Inspection on 15/01/07 for Inwood House

This inspection was carried out on 15th January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Inwood House 20/03/08

Inwood House 27/02/06

Inwood House 13/09/05

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Inwood House Inwood House 10 Bellamy Lane Salisbury Wilts SP1 2SP Lead Inspector Ms Sally Walker Unannounced Inspection 09:40 15 January 2007 th 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 Inwood House DS0000063485.V324780.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. Inwood House DS0000063485.V324780.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Inwood House Address Inwood House 10 Bellamy Lane Salisbury Wilts SP1 2SP 01722 331980 01722 331985 admin.inwood@btinternet.com 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) Mr Alan Butchers Mrs Diana Butchers Mr Alan Butchers Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (10), Old age, not falling within any other category (20) Inwood House DS0000063485.V324780.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. No more than 20 service users with old age, over 65 years of age at anyone time. No more than 10 service users with a mental disorder, over 65 years of age at anyone time Within the category of Mental Disorder (MD), no service user to be admitted under the age of 55 years 27th February 2006 Date of last inspection Brief Description of the Service: The home is an established care home in Salisbury near the city centre. It is registered to provide personal care to up to 20 older people 10 of whom may also have additional mental health needs; one of whom is under the age of 65. Accommodation is to three floors accessed by a passenger lift and stairs. All but one of the single bedrooms has en-suite toilet facilities. There are 2 bathrooms and one shower room with toilets to the ground floor near the sitting room and dining room. The staffing rota provides for a minimum of 5 care staff during the mornings, four during the afternoon and evening, with one waking night staff and one member of staff sleeping in. This is one of 2 homes run by Mr and Mrs Butchers. Mr Butchers is also the registered manager. Inwood House DS0000063485.V324780.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 9.40am and 6.15pm. Mr Butchers was present during the inspection. The inspector spoke with 6 residents and some of their comments may be included in the body of the report. The care plans, daily reports, medication administration records, staffing records, fire log book and menus were inspected. As part of the inspection process comment cards were sent to the home before hand to gain the views of some of the residents. Relatives and GPs were also asked for their comments. One relative said that their family member was well looked after and that they appreciated the level of care in the home. One of the GPs said “I regularly visit Inwood House to see the residents and have been very impressed with the standard of clinical care and social and emotional support given to the clients and my patients there.” Regarding comment cards; one resident said they had not seen a contract. One resident said that they wanted to come to this home regardless of whether they were given information. Another said that their son had helped them to visit the home before deciding to live there. One resident said that they were accompanied for hospital visits and they were quite comfortable at the home. Another said that everything seemed quite good. Another said that staff were helpful when they needed them. One resident said that Mr Butchers regularly came to speak with them. Another residents said that the staff were available if they wanted them and that they were nice people. One of the residents said that staff did not always listen to them but on the whole they did. Another said that staff listened to them most of the time but said that they were very stretched and could not attend immediately. Another said “on the whole, the carers are very attentive, if they see something that is not right they attend to it to the best of their ability.” One resident said there were activities but they did not take part in them. Another resident said the same thing. Another said that they did not do activities anymore. One resident said that they sometimes joined in with activities but there were things that they just could not do. One resident said that the meals were fair. Another said they were quite nice. One resident said they did not make complaints but they regularly saw the staff and they were nice people. Another said that they would go to the office and see Mr Butchers if they were unhappy. They said they would write their Inwood House DS0000063485.V324780.R01.S.doc Version 5.2 Page 6 complaints. Another resident said “we can speak out of we want to about anything we don’t like”. The fees for the home are between £396.00 and £465.00. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: What has improved since the last inspection? The menus had been revised and updated that week. The provision of more home cooked meals was underway with the cook from Mr and Mrs Butchers Inwood House DS0000063485.V324780.R01.S.doc Version 5.2 Page 7 other home, working in this home, to consider how the provision should be improved. The old rusty toilet surrounds that had been difficult to keep clean had been replaced with new. The fire risk assessment had been reviewed and revised following an incident. The faulty piece of equipment inherited when taking over the running of the home had been replaced with better quality equipment. Staff were now signing the fire logbook to show when they had received fire safety training. The names of those staff attending fire drills were now being recorded in the fire logbook. 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. Inwood House DS0000063485.V324780.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 Inwood House DS0000063485.V324780.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential residents can be assured that every effort will be made to fully assess their care and support needs in order to establish whether those needs can be met. EVIDENCE: The home carried out very detailed pre-admission assessments for all potential residents. Information was gathered from a range of sources; family, previous placements, consultants and from the residents themselves. The assessments covered interests and social history, likes and dislikes, day and night routines as well as medical history and physical needs. This assessment will ensure that a detailed initial care plan is in place on admission. The home confirms in writing whether or not, based on the preliminary assessment, the home can meet the person’s needs. Inwood House DS0000063485.V324780.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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed care plans direct the care. Residents have good access to healthcare professionals. Residents can administer their own medication following a risk assessment. Staff do not always sign the medication administration record when they have given medication. Staff were respectful of residents and engaged with them in a meaningful way. EVIDENCE: Each resident had a care plan that identified all their care and support needs. Residents’ social care was documented as well as their medical and physical needs. Preferred daily routines were documented. Care plans identified whether residents preferred intimate personal care to be delivered by a carer of the same gender. The care plans were very individual and detailed and included whether residents liked to have a rest on their bed after a meal, where certain items of furniture had to be placed and that the call bell must be within reach if the resident was spending time in their bedroom. Care plans showed that staff had a good understanding of the needs of residents who may have a visual impairment. Specific details were recorded, for example, that Inwood House DS0000063485.V324780.R01.S.doc Version 5.2 Page 11 the environment must never be changed for these residents. Staff were also observed to inform one of the residents with a visual impairment of what was happening, who people were and what was about to happen. The care plans also showed a good understanding of the care needs of people who had been diagnosed with depression with details of how to support them with this. Many of the care plans identified residents who should be included in events rather than left in their rooms. Loneliness was identified as a risk. There was much evidence in the daily reports and from observation of staff engaging with residents. Risks associated with bathing were identified and it was always clear if any particular was never to be left alone in the bath. Risk assessments were also in place for smoking, moving and handling residents and for those who went out unaccompanied. It was clear from the daily reports that the care plans directed the care. It was also evident that any medical concerns were promptly referred to the relevant healthcare professional. Strategies were in place to encourage residents with eating if they were refusing food or not eating. Monitoring systems were in place to ensure that these strategies were working. Fluid intake was also monitored where necessary. Care plans were regularly reviewed each month and reviewed and revised as needs changed. None of the care plans seen had assessments with regard to resident’s risk of developing pressure sores. The inspector advised that staff must receive training in tissue viability in order to carry out the assessments to establish the early indicators of residents risk. The inspector also advised that as there was no tissue viability specialist nurse in the area, this training should be sought from one of the visiting district nurses. It was clear that the district nurse was alerted when concerns over residents skin condition were noted. Pressure relieving equipment was in place. Records were kept of any marks or wounds with evidence of progress in healing. Some of the residents went out for walks or to the town. Whilst detailed risk assessments were in place for these residents, there was no guidance regarding action to be taken in the event of one of the residents not returning. The writing of meaningless terms, for example, “no problem”, in residents’ daily notes was discussed with staff. Staff should consider only recording their input with residents, any communication and their observations. Mr Butcher confirmed that he had already discussed this issue with staff. All of those residents visited in their bedrooms had their call bells within easy reach. They also had drinks nearby. Residents were very well groomed. Residents could have more than one bath or shower a week. Residents had good access to healthcare professionals. One resident talked about a cut that was being treated by the district nurse. Another resident said that they would consult with their own GP at their surgery. Inwood House DS0000063485.V324780.R01.S.doc Version 5.2 Page 12 The requirement that care plans showed guidance regarding medication that was prescribed to be taken only when required had been actioned. Residents were able to administer their own medication following a risk assessment. They had been provided with a lockable facility for safely storing their medication. Care staff are only able to administer medication following training. All medication received into the home is checked and recorded. Any unwanted or unused medication is returned to the supplying pharmacist with records kept. Residents have regular reviews of their medication with their GPs. Mr Butchers reported that the GPs had reduced some residents’ medication with some success. It was noted that the medication administration record had not been completed for 2 of 3 residents who take a specifically prescribed to be taken at a certain time of day each week. The three packs had the medication removed suggesting that the medication had been given but not signed for. One of the packs had a further tablet missing for one of these 2 residents. There was no record of a tablet being spoilt through spillage. The home’s own weekly audit of the medication did not show that an error had occurred. Mr Butchers carried out his own investigations and the following day his conclusions were that staff had not signed the record. He had discussed the matter further with them. No explanation had been found for the missing tablet. Mr Butchers said that the Primary Care Trust Pharmacist was due to inspect the arrangements for the administration and control of medication in the next few weeks. The matter would be discussed with them. There was evidence that residents or their representatives had been consulted about the carrying out of intimate personal care by male staff. Residents’ preferences were noted in their care plans and there was a list of preferences at the front of the daily staff handover file for easy reference. One of the residents confirmed that they had been asked and that residents could choose to have a member of staff of the same gender to carry out intimate personal care. Another resident said that they did not mind being cared for by staff of a different gender. Another said they had refused. Inwood House DS0000063485.V324780.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 excellent. This judgement has been made using available evidence including a visit to this service. The home ensures that they have a good understanding of residents social, religious and interests. The weekly programme of events is given to residents individually. Whilst no one person is responsible for provision of activities staffing levels enable staff to provide at least one group or individual activity each day. Residents were encouraged to retain control over their lives depending on their needs. Efforts are being made to improve the choice and quality of the meals provided. EVIDENCE: One of the residents said they received a schedule of the weekly activities. An example of what was on offer was: crosswords, table skittles, hairdressing, manicures, music, Holy Communion, bible study, ball games, keep fit and trips to a local supermarket for coffee. Some of the activities were one to one. One resident said there were games in the sitting room and that they liked to do a crossword. Another resident said that barbeques were held in the garden in the better weather. Although no single person was designated as providing activities each day, the programme identified a different member of staff each day to be responsible for activities. Mr Butchers took a resident into the town. Inwood House DS0000063485.V324780.R01.S.doc Version 5.2 Page 14 This resident had been missing their regular trips to a local coffee house due to health and the poor weather. One said they pleased themselves when they got up and what they did each day. Two residents independently talked about meeting up with each other to play scrabble. One resident said they could have a rest day in bed every now and again without being ill. One resident said they regularly did their own shopping in town and took a taxi. Another resident said that the local library visited the home every month to provide a good selection of books. Residents said their visitors could visit at a reasonable time and were always made welcome. One resident said that the food was adequate but there was a choice and an alternative if they did not like either choice. They said they had their meals brought to their bedroom. They liked fish and would eat it at least 3 days a week if they could. The menu showed that there were 2 meals each week that comprised of fish. Another resident said they only liked small portions and staff respected this. Another resident said there were odd combinations of meals, for example, curry and rice for main course and a rice pudding. The inspector could not find any meal of this nature on the menus dated January 2007 kept in the kitchen; this problem may have been addressed. However the cook from Mr and Mrs Butchers other home was working in this home to look at developing the menus to provide more home cooked meals. The lunch menu was either sausage wrapped in bacon or bacon omelette with a stir-fry of fresh vegetables, mashed potatoes and green beans. The pudding was banana pudding. The cook had just made two homemade cakes. Other residents said that a glass of sherry or juice was served before lunch. One resident said that birthdays were celebrated and they always had a cake and wine. Inwood House DS0000063485.V324780.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. The home expects residents and others to make comments on the service in order to improve it. Residents were confident in making their views known. Although not all staff had been trained in the local vulnerable adults policy and procedure, they had all been given a copy of the guidance. Those asked were familiar with what they must do when allegations were made. EVIDENCE: The home had a complaints procedure and a log was kept of investigations, action taken and response to complainants. The records showed that outcomes of complaints made by residents and actions taken were discussed with them following investigations. There was also evidence in the daily reports that residents had brought matters to staff’s attention. Staff recorded what action they had taken at the time, for example, turning the heating up when a resident was cold. It was clear from talking to residents that Mr Butchers regularly visited each one to discuss any issues and check on their health. Residents said they felt confident in discussing any issues with Mr Butchers. He confirmed that, apart from seeing residents every day, he tried to visit each resident at least once a week to discuss any issues in depth. Only 1 staff had a certificate to show that they were trained in the protection of vulnerable adults procedure. One member of staff said they had had no training in the local vulnerable adults procedure but they did have a copy of the booklet; No Secrets in Swindon and Wiltshire. They were clear about what Inwood House DS0000063485.V324780.R01.S.doc Version 5.2 Page 16 they should do if allegations were made. The inspector advised that all staff must have training in the local vulnerable adults procedure. Inwood House DS0000063485.V324780.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. Residents are provided with a warm, clean, well-maintained, homely environment. EVIDENCE: All the bedrooms are single accommodation with all but one having its own ensuite toilet facility. Bedrooms were individually decorated and personalised. Residents could bring small items of their own furniture. The requirement that all the undersides of toilet surrounds and bath hoist seats were included in the cleaning schedule to make sure there was no build up of limescale had been actioned. All the toilet surrounds that had rusted and could not be cleaned to infection control standards had been replaced. The dining room carpet was marked. Mr Butchers said he would have it cleaned within a month and if that did not improve the condition he would have it replaced by the end of September 2007. Inwood House DS0000063485.V324780.R01.S.doc Version 5.2 Page 18 The home was cleaned to a good standard and there were no unpleasant odours detected at any time. Protective clothing and disposable gloves were available. Care staff were involved in carrying out laundry as well as care. All of the residents’ laundry was sorted and processed according to temperature and delicacy. Soiled laundry was appropriately laundered. Inwood House DS0000063485.V324780.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. Staffing levels mean that residents can expect a high level of input both in care provision and activities. Staff are expected to undertake NVQs and attend the training provided. Although the home’s recruitment procedure appears robust, not all references and one Criminal Records Bureau certificate were not on file. Staff had good access to relevant training. Although mental health training had not taken place, staff showed a good understanding of the needs of those residents. EVIDENCE: The staffing rota provided a minimum of 5 care staff on duty in the mornings, four during the afternoons and evenings and one waking and one sleeping at night. This level of staffing included the weekends. All new staff were inducted and spend the first few shifts shadowing a more experienced member of staff. The requirement that a programme of regular training in working with people with mental health needs was in place had not been actioned. Mr Butchers reported difficulties in sourcing the training locally. Staff had been given reference information on paranoia and Huntingdon’s chorea. He gave assurances that other sources would be sought and he would ask the visiting community psychiatric nurse. It was evidenced by talking with staff that they Inwood House DS0000063485.V324780.R01.S.doc Version 5.2 Page 20 had a good understanding of residents’ mental health care needs. Staff were allocated time on each shift to complete their training workbooks. The workbooks are marked externally. Staff are expected to undertake NVQs. Mrs Butchers is the trained trainer for both homes in moving and handling and first aid. One staff said they had recently completed training in infection control and dementia. They had also had training on schizophrenia from the district nurse. They said they had obtained NVQ Level 2 and were completing Level 3. Training certificates were kept on file. Staff had good access to relevant training. The requirement that all the information and copies of documents required by Schedule 2 were retained on file had not been fully achieved. Two recently appointed staff each had only one reference. There was no evidence that one recently appointed member of staff had a Criminal Records Bureau certificate. However all their other documents and information was in place including records of interview and 2 references. Mr Butchers was left to investigate this. He reported the following day that the certificate had never been received from the Criminal Records Bureau and he was following it up with them. He was also chasing up the referees for the missing references. Other staff files were in order with a checklist at the front showing when each piece of information was requested and received. One of the residents said that staff respected them. Staff were seen to engage with residents finding time to sit and talk with residents as they went about their other duties. Inwood House DS0000063485.V324780.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, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mr Butchers was registered as provider manager in April 2005. Although his background is financial he has had previous experience of running the other care home with Mrs Butchers. The home is not responsible for residents finances. Staff have regular supervision. The home ensures that risks to residents and others health and safety are assessed and actioned where necessary. EVIDENCE: Mr Butchers has managed this home for nearly two years. For 6 years previously, he ran the other care home jointly with Mrs Butchers. He holds the Registered Managers award. He keeps himself up to date with current good practice by attending the training also provided to staff. He is well known to Inwood House DS0000063485.V324780.R01.S.doc Version 5.2 Page 22 all of the residents and regularly visits each one to talk about their health and discuss any issues they might have. All staff had regular supervision and appraisal with records kept on file. Residents or their representatives were encouraged to retain responsibility for their own finances. No money is held on residents behalf. If residents do need to pay for items and do not have cash, their bill will be paid and the relevant person invoiced each month. The requirement that a necessary review and revision of the fire risk assessment was carried out when events occurred had been actioned. The faulty piece of equipment had been inherited when Mr and Mrs Butchers had taken over the home and was now replaced with better quality equipment. The requirement that staff signed the fire logbook to show that they had received regular fire safety instruction had been actioned. The recommendation that the names of staff attending fire drills was recorded in the fire logbook had also been actioned. Written risk assessments were carried out on the environment, equipment and tasks carried out by staff. These assessments were regularly reviewed and revised. Guidance was placed by equipment and where tasks were to be carried out, for example, in the laundry. Inwood House DS0000063485.V324780.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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Inwood House DS0000063485.V324780.R01.S.doc Version 5.2 Page 24 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 OP30 Regulation 18(1) (c)(i) Requirement The person registered must ensure that a programme of regular training is in place for working with people with mental health problems. (Difficulties in obtaining local training were encountered. Mr Butchers agreed to find other sources so a further timescale was made.) Timescale for action 31/03/07 2. OP29 19(1)(b)& (c) The person registered must 15/01/07 ensure that all the information and copies of documents required by Schedule 2 are retained on file. (Requirement in progress) 31/03/07 3 OP8 4 OP7 13(4)(c) & The person registered must 18(1)(i) ensure that staff are trained in tissue viability in order that they can assess the early indicators of residents risk of developing pressure sores. 13(4)(b) The person registered must ensure that strategies are recorded in the risk assessments of those residents who like to go out unaccompanied in the event of them not returning at a given DS0000063485.V324780.R01.S.doc 15/01/07 Inwood House Version 5.2 Page 25 5 OP9 13(2) 6 OP18 13(6) time. The person registered must ensure that staff sign the medication administration record after having administered medication. The person registered must ensure that all staff are trained in the local vulnerable adults policy and procedure. 15/01/07 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP37 Good Practice Recommendations Consideration must be given to recording observations and interventions rather than meaningless words such as “no problem” in residents records. If the dining room carpet does not respond to deep cleaning then consideration must be given to replacing it. OP19 Inwood House DS0000063485.V324780.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Inwood House DS0000063485.V324780.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!