Inspection on 03/07/07 for Hazemore Retirement Home

This inspection was carried out on 3rd July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hazemore Retirement Home 22/08/06

Hazemore Retirement Home 22/02/06

Hazemore Retirement Home 14/07/05

Hazemore Retirement Home 19/01/05

Hazemore Retirement Home 02/09/04

Hazemore Retirement Home 14/01/04

Hazemore Retirement Home 02/09/03

Hazemore Retirement Home 24/09/02

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Well Lane 5 5 Well Lane Tibthorpe Driffield East Yorkshire YO25 9LB Lead Inspector Janet Lamb Unannounced Key Inspection 3rd July 2007 09:00 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 Well Lane 5 DS0000019805.V345129.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. Well Lane 5 DS0000019805.V345129.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Well Lane 5 Address 5 Well Lane Tibthorpe Driffield East Yorkshire YO25 9LB 01377 229298 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) didimo@bt.internet.com Mrs Maureen Ayris Mrs Maureen Ayris Care Home 3 Category(ies) of Old age, not falling within any other category registration, with number (3) of places Well Lane 5 DS0000019805.V345129.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd August 2006 Brief Description of the Service: 5 Well Lane is a privately owned care home, which is registered to provide care and accommodation for three older people of either sex. The home is situated in the village of Tibthorpe, close to the market town of Driffield in the East Riding of Yorkshire. Information is given to new and existing service users to the home detailing the accommodation, facilities and services provided. The weekly minimum and maximum fees are £386.00 and £394.40. Additional costs are made for hairdressing, toiletries, magazines and newspapers at cost price. All personal accommodation is provided in single rooms, and communal accommodation consists of a ground floor dining room and a living room with a lounge dining area and sun terrace on the first floor, close to service users bedrooms. Bathroom, shower and toilet facilities are located on the first floor. There is a stair lift to enable service users to access both floors of the home and the garden is accessible to service users. The home is in a residential area of the village and has been adapted from a domestic dwelling to become a care home. Well Lane 5 DS0000019805.V345129.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection of Hazemore has taken place over a period of time and involved sending an annual quality assurance assessment to the home in May 2007 requesting information regarding the home’s self-assessment of the standards. Information concerning service users and their family members, and staff, was requested via the telephone in June 2007. The Commission received the self-assessment information in June 2007 and questionnaires were then issued to service users and their relatives, their GP and any other health care professional with an interest in their care, to social service departments commissioning their care and to the staff working in the home. This information obtained from surveys and information already known about the home from previous inspections, was used to suggest what it must be like living there. A site visit was made to the home on 3rd July 2007 to test these suggestions, and to interview service users, staff, visitors and the home provider/manager. Some documents were viewed and some records were also looked at. The communal areas of the home were viewed, along with two bedrooms on the upper floor. The service users, one staff and the provider/manger were interviewed and one visiting District Nurse was also asked to briefly give her opinion of the service of care provided. All of the information collected was checked against the information obtained through questionnaires and details already known because of previous information gathering What the service does well: There has been no change in the service users for some years now, but clearly they were and are assessed before they are admitted to the home. They receive good information on what the home is like and what to expect, and they are provided with a good care plan for staff to follow. They are very well supported with health care that meets their needs and their expectations. Service users are encouraged to self-medicate and are carefully monitored to ensure their protection. Systems are safe and medicines are securely stored, but service users have control over what they take. Staff provide clear prompts on when to take medication. Service users experience good levels of privacy, have their dignity maintained, and their right to make decisions is respected. Well Lane 5 DS0000019805.V345129.R01.S.doc Version 5.2 Page 6 They are encouraged to maintain contact with family members and friends and enjoy visits from these people any time of the day, and they are encouraged to exercise choice and control over their lives. Service users enjoy very good food, which matches their expectations and preferences, but also offers a satisfactory level of nutrition. It also meets their individual choices. Service users are confident their complaints will be listened to and acted upon. Service users are protected from abuse by robust recruitment and selection procedures and practices, as well as by the service’s policies, procedures and practice under the safeguarding adults systems. Service users experience a safe, clean and well-maintained environment. A sufficient number of care staff work in the home alongside Mrs Ayris to meet the needs of service users. The provider/manager runs the service in the best interests of the service users, safeguards their financial interests, and maintains their health, safety and welfare. 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. Well Lane 5 DS0000019805.V345129.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 Well Lane 5 DS0000019805.V345129.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. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have their individual and diverse needs well assessed so they are confident needs will be met. They receive sufficient written information in the form of a statement of purpose and a service users guide so they can decide if the home is the right place for them. EVIDENCE: Discussion with the two service users, Mrs Ayris and Dawn the carer, and viewing of case files reveal the service users have both been fully assessed by their placing local authorities as well as an assessment of needs undertaken by the home. One service user recalls the assessment process and was happy for her files to be viewed. Documents seen confirm that service users’ diverse needs are well assessed before they take up residence. Well Lane 5 DS0000019805.V345129.R01.S.doc Version 5.2 Page 9 The home also has a statement of purpose and a service user guide so the service users living in the home are well informed of the service on offer and the kind of support and care they can expect. Well Lane 5 DS0000019805.V345129.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. People who use the service receive excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have their health and social care needs well documented in care plans, so they are confident all their needs will be met. They have good opportunities to self-medicate or their medication needs are well managed, and they enjoy good levels of privacy and their dignity is well maintained, so their overall quality of life is very good. EVIDENCE: Discussion with the service users, staff and the provider, and viewing of care plans reveals service users continue to have their personal and health care needs well represented in a care plan, which is carefully followed by the carers, and shows how needs are met. There is a comprehensive list of areas that are covered within the care plan, which is reviewed every month and review notes recorded. There is a daily diary record maintained and individual monthly recording grid showing whether the service users were assisted with Well Lane 5 DS0000019805.V345129.R01.S.doc Version 5.2 Page 11 washing, bathing, dressing, etc. or not. The monthly recording grids have a very comprehensive list of assistance topics, and those completed for May, June and July 07 were seen as evidence of care and assistance provided, whether health, social or emotionally related. There is a medication administration policy and procedure for staff to follow and this includes self-medication. Both service users say they are happy with the medication arrangements, which involve holding of their own drugs in weekly dispensers in their rooms and full support to take it at the right time and in the right measures, from staff. Because service users in effect selfmedicate there are no medication administration record sheets in place. What is held on file are only the actual details of drugs taken by service users. Storage of medication is satisfactory and remains in the control of the service users, thus allowing them to maintain their independence. One service user said, “My tablets are kept in my drawer and I take them myself, but I am just reminded to do so at the right time.” The other service user said, “I look after my own medicines, everything I show I want it to be.” Service users have their privacy and dignity very well respected and upheld. They have single rooms and use them throughout most of the day, one preferring not to leave their room at all. They receive a very individual and specialist service of care and support from the provider and her staff member and every need is met ensuring dignity and privacy are preserved. Well Lane 5 DS0000019805.V345129.R01.S.doc Version 5.2 Page 12 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. People who use the service experience excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users enjoy flexible routines, good contact with relatives and friends, good opportunities to be selfdetermining, and highly satisfying food provision, so they are confident their daily lives and social activities meet their expectations. EVIDENCE: Service users, Mrs Ayris and her staff member spoken to and documents seen in files reveal service users enjoy a good daily lifestyle and social activities that are offered. They mostly enjoy the company of the provider and the staff member, as well as from relatives and friends, but service users also engage in reading newspapers, doing crosswords and puzzles, watching television, and having books read to them by Mrs Ayris. They like discussing bygone days and take much interest in what family members are doing. Both service users say they have not been out lately and are waiting for the better weather, but both are also becoming more Well Lane 5 DS0000019805.V345129.R01.S.doc Version 5.2 Page 13 dependent and less inclined to ‘stir from’ their rooms. Their physical abilities are also on the decline, making it more of an effort to do something active. Service users are able to make their own choices throughout the day about rising, going to bed, what they shall eat, whether or not they shall engage in anything etc. One chooses to remain in their room almost constantly and never utilises the dedicated lounge on the first floor that provides access to a sun terrace and offers lovely views across the fields and hills. The other receives visitors in this lounge and also uses it to watch television or converse with the provider and staff member. Life is very relaxed and dictated only by the pace set by service users. Both service users have family members that handle their financial affairs and this suits them well. One said, “My family deal with my finances and I get an allowance. I’m happy with that. My daughter keeps me in dresses, she brought me two a few days ago.” The other said, “I look after my own money.” This service user also has some finances controlled by her family. Discussion with all concerned in the home reveals the meals provided are planned according to individual likes and usually on a daily basis. Changes are made if circumstances dictate, such as a hospital appointment or an illness etc, but usually service users choose what they want each day. Both have not been eating well recently and Mrs Ayris seeks advice from the dietician or the district nurse about service users’ physical health and nourishment. She has been providing fresh fruit in the form of blended ‘smoothie’ drinks, which service users are enjoying and benefiting from without having to eat large amounts. Preferences are catered for entirely because the home being small allows for the provider to meet dietary needs individually. One service user said, “We get what we like to eat, but I like all the wrong things.” Staff try very hard to encourage service users to eat well and healthily. There were no grumbles about the food provision form anyone with an interest in the home. The visiting District Nurse said, “Mrs Ayris buys foods the ladies want and ask for. One is particular about what she eats and doesn’t always eat well.” Well Lane 5 DS0000019805.V345129.R01.S.doc Version 5.2 Page 14 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. People who use the service experience excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users make use of informal complaint processes and systems and have all issues dealt with appropriately and they do not need to make formal complaints, so service users are confident their concerns are dealt with effectively and efficiently. They also experience good promotion and protection of their welfare and so feel confident the systems in place to protect them are robust. EVIDENCE: Service users and the staff member spoken to and information seen in the policies on complaints and protection, reveal issues are discussed as they arise and are not allowed to ‘smoulder,’ so service users have become part of a culture where everyone just talks with one another and voices their opinions and concerns. These are logged in diary notes and if necessary in the complaint register, but they are usually dealt with quickly to prevent dissatisfaction. Everyone providing information says they know how to make a complaint and both service users said they would just tell the provider. “If I were unhappy about something I would tell them and the authorities, I know how to complain and there are always two sides to every story.” “I would tell the carers if I Well Lane 5 DS0000019805.V345129.R01.S.doc Version 5.2 Page 15 were unhappy about anything. I am treated properly, they are very good to me.” One relative also states satisfaction with the arrangements for discussing issues and voicing concerns. There has been no formal complaint or safeguarding adult referral made in the last twelve months, and with the ethos within the home, that of open discussion, family atmosphere and daily personal consultation and sharing of information, it is unlikely any will need to be made. Mrs Ayris has very good relationships with service users and their relatives and always keeps them informed of issues and incidents, as well as on positive wellbeing. There is a complaint policy and procedure and a whistle blowing policy and procedure. There is a record to maintain information should either of these need to be recorded. Both Mrs Ayris and the staff member have received training on safeguarding adults’ issues and referrals; Mrs Ayris has done the manager’s training with the Hull & East Riding Safeguarding Adults’ Board and the staff member has done NVQ level 2. Although training is not specific for the staff member and was some time ago for Mrs Ayris, both are fully aware of the implications of their roles, their responsibilities and the rights of service users. Both are also mature people with a very strong sense of right and wrong and both display integrity and honourable intentions. A brief discussion was held with the visiting District Nurse on the day of the site visit and her comments were, “The home is excellent. Mrs Ayris pampers to the ladies’ every wish. She is a lovely lady herself and always keeps us informed of any changes in the condition of the service users. I have no worries about the ladies at all, if they were unhappy families would have moved them long ago.” Well Lane 5 DS0000019805.V345129.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. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have a well-maintained, clean and comfortable environment in which to live, so they are confident they have a good home. EVIDENCE: Discussion with service users, staff and Mrs Ayris and viewing of service users’ rooms and their communal lounge on the first floor of the house, reveals the house is very well maintained and is very clean, comfortable and pleasant. It also meets the needs of service users in respect of their mobility problems due to age. Well Lane 5 DS0000019805.V345129.R01.S.doc Version 5.2 Page 17 There is a large lounge/dining room with sliding patio doors onto a sun terrace, a shower, toilet and basin and three single bedrooms available to service users. These are all on the upper floor of the house and are accessed by a stair lift. Bathrooms and toilets have suitably assessed and positioned handrails. Mrs Ayris also has a bedroom on the upper floor and has a lounge, dining room, kitchen and conservatory on the ground floor for her personal use. The kitchen is also where she prepares meals for everyone. There is a rear garden in which a greenhouse is sited and in which various flowers and plants grow along with raspberries. The front of the house has parking space for three cars and a lawn area with shrubs and flowers, and is accessible, as it is on a graded levels. Inside the house is domestic in style, which provides a very comfortable and homely family environment. One service user said, “It’s lovely here, I couldn’t have a better home, it is comfy and clean.” The other said, “It’s lovely here, I am very comfortable.” The home has a domestic style kitchen, which has been fitted out to environmental health recommendations: three sinks and no laundry equipment. The washing machines and dryer are sited in the garage to the side of the house, allowing for good infection control practices to be carried out. There is no infection control policy in place but practices are of an extremely high standard in terms of maintaining service users’ continence and in maintaining cleanliness within the home. Standards are met. Well Lane 5 DS0000019805.V345129.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. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users are cared for by well-recruited, trained, confident and skilled staff in sufficient numbers to meet their needs, so they enjoy a very personalised service of care. EVIDENCE: Discussion with Mrs Ayris and the staff member and information taken from the Commission’s self-assessment and dataset document obtained as part of the inspection, reveals there are only three people ever engaged in working in the home. Mrs Ayris the provider also lives in the home. She is on duty 24 hours a day, and employs one part-time worker that does 8 hours a week and one cleaner that calls in once a week to clean the home. There is also one relief worker that covers the odd specific shift if Mrs Ayris needs to leave the home and the part-time worker is not available. Mrs Ayris is the person oncall during the night and at the moment both service users are sleeping through the night and do not require any assistance. The arrangements for staffing cover are satisfactory at present. As there are only two care staff employed in the home, one part-time regularly and one on a relief basis as necessary, and Mrs Ayris working as manager and Well Lane 5 DS0000019805.V345129.R01.S.doc Version 5.2 Page 19 carer 24 hours a day, the fact that one has NVQ level 2 means the 50 target for care staff achieving the award is met. Mrs Ayris follows a recruitment procedure, which today requires attending for interview, supplying of references and undertaking a security check, but the staff that currently work for her have been doing so for ten years or more and consequently evidence of some of these recruitment documents etc. are not available. There is evidence of the security checks however, and of staff induction undertaken and supervision that is carried out on a daily basis. Supervision is mainly about service users’ needs and changes in wellbeing so these details are recorded in their diary notes. Mrs Ayris is aware of the ‘Skills For Care’ and ‘General Social Care Council’ organisations and offers basic training and maintains a simple verbal code of conduct. She and the staff have completed food hygiene training, have good knowledge of infection control requirements and take and follow the advice of healthcare practitioners as necessary. They provide a very personalised and well-informed service of care and support. Well Lane 5 DS0000019805.V345129.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. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users live in a home that is well run and in their best interests, where good systems are in place to determine the quality of the service, and where their financial interests are safeguarded and their health, safety and welfare are well promoted and protected, so they are confident they will be safe and well cared for. EVIDENCE: Service users, Mrs Ayris and the staff spoken to and viewing of files and records, reveal the home is well managed and run with adherence to safety and wellbeing of all concerned. Well Lane 5 DS0000019805.V345129.R01.S.doc Version 5.2 Page 21 Mrs Ayris has many years experience in care and especially owning and managing the business. She demonstrates an in depth knowledge of service users and their needs. She states that she does not intend to seek qualification to NVQ Level 4 Manager’s Award based on her age. She has the support of staff and members of her family in the day-to-day operation of the home. There is now a simple but formal quality assurance system in place based on the views of service users and their relatives. It utilises evaluation questionnaires, discussions with service users, reviews of their care and placement, a suggestion book, the complaint procedure and record, consensus and comments from service users as well as determining the morale of the staff. Information is assessed and acted on as necessary. Mrs Ayris now makes comments on service users’ individual monthly grid sheets concerning these areas and amends their care plan accordingly. All that is now required is to develop the systems, carry out an annual or bi-annual review of the systems and write a short report to show this has been done. Service users explain that their relatives deal with their relatives and that they only maintain enough money on their person to purchase small items on a daily basis. The home does not handle any finances except the taking and receipting of weekly accommodation charges. One service user said, “My family handle my finances and I get an allowance. I’m happy with that. I’m not bothered about shopping, I’ve been house bound too long.” Mrs Ayris and the staff confirmed these arrangements. The home is safely maintained in respect of fire, the environment, food provision and electrical equipment. There is a fire procedure for all to follow and a system of fire detection that meets the local fire department requirements for a ‘small’ care home. Spitfire Services maintain the system, which was last done in January 2007. The smoke detectors and alarms are now tested regularly and recorded. An electrical installation check has been carried out and a report produced. This was done 07/11/06. Both of these were requested at the last inspection. An environmental health visit was made to the home on 15/05/07 and the ‘score on the door’ was set. Both Mrs Ayris and the staff have food hygiene certificates to level one foundation, and there is a Food Standards Agency booklet available, ‘Safer Food, Better Business.” The kitchen has been redecorated. Food safety standards are good. There is only one stair lift in the home and ‘Stairlift Services’ last maintained this on 15/12/06. It is not used very much except to assist service users downstairs when they go out or attend a special function organised in the main dining room. Well Lane 5 DS0000019805.V345129.R01.S.doc Version 5.2 Page 22 Barkers Mobility carried out an assessment of the home on 14/01/05. This would only need updating if the needs of service users changed drastically or if new service users were to become resident. Mrs Ayris and the staff follow instructions on the labels of cleaning and disinfecting products in respect of dilution and personal protection. They keep products stored in a safe place and ensure they are not left out. Usually they are domestic products that are purchased from the supermarket. Water temperatures were not discussed, nor records inspected. Service users are constantly under the supervision of the staff, one has difficulty in mobilising and the other has full cognitive awareness, so neither would be at risk of scolding. The staff did not know if a legionella water test had been carried out and this was not checked with Mrs Ayris on her return from the shops. The water usage is however from a domestic system, which does not hold vast amounts of hot water anyway, and which is used several times throughout the day, so water is not stored for long. Well Lane 5 DS0000019805.V345129.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 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 3 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Well Lane 5 DS0000019805.V345129.R01.S.doc Version 5.2 Page 24 No. Are there any outstanding requirements from the last inspection? 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. Refer to Standard Good Practice Recommendations Well Lane 5 DS0000019805.V345129.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 - 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. 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