CARE HOMES FOR OLDER PEOPLE
Hopton Court Hopton Mews Armley Leeds West Yorkshire LS12 3HT Lead Inspector
Sue Dunn Unannounced Inspection 8th May 2007 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 Hopton Court DS0000001467.V335559.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. Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Hopton Court Address Hopton Mews Armley Leeds West Yorkshire LS12 3HT 0113 263 2488 0113 2632509 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 Care Management Limited Mrs Elaine Parker Care Home 40 Category(ies) of Dementia - over 65 years of age (40) registration, with number of places Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15th August 2006 Brief Description of the Service: Hopton Court is a 40 bedded home which provides care for older people with dementia. The home was purpose built as a residential home for older people, though not architect designed specifically for people with dementia. The building was constructed with new environmental standards in mind so all rooms exceed the minimum standard on size and all have en suite toilet and hand washing facilities. Built on two floors, there is access to the first floor by passenger lift. Each floor operates as a separate unit with food and laundry being provided from a central area on the ground floor. A garden area to the rear of the building has been developed to provide a secure outdoor sitting area for service users, and which allows them the freedom to wander outside in safety. The home is situated in the Armley area of Leeds within walking distance of the main shopping area, a small park, two pubs, a hairdresser and a post office. Because of the vulnerability of the residents, restrictions, in the form of digital locks (linked in to the fire alarm system) prevent residents walking freely around all areas of the home. The front door can only be opened by staff for the same reason. The current weekly fees charged by the providers is £405- £447. Additional charges are made for hairdressing, private chiropody and newspapers. This information was provided to the Commission for Social Care Inspection in April 2006. The contents of Inspection reports are discussed at staff, relative and residents meetings. A copy of the report was displayed in the entrance hall. Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcomes for service users. The inspection report is divided into separate sections with judgements made for each outcome group. The judgements reflect how well the service delivers outcomes to the people using the service. The categories are “excellent”, “good”, “adequate” and “poor”. More detailed information about these changes is available on our website – www.csci.org.uk. This was the first key inspection to be carried out since the home was re registered under new ownership. The manager completed a pre-inspection questionnaire and this information with information supplied since the last inspection was used as part of the inspection process. Questionnaire leaflets were taken to the home to be given to service users and relatives asking them to comment on the service. One inspector carried out the inspection visit arriving at 11:00 am without prior arrangement and leaving at 5:10 pm. During the visit, service users, staff, visitors and the manager were spoken with and observed, the care records of two service users were case tracked, staff records and other documentation was examined, there was a tour of the building, the food was tasted and care practices were observed. What the service does well:
The information pack for prospective service users and their families had been produced on CD and tape for the benefit of those with sensory losses. The manager said background information is requested from families to help the staff care for people in a ‘person centred’ way. The friend of one person had provided an excellent autobiography, which really helped the staff to understand the personality and history of the person they were caring for. There was open affection between staff and residents and all staff were seen to acknowledge people as they passed. Staff responded and interacted with people according to the mood of the moment. For example a small group started dancing the Mambo in response to background music that was playing. This was met with obvious enjoyment by both staff and residents who were involved. Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 6 Some activities were simple daily household tasks, which is good practice, as it helps people to retain lifelong routines and skills and give a sense of purpose to the day. A new nutritional system was to be introduced the following week. This gives nutritional values of all foods, menus based on this and alternatives which maintain the same nutritional value of each meal. The system also generates instructions on how to prepare each dish and orders the ingredients from the suppliers. Drinks were plentiful during the day with plates of biscuits and slices of fresh fruit. Jugs of juice were seen the bedrooms of people who could to manage this for themselves. One person said ‘the food is always good here. There’s never been anything I can’t eat.’ The manager was observed to immediately offer an alternative to satisfy a person who said she didn’t like the food. Relatives were encouraged to become involved in the home. One relative was putting up new curtains in a bedroom and explained the family had been able to have the room decorated in a colour more to her mother’s taste. Unpleasant odours were well controlled and clothing and bedding laundered to a good standard. Maintenance and safety checks were up to date and well documented The operations manager carries out rigorous audit checks on the home, which identify areas which require action. What has improved since the last inspection?
The written service user guide is also on CD and audio tape. There had been a vast improvement in the care plans, which were easier to follow, since the inspector’s last visit. A numbered care plan index (which corresponded with numbered care plans) showed at a glance which areas of care were covered by a care plan. This section, signed by a relative, was evidence the care plan had been discussed with them. A system of frequent routine audits are carried out on the medication and recorded to ensure standards are maintained. It was evident from the pre inspection questionnaire, photographs around the home and discussion with staff and the manager that more was being done to take people out. There had been trips to the theatre and places of local interest, entertainment and a wedding anniversary celebration. The garden area included brightly coloured butterflies and windmills It was good to see that the well-equipped sensory room was open for people to use freely. The hairdressing room had been decorated with pictures and adverts and looked like any high street hairdressing salon. The cook now makes low sugar versions of desserts for people with diabetes as recommended at the last inspection visit. It was evident during a tour of the building that the manager and staff had put time and thought into how they might improve the environment for the people living in the home. Signage in the form of brightly coloured pictures, door
Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 7 photographs and a daily changing information board all helped as memory prompts. Bedroom doors had been painted in strong colours and door furniture was fitted to increase the impression of personal and private space. The lights in the corridor area were being changed, as poor lighting levels were thought to be causing some falls. The improvement in lighting levels was already apparent. Each of the staff spoken with said that the Yesterday, Today and Tomorrow (YTT) training, specifically for staff working with people with dementia, had been a great ‘eye opener’ and helped them to work towards providing more person centred care. The manager was very pleased with the way staff had responded and felt the work to review care plans and make bedrooms more personalised and inviting had resulted from this training. Nineteen staff had completed the infection control training as recommended at the last inspection. All the requirements from the last inspection report had been addressed. 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
Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 9 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 Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 10 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, 2, 3, 4, 5 (6 N/A) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Prospective residents and their representatives have the information needed to choose a home which will meet their needs. Their needs are assessed and they receive a contract which tells them what they can expect from the service. EVIDENCE: In addition to the written service user guide information telling people about the service the home has produced the information on CD and audio tape. When this information is next reviewed it is recommended that guidance regarding the supervision of children who visit the home be included. A contract signed on behalf of a person funded by the local authority was seen. Pre admission assessments were seen for two people, these followed the same
Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 11 format but varied in content according to who had completed them. The manager was aware of this and action had been taken to ensure more consistency. Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 12 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, 11 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Health and personal care was based on individual needs and the people spoken with felt the care was good. However the care plans which direct the care required must be amended when changing needs are identified in the monthly assessments to ensure care needs are not overlooked. EVIDENCE: Staff had received training which has helped them use a more person centred approach to care and improved the quality of information in care plans. This is monitored through a weekly progress report based on the care plan and what is written in the daily notes. There had been a vast improvement in the care plans, which were easier to follow, since the inspector’s last visit.
Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 13 Care files for two people were closely examined, one from each floor of the home. One did not have a photo though the person had been in the home for several weeks and was said to be prone to ‘wander’. This same person was able to strongly express views and interact verbally and physically with staff and visitors. An assessment had been done two days after admission for the purpose of creating a care plan. There was information here about personal dress. The person’s past occupation and family were also included but some statements were rather general, for example the person’s and family views on resuscitation simply said ‘when the time comes’. ‘Tends to wander’ but not where and when this occurred and was it aimless, agitated or purposeful. A check list for new admissions, which is a good way of ensuring nothing is overlooked, had not been completed. Risk assessments, which are reviewed monthly, covered pressure ulcers, dependency, moving and handling, nutrition, falls and continence. A numbered care plan index (which corresponded with numbered care plans) showed at a glance which areas of care were covered by a care plan. This section, signed by a relative, is evidence the care plan has been discussed with them. A ‘work and play’ care plan is now included in care files but this had not been completed in one case though it was clear from observation and a brief discussion with family that some of this information could have been recorded whilst waiting for more background information from the family. The manager said background information is requested from families. The friend of one person had provided an excellent autobiography, which really helped the staff to understand the personality and history of the person they were caring for. The second person whose care was closely examined was tired and withdrawn on day of visit. This admission assessment had been completed in more detail giving a diagnosis of the type of dementia and the person’s views on resuscitation were clearly recorded. There was some brief information about past working life and interest in gardening. The monthly needs assessments showed an increase in dependency levels and the nutritional assessment for the previous three months showed the person at ‘high risk’. However, the care plan had not been amended and staff continued to write ‘seems fine’ in the daily notes. Contact with the doctor had been recorded, but it was in the section to show that staff had contacted a relative to inform them of this. It was only whilst speaking to a senior care worker that it was apparent the GP had been contacted again and visited earlier in the day. This information should have been written in the daily notes and cross- referenced to the professional visitors’ record to ensure needs were not overlooked.
Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 14 There was open affection between staff and residents and all staff were seen to acknowledge people as they passed. A system of frequent routine audits are carried out on the medication and recorded. The results of the last audit were seen. The senior person carrying out the audit was thorough and any problems such as out of date medication had been quickly identified. All the staff who handle medication had received training. There were no controlled medications being used. Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 15 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 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Social and recreational activities are arranged inside and outside the home for service users. The well-balanced and nutritional home cooked meals can be adapted to suit individual needs and preferences. EVIDENCE: It was evident from the pre inspection information, photographs around the home and discussion with staff and the manager that there is more being done to take people out. There had been trips to the theatre and places of local interest, entertainment and a wedding anniversary celebration. The garden area includes brightly coloured butterflies and windmills and there are plans to place a bird table outside the window at the end of a corridor to create a focus of interest. Some staff responded and interacted with people according to the mood of the moment. This was met with obvious enjoyment by both staff and residents who were involved.
Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 16 The activity coordinator keeps a daily record of who has done what activity or task and their level of interest. This is kept in the manager’s office. Some activities are simple daily household tasks, which is good practice, as it helps people to retain lifelong routines and skills and give a sense of purpose to the day. It was good to see that the well-equipped sensory room was open for people to use freely. The hairdressing room had been decorated with pictures and adverts and looked like any high street hairdressing salon. The newsletter is a good source of information for families who cannot visit regularly. The main meal of the day offered two choices, mince or burgers. One person said ‘the food is always good here. There’s never been anything I can’t eat though some will complain about anything’. One person said she didn’t like the food and pushed the plate away. This was a question of taste as the dish was sampled and the food found to be tasty and hot. The manager calmly asked her if she would like a glass of beer and a sandwich, which was accepted. The cook is now making low sugar versions of the desserts for people with diabetes as recommended at the last inspection visit. The manager described the new nutritional system, which was to be introduced the following week. This gives nutritional values of all foods, menus based on this and alternatives which maintain the same nutritional value of each meal. The system also generates instructions on how to prepare each dish and orders the ingredients from the suppliers. Drinks were plentiful during the day with plates of biscuits and slices of fresh fruit. Jugs of juice were seen the bedrooms of people who could to manage this for themselves. Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 17 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home has an effective and open attitude to complaints. People who use the service and their relatives felt they were able to raise any concerns without fear of repercussions. Service users are protected by the home’s policies and procedures. EVIDENCE: The organisation carried out a full investigation into a complaint which had arisen since the last inspection. This was unsubstantiated and the complainant was satisfied with the outcome. The home has in the past dealt with any allegations of misconduct or abuse quickly and in accordance with procedures for the protection of vulnerable adults. The manager was observed to deal immediately to satisfy a person who said she didn’t like the food. The organisation has a training package on adult abuse. All staff were to receive further training the week following the inspection visit. The home has a procedure file on adult protection. It is particularly important for the new deputy manager to understand his role and responsibilities should any events occur in the manager’s absence.
Hopton Court DS0000001467.V335559.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, 20, 21, 22, 23, 24, 25, 26 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home provides a safe, well-maintained and comfortable environment for the people that live there. The manager and registered providers continue to look at ways in which the environment can be improved to provide interest and stimulation for people with dementia and help them to maintain some independence. EVIDENCE: It was evident during a tour of the building that the manager and staff had put time and thought into how they might improve the environment for the people living in the home. The entrance area and some of the doors had colourful eye catching pictures. The same idea with a different theme was planned for the
Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 19 upstairs unit. This type of signage is good practice as it helps people with dementia to recognise where they are. The notice boards in the dining rooms were up to date and displayed the menu choices for the day. Inspection of several bedrooms found them to be well furnished and decorated. Bedroom doors had been painted in strong colours and door furniture was fitted to increase the impression of personal and private space. One person was entertained by lifting the knockers on all the doors whilst walking along the corridors. A relative spoken to was putting up new curtains in one room and explained the family had been able to have the room decorated in a colour more to her mother’s taste. She said her mother had settled from the day of admission. Other rooms for people with no family support had been made more personalised, homely and stylish by staff, which made it easier for people to recognise when they were in their own room. Bathrooms and toilets were identified with a photograph of the interior on the doors. The lights in the corridor area were being changed as poor lighting levels were thought to be causing some falls. The improvement in lighting levels was already apparent. Communal lounges had a range of furniture including easy chairs and sofas, which gave the rooms a more homely feel. A secure outdoor patio area has the added visual interest of giant butterflies and windmills and sturdy garden furniture so that people can sit outside. The access doors to this area were locked. It was said this was only done over the lunchtime period whilst staff were otherwise occupied. There are plans to increase the occupancy levels by creating 5 more en-suite rooms in what is currently the staff area. There must be alternative provision made for staff to have a designated area where they can relax and take their breaks. The spacious, well- equipped laundry was busy on the day of the visit. A housekeeper manages this area and ensures personal bedding and clothing is laundered to a good standard. This was evidenced by the appearance of service users bedding and clothing. Staff should ensure that debris does not build up in this area as it could be a source of cross infection. Odours were well under control. Hopton Court DS0000001467.V335559.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Though the home still falls below the minimum number of staff with NVQ, residents have benefited from the dementia training staff have received and their health and safety is protected by the rolling programme of training. EVIDENCE: There were sufficient staff on duty to meet the needs of service users. All but five staff have registered to start the NVQ. Out of a total care staff team of 23, 6 have achieved the National Vocational Qualification (NVQ), which is below the minimum 50 required. However, each of the staff spoken with said that the Yesterday, Today and Tomorrow (YTT) training specifically for staff working with people with dementia had been a great ‘eye opener’ and helped them to work towards providing more person centred care. One person said it had given her more ideas for day- to- day activities. The manager was very pleased with the way staff had responded and felt the work to review care plans and make bedrooms more personalised and inviting had resulted from this training. During the visit, most of the staff were observed to be interacting with people in a more purposeful and spontaneous way. Since the last inspection 19 staff have completed the infection control training.
Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 21 The three monthly training programme includes first aid, medication, moving and handling and fire safety. The deputy manager, who had worked in the home as a senior carer, was on his first day in the post. The post was advertised and interviews held. The file for another employee showed well detailed records of the interview, two written references and a Criminal Record Bureau check (CRB) The home had just introduced an employee of the month scheme to reward staff for their good work. A member of staff said ‘I like the home because there is plenty of training’. The manager spoke of a shift handover record for staff to log and pass on information about events during each shift. This was not inspected during the visit. Hopton Court DS0000001467.V335559.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, 36, 37, 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is well managed with an eye to ongoing development to improve the facilities and services for the people who live there. The health and safety of service users and staff is protected. EVIDENCE: The manager is supported in her work by an operations manager, (who was present during the inspection ), a deputy manager and an administrator. The deputy manager is to do the managers’ award training when he has completed the NVQ 3. The manager has done the YTT training, which the deputy is
Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 23 currently doing. It is recommended that the manager undertakes a formal qualification relating to dementia care. The operations manager carries out rigorous audit checks on the home which identify areas which require action. Staff confirmed during the last inspection that they received regular supervision. This is ongoing as evidenced by the supervision planner on the office wall. The maintenance man described his areas of responsibility. Any repairs are logged in a maintenance book. Work outside his remit is reported to the organisation’s help desk who contact a contractor who should deal with any repairs within 48 hours. In his absence safety checks are carried out by the maintenance person from another home. The following safety records were checked:Fire safety checks, Water temperatures, Shower heads, Wheelchairs Call systems All the records were up to date and orderly. No health and safety hazards were noted on this visit. Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 24 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 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 3 3 4 3 4 3 4 STAFFING Standard No Score 27 3 28 2 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x x 3 2 3 Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP4 Regulation 14 Requirement There must be sufficient detail in pre admission assessments to form an initial care plan showing how needs will be met Care plans must be amended in response to results of monthly assessments which show that needs and dependency levels are changing 50 of care staff must have level 2 in NVQ care. Outstanding from previous inspections There must be consistency in the documenting of information in the care files to allow for cross referencing of information. Timescale for action 30/06/07 2 OP7 13 30/06/07 3 OP28 8 31/12/07 4 OP37 17, 13 30/06/07 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 Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 26 1. OP1 Prospective service users and their families should receive guidance on the supervision of children who visit the home for the protection of children and other people living in the home. The manager should undertake a formal qualification relating to dementia care. 2. OP31 Hopton Court DS0000001467.V335559.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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
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