Inspection on 09/11/06 for Kesteven Grange

This inspection was carried out on 9th November 2006.

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

Kesteven Grange 17/11/08

Kesteven Grange 15/11/07

Kesteven Grange 21/12/05

Kesteven Grange 11/08/05

Kesteven Grange 09/11/04

Kesteven Grange 06/07/04

Kesteven Grange 11/03/04

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

CARE HOMES FOR OLDER PEOPLE Kesteven Grange Kesteven Way Kingswood Kingston upon Hull East Yorkshire HU7 5EY Lead Inspector Janet Lamb Unannounced Inspection 10:10 9 & 10 November 2006 th 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 DS0000031929.V319455.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. DS0000031929.V319455.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kesteven Grange Address Kesteven Way Kingswood Kingston upon Hull East Yorkshire HU7 5EY 01482 837556 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) www.southerncrosshealthcare.co.uk Southern Cross Care Homes No 2 Limited Linda Portlock Care Home 54 Category(ies) of Dementia - over 65 years of age (54), Old age, registration, with number not falling within any other category (54) of places DS0000031929.V319455.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit four named service users, aged under 65. Date of last inspection 21st December 2005 Brief Description of the Service: The home is registered to provide personal care and accommodation for 54 people of either gender over the age of 65, some of whom may also suffer from dementia. This also includes up to 4 people under the age of 65. Kesteven Grange is a purpose built home situated on a large residential estate on the northern outskirts of the city of Hull. The home has 46 single and 4 double bedrooms. Four bedrooms have en-suite facilities (toilet and wash hand basin). There is a large lounge and separate dining room on the ground floor and a large lounge/dining room on the first floor. There are a number of bathrooms and toilets throughout the home and a passenger lift to access the first floor for service users unable to use either of the two stairways. Office accommodation, the kitchen and laundry are all on the ground floor. Outside is a large garden with a fenced seating area for service users to enjoy in the good weather. A newly created patio area, which is securely fenced, has been created outside the main lounge. This is the place service users go to smoke. Regular bus services stop near the home and local community facilities are a short drive away. The home has a large car park for visitors. DS0000031929.V319455.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 Kesteven Grange began at the beginning of August 2006 when a pre-inspection questionnaire was sent to the home requesting information about service users and their family members. The commission received the requested information on 5th September 2006 and survey comment cards were then issued to all service users and their relatives, their GP and any other health care professional with an interest in their care. This information obtained from surveys and information already known from having had contact with a number of people over the last few months, was used to suggest what it must be like living in the home. A site visit was made to the home on 9th and 10th November 2006 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. A total of six service users, and nine staff, including the Manager, were spoken to or interviewed during the site visit days and all of the information collected was checked against the information obtained from comment cards and details already known because of previous inspections and contact with the home. What the service does well: Service users are well assessed on entry to the home and 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. Service users experience good levels of privacy, have their dignity maintained, and their right to make decisions 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. Service users enjoy good food, which matches their expectations and preferences, but also offers a satisfactory level of nutrition. DS0000031929.V319455.R01.S.doc Version 5.2 Page 6 They are confident their complaints will be listened to and acted upon, and they are satisfied with the protection from abuse that is available to them, in the form of procedures to be followed and in the form of robust recruitment and selection procedures and practices. Service users experience a safe, clean and well-maintained environment. They are cared for by competent staff that are managed by an efficient Manager. The Manager runs the home in the best interests of the service users, safeguards their financial interests, and maintains their health, safety and welfare. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000031929.V319455.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000031929.V319455.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 only. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. EVIDENCE: Service users are fully assessed by their placing authority and also assessed by the home during their trial stay. Three service users gave permission for their files to be viewed and during interviews two of them could remember being included in the assessment process. One could not, saying “I don’t know about an assessment or a care plan, I left all that to my daughter.” Copies of the placing authority community care assessment documents and of the home’s own assessment documents are held on files. The Manager confirmed the assessment process and that care plans are generated from the information obtained. Care plans are comprehensive in the information they DS0000031929.V319455.R01.S.doc Version 5.2 Page 9 hold. Service users also have contracts on files and where possible all documents are signed by them or their relatives. Two of the documents seen had no signatures and were not dated either. This was discussed with the Manager. Other examples of documents containing signatures were shown, and confirmed the general rule is to obtain signatures. One staff was asked about omitting dates on forms and agreed to having forgotten to include them on one document she had completed. The Manager explained that new documents are soon to be used, which record a very comprehensive Pre-Admission Assessment that would be carried out in prospective service users’ own homes. A blank one was available for viewing. There is also information available in the form of statement of purpose and service user guide, for service users to make a decision about the home before they consider moving in. These documents are held in the foyer of the home. Standard 6 is not applicable, as the home does not take service users for intermediate care. DS0000031929.V319455.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive good health and personal care and support, so their needs are well met. They benefit from good medication administration and from good levels of privacy and dignity within the home, so their health care needs are also well met. EVIDENCE: Service users and family members are involved in the drawing up of care plans and any restrictions on choice and freedom imposed by specialist programmes are properly recorded. Evidence was seen of those involved on care plans inspected. Care plans are reviewed every six months on a formal basis, or sooner if necessary, and every month in respect of the paperwork being checked for continuing relevance. Dates of reviews were clearly seen on documents and all three service users spoken to confirm they take part in their reviews. Service users spoken to say, “I don’t need any help with my care, I look after myself,” and “The girls are very nice, they help me when I need it, with DS0000031929.V319455.R01.S.doc Version 5.2 Page 11 dressing and undressing. I can’t walk very well.” Another said, “Everyone is kind, nothing is too much for them. They do what I ask them to do depending upon how many staff there are on duty. Sometimes they are short staffed.” Staffing levels have been discussed and considered in the section on staffing. Staff spoken to explain that only senior carers, trained to give out medication, actually administer it. Some of the procedure was observed and administration is done professionally with no interruptions and is stored separately on both ground and upper floors. Staff wear a tabard saying they are not to be disturbed as they are administering medication. Staff give out drugs and sign on administration. Staff maintain a robust medication trail of receipted, administered or disposed of medicines. Medication administration record (MAR) sheets were appropriately completed and staff training in administration was confirmed with the Manager and the viewing of certificates. There were many unused prescribed food supplement drinks held in cupboards, which need to be returned to the pharmacist as soon as possible. DS0000031929.V319455.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Outcomes for service users regarding daily life and social activities are good so they enjoy doing the things on offer, see visitors regularly, make their own decisions as much as possible and are positive about the food provision. EVIDENCE: Service users spoken to are satisfied with the routines of daily life in respect of their personal care needs, and all three are aware of the care plans in place to guide staff to meeting identified needs. Care plans were discussed with staff and all felt that service users’ personal needs are well met. Service users expressed satisfaction with the opportunities to engage in activities within the home and in the community. Some have enjoyed a lot of attention over the past year or so, and have taken part regularly in outings to the seaside, pubs, restraints etc. However, it has come to the Manager’s attention that the same service users have been given all of these opportunities and the activities on offer have not been shared more evenly amongst the whole service users group. This imbalance has now been addressed with the taking on of a new activities coordinator. More service users now have opportunities to take part in outings. DS0000031929.V319455.R01.S.doc Version 5.2 Page 13 Several service users were enjoying bingo in the lounge on one of the days of the site visit. Others were listening to music or watching television in their rooms. Many are now quite frail, especially those service users in the special unit upstairs. Their entertainment tends to be in short spells and can involve either going downstairs to join in with such as bingo or a quiz, or engaging in conversation with staff about past years. A very simple, but effective pastime for those service users that wander and have high levels of confusion, is the positioning and attaching of items to the corridor handrails. These are curtain tie-backs, gentleman’s ties, netting toiletry bags containing sponges and flannels, soft toys etc. There are also boards fixed to the wall on which all manner of everyday items are glued. The aim is to encourage tactile exploration of everyday items, and maintain a business handling things that do not belong to anyone in particular. This also reduces the loss of personal belongings as service users enter bedrooms less often. There are many visitors to Kesteven Grange, observed during the site visits and from inspection of the visitor’s signing in book. Service users spoken to say they can receive visitors when they choose, within reasonable times. Service users say they can also take part in community activities when they choose. Individual activity plans and records are held and show just what service users do on a daily basis. Service users were asked about the meal provision within the home and all were satisfied with the variety of foods on offer, the choice of foods at teatime, and the way in which menus are compiled. Comments include, “The food’s lovely, I enjoy it. I only have mash and cabbage, that’s what I like,” “The food’s alright, I mostly like everything,” and “Sometimes the sandwiches are poor, they only have a small piece of meat in. I much prefer tuna sandwiches. I’ve not had liver, sausage and onions yet, but I will if I can.” The cook and Manager compile menus after consulting service users in meetings about likes and preferences. Menus are changed seasonally, do not offer an alternative at lunchtime, but do offer a selection of foods at teatime. Service users when asked what happens if they do not like the lunch on offer, said they are given something else. Discussion with the cook and observation of a staff member going around the home asking service users what they would like for tea revealed there is a choice of teatime foods; sandwiches are always available, as is soup, and then quiche, pork pie, beans/spaghetti on toast etc. can be chosen. Cakes, fruit and yoghurts are always available too. One service user has family that bring in special dishes for her to eat at the time they bring them, but the home rightly refuses to store any such foods for DS0000031929.V319455.R01.S.doc Version 5.2 Page 14 later meals. This service user is offered steamed fish and vegetables on a more regular basis than would be usual. Generally the service users’ cultural diversity needs are well met in respect of food. There is some difficulty in meeting her needs in other ways, but her family help with language interpretation and assist the staff to understand her behavioural needs. There are two care staff working in the home that come from overseas, but neither have any special needs in terms of their race, culture, language or religion. Management are sensitive to equality and diversity issues and strive to meet all identified needs. DS0000031929.V319455.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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaint management and protection of service users are good, so service users are listened to and they are confident they will be protected. EVIDENCE: Service users were consulted about their experiences of making complaints and everyone said how they did not need to make a complaint because generally everything is fine. Their comments include, “I have no complaints and if I had I would keep quiet anyway, as I never grumble. Her next door is always grumbling, there’s nothing to grumble about,” and “I have no complaints, the place is nice.” Staff were asked about their understanding of the complaint procedure and discussions revealed they consider the procedure to be mainly for service users and relatives, but also for them if appropriate. Staff are aware of the forms to fill out in the event of someone making a complaint, know the procedure is posted on the service users’ notice board and around the home, and explained they would take issues to the Manager or the Registered Provider if necessary. Discussion with staff also revealed they are aware of the Protection Of Vulnerable Adults procedures and have undertaken vulnerable adults awareness training. Service users are not very aware of the protection procedures and systems in place, but those spoken to are confident they can DS0000031929.V319455.R01.S.doc Version 5.2 Page 16 make their views known without fear of recrimination. They indicated they could talk to almost all of the staff, especially seniors, about any worries or dissatisfaction. There are only two comments on service user questionnaires, which show the level of dissatisfaction, and those are, “My room is only sometimes cleaned,” and “I sometimes have to wait to go to the toilet.” Both statements had the added view that this only happens when the staff team are short staffed. DS0000031929.V319455.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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is suitable for its stated purpose, and both cleanliness and maintenance are good, so service users enjoy a safe, homely environment. EVIDENCE: Several rooms were viewed with service users’ permission and mostly during interviews with them. Parts of the communal areas were inspected and were generally found to be clean, well maintained and comfortable. Service users’ rooms seen were very personalised, clean and satisfactorily equipped where necessary. A drinks/bar area is being built in the lounge to offer a social facility, but it is not intended for the selling of alcohol. The handyman is also erecting a shed in the grounds to store garden furniture etc. Some service users are interested in both of these projects. DS0000031929.V319455.R01.S.doc Version 5.2 Page 18 There were no comments from service users regarding their accommodation. One service user spoken to spends many hours in her room on bed rest and made some comments on the security of personal belongings, saying, “One lady here is disabled and takes things from my room. To be honest I think they should keep the disabled ones together in one section. They feel safer that way and we don’t have our things touched. We get over it though.” Another service user has a key to her room and is happy to lock it when she is not in. Not all service users have keys to rooms though, in fact only a “handful” do. DS0000031929.V319455.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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing complement is only adequate, although the competence of staff is improving. Great improvements can be made in staffing levels and qualifications, so that the right number and skills mix of staff meet service users’ needs. Recruitment and training opportunities for staff are good and so service users are cared for by carefully selected workers that are equipped with the awareness to do the job. EVIDENCE: Discussion with service users revealed they are of the opinion that staff are usually quite busy throughout the day, but they had no idea how many staff are usually on each shift. Four of the nine relatives’ comment cards received and six of the eight staff questionnaires received stated that in their opinion the home is not always sufficiently staffed. Staff, when interviewed expressed the view that when they are short staffed, for whatever reason, the workload is too much for them to handle, especially on the unit upstairs. The Residential Staffing Forum figures calculated for the numbers of older people actually in the home on the day of the site visit - 14 elderly service users with High dependency, 16 with Medium dependency and 18 with Low dependency, requires there be a minimum of 898.36 hours provided each week. The information received on the pre-inspection questionnaire shows contracted hours per week to be 814, plus an average of 37.5 hours worked by DS0000031929.V319455.R01.S.doc Version 5.2 Page 20 bank staff over an eight week period results in a total of 851.5 hours. This shows there to be a shortfall of 46.86 hours per week. The home is not meeting the recommended Residential Staffing Forum figures for the numbers of service users in the home, and therefore a requirement is being made to do so. Information provided on the pre-inspection questionnaire, from staff interviews and discussion with the Manager, and from staff training records shows there to be currently 4 staff with and 18 staff completing NVQ level 2, from a total of 28 care staff – giving a potential completion percentage of 78.5 (the actual figure is 15 ). Efforts need to continue to ensure all staff doing the course complete it. Other training undertaken by staff, and verified from conversations with them and the Manager and seen in training records and the training matrix held by the home, includes mandatory courses in fire safety awareness, medication administration, moving and handling, health and safety, abuse and POVA, infection control, nutrition and food hygiene. Selected staff have done an awareness course on the control of substances hazardous to health (COSHH) and almost all have completed supplemental training on bed rail safety and six on dementia care. Generally the Manager maintains regular updates for staff on all the mandatory training courses expected by Southern Cross. There is a robust recruitment and selection policy and procedure to follow and staff files seen with their permission contained the required information as listed in schedule 2 of the Care Homes for Older people National Minimum Standards, Care Homes Regulations. Staff spoken to in interview are confident they have clearance through the Criminal Records Bureau checks. Files seen confirmed this. DS0000031929.V319455.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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is effective and the health, safety and welfare of service users and staff is satisfactorily maintained, so that service users know the home is safely run in their best interests. EVIDENCE: The Registered Manager continues to provide consistent management of the home. She meets all of the requirements of the standard. The home has a system for assessing quality of care that includes themed monthly audits, bi-monthly audits in other areas of the care provided, monthly health and safety meetings, service user and relative surveys, relatives meetings and staff meetings. Service user meetings are only held when DS0000031929.V319455.R01.S.doc Version 5.2 Page 22 specific issues need to be discussed with them or to determine their views on planned changes. Regulation 26 visits are carried out and reported on and copies are sent to the commission. A regulation 24 report has not been completed yet, but the quality assurance systems have not been fully reviewed to date. Records, completed surveys and monitoring forms are available to evidence the effectiveness of the quality assurance systems, and some of the information is collated in the home’s annual report. Most service users within the home handle their own finances or have family members that do so. Those spoken to were satisfied with the financial arrangements in place for them: one said, “My daughter deals with all my affairs, I have no worries about money.” An interview with the home’s administrator revealed most service users have some money held in safe-keeping, which is banked altogether in one very low interest bearing account. The account has a bankbook and statements, and the administrator maintains computer records of money put in for or taken out by service users, and issues receipts for all transactions. The very small amount of interest is transferred into the service users’ activity fund once a year, so almost all service users benefit. Staff fund raise throughout the year to put money into the service users’ activity account. There are policies, procedures and guidelines on handling finances, assisting service users to make purchases and on such as receiving gifts etc. to protect service users from financial harm. Health and safety issues were discussed with the care manager and staff and generally the staff have a good understanding of their responsibilities as employees. They are aware of the polices and procedures manual, sign copies of documents on reading them and report any health and safety issues to the handyman, as soon as possible. Fire safety was inspected and proved to be effective and up-to-date. Extinguishers were serviced in March 2006, weekly checks on the detecting equipment are carried out and recorded, and fire drills are held every month and are also recorded. There is a fire risk assessment in place and the whole of the fire safety system is maintained annually on a service contract. There are Control Of Substances Hazardous to Health information documents held for each product used in the home, which cleaners are fully aware of and follow. Cleaning products are safely locked away in the cleaning store cupboard and staff spoken to are aware of their responsibilities in respect of safe use of materials. Practice was observed to be good. DS0000031929.V319455.R01.S.doc Version 5.2 Page 23 All lifting hoists and bath hoist were last maintained on service contract on 08/08/06. Staff are trained in their correct use and a training record is held. There are checks on the water temperature on a regular basis and these are carried out by the maintenance man and recorded. The last legionella water test was done in 2005. Staff are aware of their responsibilities to ensure service users are safe when bathing by following good practice guidelines. Overall there is good evidence to show that the home is well managed and service user and staff have their health, safety and welfare well protected. DS0000031929.V319455.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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 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 DS0000031929.V319455.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP27 Regulation 18 Requirement The Registered Provider shall ensure that at all times suitably qualified, competent and experienced persons are working in the home in such numbers as are appropriate for the health and welfare of service users. The recommended Residential Staffing Forum figures should be adhered to. Timescale for action 28/02/07 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. Refer to Standard OP28 Good Practice Recommendations The Registered Provider should make sure all staff undertaking NVQ level 2 complete it, to achieve a minimum of 50 care staff with the award. DS0000031929.V319455.R01.S.doc Version 5.2 Page 26 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 DS0000031929.V319455.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!