Inspection on 08/05/08 for Harriet`s

This inspection was carried out on 8th May 2008.

CSCI found this care home to be providing an Good 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

Harriet`s 27/04/10

Harriet`s 16/05/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Harriet`s 119 Main Street Distington Workington Cumbria CA14 5TA Lead Inspector Nancy Saich Unannounced Inspection 8th May 2008 9:00 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 Harriet`s DS0000069676.V363891.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. Harriet`s DS0000069676.V363891.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Harriet`s Address 119 Main Street Distington Workington Cumbria CA14 5TA 01946 831166 01946 834373 harriets@schealthcare.co.uk 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) Southern Cross Healthcare (Focus) Limited Margaret Rose Visick Care Home 41 Category(ies) of Dementia (41), Old age, not falling within any registration, with number other category (41) of places Harriet`s DS0000069676.V363891.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places: 41 Dementia - Code DE, maximum number of places: 41 The maximum number of service users who may be accommodated is 41. Date of last inspection 16th May 2007 Brief Description of the Service: Harriets is a purpose built home situated in the village of Distington, midway between Workington and Whitehaven. The home has been open for a number of years but has recently been taken over by Southern Cross Healthcare. The Southern Cross group of companies operate a number of care and nursing homes throughout Britain. The home is registered to care for older adults or people who need care because they suffer from dementia. Charges range from £363 to £422 per week depending on needs. Further information may be accessed from the home or via the Southern Cross website Harriet`s DS0000069676.V363891.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 2 star. This means the people who use this service experience good quality outcomes. This was the main or key inspection for the year. The lead inspector Nancy Saich asked the manager to fill out a form called the Annual Quality Assurance Audit (the AQAA). This asks for details of what has improved in the home since the last inspection and for the plans for the coming year. This was completed promptly with plenty of detail. We then sent out postal surveys to people who live in the home and their relatives and friends and to the staff group. We had a good response to these surveys and we quote from them in the report. The responses were fairly positive and gave us a good picture of what its like to live and work in the home. Several surveys assured us that the home had improved dramatically in the last few months. Nancy Saich and Margaret Drury conducted this key inspection. We arrived at nine oclock in the morning and spent some time with the manager, the staff and people who live in the home. We toured the building, sat in lounges and shared a meal with residents. We also looked at files and documents that backed up what was said and what was seen. We had also visited the home on 30/01/08 and again on 08/01/08 when we completed unannounced random visits where we looked at specific standards around personal and health care and keeping people safe. These reports are not available on our website but can be requested by telephoning the Preston office. What the service does well: The home is good at managing peoples medication and in making sure staff are properly trained in how to do this correctly. People told us that they were very happy with the meals they were offered and we saw that staff paid good attention to peoples nutritional needs. The home has a good number of staff who are trained and qualified to National Vocational Qualification standards. The manager makes sure that any new members of staff are the right kind of people to care for vulnerable older adults. Harriet`s DS0000069676.V363891.R01.S.doc Version 5.2 Page 6 This home is good at making sure that things like fire and food safety are followed correctly and that equipment and services are properly maintained. What has improved since the last inspection? We judged that the brochure for new residents and other documents explaining what the home can offer had been updated and gave plenty of details of what life is like in the home. We saw that the manager had made a lot of improvements to the way new admissions are handled. The manager and the staff team had put a lot of work into improving the written plans that help staff to give residents the right care. We also had evidence to show that residents were getting health care more promptly and that staff were beginning to record the advice given in more detail. People told us that the manager and the company had done a lot of work to guide and support staff in how to give people more dignity, privacy and independence. We could see that there had been an improvement to the way people were supported in making choices about how they want to live their lives. People felt that their wishes were being followed. We also saw a dramatic improvement in the activities on offer. Relatives and friends are invited to more parties and entertainments and it has become more common for relatives to have a meal in the home when they are visiting. These things are encouraging more involvement from families. Southern Cross have worked very hard to listen to residents’ complaints and concerns and have put several problems right in a professional and sensitive way. The entire home has benefited from redecoration, new carpets and furniture. Residents were delighted with the changes to their environment. The manager has made sure that staff always follow good infection control measures and the home was clean and tidy on the day of the visit. There had been some problems covering staff absences but this has been improved by changes to the roster and by new recruitment. We learnt from staff and people who live in the home that an extensive training programme had been undertaken and the residents felt that their care had improved because of this. The manager of this home is growing into her new role and has made a lot of significant changes that have improved the lives of the residents. This home now has a good system in place that makes sure people are consulted about the quality of the service. More importantly the manager and the company listen to what residents and their families say and act upon it. Harriet`s DS0000069676.V363891.R01.S.doc Version 5.2 Page 7 We found that the arrangements for supporting people with their finances had improved. We also saw that all staff receive regular supervision when they are at work and that their practice has improved because of this. 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. Harriet`s DS0000069676.V363891.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 Harriet`s DS0000069676.V363891.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home has become much more careful about how they admit people so that all new residents will feel at home and properly cared for by the service. EVIDENCE: We asked to see a document called the Statement of Purpose that explains to prospective residents and other interested people the aims and objectives of the home, what kind of care they can deliver and gives details of the way the home is staffed. There were copies of this around the home. This document and the home’s brochure explain the care and services that people can expect in this home. There were one or two minor adjustments to be made about the details and the manager agreed to do this. Generally these were a good standard. We spoke to a number of people who had not been in the home for long. We also spoke to a relative about how the admission to care had been handled. Harriet`s DS0000069676.V363891.R01.S.doc Version 5.2 Page 10 Generally people were happy with this and said it helped them to settle in well. When we visited in April we learnt that one admission had not been suitable but we were pleased to see that the manager had dealt with this problem to good effect. We read some admission forms and looked at notes in files that showed that the manager or her deputy went out to visit new people to make sure that they could be cared for properly by the home. Harriet`s DS0000069676.V363891.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This service is working hard to improve the standards of health and personal care for every resident. EVIDENCE: We had been concerned at our visit in January that the written plans that tell staff of residents’ wishes and needs were not as detailed or up to date as they might be. When we returned in April we could see that the company and the manager had started to improve on these plans. At this visit we read approximately half of the care plans in some detail and checked on those care plans we had looked at earlier in the year. All the plans we looked at were up-to-date and most of them had included some new details; many of them had improved greatly and were much clearer to follow. We spoke to a number of residents who told us that they had been fully involved in drawing up the plans. We did see some that needed a little more detail and a little more clarity. We judged that the manager had made Harriet`s DS0000069676.V363891.R01.S.doc Version 5.2 Page 12 good progress in developing the plans and we trust that this will continue. We made some suggestions about how plans for people with dementia needed to develop. We make a general recommendation about this and other aspects of care for people who have memory problems or mental health problems. In January we had some concerns that medical care was not always as prompt as it might be. We spoke to various professionals about this issue. We concluded that there was no evidence to show that residents it didnt get good health care but we did judge that the way staff recorded the care given needed to be improved. At this visit we could see that staff were writing down much more clearly the symptoms, the actions they took and the instructions given by a doctor or nurse. We were pleased to see that a number of people had their medicines checked by a doctor, that one person had put on weight, another had a remarkable improvement to one aspect of the health and that several people had been helped and supported through periods of illness. Residents told us that they could have visits from the doctor or nurse or go to the surgery and were given the kind of health care support they wanted. We checked on the medicines kept on behalf of residents and we found these to be in order. On the day of the visit the deputy manager was instructing a new senior carer on how medicines were managed. We thought this careful mentoring was an example of good practice. Several staff told us that they had completed training on how to manage medicines and how to use the systems in place. We watched them give people their medicines and this was done with care and patience. Earlier in the year we had some concerns that staff needed more guidance on how to give people support in the right kind of way. The manager showed us minutes of staff meetings where things like dignity, respect and residents’ rights were discussed. We saw some notes of meetings between management and individual staff and we could see that these things were being addressed appropriately. On the visit we saw a lot of sensitive, caring and friendly interactions between staff and residents. We thought that some staff would benefit from a little more input from experienced workers when they work with people who have dementia. As one person put it: • Our staff are really very good and we know that we can rely on them -sometimes newer people need to learn how to smile a bit more when they are at work -- one or two just need their corners rounded off a little”. Several of the surveys told us that where there had been a concern about staff attitudes the manager and senior people from Southern Cross had acted in a sensitive but effective way to help specific members of the team to improve their practice. We saw well written evidence of this having happened when we looked at some of the care plans and at staff files. Harriet`s DS0000069676.V363891.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents told us that they were enjoying the improvements in activities and were happy with the routines of the day. EVIDENCE: At our previous visits we had had some concerns about the routines of the day being a bit rigid for older people. We had also discovered that the residents were unhappy with a reduction in activities and entertainments. We received a number of complaints about hair dressing. We discussed these things with a manager of the home and with the company. At this key inspection visit we discovered that changes had been made so that residents had more choice about how they spent each day. At the April and May visits we saw that residents got up when they wanted and could have breakfast in their rooms. They told us that they could stay in their rooms all day if they wanted and could eat every meal on their own. One of the staff had been appointed as activities organiser and we saw a dramatic improvement in group and individual activities and in entertainments and outings. During the inspection we saw preparations for a cheese and wine Harriet`s DS0000069676.V363891.R01.S.doc Version 5.2 Page 14 party for relatives and residents. The residents had had a visit from a harpist and we saw photographs of people trying out this instrument. People spoke about a reminiscence afternoon about life in the 1950s and several people said how much they had enjoyed this. During the inspection the activities organiser was doing exercises with residents and there was lots of other evidence to show that things had really dramatically improved. We also saw written evidence that showed how many more people were attending the activities organised every day. We could see the benefits of this for a number of people whose self esteem and mood had improved because of this work. As one survey said: • “My mother is much happier now she is given more choice and opportunity. I am surprised at how much she wants to join in”. We spoke to residents about how well they felt their needs were met. Some people said they enjoyed being able to get out in the home’s own transport, others said they enjoyed things like quizzes and one or two people spoke at some length about how nice was to go out to worship as well as attending services in the home. The manager and her staff have responded to residents’ requests for more interesting things to do and the changes they have made have resulted in a happier and more lively group of residents. We were pleased to see the people with dementia were included in these activities. We discussed activities for people with dementia with the manager and staff and we would like to see more work being done to meet the needs of this group. Residents said that they enjoyed their food and both inspectors joined them in a very well-prepared lunch. We were pleased to see that people with weight problems had good nutritional plans in place. We also noted that relatives were now invited to share meals with the residents just as they would at home. Harriet`s DS0000069676.V363891.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This service has made sure that any complaints or concerns are dealt with correctly so that residents feel comfortable about speaking up. EVIDENCE: There were copies of the complaints procedure around the home and we noticed that that this was available in a room for a new person coming in. Residents said that they knew how to complain and that they had complained and things had improved. Every person who was asked said that they would go straight to the manager, as they trusted her to deal with any problems. Residents and relatives also said that they would speak to the most senior person on duty and that they have the opportunity to talk to a manager from Southern Cross on a regular basis. We had two surveys where relatives told us how impressed they had been with the operations managers handling of complaints and concerns. • “ I was impressed with the way a senior manager dealt with mother’s concerns -- it was done very professionally with no bad feelings on either side.” We had received one formal complaint that we returned to Southern Cross and they had dealt with this in the given time and to good effect. Harriet`s DS0000069676.V363891.R01.S.doc Version 5.2 Page 16 We asked residents and their family members whether there was anything of concern going on in the home. They said that nothing abusive was going on and some people told us that concerns had been handled correctly. We saw written evidence that backed this up. We spoke to staff at length about this and were impressed that everyone we spoke to understood what kind of behaviour was abusive and also understood the importance of reporting this correctly. Even very recently appointed staff could explain how they would report a concern. We could see that the managers training on this had improved their understanding. Harriet`s DS0000069676.V363891.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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment of this home continues to improve and now provides a comfortable home for the residents. EVIDENCE: In the year since our last key inspection Southern Cross has made a lot of changes to the home. On the day of this visit the home was bright, clean and fresh. The lounges and the dining room had been totally redecorated and new furniture purchased. Corridors and the front door area had been redecorated and recarpetted. All around the building we could see that pictures and ornaments had been replaced and most of the home was now much brighter and tastefully arranged. Harriet`s DS0000069676.V363891.R01.S.doc Version 5.2 Page 18 The manager said that they still had some areas to work on. She said she had some quotes from companies for a secure, enclosed garden space where people with dementia could feel safe. She also said that she planned to freshen up the smoking room and was going to try to get an even more powerful extractor fan for the room. We saw a number of residents’ bedrooms and these had been redecorated and had new carpets. A good proportion of these rooms had new furniture and the manager told us that they were buying new bedroom suites every month. One of the surveys had commented on hygiene measures in the home and we had asked the manager to make sure that all staff were aware of their responsibilities. She had discussed this with the staff group in a meeting and then had made sure that everyone had up to date training on infection control. On the day of our visit we saw staff following good hygiene procedures and we found that there were plenty of things like hand wash around the building that would keep infection down. Residents bedding and personal clothing were freshly laundered and ironed. People told us that they were happy with the way the home was kept clean. • “ Everything is now much brighter and more a comfortable. We have had a lot of new carpets and furniture and there is always decorating going on.” Harriet`s DS0000069676.V363891.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 good. This judgement has been made using available evidence including a visit to this service. The home now has a settled team who are keen to learn more and work together for the benefit of the residents. EVIDENCE: There had been some staff sickness and other absences earlier in the year. The manager had been away from the home for some weeks. Southern Cross had tried their best to cover some of these absences but we judged that these difficulties had created some problems in the home. We asked for copies of rosters for some weeks before this visit and had also looked at these in January and April. We could see that the manager was dealing with these staffing problems very well. She had recruited some new staff and had appointed people to different jobs inside the home. We found that staffing levels were much better and that a number of people were now doing jobs that really suited their talents and skills. We judged that staffing levels now met the needs of the residents. We looked at the files of new staff and files of people who were waiting to start. Every one of these files had details of the staff member and showed that the company had made suitable checks so that they were employing the right kind of people to look after older, vulnerable people. Harriet`s DS0000069676.V363891.R01.S.doc Version 5.2 Page 20 A number of staff told us about their training. We also saw training records and together this showed us that the staff group were trained in all the basic tasks needed for their job. People had received training in fire and food safety, manual handling, safeguarding vulnerable people, managing medicines, controlling infection and more general training in how to maintain peoples rights, maintain independence and support dignity. Some of the senior carers had also received training in planning care and in working with people with dementia. When we spoke to staff about the work they, did all of them -- whether they were carers or housekeeping staff -- could give a good account of themselves and showed us that they were eager to learn more. A good number of staff in the home had National Vocational Qualifications in care at levels two and three. At the entrance to the home there are pictures of every member of staff and details of their qualifications and we thought that that was a good way to help residents and visitors understand who they could turn to in the team. We judged that this home now has a well managed staff team who are eager to play a part in future improvements to this service. Harriet`s DS0000069676.V363891.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): 31,32,33,35,36,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management systems in this home are now beginning to work very well and this means that care and services are improving. EVIDENCE: Margaret Visick has only been a registered manager of this home for a relatively short time. She has worked in the home for a number of years as the deputy manager. She has experience of working with older people and in supervising staff. The managers role is relatively new to her and she told us that she was learning all the time. She had been absent from home due to illhealth but on her return she had dealt with all the issues that we had picked up during our random visit in January. Harriet`s DS0000069676.V363891.R01.S.doc Version 5.2 Page 22 Southern Cross have not owned this home for very long and the manager has taken on her new role, introduced Southern Cross policies and procedures and dealt with some difficulties in the staff team. She has had good support from senior management in the company and there has been a remarkable improvement to the way care and services are provided. Both of the inspectors who visited in May judged that things in the home were beginning to settle and that there was a promise of even more improvement to this service in the future. We checked on a number of management systems in the home and found that the manager was making very good use of Southern Cross’ systems. We saw that residents personal finances were now being managed in a much improved fashion, that the maintenance and checks on things like the fire safety were operating very well and that the kitchen had received a four star assessment by the local environmental health officer. We looked at the way the manager and her senior staff recorded the one-toone meetings they had with the staff, and we also asked staff about this supervision and the way their work was monitored. Staff told us that they were closely supervised when dealing with residents and that they were given the opportunity to sit down and talk about their work. We judged that the supervision notes met the standard but we suggested ways to get a little more detail into these recordings. We looked at a number of records in the home and we saw that some of them were very much improved but we also saw areas where staff could be clearer and more focused. The manager understood our view of this and had already started to make some changes. Again we judged that she was moving things forward and we are aware that the company will be keeping a careful watch on this. We saw plenty of evidence to show that this manager was consulting people who lived in the home, their relatives and the people who worked and visited the home about the quality of care and services provided. We liked the fact that relatives were much more welcome in the home and they were given opportunities to attend meetings about individual care and the future of the home. She had also used surveys to find out what people thought and there were regular checks on all aspects of the home. She had used this quality monitoring exercise to develop a plan for the future of the home. We judged that after a very difficult start all aspects of the home were improving greatly and we could see the promise of further developments and improvements to the service. Harriet`s DS0000069676.V363891.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 2 3 Harriet`s DS0000069676.V363891.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations It is recommended that care planning for people with dementia be reviewed so that their health and personal care, activities and their environment meet the specific needs of this group. It is recommended that the manager makes sure that all staff record the activities of the home in as much detail as possible and that they follow company policies and procedures and meet with current good practice. 2 OP37 Harriet`s DS0000069676.V363891.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Harriet`s DS0000069676.V363891.R01.S.doc Version 5.2 Page 26 - 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!