such a nature needs to be kept in a secure place and in a confidential manner. An Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 24 example of this was a person who required the assistance of a wheelchair had their fluid intake chart attached to the wheelchair throughout the day. From touring the premises, looking at records and discussions with staff and residents, it is evident that measures are in place to promote the health and safety of residents. Records sampled confirm that equipment, such as hoists, passenger lift and portable electrical appliances etc are regularly serviced. Radiator surfaces are guarded in bedrooms and communal areas to prevent direct contact with very hot surfaces. All substances that could be potentially hazardous to health continue to be stored safely. Staff demonstrated an awareness of health and safety issues. Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 3 x x 3 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 2 2 3 x x 2 x 3 Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Timescale for action 15/10/08 2 OP9 13(2) 3 OP38 13(4)(c) The management must ensure that all care plans and assessments are regularly reviewed and updated in order to protect the people who use the service. The management must ensure 10/10/08 that there is a recorded rationale for the administration of medication via the Per Required needs route. This is to ensure the safe administration of medication and protect those who live at the home from abuse The management must ensure 10/10/08 that all risks are assessed and action taken to minimise risks carried out in order to protect the people who use the service. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 27 No. 1 2 Refer to Standard OP22 OP36 Good Practice Recommendations It is recommended that more thought is given to provider an environment where people with enduring mental health problems can use as independently as possible. The management must ensure that all staff receive regularly recorded supervision Hannah Levy House Trust DS0000003944.V371661.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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