Inspection on 25/04/07 for Lake View Manor

This inspection was carried out on 25th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Lake View Manor 09/11/05

Lake View Manor 21/06/05

Lake View Manor 16/11/04

Lake View Manor 24/08/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Lake View Manor 29-30 Pearson Park Hull East Yorkshire HU5 2TD Lead Inspector Janet Lamb Unannounced Inspection 25th April 2007 09:00 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 DS0000000858.V337709.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. DS0000000858.V337709.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lake View Manor Address 29-30 Pearson Park Hull East Yorkshire HU5 2TD 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) 01482 447476 Mr G Davies Mr G Abel Ms Elaine Garland Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places DS0000000858.V337709.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th November 2005 Brief Description of the Service: Lake View Manor is a large Victorian property made from two houses in Pearson Park in the west of the city of Hull. There is a bus route close by, a rear garden for residents to use and a small car park to the front. There are shops, pubs and health services close by. The home accommodates up to 26 residents who are elderly, in ten single and eight double rooms on three floors, accessed by a passenger lift. The house is well maintained and decorated and rooms are personalised. Staff provide personal care and support. Meals, entertainment and laundry are included in the care, and the weekly charge for receiving the service is currently £327.50. DS0000000858.V337709.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 Lake View Manor has taken place over a period of time and involved sending a request for information to the home in November 2006 concerning service users and their family members, as well as staff and details of the home’s policies, procedures and practices. The Commission received the requested information in early February 2007 and questionnaires were then issued to all service users and their relatives, their GP and any other health care professional with an interest in their care, to social service departments commissioning their care and to the staff working in the home. This information obtained from surveys and information already known from having had contact with the home over the last few months, was used to suggest what it must be like living there. A site visit was made to the home on 25th April 2007 to test these suggestions, and to interview service users, staff, visitors and the home Manager. Some documents were viewed with permission from those people they concerned, and some records were also looked at. The communal areas of the home were viewed, along with two bedrooms on the ground floor. A total of three service users and three staff were interviewed and the Manager, two GPs and one relative asked to provide information or were spoken to during the site visit and all of the information collected was checked against the information obtained through questionnaires and details already known because of previous information gathering and contact with the home. What the service does well: Service users are well assessed on entry to the home, having been given good information on what the home is like and what to expect, and they are provided with a good care plan for staff to follow. They are very well supported with health care that meets their needs and their expectations. They are protected from possible harm due to taking the wrong medication, because they have their medication handled by the staff in the home, and the staff follow robust practices and procedures. The service handles medication extremely well and staff are highly trained in medication administration. DS0000000858.V337709.R01.S.doc Version 5.2 Page 6 Service users experience good levels of privacy, have their dignity maintained, and their right to make decisions is respected. They are encouraged to maintain contact with family members and friends and enjoy visits from these people any time of the day, and they are encouraged to exercise choice and control over their lives. Service users enjoy very good food, which matches their expectations and preferences, but also offers a satisfactory level of nutrition, the cook being awarded the Heart Beat Award at least five years in a row. Service users are confident their complaints will be listened to and acted upon. Service users are protected from abuse by robust recruitment and selection procedures and practices, as well as by the service’s policies, procedures and practice under the safeguarding adults systems. Service users experience a safe, clean and well-maintained environment. A sufficient number of care staff work in the home on each shift to meet the needs of service users. The Manager runs the service in the best interests of the service users, safeguards their financial interests, and maintains their health, safety and welfare. What has improved since the last inspection? The service’s quality assurance system now includes the surveying of staff as well as other people interested and involved in the care of service users. All staff required to administer medication have completed NVQ level 2 ‘Medicines Management Course.’ Service users are now consulted as part of the recruitment and selection process by being asked their opinion of new staff during their induction period. DS0000000858.V337709.R01.S.doc Version 5.2 Page 7 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. DS0000000858.V337709.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000000858.V337709.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 only. Standard 6 is not applicable. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users’ individual and diverse needs are well assessed so they are confident needs will be met. They receive sufficient written information in the form of a statement of purpose and a service users guide so they can decide if the home is the right place for them. EVIDENCE: Two service users were interviewed and their permission was obtained to view their care plans and other documentation. One has been resident for eight years and could not remember having had an assessment done, having been given a contract of residence, or having seen any information on the home. The other has only been resident for four weeks, came from hospital and could not remember any documents either. Both have Hull City Council assessment DS0000000858.V337709.R01.S.doc Version 5.2 Page 10 documents in their files, which show their individual and diverse needs in respect of religion, culture, disability because of old age, and social and personal health preferences, etc. These documents date back to 2000 for one (reassessed in 2002) and done in February 2007 for the other. Both service users also have the home’s assessment on admission sheet in their files, which show basic needs as supplementary to the HCC ones. Most of these documents in files show signatures of either the service users or their relatives. Discussion with the Manager revealed one service user admitted in December 2006 from the west coast of England, was admitted without a proper assessment having been done, but the reasons for this happening were clearly explained and it was decided information was lacking through no fault of the Manager. One of the files seen shows a relative signed to acknowledge the receipt of a statement of purpose and a service user guide, on behalf of the service user. These two documents are combined into one for easy provision and easy updating. The other file does not have such evidence as this service user has been living in the home since before these documents were produced. She would have been in receipt of an old style brochure. There are no service users ever admitted to the home for intermediate care, so standard 6 is not applicable. DS0000000858.V337709.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service receive excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have their health and social care needs well documented in care plans, so they are confident all their needs will be met. They have good opportunities to self-medicate or their medication needs are well managed, and they enjoy good levels of privacy and their dignity is well maintained, so their overall quality of life is good. EVIDENCE: Service users, staff and management spoken to, and service users’ files seen, reveal all service users have a Hull City Council ‘Community Care’ care plan generated from the assessment form, and a shorter supplemental care plan according to the ‘David Mason Associates’ systems documentation, generated form the home’s and the council’s assessments forms. Individual and diverse needs in respect of religion, social activities and physical impairment in particular, are recorded to ensure service users have their individual needs DS0000000858.V337709.R01.S.doc Version 5.2 Page 12 met, and according to their preferences. Action plans and risk assessments are also written in the care plans. Care plans are reviewed monthly in the home, and annually with the council and other stakeholders, and all dates are maintained and copies of statutory reviews are held. Service users or their relatives sign care plans. Details of health care needs and action plans are also recorded and followed. There are also supervision forms showing discussions with service users about their preferences on rising, going to bed, eating, going out etc. as well as social plans in place. Service users with medical ailments or problems are referred to their GP, and the District Nursing services are accessed, along with outpatient services and treatment. All of these visits are recorded on file. Some service users have recently been joining in with Tai Chi exercises once a week. Dieticians are accessed as necessary and risk assessments are completed, especially on such as falls. Hearing, sight and dental appointments are carried out as necessary and such as physiotherapy is considered and tried, as was observed for one service user on the day of the site visit. Two GPs visited during the site visit and both made a point of informing the Inspector that they are very satisfied with the high levels of health care given in the home. Both commended the home on its excellent care and the excellent attitude of the Manager and staff. There is a policy, procedure and practice guidelines on medication administration for staff to follow. Handling and storage of medication is good and a robust medication administration trail is in place and followed. Staff that administer medication have been trained to do so via a basic medication administration course and also via an NVQ Level 2 ‘Medicines Management Course.’ The Manager is planning to provide basic medication administration training for night care workers that may be required to give out homely remedies only, so that they do so safely. Medication administration record sheets are signed after giving service users their drugs, from a monitored dosage system. Controlled drugs are recorded in a register, double signed and double locked. Service users spoken to are satisfied their medication is handled for them because as one of them put it, “I take 30 tablets a day and would not like to look after them, I would be frightened of mixing them up.” Another said, “I really don’t mind who looks after them, it doesn’t matter to me. Sometimes I have to remind staff I need my eye drops though.” Service users may selfmedicate if they wish and if they are capable and have been risk assessed, and a locked facility will be provided. Service users spoken to acknowledge that they are afforded privacy and dignity with personal care, spending time in their room, seeing visitors if DS0000000858.V337709.R01.S.doc Version 5.2 Page 13 requested, etc. and that they have no concerns over the way their personal care needs are met. One male said he was not particularly keen on female care staff bathing him, but when asked if he should like a male carer to be employed, he did not want for this to be a special consideration. He said, “I’m getting used to it now.” Another expressed dissatisfaction at everything in the home, but acknowledged this was because she simply did not want to be in care, and had resigned herself to believing she would never be happy. She said, “I’ve made up my mind I shall never settle.” DS0000000858.V337709.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users enjoy flexible routines, good contact with relatives and friends, good opportunities to be selfdetermining, and highly satisfying food provision, so they are confident their daily lives and social activities meet their expectations. EVIDENCE: Service users, staff and management spoken to and some documents seen reveal service users lead fulfilling lifestyles of their choosing and preference. There are routines within the home around rising and having meals etc. but individuals can disregarded them if they wish. Service users said they come and go as they please, decide when to rise or go to bed and that they enjoy some level of exercise where possible, but many of them have mobility problems. One said, “I get told off for trying to help the others, because I am always falling, I know I shouldn’t, but I can’t help it. Me and my friend get up at 5a.m. but that’s because we like to have a couple of hours in the lounge DS0000000858.V337709.R01.S.doc Version 5.2 Page 15 together talking in private before anyone else gets up. And we are in bed by 6p.m. where we watch television. I do go to bed later if I’ve been out with my family.” There are opportunities to take part in activities, although these have tailed off over the last year, and service users made comments on questionnaires that sometimes there are things they like to do, while the Manager confirmed not as much happens as used to because she and the staff want to concentrate on maintaining good health amongst the group. Contact with family and friends is very good and often facilitated by staff. Maintaining relationships is important in the home and there are regular ‘get together’ sessions, which act as a socialising opportunity for everyone, as confirmed in relative questionnaires. Relatives visit the home regularly, as seen on the day of the site visit, some people being recognised from previous CSCI visits to the home. Documents record all of these activities. Service users and the Manager said they handle their own finances, wherever possible, or family members do. Some service users have a small amount of money held in safekeeping for which individual record books are kept, showing amount in/out, the balance and the signature of the service user. Service users said they were quite satisfied with these arrangements and were pleased they no longer had the responsibilities of budgeting, and cooking or cleaning even. Service users take part in monthly meetings, which the Manager chairs, to discuss areas of concern or preferences they may have. Staff and management provide support to contact any external agencies service users may feel the need to. All people having a ‘stake’ or interest in the home made comments that the food provision is very good. The cook compiles menus after consulting service users about their likes and preferences, and changes these according to seasons, medical diets and healthy eating. Each morning she asks each service user what they would like form the menu for the two main meals of the day, records this and prepares it accordingly. There is usually a soup, a main meal and a pudding for lunch, and two courses for tea. The kitchen is always maintained in a very clean condition, equipment is replaced as requested and foodstuff is purchased to suit menus and tastes. The cook has been awarded the ‘Heart Beat Award’ for many years in succession, and is hopeful this will continue. All meals are served at tables from tureens and gravy boats, tables are pleasantly set, and meal times are a sociable event. The standard of food provision is very good and the cook prides herself on giving satisfaction to the service users. A birthday cake had been made for one service user on the day of the site visit, and drinks and cake were also planned for the following day for two service users to celebrate their wedding anniversary. DS0000000858.V337709.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users make use of informal complaint processes and systems and have all issues dealt with appropriately and they do not need to make formal complaints, so service users are confident their concerns are dealt with effectively and efficiently. They also experience good promotion and protection of their welfare and so feel confident the systems in place to protect them are robust. EVIDENCE: Service users, staff and management spoken to, information in questionnaires and records viewed reveal service users have good opportunities to make their concerns or complaints known before they become major issues and have good systems in place for their protection. Service users said, “We have a meeting once a month and any problems can be discussed there. If you have a complaint it’s best to go to the Manager,” “I wasn’t told how to complain,” and “If we are cold or anything we ask for more blankets, but we have nothing to complain about.” There are complaint and protection policies and procedures in place, staff have signed to say they understand them, and have had training in handling DS0000000858.V337709.R01.S.doc Version 5.2 Page 17 complaints and in safeguarding adults. However the training in safeguarding adults was done approximately three years ago and now needs updating. The Manager acknowledges there are new safeguarding adult protocols in place that she needs to become familiar with and to pass on to staff. She made a commitment to contact the Manager of the Hull and East Riding Safeguarding Adults Board to seek clarification and information, and to look at the possibility of updating training. Staff demonstrate in conversation and via their questionnaires that they know the procedures to follow and the importance of whistle blowing to the Manager and making referrals to social services. They said they had used the whistle blowing process to good effect in the past and would use it again. There is a good ethos amongst the staff group and lead by the Manager, that shows they are open to suggestions for improvement, consider complaints to be a means of helping the service move forward with improvements, and that service users views must be listened to. Records for complaints and safeguarding adults have not been completed for well over a year or more because they have not been needed. DS0000000858.V337709.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users have a well-maintained, clean and comfortable environment in which to live, so they are confident they have a good home. EVIDENCE: Communal areas of the home were viewed, but service users permission to see their rooms was only obtained from two and so only two bedrooms were seen. These are satisfactorily furnished and decorated and are very personalised. The house is suitable for its stated purpose of providing care and accommodation to older people. DS0000000858.V337709.R01.S.doc Version 5.2 Page 19 Service users spoken to are satisfied with the cleanliness of the home, their rooms and the opportunities they have to mix with different people in the lounge, dining room and conservatory. There is a maintenance man employed in the home 16 hours a week, who keeps on top of minor repairs and redecoration. There is a paved area leading form the conservatory with chairs and tables in the warmer months, and a lawn area beyond. Service users have access to the garden via a ramp. The last Fire Prevention Officer visit to the home was undertaken in April 2006 and the last Environmental Health Officer visit was undertaken in May 2006. The home currently complies with requirements of both organisations. The house is well maintained, and is kept clean and comfortable. The laundry is away from the kitchen and has separate access. It meets the Water Supply (Water Fittings) Regulations 1999 and provides sluicing and hand washing facilities. Staff have infection control policies to follow, have access to strategically placed disinfecting hand gel, and have done infection control training. DS0000000858.V337709.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users are cared for by wellrecruited, well-trained, confident and skilled staff in satisfactory numbers to meet their needs, so they enjoy an excellent service of care. EVIDENCE: Three staff were interviewed and their permission was obtained to view their recruitment and selection, their training and their supervision files. Discussion with the Manager, viewing of rosters over a two week period and information supplied by the home, as well as determining the Residential Staffing Forum figures were all used to show the home is sufficiently staffed in terms of staffing hours provided per week. Forum figures require 512.70 hours for 9 high, 4 medium and 13 low dependency service users. The home provided 546 and 574 hours over two weeks in February 2007. Information provided and discussion with staff reveals there are currently 10 with and 2 doing NVQ level 2 in Care, and 1 of these has level 3 and another is doing level 3. Another 5 staff are registered with a new training company to DS0000000858.V337709.R01.S.doc Version 5.2 Page 21 do the award at level 2. This gives 65 of the care staff with level 2 or above in NVQ. Discussion with staff and viewing of files reveal recruitment is robust and protects service users. Identification information and details used to determine the first level checks with the Criminal Records Bureau and evidence of the enhanced checks actually undertaken are held on files in line with the requirements of schedule 2. Service users are now included in the processes of staff selection, by being asked their opinion of new staff during their induction and probation period. Recruitment practices are satisfactory. Information obtained from discussion and also from files shows staff undertake statutory training in fire safety, first aid, infection control, safeguarding adults, moving and handling, food hygiene, health and safety and medication administration, as well as in other relevant subjects such as dementia, incontinence, stroke awareness, etc. The staff group are well trained and skilled in caring for older people. DS0000000858.V337709.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. People who use the service experience excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. Service users live in a home that is well run and in their best interests, where good systems are in place to determine the quality of the service, and where their financial interests are safeguarded and their health, safety and welfare are well promoted and protected, so they are confident they will be safe and well cared for. EVIDENCE: Discussion with the Manager and staff, and viewing of documentation, safety records and certificates reveals, service users and staff benefit from a safe and well-run home. DS0000000858.V337709.R01.S.doc Version 5.2 Page 23 The Manager has now completed the NVQ level 4 Registered Manager’s Award, and is undertaking NVQ level 4 In Care. She has 9 years experience as Manager of the home and constantly strives to improve her own knowledge and understanding of the care business for the benefit of improved services to service users. There have been no changes to the systems for quality assuring the service provided in the home since the last inspection except to improve on the surveying of stakeholders. Staff are now surveyed as part of the process. The home is awaiting another audit by Hull City Council to decide whether or not it continues to have the council’s award under its quality development scheme. Quality assurance systems were not fully checked on this site visit. Service users have control of their own finances, where possible, and if unable then their relatives do. Some have a small amount of money held in safekeeping for which the home maintains a record of money in and out, with signatures and running balance. These were not seen on the site visit, but service users spoken to explain how the system works and stated their satisfaction with it. The Manager maintains a safe environment for service users and staff by ensuring all equipment is regularly serviced and certificated if necessary, by following all relevant legislation in respect of health and safety responsibilities, and by maintaining appropriate records of safety checks, etc. Areas sampled to determine whether or not standard 38 is met are, fire and electrical safety, passenger lift and hoist maintenance, water legionella testing and safety in the use of cleaning substances etc. Although the weekly fire safety checks have been done on the fire systems and detecting equipment and they have been recorded, there has been a lapse in fire safety drills carried out on a regular basis. These need re-instating to ensure all staff receive a minimum of two fire safety training drills per year. The Manager gave an assurance they would be revived and recorded again. Staff undertake fire safety training annually and they confirmed this in interview, while certificates around the home and in files back it up. Some new staff are still to do the training. Systems are shown to be checked regularly and to be working well. A full fire prevention officer visit was undertaken in April 2006, extinguishers were last serviced in June 2006 and the home’s fire risk assessment was reviewed in February 2006 after being completely rewritten for the fire officer’s strike a few years ago. A full electrical audit in the home and including the nurse call system was completed on 11/04/07, for which a certificate is yet to be sent to the home. DS0000000858.V337709.R01.S.doc Version 5.2 Page 24 The home’s passenger lift, which has been broken since the last inspection and necessitating a major contingency plan to be put in place, has been repaired and was fully serviced, along with the lifting hoists, on 23/10/06. Equipment is now fully functional. A hot water storage legionella test was carried out in March 2006 and the result was negative. All materials used in the home for cleaning etc. are kept locked safely away, have appropriate safety instructions and dilutions and are used in conjunction with the necessary safety guidelines under Control of Substances Hazardous to Health Regulations 1988. Safety instructions are maintained in a file in the office. DS0000000858.V337709.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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 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 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 DS0000000858.V337709.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 Refer to Standard OP18 Good Practice Recommendations The Registered Provider and Registered Manager should ensure all staff working in the home undertakes current safeguarding adults training to bring them up to date with the new protocols and procedures in place, so that service users are confident they are protected. The Registered Provider and Registered Manager should make sure fire safety drills are carried out regularly and recorded, so that service users and staff health, safety and welfare are promoted and protected. 2 OP38 DS0000000858.V337709.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000000858.V337709.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!