Inspection on 09/08/07 for Little Oldway

This inspection was carried out on 9th August 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

Little Oldway 02/06/06

Little Oldway 01/11/05

Little Oldway 16/11/04

Little Oldway 10/06/04

Similar services:

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Fairfields Country Rest Home

Poldhu

Queensmount

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

CARE HOMES FOR OLDER PEOPLE Little Oldway Little Oldway Torquay Road Paignton Devon TQ3 2TD Lead Inspector Rachel Proctor Unannounced Inspection 9th August 2007 10:00 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 Little Oldway DS0000018389.V341890.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. Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Little Oldway Address Little Oldway Torquay Road Paignton Devon TQ3 2TD 01803 527156 01803 663670 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) Mr Barry Michael Privett Mrs Jacqueline Ann Privett Vacant Mrs Jacqueline Ann Privett Care Home 35 Category(ies) of Dementia - over 65 years of age (35), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (35), Old age, not falling within any other category (35), Physical disability over 65 years of age (35) Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 02/06/06 Brief Description of the Service: Little Oldway is a large, listed building, which provides accommodation for up to 35 service users on two levels. The home is surrounded by a large, level attractive garden, and is adjacent to Oldway Mansion and its grounds. The home provides personal care for elderly service users with or without a physical and/or mental health frailty. The statement of purpose is available in the office of the home and each person has a copy of the service users guide. The fee range on 09.08.07 was stated as from £302 to £380. We were told the fee charged depended on the care needs of the individual and the way funding is agreed. Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which took place on the 9th August 2007. Besides the information gathered from the visit to the home information obtained since the last inspection of Little Oldway in June 2006 has been included in this report. Selected people had their care followed, this included looking at the way their plan of care was recorded and speaking to them about the service they were receiving. The manager provided information for the inspection prior to the visit to the home. This gave information about how Little Oldway was meeting the Care Standards. People living at Little Oldway, their relatives and staff working at home were spoken with as part of this inspection. A tour of the home was completed and some records were inspected. What the service does well: What has improved since the last inspection? The Requirements made at the last inspection to improve the way controlled drugs are monitored and recorded and complete the Requirements made by the Fire officer had been completed. Several areas in the home have been redecorated and some carpets in communal areas have been replaced. A new weighing scale, capable of weighing people who are unable to stand, has been provided since the last inspection. This enables staff to monitor weight gain and loss for those people identified as at risk. A clear plan of how identified risks are being managed for individuals, which relate to the environment of the home, has been provided. This shows that the management team at Little Oldway have a clear commitment to ensuring the safety of the environment for people who live there. Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Little Oldway DS0000018389.V341890.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 Little Oldway DS0000018389.V341890.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): 1,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Little Oldway have access to information that enables them to know if the home can meet their needs. The information provided is clear and easily available to them or their relatives. The way people have their care needs assessed and recorded should ensure that they receive the care they need. EVIDENCE: Prior to this inspection visit the manager provided information regarding the level of information available to people living at the home and the assessment process they use. The statement of purpose and service users guide were easily available for the people who live at Little Oldway. Each of the people living in a home had their Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 9 own copy of the service users guide. The manager advised that where possible people and/or their relatives are encouraged to visit the home prior to their admission. People spoken to during the inspection said they were given the opportunity to meet staff and/or visit the home prior to their admission. One relative spoken to said that they had been able to visit the home prior to the admission of their relative and that help them choose the room they would occupy. They also said that staff were friendly, helpful and informative about the services provided at the home. The manager uses a recognised assessment and care planning template. Four people whose care was followed had assessments of their care needs completed using this documentation. The assessment records included personal safety and risk such as manual handling; risking falls, nutritional risk and risk a pressure sore development. The manager advised that she would be introducing a new record, which would recorded information about the persons life history, the people and things that were important to them and what their likes and dislikes were. She commented that she felt this would enable the staff to better understand the individuals they were caring for. At the time of this inspection Little Oldway was not provide facilities for intermediate care. However they do have a system in place for respite care for individuals. One person admitted to the home for respite had recently agreed to a long-term placement. This person had a clear record of their needs assessment. The manager had introduced a new system for care planning for people admitted for respite. This person had one of these care plans completed, which linked to their assessment of need. The manager advised that she was in the process of introducing this to other people living in the home as part of their care planning assessment process. She commented that this would improve the information available for staff about individuals care needs. Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The way care plan information is recorded for individual people living at Little Oldway should ensure they receive the health and personal care they need. Medication practices in the home meet the required standards, this should ensure that people receive the medication they need form staff who understand. EVIDENCE: Four people had their care followed as part of this inspection. Each of these had a plan of care in place, which showed how staff should meet their needs. Risk assessments were an integral part of the care planning assessments seen during the inspection. Where risk of falls or nutritional risk had been identified plans of care had been put in place to address the identified risk. Discussion with the manager revealed how the staff had managed one person who had been prone to wandering. Close working with the persons family and their GP had it enabled this person to settle in the home. The manager had used Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 11 orientation to the environment both the garden and inside the home to help this person settle. The individual personal plans of care viewed had been reviewed monthly or sooner if the care needs had changed. Where changes had occurred the care plan had been signed and dated. The person whose care was described had signed their plan of care in two of the four plans of care viewed. The other two plans of care seen were for new people to the home within the last month. The manager advised that the plan of care would be discussed with them and their relatives if they wished when the monthly review was completed. During the inspection district nurses were seeing people who required healthcare treatment. The manager advised that the district nurses keep their own documentation within the persons room where possible. A district nurse spoken to since the last inspection had advised that they were satisfied with the way people they visited were being cared for at Little Oldway. One care manager spoken to advised that the home’s staff had been skilful in managing one of the clients they had placed in the home. The manager confirmed that people are able to see their GP in the privacy of their own room. The plans of care for individuals indicated self-care ability as well as the help they needed for personal care. The preinspection information and discussion with the manager revealed that only people who are trained to do so assess the people living at little Oldway. The manager advised that each person who required an assessment of need, which related to continence care had this completed. Individual people who required continence aids were having these stored in their individual rooms during the inspection. The manager advised that each person is assessed to ensure that the aids they are provided with are sufficient and suitable to meet their needs. The manager explained how one person who had appeared distressed when they were first admitted to the home had been helped to settle into the life of the home. Staff observed during the inspection was skilful managing the people they cared for. They were heard giving the same helpful response when individuals asked the same question more than once. They were able to divert someones attention away from what was distressing them to something they knew they were interested in. The way medication is stored and managed has improve since the last inspection. Medication was being stored in a locked room. A lockable medicine trolley was also stored in this room; this had been fixed to the wall. The manager advised that only staff that had received training in managing medication administered medication for people living in the home. The record of medication given had been signed. Good medication stock control was in place and records of returned medication were clearly recorded, signed and Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 12 dated. The manager was aware of the need to keep medication for people who had died for seven days after their death. The controlled drug record was checked against the stock for one person as correct. Two members of staff had signed the controlled drug book. Staff were observed speaking to people who live at the home in a respectful friendly way. People were responding to conversations with staff in a positive way. People spoken to and relatives visiting the home said staff are always respectful and friendly and they felt well cared for. The laundry system in place ensures that people have their own cloths to wear. Little Oldway DS0000018389.V341890.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information recorded for people’s social care did not always include the activities they enjoy or prefer to take part in. This may mean that the people living at Little Oldway may not have access to the activities that stimulate and interest them. Meal times are a pleasant experience for the people who live at Little Oldway. Meals are attractively presented and provide for the nutritional need of those who live there. EVIDENCE: The people who live at Little Oldway spoken to during the inspection told the inspector they were satisfied with the activities provided for them. There are two lounges and a conservatory within the home; those people who dont want to take part in activities are able to go to a small lounge or conservatory. A list of activities is provided. One activity provider was visiting during the inspection. They were providing opportunity for people to sing a long to familiar tunes. The people asked said they had enjoyed taking part in the mornings activities. A written record of the activities is provided for the home manager. Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 14 However the records of individual’s personal preferences and choices for social care and the activities they enjoyed were not all fully completed. The manager advised that she was in the process of introducing life plans for the people living at the home, which would enable their life experiences to be recorded and the personal choices likes and dislikes. The manager advised that she felt this would enable staff to better understand the people they were caring for. Visitors were coming and going during the inspection, they were seeing their relatives/friends in the privacy of their own rooms or one of the communal areas in the home. The statement of purpose and service uses guide available in each person’s room gives information about the homes policy on maintaining relatives and friends involvement. The way the environment is set out with three key communal lounge areas and a dining-room allows people to choose where they wish to sit. Each of the individual peoples rooms entered had been personalised with items of their choice. The mealtime observed during the inspection was unhurried with people eating their meals at their own pace. People were given the opportunity to have second helpings if they wished. The staff assisting the people who needed help to cut their food were doing this in a friendly supportive way. Very little wastage was seen at the lunchtime meal. Those people asked said the food is always good and plenty of it. The varied menu supplied showed that the nutritional content of meals provided for people at he home had been taken into account. The people whose care was followed had a nutritional risk assessment completed and a record of their weight was being kept. The manager advised that this process had help to make it easier to identify those people at risk of malnutrition. New scales capable of weighing people who were unable to stand had been purchased since the last inspection. Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at Little Oldway can have confidence that any concerns they raise will be dealt with sensitively by a staff team who understand them and have their best interests at heart. EVIDENCE: The Commission has been made aware of two complaints in the last twelve months one of these was referred to the adult protection team. The manager provided information for the Commission, which showed she had acted in the best interests of the people living at Little Oldway. Each person has a copy of the complaints procedure with the service users guide provided in each person’s room. The people spoken to during the inspection said the staff deal with any concerns they have in a sensitive way. Those asked said their concerns were taken seriously, staff were approachable and they knew who to speak to if they had any concerns. The manager advised that she was continuing to use the adult protectiontraining programme used at the time of the last inspection. This gives staff the opportunity to read course material and answer set questions, which test their learning. The manager advised that in addition to this she intended to seek an external trainer for adult protection to ensure staff had good understanding of the issues. The recruitment process and procedures in place protect the people living at Little Oldway from unsuitable staff. Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at Little Oldway have a pleasant, clean fresh and homely place to live in that is able to meet their needs. EVIDENCE: A tour of the home was completed as part of this inspection. Several areas in the home had been redecorated since the last inspection. The home was fresh and clean in all areas that the people who live there have access to. Individual peoples rooms entered during an inspection had been personalised with items of their choice. One person said the cleaners make sure their room is clean and fresh for them. One relative commented that is always fresh and clean when they visit. People living at Little Oldway have access to two lounge areas, a conservatory and dining room. All these areas were being used during the inspection. Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 17 People who preferred a quiet space were using the smaller lounge and conservatory. The smaller lounge had been designated for those people who wish to smoke. During the inspection the large lounge was being used to provide activities for the people who wish to take part in them. The gardens surrounding the home continue to be attractively presented, with a variety of flowering summer plants for people to enjoy. Several of the people living at Little Oldway and their relatives commented how much they liked the gardens around the home. Discussion with the manager revealed that it was the intention to put gates on the garden, which would allow those people who are prone to wander free access to the garden. Environmental risk assessments are completed for the home, these were available for inspection. Preinspection information indicated over the last 12 months maintenance has continued within the home both internally and externally. A permanent part-time gardener and a flexible maintenance engineer had been appointed since last inspection. The manager advised that the people who live at Little Oldway are regularly asked to feedback about services and care they receive. Completed questionnaires were available for inspection they showed that people are asked about the home’s environment. Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The commitment of the homes management team to ensure staff have qualifications in care should ensure that people who live at Little Oldway are in safe hands at all times. The recruitment practices in place at Little Oldway should protect people from unsuitable staff. The people who live at Little Oldway can have confidence that the staff team who care for them have access to training that will help them understand their care needs. EVIDENCE: The manager provided a duty rota, which showed the number of staff on duty and in which capacity they were employed for each shift. This showed that more staff were on duty at peak times. The manager confirmed additional staff were provided if the needs of the individuals change. The staff spoken to during the inspection commented that sufficient staff are available on duty for them to complete their work. In addition to the care staff the home also employs ancillary staff, which includes domestic staff that carry out cleaning and laundry, a maintenance Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 19 man and gardener. Two domestic staff spoken to during the inspection said they enjoyed their work and felt usually they had sufficient time to complete all the tasks they needed to keep the home fresh and clean. The manager provided a list of staff who were in progress of completing an NVQ (National Vocational Qualification) in care or had already achieved this. This showed that of the 20 care staff employed 13 had achieved an NVQ level 2 or above and 4 staff were in the process of working towards an NVQ level 2. 8 of these staff had achieved an NVQ level 3 and 1 of these had also achieved an NVQ level 4. This information showed that the home had achieved over 50 of its staff with NVQ level 2 or above. Three staff files were viewed during the inspection. This showed that staff had the necessary pre-employment checks completed prior to starting work. This included a completed application form, two references and police checks. The staff files viewed also contained a contract, which included a statement of the terms and conditions of employment. The home manager has copies of the General Social Care Council code of conduct the home also has its own code of conduct available with the policies for staff. The manager advised in that she was in the process of introducing a new training pack, which followed the skills for care guidelines for the induction of new staff. The records of induction programs completed by staff employed since the last inspection were available for inspection. The training information provided by the manager showed that staff have access to training that enables them to do the job. A list of mandatory training completed by staff in the last 12 months was provided for inspection in. Mandatory training included fire safety, manual handling and protection of vulnerable adults. The manager advised that senior staff also completed medication management training. The home caters for people who suffer with dementia. However the staff training record showed that only two staff had completed dementia care. The manager advised that the Alzheimers disease Society had been very supported and had offered advice and information about forthcoming training. She also advised that the community psychiatric nurses who provided support for some of the people living at Little Oldway had been helpful supporting her and the staff at the home to care for people with dementia. The manager advised that she would be introducing life history booklets for the people who live at Little Oldway. These provided information about the important events in the persons life the work they undertook and the activities they enjoyed when they were younger. The manager said that she felt completing these booklets would enable staff to care for the people living at little Oldway in a holistic way. Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The new manager has continued to improve the way care is delivered and directed for the people who live at Little Oldway. The homes management team seek the views of people who use their service. However the results of a recent quality audit had not been made available to the people who live at Little Oldway or the Commission. The records of health and safety management available showed that the homes management team have a clear system for ensuring people who live at Little Oldway have their Health and Safety protected. Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager has changed since the last inspection. The owner advised that she would be putting forward this manager for registration with the Commission. The manager has experience working in a senior position in a older Persons care home. She has kept herself up to date with care practices by accessing relevant training. At job description was available for the manager at the last inspection. Observation during the visit to the home showed there were clear lines of accountability with in the home. Senior carers who take responsibility for the shifts they cover were supporting the manager. The manager advised that questionnaires had been sent out to family and people who live at Little Oldway to give them the opportunity to comment on the services they provide. Some completed quality audit forms are available for inspection. However these had not been analysed and has not been made available to the people who live at Little Oldway or the Commission. The manager explained how staff worked with individual people living at Little Oldway to help them develop and come to terms with their disability. She advised how one person who had been prone to wander had been helped. Relatives spoken to during the inspection advised that they were kept informed about things that were happening in the home and they knew their relatives had been asked their opinions about events that were organised. Policies and procedures are in place, which were easily available for staff. The Requirements made at the last inspection have been met. The Requirements made by the fire officer at the last inspection had been completed by the owners. The controlled drugs records reflected the prescribed medication amounts held by the home and medication for return had been recorded in a controlled drug book as well as the pharmacy/returns book this inspection. The Register Provider is the appointed agent for one person living at Little Oldway who has lived there for several years. Records of how this money was managed were available. The manager advised that they dont routinely keep valuables on behalf of people living at Little Oldway. However there are secure facilities available should this be required in an emergency. The manager further advised that people are billed on a monthly basis for things they purchase, such as newspapers, chiropody and toiletries. This means that people who live at Little Oldway do not need to keep money with them in order to make purchases. The records of money being held for safekeeping for one person living at home were viewed. Records and receipts of expenditures were being kept for this person. The manager was able to provide evidence that staff had received health and safety training, which included manual handling, fire safety, food hygiene and first aid. Copies of certificates staff had received were training their completed Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 22 were available with their staff files. The staff spoken to during the inspection confirmed that they had received the mandatory training they needed. A comprehensive risk assessment of the environment had been completed. The manager provided a list of personal rooms and assisted bathrooms, which had radiator covers, a lock on the door or water temperature thermostat, a window restricted and fire door closures. This showed that all the radiators in areas people who live at Little Oldway have access to had radiators covered. The record for the provision of a lockable door to individual room showed that some people had a lock fitted to their personal room and others had refused a lock for the room and some others had been assessed as unsafe. The accident records were available for inspection. A system for reporting injuries, diseases and dangerous occurrences regulations (RIDDOR) 1985 is in place. The manager was aware of her responsibilities in relation to reporting through the system. Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 24 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 1 2 3. Refer to Standard OP12 OP30 OP31 OP33 Good Practice Recommendations The activities people who live at Little Oldway prefer and enjoy should be recorded as part of their care planning process. Staff should receive training for managing dementia care and behaviour that challenges the service. The new manager should complete the commissions fit person processes The results of quality audits should be available for the service users and the Commission. Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton 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 Little Oldway DS0000018389.V341890.R01.S.doc Version 5.2 Page 26 - 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!