Inspection on 07/03/07 for Kinloch Tay

This inspection was carried out on 7th 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

Kinloch Tay 16/02/06

Kinloch Tay 08/09/05

Kinloch Tay 08/02/05

Kinloch Tay 16/09/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Kinloch Tay Granville Road Totland Isle Of Wight PO39 0AX Lead Inspector Annie Kentfield Key Unannounced Inspection 7th March 2007 13:30 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 Kinloch Tay DS0000012504.V327699.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. Kinloch Tay DS0000012504.V327699.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kinloch Tay Address Granville Road Totland Isle Of Wight PO39 0AX 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) 01983 756096 01983 756096 maureen.fuller1@virgin.net Mrs Maureen Fuller Mrs Terri Lynn Harris Care Home 16 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (16), of places Physical disability over 65 years of age (1) Kinloch Tay DS0000012504.V327699.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 Brief Description of the Service: Kinloch Tay is a home providing care and accommodation for up to sixteen older people and is registered with the local authority to provide up to four day-care places. It is a detached two-storey property centrally located in Totland. A convenience store is sited opposite the home and the main bus service runs past the end of Granville Road with a bus stop a short distance away. The accommodation comprises a range of single and shared rooms on the ground and first floors. The home has no passenger or stair lift; therefore it is important that only those service users who are fully ambulant occupy the rooms on the first floor. There is limited off-road parking to the front of the property and level access into the home. A reasonable sized garden at the rear is available for use by the residents. There are plans in place for the building to be extended for additional bedrooms and communal space and for a passenger lift to be installed. The current scale of charges is from £361.97 to £450 per week. There are additional charges for hairdressing and chiropody. Kinloch Tay DS0000012504.V327699.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the results of an evaluation of the quality of the service provided by Kinloch Tay and brings together accumulated evidence of activity in the home since the last key inspection on 16 February 2006. Included in the report is information supplied by the registered manager prior to the site visit in the form of a pre-inspection questionnaire. Part of the process has been to consult with people who use the service. There were six responses to the care homes survey received from residents in the home (completed with assistance from care staff) one from a relative, and one response from a District Nurse. Included in the inspection was an unannounced site visit to Kinloch Tay by an inspector on 7 March 2007 from 1pm to 6pm. As the registered manager was not available, Mrs Fuller, the registered owner, and the two deputy managers provided every assistance with the inspection visit. During the visit the inspector spoke with staff on duty, met several residents as a group and others in the privacy of their rooms. The inspector toured the building with a deputy manager and looked at a selection of records. The ability of the residents to comment on their experience of living in the home is limited due to cognitive impairment related to dementia, however, the inspector was able to speak to one resident at length. The inspector observed that all of the residents appeared comfortable and well cared for. The responses from the consultations were positive. What the service does well: What has improved since the last inspection? Kinloch Tay DS0000012504.V327699.R01.S.doc Version 5.2 Page 6 Since the last inspection there has been some re-decoration and refurbishment to some of the bedrooms. Work is due to start on the drive and dropping the kerb, installing a porch to the front of the house, and removing a chimney and fireplace in one the bedrooms to increase the size of the room. The owner confirmed that planning permission has been granted to go ahead with the extension and installation of a lift. It is hoped that this work will start as soon as possible. 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. Kinloch Tay DS0000012504.V327699.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 Kinloch Tay DS0000012504.V327699.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 and 5 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are encouraged to visit the home before deciding to move in. No new resident moves into the home without having their care needs assessed and they can be confident that staff have the skills and experience to meet their care needs. EVIDENCE: The inspector looked at records for residents who have moved into the home since the last inspection. A pre-admission assessment is always carried out and relevant information gathered from those involved in the care of the resident. The inspector spoke to one resident who had visited two care homes before deciding to move to Kinloch Tay. The home has devised their own assessment forms that capture all relevant information about residents’ health, social and psychological care needs. Kinloch Tay DS0000012504.V327699.R01.S.doc Version 5.2 Page 9 The previous inspection recommended that the staff training programme would benefit from additional input in dementia awareness and the management of challenging behaviour and this has been implemented. The inspector was showing training booklets with relevant information and a question and answer assessment. It was noted that the training information included a guide to effective and good communication with residents who experience some confusion and memory loss due to their dementia. Staff spoken to were confident that they had the relevant skills and knowledge to meet the needs of residents in the home. The home does not provide dedicated rehabilitation facilities or respite care. They do have a contract to provide up to four places for day care. Kinloch Tay DS0000012504.V327699.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. The home has a system of care planning with an individual plan for each resident. They provide a good demonstration that residents’ health and social care needs are identified and met and include risk assessments and monthly reviews. The home promotes and maintains residents’ healthcare and ensures that access to healthcare services is available at all times. Medication is securely held and appropriate records maintained. The home ensures that staff respect residents’ privacy and dignity at all times, especially with regard to the arrangements for health and personal care. EVIDENCE: The home has a system of care planning with an individual personal plan for each resident. The inspector looked at a sample of three plans and each contained a medical and social history, appropriate charts and records, Kinloch Tay DS0000012504.V327699.R01.S.doc Version 5.2 Page 11 specific, falls and manual handling risk assessments, personal care routine, daily recording of information and night log, and guidance for staff on completing the plans. Some of the charts had not been updated, however, the inspector was shown the daily record of care that confirmed the care had been given. In discussion with the owner and deputy managers the inspector queried how useful some of the risk assessment forms were in providing guidance to staff on the care to be provided. For example, the mental health risk assessment form has a number scoring system but could provide more information on how identified risks are managed or minimised. Care staff were able to give a good verbal update of how care is provided but it was agreed that some of the risk assessments would be reviewed to ensure that they provided up to date and relevant written information for all care staff. Staff spoken with confirmed that care plans were reviewed and updated monthly. The home has a key worker system. There were positive comments from a District Nurse who said “we have always had a good working relationship with the staff who always seem to have the best interests of the residents as their main concern”. The inspector noted that specific risk assessments had been discussed with and signed by residents’ relatives where a need for bed rails had been identified to maintain the safety of the resident. The home manages pressure care well and explained that they do not use the Waterlow pressure care risk assessment tool but have a policy that if any resident is not fully mobile, pressure care equipment such as mattresses and cushions is provided and tissue viability monitored daily. In discussion with a deputy manager it was clear that while a minority of residents were vulnerable to pressure sores none had them at the time of the inspector’s visit. It was due, according to this member of staff, to the use of equipment and good practice by staff, in close co-operation with the district nurses. Medication is dispensed by means of a monitored dosage (blister pack) system by staff that have completed in-house medication training, and deemed competent by the manager. The home has a policy and system to ensure residents’ medication is stored, administered and recorded safely. During the site visit the inspector looked at the arrangements in place and noted all medication to be stored under secure conditions and records well maintained. Only one resident has medicine that is given as and when required (PRN). Although staff are aware of how to dispense this medicine, it is essential good practice for any PRN medicine to have written guidance for staff as to how and when the medicine is given to a resident, in order to ensure that medication is dispensed according to the instructions of the prescribing GP. The deputy manager agreed that a written protocol would be put into place for all PRN medicines. Kinloch Tay DS0000012504.V327699.R01.S.doc Version 5.2 Page 12 Staff spoken with confirmed that the importance of respect for people’s dignity and privacy is covered in the induction training for new staff. Shared bedrooms have portable screens to maintain privacy and dignity. On the day of the site visit the inspector spent some time with residents in the home and observed the staff at work. Staff were at all times good humoured and kind towards residents, calling them by their preferred names and knocking on doors before entering rooms. Residents can use the facility of the home’s portable phone to make and receives calls. Kinloch Tay DS0000012504.V327699.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 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Daily routines and activities at Kinloch Tay are flexibly arranged to meet the needs and wishes of the residents. Visitors are welcome at any time and are able to meet with residents in private. Importance is given to providing a nutritious and balanced diet with residents’ choices, preferences and special dietary needs catered for. EVIDENCE: Activities vary according to residents’ individual abilities and among those provided daily by the home are jigsaws, games, exercises and music, all of which are provided in-house by staff in the afternoons. On the afternoon of the inspection visit, one of the residents was playing the piano and both residents and staff were enjoying this. The inspector noted a good level of interaction between staff and residents. Where residents are able to go out independently, staff support this in line with an agreed risk assessment and management plan. Residents who wish to take part in religious worship can do Kinloch Tay DS0000012504.V327699.R01.S.doc Version 5.2 Page 14 so; the staff would ensure that the resident was supported to have someone visit them in the home. The home encourages residents to maintain contact with family and friends and visitors are always welcome. The owner explained that visitors can come at any time and are welcome to stay for meals with their relative. One relative described Kinloch Tay as “home from home”. The owner explained that she keeps a record of the birthdays of residents’ relatives and she and the staff help the residents to purchase cards and presents. Residents’ birthdays are always celebrated. Although there is only one sitting room, residents can meet with relatives and friends in the privacy of their own rooms if they wish. Some of the more frail residents are not able to join in with mealtimes or social activities and one of the deputy managers explained that care staff would go and sit with residents in their room to provide some social interaction. Care staff had arranged for one frail resident who is unable to communicate verbally, to have their bed moved so that they had a view from the window that they enjoyed. Since the last inspection the home have appointed a cook. There is a 4-week menu and emphasis is placed on providing freshly prepared nutritious meals. The care staff told the inspector that they judge how residents enjoy their meals by the number of empty plates. Care staff know the residents’ well and are familiar with their likes and dislikes of food. A choice is always offered. One resident likes to have a beer with their main meal and this is arranged. Kinloch Tay DS0000012504.V327699.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, 17 and 18 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be confident that their complaints will be listened to, taken seriously, and acted upon. The home’s policies, procedures and practice ensure that residents are safeguarded from abuse. EVIDENCE: The home has a complaints procedure and a written response from a relative confirmed that they were aware of this but had never had occasion to use it. The practice in the home is for all comments that are received, to be recorded in the complaints book with a record of the action taken. The inspector looked at the records and it was evident that any comments made by residents, relatives, or visitors, are listened to, taken seriously, and acted upon. Staff are given their own information booklets on ‘Recognising and Preventing Abuse’ that also provide information on how to report any concerns. The guidance meets the local authority policy on safeguarding adults provided by Isle of Wight Social Services. As further protection for the residents, it is the policy of the home that the manager and staff do not take responsibility for residents’ finances. Responsibility is left with relatives or residents’ representatives. Where Kinloch Tay DS0000012504.V327699.R01.S.doc Version 5.2 Page 16 residents have no one to act for them, the manager would make a referral to Social Services for an independent advocate to be appointed. Any expenses incurred on behalf of a resident are invoiced to the resident or their representative. Kinloch Tay DS0000012504.V327699.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 location and layout of the home is suitable for its stated purpose in providing a safe and comfortable environment for those who live and work there. Decoration and maintenance are ongoing. All areas of the home are kept clean, hygienic and there are no unpleasant odours. EVIDENCE: Kinloch Tay has been a residential care home for older people for many years and whilst not purpose built has been adapted over the years to be suitable for its stated purpose of providing a safe, manageable and comfortable environment for the people who live there. The home is centrally located in Totland. Kinloch Tay DS0000012504.V327699.R01.S.doc Version 5.2 Page 18 There was evidence of an ongoing programme of refurbishment for the bedrooms and the owner explained that when the new building work starts further work would be done to upgrade other bedrooms and the toilets and ensuite facilities. There is an assisted bathroom on the first floor, an assisted shower room on the ground floor, with two other separate toilets, both in need of upgrading. Work is planned to start as soon as possible on upgrading the front of the building and the parking area will be levelled, the kerb dropped, and a porch put onto the front of the house. When the new building work is completed the facilities will be greatly enhanced with a passenger lift, increased communal space, and additional bedrooms. The inspector toured the building with one of the deputy managers. The home was clean, hygienic and free from unpleasant odours. The home employs a cleaner and carpets are regularly cleaned to maintain good hygiene. There are suitable hand washing facilities of paper towels and liquid soap and staff follow guidelines for good practice in infection control. During the inspection a discussion was held with the owner about the sleep-in arrangements for night staff, which are considered unsuitable. However, the owner explained that with the new building work and the increased number of residents, staff on duty at night would be awake. A new room for staff is planned in the new build. Kinloch Tay DS0000012504.V327699.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 good. This judgement has been made using available evidence including a visit to this service. Staff in the home are deployed in sufficient numbers and have the necessary skills and experience to meet the needs of the people who live there. To ensure residents are in safe hands arrangements are made for staff to undertake NVQ training. The home operates a robust staff recruitment procedure, which ensures service users are protected. The staff training and development programme ensures the residents’ needs are met in line with the aims of the home. EVIDENCE: The home employs seventeen care staff, with additional domestic, and catering staff. Staff rosters showed that two care staff are deployed during the morning, two in the afternoon and evening, with one sleep-in and one waking overnight. The manager, and the owner, who is often available within the home, works additional to those on roster. Kinloch Tay DS0000012504.V327699.R01.S.doc Version 5.2 Page 20 On the day of the site visit there were fourteen service users resident in the home with two care staff. The manager was not working but there was a deputy manager on duty. These staffing levels are considered sufficient for the current needs and numbers of residents in the home. The cook and cleaner work on 6 days per week. Training records show that the cook has a certificate in food hygiene and other care staff are doing basic food hygiene awareness training. Mrs Fuller confirmed and staff training records showed that currently 35 of care staff have achieved the National Vocational Qualification (NVQ) in care at levels 2 or above and two care staff are in the process of achieving this. The National Minimum Standard recommends that at least 50 of care staff should have the minimum qualification of NVQ level 2 in care and although the home have not achieved this, the owner confirmed that there is an ongoing programme for care staff to achieve the qualification. Individual staff recruitment files were available for inspection and showed that the home’s recruitment procedure includes an application form, job description, medical and health information, proof of identification, two written references and police and Protection of Vulnerable Adults (POVA) checks on all staff. Either the deputy managers or a senior carer supervises new staff. During the inspection the recruitment records of two new members of staff recruited since the standard was last assessed were checked and found to be in good order. The home operates an induction programme for new staff, with training booklets that have been purchased from a training organisation. In discussion, the inspector referred to the National Minimum Standards, which recommend that new care staff follow a nationally agreed induction programme that is linked to the National Vocational Qualifications in care, produced by the National Training Organisation – ‘Skills for Care’. Mrs Fuller agreed that she would look into this. The inspector spoke with one of the care staff who performs a mentoring role in the home, and ensures that any gaps in staff training are identified and filled. She was clear that the home provides a good training package using mostly in-house training resources and training videos. Records showed that staff training includes: Moving and handling Basic food hygiene First aid Health and safety Safeguarding Adults Fire safety Infection control Dementia care Palliative Care Infection Control The home has just purchased a video training programme for care staff to be trained in basic first aid suitable for a care home. Kinloch Tay DS0000012504.V327699.R01.S.doc Version 5.2 Page 21 Kinloch Tay DS0000012504.V327699.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 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager has the experience together with the relevant management qualifications to run the home and meet its stated purpose, aims and objectives. There are good quality assurance measures in place to ensure the home continues to meet its aims and objectives. The home has no involvement with service users’ financial affairs. Policies, procedures and practices ensure so far as is reasonably practicable the health, safety and welfare of service users and staff. EVIDENCE: Kinloch Tay DS0000012504.V327699.R01.S.doc Version 5.2 Page 23 The registered manager Mrs Terri Harris has been in post for a number of years and has experience of working in a residential care setting. She has achieved the NVQ level 4 in management and is currently enrolled to achieve the NVQ level 4 in care, which she hopes to complete by September 2007. This will ensure that the registered manager meets the minimum qualifications for registered managers in care homes. The homeowner, Mrs Fuller, and one of the deputy managers also have the NVQ level 4 qualification in management. Staff spoken with during the site visit felt the home was well managed; staff morale was high and communication was good. The inspector noted that there is continuous self-monitoring of all areas of the service using an questionnaire that is given to residents, relatives, District Nurses, GP’s and Care Managers. The inspector saw records of the home’s approach to quality assurance, which includes: • • • Resident satisfaction surveys are carried out, involving relatives where appropriate. There are regular care reviews involving the social services care manager, the resident and a relative. As a small home, the manager, care staff, and the owner are in regular and daily contact with residents and visitors and issues and concerns are addressed on an informal basis. The home is not directly involved with the management or administration of residents finances, offering instead to support them if they wish, by purchasing incidental items and invoicing them or their representative against receipt. The home’s pre-inspection information signed by Mrs Harris confirmed that policies and procedures are in place to ensure safe working practices in the home. A sample of records was viewed including fire alarm tests, health and safety risk assessments, electrical wiring certificate and records of the last food safety inspection, all of which were in good order. The manger must ensure that the Fire Safety Risk Assessment is regularly reviewed and advice sought from the Fire Safety Officer on the recommended frequency of review. Records should be kept of fire safety drills or practices. Staff training records showed, and staff confirmed that statutory training is scheduled and updated in manual handling, first aid, fire training, health and safety and food hygiene. Kinloch Tay DS0000012504.V327699.R01.S.doc Version 5.2 Page 24 Kinloch Tay DS0000012504.V327699.R01.S.doc Version 5.2 Page 25 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 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 3 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Kinloch Tay DS0000012504.V327699.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP28 OP30 OP31 Good Practice Recommendations A minimum ratio of 50 of care staff in the home should have achieved at least NVQ level 2 in care. All members of staff receive induction training to the National Training organisation (Skills for Care) standards. The registered manager should advise the Commission when the NVQ level 4 in care is achieved. Kinloch Tay DS0000012504.V327699.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Kinloch Tay DS0000012504.V327699.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. 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