Inspection on 23/07/07 for Keb House

This inspection was carried out on 23rd July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Keb House 21/07/08

Keb House 25/07/06

Keb House 18/01/06

Keb House 19/07/05

Keb House 22/11/04

Keb House 15/06/04

Keb House 17/02/04

Keb House 14/11/03

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Keb House Haytons Lane Appleby Scunthorpe North Lincolnshire DN15 0AP Lead Inspector Janet Lamb Key Unannounced Inspection 23rd July 2007 09:25 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 DS0000002886.V346443.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. DS0000002886.V346443.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Keb House Address Haytons Lane Appleby Scunthorpe North Lincolnshire DN15 0AP 01724 733956 01724 734800 kebhy@aol.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) Mrs Helen Elizabeth Young Mrs Helen Elizabeth Young Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18) of places DS0000002886.V346443.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2006 Brief Description of the Service: Keb House is a care home situated in the village of Appleby near to the town of Scunthorpe. It comprises of an older Victorian style house and an annexe of a single storey purpose built extension. There is a courtyard used for parking and domestic needs and a garden and sitting area to the front of the home. The newer part of the home has its own kitchenette, dining area and lounges. There are no retail providers in the village, but residents can access a nearby church and public transport is available. The home has 14 single bedrooms and 2 shared bedrooms, 7 of which have en suite facilities. Information provided by the homes management shortly after the site visit identified that the weekly fees charged are between £328.00 and £377.00, additional charges are made for chiropody, hairdressing and toiletries. Information relating to the home is available from the manager upon request. DS0000002886.V346443.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 Keb House has taken place over a period of time and involved sending a request for information to the home in May 2007 concerning service users and their family members, as well as staff and details of the home’s policies, procedures and practices. The Commission received the requested information in June 2007 and questionnaires were then issued to all service users and their relatives and GPs. They were also sent to social service departments commissioning their care and to the staff working in the home. This information obtained from surveys and information already known from having had contact with the home over the last few months, was used to suggest what it must be like living there. A site visit was made to the home on 23rd July 2007 to test these suggestions, and to interview service users, staff, visitors and the home manager. Some documents were viewed with permission from those people they concerned, and some records were also looked at. The communal areas of the home were viewed, along with two bedrooms. Four service users, two staff and the manager were interviewed and one visitor was also briefly spoken to. All of the information collected was checked against that obtained through questionnaires and details already known because of previous information gathering and contact with the home. What the service does well: Service users are assessed on entry to the home, having been given 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 well supported with health care that meets their needs and their expectations. They are protected from possible harm due to taking the wrong medication, because they have their medication handled by the staff in the home, and the staff follow robust practices and procedures. The service handles medication well and staff are trained in medication administration. Service users experience good levels of privacy, have their dignity maintained, and their right to make decisions is respected. 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. DS0000002886.V346443.R01.S.doc Version 5.2 Page 6 Service users are confident their complaints will be listened to and acted upon. They 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 and well-maintained environment. A sufficient number of care staff work in the home on each shift to meet the needs of service users. The staff are skilled and trained. The home follows robust recruitment and selection procedures and makes sure it employs good staff. The manager and deputy have both completed the Registered Manager’s Award. The 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: The service could provide a wider variety of activities and pastimes and consult service users more regularly on the food provision, so that they have an increased lifestyle that meets their expectations and so that they can have more input into the running of the home. DS0000002886.V346443.R01.S.doc Version 5.2 Page 7 The service could make sure all staff receive updated and reviewed safeguarding adults’ training. It could also make sure information about service users is always kept confidential, so that service users are confident they are being well protected. The service could make sure all areas, furniture and bedding in service users rooms are clean and comfortable. 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. DS0000002886.V346443.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 DS0000002886.V346443.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 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. EVIDENCE: Discussion with three service users and the provider/manager and viewing of case files with service users’ permission reveals placing councils assess service users prior to their admission into the home wherever possible. The manager also carries out an assessment of need before service users become resident in the home. Both of these documents are held on file and include an assessment of service users’ different and personal, social and health needs. They take into consideration all aspects of the individuals’ lifestyle and their expectations. DS0000002886.V346443.R01.S.doc Version 5.2 Page 10 One service user could not remember having had an assessment done and said, “I had a fall at home and had to go to hospital. I think I broke something. Anyway I went to another home first but only temporary. Someone came to see me there and then Helen came to see me and I moved to Keb House. I don’t remember an assessment being done.” Where possible service users sign these documents, or their relatives do so, to show they agree with the content and action plan to meet needs. The home has a statement of purpose and a service user guide, both of which are held in service users’ rooms. These documents have been reviewed over a year ago and now need updating to include the increase in staff having completed the recommended training. DS0000002886.V346443.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service receive 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 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 good. EVIDENCE: Service users, staff and management spoken to, documents seen in files and information taken from that provided to the Commission prior to the site visit, reveals service users have a care plan, which is generated from the information obtained during assessment and from information provided by relatives. DS0000002886.V346443.R01.S.doc Version 5.2 Page 12 Individual and diverse needs in respect of religion, social activities and physical impairment in particular, are recorded to ensure service users have their individual needs met, and according to their preferences. These are made clear in service users’ care plans. Action plans and risk assessments are also written in the care plans. The placing authorities also assist in preparing and updating their own care plans for the home to use and adapt. Care plans are reviewed monthly in the home, and annually with the council and other stakeholders, and all dates are maintained and copies of reviews are held. Where possible service users or their relatives sign documents. Those service users with particular health issues or ailments receive support from the District Nursing Services and visits from their GP, while assistance is given to accompany them to hospital appointments etc. Diary notes show when and how health care professionals see service users. Much assistance is obtained from the occupational therapist in respect of those service users with mobility problems and advice is taken on hoisting and aiding people to move. There is a policy on medication administration, which includes self-medication although no one does self-medicate at the moment. A monitored dosage system is stored in locked metal tins in cupboards, but this system has recently been changed to include a new wooden locker. There are two medicine stores, one in the main house and one in the annexe. Only senior staff that are trained to do so administer drugs. Systems are satisfactorily maintained. Service users spoken to are satisfied their medicines are being administered to them, one said, “Helen does them, I’m unable to do my medicines and I’m not bothered about it.” Another said, “I always get my first medication at 8 a.m. and then I get up with help from the girls.” Service users also spoke about the assistance they receive and that it is always given with respect to their privacy and dignity. One needed help to change position in her chair and requested hoisting. This was done while the Inspector observed, the service user having given permission. It was done appropriately. The service user explained the hoist is very uncomfortable and discussion followed with staff about it being the right size and in the right position etc. Staff always have access to the advice of the occupational therapist and discussion also followed about an appropriately designed wheelchair for the service user. DS0000002886.V346443.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 and 15. People who use the service experience adequate 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, and adequate opportunities to be selfdetermining. Their opportunities to do different activities and choose food provision could improve, so they are confident their daily lives and social activities fully meet their expectations. EVIDENCE: Discussion with service users, staff and the manager and viewing of diary notes reveals there could be more effort put into providing service users with activities and entertainment. Daily life tends to relate to individuals’ personal and health care needs being met first and of course to making sure everyone gets a reasonable diet. Mealtimes provide some structure to the day as do rising and going to bed. Some service users feel there is insufficient activity to keep them occupied throughout the day. All, except one, spoken to are happy with the arranged DS0000002886.V346443.R01.S.doc Version 5.2 Page 14 outings each Wednesday and Friday with an activities employee, but this can only ever be for two or three people at once. One service user felt she was unable to go out on Fridays, as this was usually to the pub and she did not like going to pubs. Most said they would also like to do other things in the house, as all they ever do, in the words of one is “sleep in their chairs.” One service user said they did occasionally play dominoes or cards. What does not seem to happen much is staff sitting with service users and talking, helping with letters or sharing life experiences. One service user wanted only to talk about his days in the forces. There needs to be a balance between providing outings, offering activities in the home and just spending time with service users. The activities employee maintains a record of what service users do and where they go, but she should also state her and their opinions of the outings and ask what else they wish to do. Service users have contact with family and friends in the home and sometimes go to visit them. No one expressed any dissatisfaction with this. Where possible service users handle their finances, but mostly those spoken to say their relatives have control over their money. One said, “My daughter deals with my money, I have no money here at all. I have my hair set weekly and my daughter settles up with the hairdresser. These arrangements are fine.” Another said, “My son handles my finances, I have no money on me at all.” A third said, “I look after my own finances, my money is locked safely in my room. I ask staff to get it out for me when I need it.” Where money is held in safekeeping the manager maintains a running balance and obtains receipts for any expenditure like hair dressing, sweets and newspapers etc. Discussions reveal that service users do not have a formal input into compiling menus, but some suggestions and likes are taken into account when the cook and manager put menus together. One service user said, “The cook tells us what’s for dinner and asks for our choice. We don’t get asked what goes on the menu though. I suppose Helen chooses.” The manager states service users are asked about items for the menu every three-months, but they must forget this happens. Consulting service users about menu planning could become an activity of the week or month in order to offer greater independence and choice, and to assist in helping them remember they are consulted. Mostly service users said the food is all right and if they don’t like a particular dish they can have something different. One said she doesn’t like the food and has problems with meals being too close together, but then it is her preference to take a late breakfast. The lunch seen on the day of the site visit looked and smelled satisfactory, a choice of chicken and vegetable pie or steak DS0000002886.V346443.R01.S.doc Version 5.2 Page 15 pie. One service user being asked by the cook to make her choice for the day, as is the cook’s practice, requested fish cakes instead. The service user later explained that pastry does not agree with her medically so she has an extra choice made available. There were no adverse comments about food that caused concern. DS0000002886.V346443.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience adequate 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 do not experience very good promotion and protection of their welfare and so cannot feel fully confident the systems in place to protect them are robust. EVIDENCE: Service users spoken to understand they have a right to complain if they feel it necessary, but that very few do so because they have nothing to complain about. They said, “If I’m unhappy about something and have a complaint I tell Helen.” Another said “I do make my wishes known, but sometimes the staff look cross if I make requests too often.” There is a policy and procedure in place and staff spoken to are aware of their role in passing on complaints to the manager if they are unable to resolve them. There have been no formal complaints in the last twelve-months and the manager is planning on providing more in-depth complaint handling training for staff. DS0000002886.V346443.R01.S.doc Version 5.2 Page 17 There is a safeguarding adults policy and procedure and again there have been no referrals to the social services adult protection team in the last twelve-months. Staff spoken to are somewhat aware of their responsibilities to protect service users and have done safeguarding adults training, but may not be fully aware of the consequences for not passing on information they have or incidents they may be witness to. Staff last undertook training with Aaron Associates in November 2005. There are new guidelines concerning the safeguarding adults protocols within social care in general and therefore the manager is advised to seek any new training that may be available with the social service in the area and ensure all staff undertake it, to make sure they are refreshed in their understanding and responsibilities. An issue raised at the last inspection that had a recommendation set against it was the use of the hall diary, which does not provide any privacy of information or protection of data. The diary is a communication aid for staff when the manager or deputy is not in the home. The manager and deputy then have access to recorded happenings and telephone calls on their return. However although in practice using it is supposed to avoid disclosing names etc. since the recommendation was made, on viewing the diary at the site visit, it is evident names are still included. It is not sufficient to ‘hope’ that the diary is kept closed as was implied by the manager. If the book is to continue to be used then it should at the very least be kept locked in a cabinet beneath the telephone in the hall and only be brought out for immediate use as necessary. The recommendation still remains for confidentiality to be upheld. DS0000002886.V346443.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 and 26. People who use the service experience adequate 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, safe, but not always clean and comfortable environment in which to live, so they cannot always be confident they have a good home. EVIDENCE: Discussion with service users and staff and observation of some areas of the house reveals the home is suitable for its stated purpose of providing residential care to older people and the general cleanliness is satisfactory. However while interviewing a service user it was noticed that a metal-framed armchair was very dusty and while looking at the comfort of her bed that it had been made up leaving a stained sheet on it. Information was passed to DS0000002886.V346443.R01.S.doc Version 5.2 Page 19 the manager to consider the improved comfort of service users in bed by using something between their pressure relief mattress and their cotton sheet, such as a sheepskin sheet, and to make sure staff change beds if they are not clean. The lounge curtains in the annexe have not been replaced after redecorating the room and the lounge carpet in the main house smells malodorous. Otherwise those service users’ rooms seen are clean and tidy and very personalised. No service user made any adverse comment about the house or the living environment, except one to say she preferred there to be no curtains in the lounge as it gave extra light in the room. The kitchen was only viewed in passing and looked clean and organised. The laundry was not viewed on this site visit. DS0000002886.V346443.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 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, well-trained, confident and skilled staff in satisfactory numbers to meet their needs, so they enjoy a good service of care. EVIDENCE: Discussion with the staff and manager, viewing of rosters and taking of information from that supplied by the home reveals there are sufficient numbers of staff on duty with the appropriate qualifications. Staff have been effectively recruited. The Residential Staffing Forum calculation requires for 3 high, 1 medium and 12 low dependency service users, that there are 390.71 staffing hours per week. The home provides 435 and is therefore meeting this requirement. Staff express there are sufficient of them on duty to meet the needs of service users. Of the 14 care staff employed in the home there are five with and nine doing the recommended qualification at level 2. This means the home has 100 care staff working towards achieving the award to meet the standard. DS0000002886.V346443.R01.S.doc Version 5.2 Page 21 There is a recruitment and selection policy and procedure in place for management to follow and discussion with staff and viewing of files reveal these to be satisfactorily followed. Requirements under regulation 19, schedule 2 are being met. Staff files contain details of their application for the job, security check, employment contract and so on. The two files viewed have security checks that were completed in 2003 and 2004 and therefore it is recommended these be redone and updated. Staff do not undertake induction training in line with Skills For Care, but they do watch training videos in their first few days as new carers. There is no record of any induction held on files however. They do complete mandatory training in such as fire safety, food hygiene, moving and handling, infection control, care of vulnerable adults, dementia, health and safety, use of incontinence aids, first aid and medication administration. These are evidenced by certificates of completion and held in files. Staff receive regular supervision every 6 – 8 weeks and there is a simple appraisal system in operation that is completed each year. Both of these are recorded. DS0000002886.V346443.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, 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 promoted and protected, so they are confident they will be safe and well cared for. EVIDENCE: Discussion with the manager and staff and viewing of documents and records in relation to the health and safety within the home reveals standards are met. DS0000002886.V346443.R01.S.doc Version 5.2 Page 23 The manager and the deputy have both completed the Registered Manager’s Award and have many years caring and managerial experience. The manager and deputy carry out the leadership of the home in an appropriate and open management style. Staff members are able to speak with the manager or deputy freely in relation to the running of the home. There is a quality assurance system in place, which was not inspected on this site visit, but which, the Commission is informed, has not changed too much since the last inspection. Service users and their relatives are surveyed each month in relation to different topics and areas of the service. The staff appraisal system also informs the quality assurance system and an appraisal record for one of the staff was seen, though it did not contain a date. The quality assurance systems have yet to be reviewed in line with regulation 24 and therefore no report has been received at the Commission for this reason. Staff are not fully aware of the systems but do acknowledge they are consulted about suggestions for a smoother running of the home and on how they think things could be improved. Staff often have involved talks with relatives to seek their views of how the service could be improved, but this is not formally recorded. Where possible service users handle their own finances, though mostly it is relatives that do so for them. See information in section on ‘Daily Life and Social Activity’ for more detail. Health safety and welfare of service users, staff and visitors is assured because of the home maintaining safety equipment checks as necessary. The manager promotes and protects the health, safety and welfare of service users and staff by ensuring safety certificates are up to date and appropriate risk assessments are carried out. Contracts are held with local providers to ensure fire detection equipment, electrical and gas equipment is maintained regularly. Accident records are completed and held appropriately. All policies and procedures required for the protection of residents and the smooth running of the home are available. DS0000002886.V346443.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 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 DS0000002886.V346443.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No, only recommendations. 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 DS0000002886.V346443.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP18 Good Practice Recommendations It would be of benefit if the diary, recording residents planned appointments, were to be held more confidentially, so service users are confident their personal information is held in line with the data protection act, and so their privacy is upheld. The registered provider should offer a wider variety of activities and pastimes, both in and out of the home, so that service users are confident their lifestyles match their expectations. The registered provider should consult service users more often regarding what they would like to see on the menu, so that they feel confident they are being included in the day-to-day running of the home. The registered provider should make sure all staff receive update and reviewed safeguarding adults’ training so that service users are confident their safety will be promoted and protected. The registered provider should make sure all areas of service users’ rooms, their furniture and bedding are kept clean, so that they are confident they have a clean home to live in. 2 OP12 3 OP15 4 OP18 5 OP26 DS0000002886.V346443.R01.S.doc Version 5.2 Page 27 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 DS0000002886.V346443.R01.S.doc Version 5.2 Page 28 - 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!