Inspection on 05/03/07 for Key West

This inspection was carried out on 5th March 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

Key West 09/02/06

Key West 13/10/05

Key West 18/03/05

Key West 20/08/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Key West 203 Tamworth Road Long Eaton Nottinghamshire NG10 1DH Lead Inspector Tony Barker Key Unannounced Inspection 09:15 5th March 2007 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 Key West DS0000020024.V329360.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. Key West DS0000020024.V329360.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Key West Address 203 Tamworth Road Long Eaton Nottinghamshire NG10 1DH 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) (0115) 9732031 Mrs Hilary Ann Majtas Mr Leszek Jan Majtas Mrs Hilary Ann Majtas Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places Key West DS0000020024.V329360.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 PD Place. On a named person basis for the person named in the notice of proposal letter. 9th February 2006 Date of last inspection Brief Description of the Service: Key West is a detached building situated on the Tamworth Road out of Long Eaton. It provides care for 9 older people within seven single rooms and one double room. One of the single rooms has en-suite facilities. All parts of the building are accessible to residents. It is a family run Home with one of the proprietors being the Home’s manager. Care is provided by a group of part time and full time staff, plus the Manager. The fees currently range from £340 to £370 per week. Key West DS0000020024.V329360.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 7.75 hours and was a key unannounced inspection. Three residents, the Manager, Deputy Manager one care assistant and one visiting relative were spoken to, records were inspected and there was a tour of the premises. Two residents were case tracked so as to determine the quality of service from their perspective. Survey forms were posted to residents and all nine were returned. The information supplied in this way was analysed before the inspection and the outcomes included in the inspection process and reflected in this report. This inspection focussed on all the key standards and on the progress made towards achieving the requirements and recommendations made at the last inspection. The pre-inspection questionnaire was reviewed prior to this inspection. What the service does well: What has improved since the last inspection? The laundry room had been re-tiled, and one bedroom re-carpeted. Also, two replacement exterior doors had been fitted and there was a new fridge/freezer, freezer and dishwasher in the kitchen. The Manager had attended a suitable training course in ‘Safeguarding Adults’. Staffing levels had significantly improved and the staffing rota was an accurate record of hours worked. All of the requirements made at the last inspection had been met, though the need for the Manager to achieve a Registered Manager’s qualification has become a recommendation in this report. There were no recommendations in the last report. Key West DS0000020024.V329360.R01.S.doc Version 5.2 Page 6 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. Key West DS0000020024.V329360.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 Key West DS0000020024.V329360.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): 3,4 & 6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents were having their needs assessed before admission to the Home so that staff could provide individually tailored care. Residents and their relatives knew that residents’ assessed needs were being well met. EVIDENCE: The most recently admitted resident was case tracked. This person’s personal file was examined and was found to contain a comprehensive assessment of their needs, dated the month prior to admission. This record contained all the items listed in Standard 3.3 and indicated that the resident’s needs could be met by the Home, the Manager said. She added that all residents are admitted on a month’s trial basis during which time a full assessment of needs is undertaken. Where possible, a document is sent to relatives to complete that provides a complete profile of the new resident’s life, family and interests. The Manager stated that the Home was providing ‘person centred care’ to its residents and said that “individuality is a central matter to the Home”. There was documentary evidence of this in the form the Home’s ‘Outline Question Key West DS0000020024.V329360.R01.S.doc Version 5.2 Page 9 Sheet’, completed at the time of admission. This was a very individualised document and detailed, for example, new residents’ preferred times of rising and going to bed and the number of pillows preferred. All the residents and relatives surveyed by post, and seen personally, felt that residents received the care and support they needed. Comments from the survey included... • “Very good in every way(resident)”, • “Exceptional care and support”, • “Staff are always nearby and attend to residents’ needs promptly. They notice when help is need, understand each resident and their individual needs and anticipate when extra care is, or will be, needed (relative)”. The care assistant spoken to said that, “Staff bend over backwards for residents”. All these comments were consistent with observations made at the inspection and shows that commendable levels of care were being provided. The Home was not providing intermediate care. Key West DS0000020024.V329360.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 excellent. This judgement has been made using available evidence including a visit to this service. Residents’ health, personal and social care needs were clearly set out in individual plans of care. They were being protected by the Home’s policies for dealing with medicines. Residents clearly felt they were treated with respect and their right to privacy was being upheld. EVIDENCE: The care plans of two residents, including the resident most recently admitted in July 2006, were examined. These were holistic and constructive and included a photograph of the individual residents. The care plan review sheets were comprehensive and covered all aspects of the care plan. The Manager stated that, as part of the review process, key workers work through the care plan with each resident every month and record any changes. There was evidence of this by means of staff and residents’ initials on the care plan review sheets and the care assistant spoken to also confirmed this. Residents’ likes and dislikes were recorded on their personal files. The Manager was the designated person to monitor issues of continence management and skin viability within the Home. She and the Deputy Manager Key West DS0000020024.V329360.R01.S.doc Version 5.2 Page 11 had undertaken training on continence management in 2005. Risk assessments included the risk of residents falling, moving and handling as well as ones individual to the two case tracked residents. The Manager said that Fluid Balance charts had been used in the past. Health professionals were involved on a regular basis with residents and there was a system to record this contact. District nurses had supplied specialist mattresses for residents prone to pressure sores and the Home had its own supply of pressure cushions. The Manager spoke positively about the Home’s relationship with the local district nursing team. Tissue viability assessment charts were being maintained as well as residents’ weight records. One relative reported, in the postal survey, that the Manager was “well aware of (the resident’s) health weaknesses...has been taken to the local hospital twice when (the resident) has appeared to need treatment quickly...no time was wasted”. Residents’ medicines were being securely stored. A sample of the Home’s medication records were examined and found to be satisfactory. Handwritten entries were being signed, dated and countersigned. When codes were used on the medication records they were circled to distinguish them from staff initials that looked similar – this was good practice. There was an appropriate document, signed by one case tracked resident, reflecting agreement to selfadminister ointment. All staff who administer medication had been provided with appropriate training in the safe use of medicines. Staff were observed taking a personal interest in residents and treating them with a commendable level of care and dignity. The standard of residents’ clothing appeared to be good. Both case tracked residents said the standard of clothes’ laundering was good and one said it was, “excellent”. They both thought they were treated with respect and their privacy needs were met. One said, “All staff knock on my door” before entering. The care assistant spoken to gave appropriate examples of how residents’ privacy needs were met by staff. A cordless telephone was available to residents who wish to make calls in private. Files indicated that residents are asked about their preferred term of address at the time of admission. Key West DS0000020024.V329360.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 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents were benefiting from a good range of social activities and relationships. They had choice and control over their lives and received a wholesome and balanced diet. EVIDENCE: The Home’s routines were flexible and reflected individual needs and preferences. This was confirmed in discussion with residents – one reporting that staff help them to wash and dress at their preferred time and they go to bed when they want. Although this case tracked resident would have preferred to have people around with whom to have “intellectual conversations”, the person read a lot and regularly visited a friend who lives nearby. This resident commented that more outings would be preferred. The Manager stated that in response to similar requests from residents she had started, with effect from February 2007, to offer a trip out every month. Seven residents had taken up this recent opportunity to visit a local pub. These outings were extensions to the regular outings already undertaken during warmer months. Another case tracked resident said they went out somewhere every day, independently, and enjoyed reading books and listening to CDs in their bedroom. It was clear, from this inspection, that residents’ need for social, recreational and physical stimulation were being well met and Key West DS0000020024.V329360.R01.S.doc Version 5.2 Page 13 their requests listened to. The care assistant spoken to said that there was a “very good range of varied activities provided”...including staff supported “bingo, dominoes and cards” as well as visiting people including an “exercise lady, hand massage lady and musicians”. There was evidence from several sources of a good range of activities provided both within the Home and within the local community. There was a displayed programme of future activities in the entrance hall – including visiting entertainers and in-house activities. Two staff were involving four residents in a game of ‘floor Snakes and Ladders’ during the morning of the inspection. Frequent laughter was heard in the lounge – there was a good atmosphere during this inspection. The Home is commended on the social opportunities provided to residents. All nine of the residents had some contact from visitors, the Manager stated. Some of these visitors continued to visit the Home after the resident had left. There were no restrictions on visiting times – visitors were “welcome at any time”, the Manager said. A relative, responding to the postal survey, stated that, “Visitors are always made welcome and given a drink on each visit. A member of staff always finds time to talk about my (relative) and discuss any problems”. Another said, “I receive a lovely welcome from everybody there and the atmosphere is so friendly and happy”. Both case tracked residents described regular and satisfying contacts being maintained with friends and relatives. A visiting relative was spoken to during this inspection. She said she was very pleased with the standard of care received by her relative and felt, due to the frequency of her visits, she was in a good position to make this assessment. Some residents were managing small amounts of money for items such as hairdressing. Bedrooms reflected the Home’s policy of enabling residents to bring personal possessions with them – bedrooms were well personalised. There was clear evidence of residents being offered choices in daily events. The Manager had organised for a volunteer, from the local Council for Voluntary Service (CVS), to befriend one resident and this person was now a befriender for two other residents. He was a regular weekly visitor to them both and one case tracked resident spoke positively of this relationship, saying, “I enjoy my time out with Dave”. Some residents were still eating breakfast at the start of this inspection. One resident confirmed that breakfast time was flexible and was positive about the fact that his preference for a cooked breakfast was being met every day. The residents were positive about the meals at the Home in their responses to the postal survey. One relative said, “(the resident) looks forward to mealtimes...(the resident) naturally eats slowly but is never rushed”. Food stocks were at a very good level and included fresh fruit and vegetables. The four-week rolling menu indicated that residents were being provided with a nutritious and varied diet. It was displayed in the hallway along with a black board showing the day’s actual menu. It was clear that personal choices were catered for. The Home kept a record of food provided to individually named Key West DS0000020024.V329360.R01.S.doc Version 5.2 Page 14 residents – this included the meal description as well as a note of whether it was a small or normal sized helping or whether it was refused. This was a useful nutritional tool. The Home is commended on its standard of catering. Key West DS0000020024.V329360.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. Residents were benefiting from the Home’s complaints policy and procedures. They were also being protected from abuse. EVIDENCE: The Home’s written complaints procedure was displayed in the entrance hall and was well worded. It explicitly stated that a complainant could approach the Commission for Social care Inspection directly rather than the Home’s Manager if they so chose, and also made reference to the Health Ombudsman. There had been no complaints received within the previous 12 months. All residents and relatives confirmed, in the postal survey, that staff listen and act on what they say. One relative commented, “They make time to listen properly to what residents have to say. They are all very patient and keen to help”. One case tracked resident confirmed knowledge of the Home’s complaints procedure and stated they would approach the Manager if they had any problems. The other case tracked resident said that minor complaints made to the Manager had been responded to and “all issues have been sorted”. There were notes on file of a meeting held with this case tracked resident, covering six items of concern. These had been clearly documented and had been signed by the resident and Deputy Manager. The Manager stated that she had undertaken a four-day ‘Safeguarding Adults’ ‘Training for Trainers’ course provided by Derbyshire County Council (DCC). This had enabled her to provide training to care staff on keeping adults safe from abuse. She, her Deputy and one care assistant had previously attended a Key West DS0000020024.V329360.R01.S.doc Version 5.2 Page 16 DCC training course in August 2005. All but two more recently appointed staff had undertaken ‘Safeguarding Adults’ training, the Manager stated. There was a comprehensive ‘whistle blowing’ policy and the member of care staff spoken to showed good awareness of this. DCC Guidance on ‘Safeguarding Adults’, and associated Report Cards, was in place and the Home had its own ‘Guidance to Residents and Families on Adult Protection’. However, there were no actual written procedures, for the Home, on alerting other agencies in the event of suspicion of abuse to residents. Key West DS0000020024.V329360.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 excellent. This judgement has been made using available evidence including a visit to this service. Residents were living in a comfortable and well-maintained environment that was clean, pleasant and hygienic. EVIDENCE: All areas of the premises that were inspected on this occasion were found to be extremely clean and tidy and the standards of furnishing and decoration were very tasteful. The bedrooms of the two case tracked residents were seen. They were nicely personalised and the residents were pleased with their accommodation. The laundry room had been re-tiled, and one bedroom recarpeted, since the previous inspection. Also, two replacement exterior doors had been fitted and there was a new fridge/freezer, freezer and dishwasher in the kitchen. Further attractive pictures had been hung on the ground floor corridor walls - adding to the homeliness of the premises. The Registered Providers were planning to make a £5000 bid from Derbyshire County Council’s Improvement grant budget – to fund the replacement of the existing first floor bathroom with a ‘wet room’. This would benefit the Home’s wheel chair users. Key West DS0000020024.V329360.R01.S.doc Version 5.2 Page 18 The Home was well maintained and the front exterior was particularly pleasing in appearance. The Home is commended on maintaining high physical standards. All the residents and relatives surveyed by post said that the Home was fresh and clean. On relative stated that the Home was “always well kept, bright, fresh and clean and warm”. There were no unpleasant odours at the time of this inspection and the care assistant spoken to described good infection control practices. There was a good laundry system in place including a washing machine with a sluicing facility. Paper towel dispensers had been fitted in the kitchen and laundry room since the previous inspection. There were notices in the bathrooms and toilets stating that ‘Towels are changed regularly but ask if you want one changed’. Bundles of spare towels were noted in the ground floor bathroom. The Home is commended on maintaining very good levels of hygiene. Key West DS0000020024.V329360.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. Residents’ needs were being met by good staffing levels and a consistent staff group. They were being supported by a well-trained and qualified staff group and were protected by the Home’s recruitment procedures. EVIDENCE: The staffing rotas for the weeks prior to this inspection were examined. They confirmed that staffing levels exceeded the standards recommended by the Residential Forum – an improvement on the previous inspection. The majority of staff had a combined care, domestic and catering role. The rota was clearly laid out and it identified the person-in-charge when the Manager was absent. A ‘Meet the Staff’ board was displayed in the entrance hall with photographs of staff. No staff had left the Home since the previous inspection, or indeed since the October 2005 inspection. Both case tracked residents felt that there were adequate levels of staffing and the residents were clearly benefiting from a consistent staff group. The Manager’s pre-inspection questionnaire showed that 60 of care staff had achieved a National Vocational Qualification (NVQ) in Care at level 2 – an improvement from the previous inspection. This met the 50 level required by the National Minimum Standards. Two further staff were currently attending NVQ training. Key West DS0000020024.V329360.R01.S.doc Version 5.2 Page 20 The file of a care assistant appointed on a flexible contract, in May 2006, was examined. All matters relating to her recruitment were satisfactory, except that the Home’s job application form did not ask the applicant to provide details of ‘any criminal offences in respect of which (s)he has been cautioned by a constable and which, at the time the caution was given, (s)he admitted’, as required by the Regulations. Also, there was no disclosure from the Criminal Records Bureau (CRB) in place. The Manager provided recorded evidence of the application having been made and of several follow-up requests to the CRB, including a re-submission in December 2006. Training records showed that all staff had been provided with mandatory training, or this was currently in hand. The Manager stated that eight staff had undertaken a distance learning course on ‘Dementia’. The care assistant spoken to confirmed she had been provided with a number of training courses over the previous 12 months. Key West DS0000020024.V329360.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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were benefiting from a well run home that was being managed in their best interests. Their health and safety was being fully promoted. EVIDENCE: The Manager said that she was about six months away from completing the Registered Managers Award. The Deputy Manager had now completed this qualification. The Manager is very experienced, having been owner/manager of Key West for 19 years. Her competence can be measured by the high service standards maintained. The Manager was continuing to undertake the same training courses her staff have attended and she showed she was familiar with the conditions associated with the aging process. Since the creation of the deputy post three years ago the Manager had been able to take a more ‘hands-on’ role and ensure high staffing standards through direct observation. Key West DS0000020024.V329360.R01.S.doc Version 5.2 Page 22 The staff member spoken to was very positive about working at Key West, saying that the Home was “very friendly, homely and relaxed... the management and staff are all approachable...there are good standards”. These comments were consistent with those made by staff at previous inspections. One relative stated, in the postal survey, “I listen to the conversation of the other residents and I frequently hear praise for Hilary and her staff”. Other aspects of Standard 32 were not assessed on this occasion. There was a current Annual Plan dated May 2006. The proposed actions were appropriate to the work of the Home although the use of the words and phrases, “Continue with...” and “Ongoing”, in the Action and Review Date columns, were not effective in enabling progress to be measured. Annual satisfaction questionnaires were last sent to residents and their relatives in October 2006, although the results had not been collated. The Manager said she planned to send out these questionnaires every six months in future. No questionnaires had been sent to staff or external professionals. Monthly Health and Safety Audit Sheets were examined. The Home had an extensive policies and procedures folder. There was an ongoing ‘Policy of the Month’ system and this had been working for some years. The Deputy Manager stated that all the Home’s policies had been covered at least once. Certain policies, such as Fire Safety, Health and Safety, and Equal Opportunities, come round more frequently for staff discussion, she added. Staff recorded their signatures when they had read a policy. The Manager stated that the Home held no money on behalf of residents. There was a safe, and receipt book system, should they request that valuables were kept for them. Cleaning materials were being safely stored in a locked cupboard in the laundry room along with Product Information Sheets. The pre-inspection questionnaire showed that equipment was being checked and maintained appropriately. Good food hygiene practices were being followed, with twice daily records of refrigerator and freezer temperatures being maintained. The Environmental Health Officer visited in June 2006 and made no recommendations. Each hot water tap used by residents had a mixer valve fitted nearby to prevent scalding. A First Aid box was clearly available on a kitchen wall. There were several notices in the kitchen, and elsewhere, reflecting and addressing good hygiene practices. There was a recorded risk assessment relating to each room in the premises. These risk assessments were being reviewed annually. All staff had been provided with Health and Safety training. The Home’s attention to Health and Safety within the Home was commendable. Key West DS0000020024.V329360.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 4 X N/A 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 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 4 Key West DS0000020024.V329360.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action THERE ARE NO REQUIREMENTS ARISING FROM THIS INSPECTION 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 Written procedures should be in place regarding ‘Safeguarding Adults’. These should include the procedure to follow regarding alerting other agencies in the event of suspicion of abuse to residents and should reflect DCC Guidance. The Home’s job application form should include a question to elicit details of any criminal offences in respect of which the applicant has been cautioned by a constable and which, at the time the caution was given, the applicant admitted. The Manager should continue to pursue the Criminal Records Bureau (CRB) regarding the disclosure for the latest recruited staff member. The registered manager should achieve a qualification, at level 4 NVQ, in management and care or equivalent. (This was a previous requirement) DS0000020024.V329360.R01.S.doc Version 5.2 Page 25 2. OP29 3. 4. OP29 OP31 Key West 5. OP33 The wording of the Annual Plan should be reviewed so as to enable progress to be measured. Key West DS0000020024.V329360.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Key West DS0000020024.V329360.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. 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