Inspection on 20/06/07 for Langholme

This inspection was carried out on 20th June 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

Langholme 03/11/06

Langholme 18/05/06

Langholme 05/12/05

Langholme 06/06/05

Langholme 01/02/05

Langholme 09/08/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Langholme Arwenack Avenue Falmouth Cornwall TR11 3JP Lead Inspector Paul Freeman Unannounced Inspection 20th June 2007 10:45 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 Langholme DS0000009108.V340436.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. Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Langholme Address Arwenack Avenue Falmouth Cornwall TR11 3JP 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) 01326 314512 01326 317577 home.fal@mha.org.uk home.fxg@mha.org.uk Methodist Homes for the Aged Mrs Patricia Ann Bagley Care Home 39 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (33) of places Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd November 2006 Brief Description of the Service: Langholme Residential Home is registered to provide accommodation and care for a maximum of 39 service users. The home is purpose built and provides accommodation on two floors. There is a large lounge on the first floor and dining room on the ground floor. The home is suitable for a resident who requires a wheelchair, and two lifts provide access to the first floor. Attractive garden are located at the rear of the home that are also wheelchair accessible. The home and grounds are maintained to a reasonable standard. Langholme is situated a short walking distance from the town centre of Falmouth and the Maritime Museum. All the facilities the town has to offer are within easy reach of the Home. Car parking is available for visitors to the home. Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A planned unannounced key inspection took place on 20 June 2007 and 21 June 2007. The purpose of the inspection was to consider the work that had been undertaken on the requirements and recommendations set at the last inspection on 3 November 2006 and to inspect key standards. Therefore some of the key standards that were considered include assessment and care planning, health and safety and staff recruitment. The manager, residents and staff were consulted about the services and facilities provided. The environment, records and documents were also considered. Prior to the inspection the Registered Manager had provided the Commission with written information about the services and facilities. What the service does well: Each prospective residents needs are assessed by the Providers to make sure the services and facilities are able to meet the needs, preferences and choices of the person concerned. Good arrangements are in place to meet residents’ health needs and services are promptly accessed when required. The evidence indicates that medical practitioners regularly visit the home and good multi disciplinary working occurs. The Providers have also established robust arrangements for the storage, administration and disposal of medicines and the staff administering medication are all suitably trained. Residents are also able to administer their own medicines when it is safe to do so. Residents said they were treated with dignity and were pleased with the manner in which staff undertook their duties. Residents also commented they felt in control of their lives and felt able to direct the care and support provided. Good arrangements are in place to meet residents’ social and recreational needs. A range of recreational activities is provided at the care home and in the local community if residents wish to participate. Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 6 Residents’ stated the meals at the home were “very good” and a nutritional and varied menu is provided. Residents have a choice of what they eat at each mealtime and residents stated that every reasonable effort was made to meet their personal preferences. The kitchen is appropriately equipped and the kitchen staff is suitably trained. The equipment in the kitchen is regularly maintained and serviced and generally the health and safety practises are satisfactory. The Providers have established satisfactory arrangements to deal with any complaints or concerns raised by residents or their representatives or relatives. The evidence indicates that complaints are dealt with promptly and efficiently. Residents said there were no barriers to raising any issues with the management and staff of the home and were confidant that any matters would be dealt with in a satisfactory manner. Appropriate arrangements are also in place to protect residents from abuse and any concerns are reported to the statutory authorities for investigation. Residents are satisfied with standard of the environment and the facilities provided. Residents stated they were pleased with their bedrooms and the majority of rooms have been personalised by the occupants. A number of bedrooms have also recently been redecorated. Some of the bedrooms have en-suite facilities and a number of communal bathrooms and toilets are distributed throughout the care home. These facilities are within a reasonable distance from communal areas and residents bedrooms. Specialist disability equipment is available to residents throughout the home in order to promote and maintain independence and individual residents are provided with appropriate equipment when this is required. The home is clean and hygienic and residents confirmed that a good standard is maintained at all times. Residents also said that a good laundry service was in operation. Good arrangements are in place to recruit and select and vet new staff that safeguards the residents. The Providers have established robust arrangements for the induction of new staff, which occurs over the first six months that staff member, is in post. Staff recently appointed said they had been well supported and suitable records are maintained. The staff group also receive regular training to make sure their knowledge; skills are are up to date. The management arrangements were found to be sound and the registered manager has made a significant impact in improving and developing the services and facilities in a relatively short period of time. It is clear that Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 7 residents and staff are confidant about the arrangements in place and there are no barriers to anyone raising any issues of concerns. There are some positive arrangements in place to promote safe working practices for the staff and residents. A detailed health and safety audit has also been completed for the environment that is regularly reviewed. The equipment and services at the home are also appropriately maintained and serviced. The Providers have also established policies and procedures to promote the health and welfare of residents and staff. Good arrangements are also in place regarding fire prevention and fire safety. What has improved since the last inspection? What they could do better: The records about the administration of medication were found to be incomplete. This needs to be addressed to make sure the health of residents is not potentially compromised. The completion of the three year environment improvement plan will result in the providers meeting the minimum standards required. As part of the plan the providers should also carefully consider the availability of communal space given the current arrangements have certain limitations. The providers need to review the staffing arrangements to make sure that sufficient staff are in duty to provide the care and support required at all times. Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 8 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. Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 9 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 Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 10 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): The standards considered were 3 and 6. Quality in this outcome area is good. Residents’ needs assessments are completed before they move to the setting. This makes sure the providers are able to meet their needs and offer the care and support required from the point of admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Prospective residents are assessed by the Provider to determine their needs, preferences and choices. The assessments enable the Provider to determine if the care home is able to meet the needs of the person concerned. The Providers have established a format for recording the assessments and the assessments were completed up to the required standard. This makes sure Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 11 the providers are confidant the facilities and services are suitable to meet the needs of each prospective resident. The records indicated that a number of the people assessed were also in regular contact with specialist workers including social workers and nurses. It was clear the opinions of specialist workers had also been taken into account. Residents that have recently moved to the home confirmed they were consulted about their needs as part of the assessment process. The residents said they had been well received at the home when they were admitted and were positive about the manner in which the staff provided the care and support they require. One resident commented “I don’t think there could be anywhere better.” The Providers do not offer intermediate care or rehabilitation services. The Providers are however committed to maximising residents’ independence as part of the care and support they provide to the residents. Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 12 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): The standards considered were 7, 8, 9 and 10. Quality in this outcome area is good. Each resident has a care plan that summarises the care and support they require. Good arrangements are in place to meet health needs and medical services are promptly accessed when required. Medicines are stored safely but the records about the administration of medication are incomplete. Improvements need to take place to make sure that residents’ health is not potentially compromised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The providers have recently introduced a new care planning and review format that is designed to be more user friendly and accessible. Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 13 This has resulted in a review of each su needs and the key information has then been transferred to the new format. This has meant the residents care and support needs are clearly documented and summarised. There is also evidence that reviews are regularly taking place but the records of the reviews were variable. Some of the records succinctly summarised the events while others provided little information. The providers therefore need to take further steps to make sure the plans are complete and provide comprehensive information about the care and support required. Residents said they were generally very satisfied with the manner in which the staff meet their needs and provided the care and support required. The staff commented the care plans had improved and provided reliable information about the care and support required. Some staff recognised there were currently some inconsistencies in the recording arrangements. Residents said they had confidence in the manner in which their health needs are met and commented that medical services were accessed promptly when required. The evidence indicates that General Practitioners and nurses regularly visit the home. On the days of the inspection a General practitioner, District Nurses and other health professionals also visited the home. When it is safe to do so residents are able to manage their medication but staff also assist where required. Medicines are kept in secure facilities and the staff administering medicines are all appropriately trained and a good working relationship is in place with a Pharmacist. Medicines that are no longer required are disposed of safely and a suitable policy and procedure is in place to guide, direct and inform the staff. However the records maintained by the staff about the administration of medication were incomplete. Langholme DS0000009108.V340436.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): The standards considered were 12, 13, 14 and 15. Quality in this outcome area is good. Good arrangements are in place to meet residents’ social and recreational needs and a range of opportunities are in place at the care home and in the local community. Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets residents tastes and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents said the routines of daily life were flexible and met with their expectations. Flexible visiting arrangements are in place and residents said the staff always positively welcomed visitors. Residents are able to decide where they meet Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 15 with visitors and the staff will support the resident if they decide not to have any contact with a visitor. The Providers have established a range of activities at the home and in the local community that reflect the interests and pastimes of residents. The programme has continued to be improved and developed and many activities are well attended. Some of the residents choose not to participate in the activities provided and prefer to manage their own recreational opportunities. The residents were very positive about the food provided at the home. A varied nutritional menu is in operation and residents have a good choice at each mealtime. The kitchen also provides a ‘meals on wheels’ service to around thirty local people each day. Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets residents’ tastes and choices. The kitchen facilities are maintained to the required standards to make sure that good and robust health and safety practices are in place. The kitchen is appropriately staffed and the staff concerned is trained to the required standard. Appropriate equipment is in place that is regularly serviced and maintained. There was also evidence that appropriate health and safety practices are in operation. Regular opportunities are also in place to consult with the residents about the meals provided. Langholme DS0000009108.V340436.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): The standards considered were 16 and 18. Quality in this outcome area is good. Satisfactory arrangements are in place for dealing with any concerns, complaints or allegations of abuse. This makes sure that residents are safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Providers have established a satisfactory complaints policy and procedure. Following the last inspection the Commission has received no complaints. The providers have received one complaint that has been satisfactorily resolved. Residents said there were no barriers to raising any issues or concerns with the Providers. The residents were confidant that any issues would be dealt with promptly. A satisfactory policy and procedure has also been established for dealing with any concerns or allegations of abuse. Any issues of concern are reported to the Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 17 statutory authorities for investigation to make sure that every reasonable step is taken to protect residents. A whistle blowing policy is also in place. This enables staff to report any concerns to a third party if they feel unable to directly raise the issue with the Providers. This provides residents with further safeguards from abuse. Langholme DS0000009108.V340436.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): The standards considered were 19, 21, 25 and 26. Quality in this outcome area is adequate. The providers have identified the environment requires refurbishment and plans are in place to undertake significant improvements over the next three years. In the interim the providers are making every reasonable effort to provide a comfortable and homely setting for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care home is a two-storey building and the communal areas that are located in the centre of the home on both floors. The home is located near to the centre of Falmouth and therefore a wide range of facilities is within easy access. Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 19 The providers have established a three-year plan to improve and refurbish the environment. The plan has been prioritised and it is clear that some work has been completed following the last inspection. This includes the refurbishment of three communal bathrooms and other priority works. The plan also includes improvements to the dinning room and the replacement of the carpets in certain communal corridors. Car parking is provided at the front and one end of the building and there are attractive accessible gardens to the rear. The dining room is situated on the ground floor and the sitting room on the first floor. Two lifts are provided to ensure residents have easy access to both areas. The providers do need to review the communal space available given the residents are reliant upon one large sitting room. Theses arrangements do not suit all residents and additional space is needed. A large dining room is located next to the kitchen and overlooks the garden on two aspects. The room is principally a large oblong room with a small alcove next to the internal entrance. Apart from the alcove the dinning room is carpeted and provides a positive setting for residents to take their meals. The alcove is not carpeted and also is a multi purpose area that has a sink and kitchen units as well as a storage area for other items. The manager stated this area is part of the improvement plan and will eventually mirror the standard provided in the main dining area. A range of toilet and bathroom facilities is distributed throughout the care home and within a reasonable distance from the communal areas and residents bedrooms. Three of the bathrooms have been refurbished to a high standard. One communal bathroom continued to need improvement. The bedrooms are situated at the two ends of the home and the corridors are painted different colours to assist residents’ orientation. A number of bedrooms are provided with en-suite facilities and there are adequate toilets and bathrooms located throughout the home. These facilities are within a reasonable distance of the communal areas and residents bedrooms. The registered manager has put in place a rolling programme of decoration for the bedrooms to make sure minimum standards are met. It is evident that a wide rage of disability equipment is provided throughout the care home to assist residents to maintain their independence. In addition residents are individually provided with equipment when this is required following the completion of a specialist assessment. Residents said they were generally satisfied with the facilities provided and the majority have clearly personalised their own rooms. Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 20 The home is clean and hygienic and no offensive odours were evident. Residents stated that good standard of hygiene and cleanliness was maintained at all times. Residents were also satisfied with the laundry service provided at the home. Residents said the service was reliable and a good standard was maintained. The providers have also taken positive steps to make sure there are no interruptions to the service by improving the staffing arrangements. Storage at the home continues to be a challenge but the environment was relatively tidy and had improved from the last inspection. The manager said they were continuing to consider how the storage arrangements could be improved. Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 21 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): The standards considered were 27, 28, 29 and 30. Quality in this outcome area is good. The providers regularly monitor and review staffing levels to make sure residents needs are not compromised. The staffing arrangements first thing each day require review given there are some indication more resources are required to meet the assessed needs. Appropriate arrangements are in place to recruit new staff and provide the newly recruited staff with a suitable induction. This makes sure that residents are safeguarded. The staff group are trained to a good standard in order they have the knowledge and skills to meet residents’ needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each day six care staff is employed each morning and four every afternoon and evening. In addition waking night staff are on duty each night and additional staff can be called upon in an emergency. Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 22 Some residents and staff did consider that additional staff were required first thing each morning to assist residents to get up. They said this was a very busy time when demands were high and this caused delays on regular occasions. Staff were also mindful that generally residents continue to have a higher level of dependency regarding the care and support they require. The level of housekeeping staff has been reviewed and improved and sufficient numbers of staff are employed in the kitchen and on maintenance duties. The recruitment, selection and vetting records of staff that have recently been recruited indicated robust arrangements are in place and every reasonable step is taken to protect residents. Newly appointed staff complete a comprehensive induction programme to make sure they are able to provide the care and support required. Recently appointed staff said they were provided with a balanced induction and were well supported by experienced staff. The registered manager has also established an annual staff training programme so that staff have the required knowledge and skills to meet residents’ needs safely. In addition a high percentage of staff hold the NVQ 2 qualification and a number of staff are also qualified to NVQ 3 standard. Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 23 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): The standards considered were 31, 33, 35 and 38. Quality in this outcome area is good. The service is well managed for the benefit of the residents and good arrangements are in place to regularly monitor and consult about the quality of the services and facilities. A range of measures are in place to promote safe working practices and the arrangements have continued to improve and develop. However there continues to be occasions when the records are incomplete or do not provide good information and guidance. This could potentially compromise the health safety and well being of residents. The providers have continued to improve the safe working practise arrangements. There are some good examples of safe working practices but the risk assessment and risk management arrangements on occasions require further improvement to make sure that residents and staff are safeguarded. This judgement has been made using available evidence including a visit to Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 24 this service. EVIDENCE: The current registered manager took up the post in February 2006 and has made a significant impact in improving the quality of the facilities and services provided. This is significant given many aspects of the service were considered to be poor at the time of the managers appointment. In addition the post holder has also been appointed as the registered manager for the Domiciliary Care Service that operates from the care home. The manager has extensive experience in the field of social care and has recently completed the Registered Managers Award. It is evident the registered manager has improved the management arrangements and provided a clear structure for operational staff. This has included reviewing the roles and responsibilities of senior staff. The staff group were positive about the impact of the arrangements. A senior member of staff is on duty for all waking hours to make sure that staff is well supported. On a daily basis senior staff also assist the registered manager in the coordination and delivery of care. Residents were positive about the registered manager and had confident in the management arrangements. The providers have also appointed officers to undertake regulation 26 visits each month and the Commission regularly receives a report of their findings. A range of quality assurance measures are also in place to make sure the home is run in the best interests of the residents. It is clear the providers are committed to treating residents and staff in a manner that promotes equity and diversity. The Providers will assist residents to manage their personal allowances where there is no third person available to offer assistance and good record keeping arrangements are in place. The records are also regularly monitored and audited. Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 25 There are some positive arrangements in place to promote safe working practices for the staff and residents. A detailed health and safety audit has been completed for the environment that is regularly reviewed. In addition the equipment and services at the home are regularly maintained and serviced. The Providers have also established policies and procedures to promote the health and welfare of residents and staff. The risk assessment and risk management arrangements have continued to improve but there continue to be occasions when the required documentation is not completed. The Inspector believes this is principally related to the new care planning arrangements that also provide guidance about safe working practices. However steps needs to be taken to make sure that all residents are safeguarded and staff are provided with good information and guidance. The Providers have also established robust policies for fire prevention and fire safety. The records confirm the fire equipment is regularly checked and regular fire practices and training for staff are in place. Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 26 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 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 3 2 X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The provider must make sure that comprehensive records are in place about the storage and administration of medication. The 3 year environmental refurbishment and replacement plan must be fully completed. The fabric, decoration, furnishings and floor coverings must meet the required standard. All communal bathrooms must be redecorated and refurbished to the required standard. Sufficient numbers of competent and experienced staff as are appropriate for the health and welfare of service users must be on duty. Timescale for action 30/07/07 2. OP19 3. OP19 23(1) (a-b) (2)(b,d,e, g) 23(1)(a)( 2)(b)(d) 30/07/08 30/07/08 4. OP21 23(1)(a)2 (j) 18(1)(a) 30/07/08 5. OP27 30/08/07 6. OP38 13(4)(a-c) Risk assessments and where appropriate risk management plans must be completed on each occasion an accident or incident occurs or there are any DS0000009108.V340436.R01.S.doc 30/09/07 Langholme Version 5.2 Page 28 concerns about the safety of service users or staff. . 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 OP7 Good Practice Recommendations The providers should take steps to make sure all staff consistently apply the new care planning procedures. The communal areas should be increased. The alcove in the dining room should be improved and developed. Sufficient storage space should be provided. 2. 3. 4. OP20 OP20 OP23 Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton Devon TQ13 7UP 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 Langholme DS0000009108.V340436.R01.S.doc Version 5.2 Page 30 - 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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