CARE HOMES FOR OLDER PEOPLE
Madley Park House Madley Park Witney Oxon OX28 1AT Lead Inspector
Jane Handscombe Unannounced 09 June 2005 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 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. Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Madley Park House Address Madley Park, Witney, Oxon. OX28 1AT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01993 890720 01993 890724 manager.madleypark@osjctoxon.co.uk Order of St John Care Trust Vacant Care Home 60 Category(ies) of OP, LD(E), PD(E), TI(E), SI(E), DE(E), MD(E) registration, with number of places Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: The total number of residents accommodated at any one time should not exceed 60. An application for registered manager must be received within three months of initial registration. Date of last inspection N/A Brief Description of the Service: Madley Park is a care home providing personal care and accommodation for 60 older people. It is located on the outskirts of Witney in the centre of a housing estate and close to many amenities; the care home is provided by The Orders of St John Care Trust. The home is built in semi-contained care wings, which allows residents to relax in their own rooms, the lounge areas or the dining room. There is also a large central area on the ground floor known as the heart of the home which provides a friendly social area to residents for relaxing and entertainment. Attached to this area is a hairdressing salon serviced by a visiting hairdresser three times a week. There is also access to a pleasant, safe enclosed garden accessible for residents and their visitors to enjoy. Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, lasting seven hours, which took place on the 9th June 2005. The purpose of the visit was to see how the home is meeting the National Minimum Standards. Two inspectors undertook the visit during which a tour of the building was made and the kitchen visited. Nine residents and two visitors were spoken to in order to ascertain their views on the care and the services they receive at the home, as were the manager, the activities co-ordinator, a cook, a kitchen assistant and two carers. Four residents’ assessment and care records were looked at in detail plus four staff personnel files. Medication administration records and medication storage in the medicine trolleys and cupboards were also viewed. The home presented as and clean and tidy throughout and had a homely atmosphere. Residents were going about their daily activities in a calm, relaxed manner. Staff were observed to provide care and support in an unhurried manner whilst respecting the residents’ dignity and showing respect at all times. What the service does well:
There are many positive practices taking place within the home, all of which add to the richness of the home. The home has an activities co-ordinator who is to be commended in putting a great deal of thought into the daily activities and organised trips that are provided at Madley Park. Furthermore, much one-to-one work takes place to ascertain any lifetime ambitions the residents have not attained but would like to attain. At present there is a falls specialist nurse involved in the home who provides training and works with residents and their families. Where the home has concerns, they refer the resident to the nurse who develops strategies with the client to minimise the risks of falling and enables the resident to access any equipment, via the occupational therapist, that may be needed with regard to their falls. Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 Page 6 The home offers the residents choice and variety around both food and activities and keeps residents well informed of social events taking place in the home. The manager and her team of staff have worked very hard to settle the residents into their new surroundings, since they are of a greater size than their previous residencies, coupled with which they have had to familiarise themselves with new members of staff. Likewise, the staff having come from two different homes have worked well together and gelled as dedicated team members. Moving from smaller homes to one of a considerably larger size than they have been used to with a larger number of residents has taken some getting used to, and getting to know the clients with whom they were not previously familiar with. Staff were observed to be a dedicated team who attended to the residents’ needs in a professional manner whilst respecting their privacy, dignity and individuality. The home presents as very clean, hygienic and welcoming. What has improved since the last inspection?
This is the first inspection of the home so it is not possible to see where improvements have been made. Earlier this year in March residents from Witan House and Langston House moved into the newly built home which is very much larger than they were previously accustomed to. Moving to a different environment, much larger in scale, and getting to know staff members and fellow residents with whom they were unfamiliar, along with familiarising themselves with a new manager of the home has been a challenge to both the residents and the team of staff. The manager and her staff members must be commended; they have worked very hard together, as a team, to settle the residents into the home and their new environment, whilst providing a consistent provision of care and consolidating what the inspectors viewed as a warm, friendly, welcoming home that has been managed well during a difficult transitional period for all concerned. Residents spoken to were most complimentary of their new home and the provision of care they receive, despite reservations they did have regarding the move. Whilst there are some shortcomings that will be observed within this report, it is felt that the home has achieved a great deal in the three months that it has been opened.
Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 Page 7 The acting manager was previously a care services manager with the Order of St John Care Trust, whose role was to support and advise fellow managers within a number of OSJCT homes. Prior to this she has had experience in managing one of the Trust’s homes for older people in Oxfordshire. She is now in the process of registering her position as manager with the Commission. Residents and staff members spoke positively of the manager who they confirmed is very approachable and runs the home in an open, transparent, inclusive manner. What they could do better:
Since there have been no new admissions to Madley Park since its opening in March, the inspector viewed four existing residents’ files whose initial assessments of need, prior to admission to a care home, were carried out by the previous managers of their respective homes. These initial assessments were of poor quality, with no evidence of service users/their representatives having signed the assessments to ascertain that they had been involved in the process. The inspector, in discussion with the manager around the subject of assessments, pointed out their failings and acknowledged that these had been carried out before her position at Madley Park. The manager informed the inspector that a new process for assessing prospective residents’ needs was now in place, which should allow for a fully comprehensive assessment. Care leaders and the manager herself have undertaken training in the new format, and are cascading the training down to other members of staff. It is anticipated that the new format will result in assessments, care planning and the reviewing of care needs being complete and comprehensive. The inspectors made a requirement whereby the manager must ensure that all new residents are assessed in the new format and that these assessments are comprehensive, and that all existing residents’ assessments must be transferred to the new format within a given time period. The home should ensure that the correct storage of hazardous substances is observed and maintained. Hazardous substances were found to be in unlocked cupboards accessible to residents thereby potentialy jeopardising the residents’ safety and well being. An immediate requirement was made during the inspection to ensure hazardous substances are stored appropriately and safely. There were poor practices taking place surrounding medication issues. It was apparent that staff members who administered medication were unaware of procedures regarding the disposal of medication where residents have refused medication. Likewise, eye drops were found in the medication trolley without an acknowledgement of their date of opening. Since this type of medication has a lifetime of one month after opening, it is a requirement that they be dated to ensure that out of date medication is not administered. Two bottles of eye drops were found undated, one having been dispensed in March, which the inspector recommended be disposed of and contact be made with the
Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 Page 8 pharmacy regarding a further supply. A second bottle had only recently been dispensed and was therefore still within the expiry date. A discussion with the manager regarding these issues took place. The manager informed the inspector that medication training would be revisited with all staff members responsible for medication and a requirement has been made within this report to ensure that staff adhere to the policies and procedures, and that training is revisited to ensure that the health, welfare and safety of residents in their care is paramount. Staff personnel files were observed to lack the inclusion of a photograph as is expected under the Health and Social Care Act, so a requirement has been made to ensure that all staff files are updated to include a photograph. 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. Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Information for prospective service users is in production and awaiting finalisation. Presently information consists of a small leaflet and other material specific to Madley Park which does not fully comply with Schedule 1 of the Care Homes Regulations 2001. EVIDENCE: The home provides good, clear information for prospective service users about the services provided at Madley Park, although it is not yet fully completed. A Statement of Purpose, which is in the process of being printed, was viewed, and it was noted that whilst it nearly meets the requirements as detailed in Schedule 1 of The Care Homes Regulations 2001, it failed to contain details on the number and size of the rooms or any details on fire precautions and the respective emergency procedures in the home. A requirement has been made within this report to address the omissions. An information pack is given to any prospective service user, their relative or advocate. The information pack contains details of the aims & objectives of the care home along with a statement about the ‘Ethos of Care’, sample menus and details on the activities offered within the home.
Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 Page 11 The manager informed the inspectors that no new service user would move into the home before a full assessment of their needs had been undertaken. Since there were no new residents to the home, the inspectors viewed a sample of four existing service users’ files, one of which did not show evidence of an assessment being carried out prior to admission. A requirement has been made to address the issue. Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The system of care planning is unclear, inconsistent and incomplete thereby placing the residents within the home at high risk of not having their needs fully met; their health, safety and well being is not being addressed fully. Poor procedures and practices around medication further jeopardise the health and safety of residents in their care. Staff treat the residents and their families in a sensitive manner, respecting their dignity and showing respect at all times. EVIDENCE: The inspectors viewed four residents’ care plans and found a number of issues running consistently throughout all those viewed. One care plan viewed informed the inspectors that the resident has a history of falls, one of which resulted in hospitalisation. This would indicate that a personal safety risk assessment be undertaken in order to address how to manage and protect the health and safety of the resident. However, no evidence of such an assessment or plan of care to manage and monitor the falls was evident. Furthermore, the hospitalisation was not logged in the section for hospital stays.
Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 Page 13 The same care plan had no evidence of any nutritional assessment ever having taken place although this resident is a diet controlled diabetic. Further omissions within the resident’s file were the date of admission, no signature to evidence that the resident/representative had been involved in the assessment and reviewing of care process, and no personal inventory was included to detail belongings that the resident had brought into the home upon admission. Another resident’s file informed the inspectors that there had been GP and community psychiatric nurse involvement in December. The inspectors noted that, whilst input had been requested for the client, the reviews of care carried out in the very same month did not reflect this, the entry being that of ‘no change’. A third resident’s file viewed indicated that the resident uses a frame to aid in mobility. However, this was not acknowledged on a manual handling and movement assessment to highlight risk factors and how these will be managed in order to protect the health, safety and welfare of the resident. This same file showed no date of admission and the assessment of needs undertaken prior to admission failed to contain a date or any evidence that the person who undertook the assessment was qualified to do so, since the signature of the assessing nurse/carer was omitted. Requirements have been made to address the poor quality of assessing residents’ needs, reviewing these needs and the care planning drawn up from the assessments and reviews, so as to protect the health, safety and welfare of residents living in the home. All new residents admitted to the home must undergo a comprehensive detailed assessment by a person qualified to do so and a detailed plan of care must be drawn up from this assessment in order that all staff know how to address needs fully. Information in existing residents’ files must be transferred to the new format, within a given time scale found within this report. They must be updated to provide a fuller, clearer picture of the residents’ assessed needs and a detailed care plan informing how the needs will be addressed. Risk assessments must be undertaken and a regular review of the residents’ needs must be evident. The inspectors observed the medication round whilst they were visiting the home. Whilst the home has policies and procedures around medication, poor practices were evident. Eye drops, which have a shelf life of one month after having been opened, were found with no date of opening. Since the said eye drops were dispensed in March, some two months prior to the inspection, the inspectors advised they be destroyed and contact be made with the pharmacy to obtain a replacement, and these be dated when opened. Further eye drops were found to be opened and lacking the date of opening. However, they had been recently dispensed and it was possible to determine the date of opening from the medication administration records so these were dated whilst the inspectors were at the home.
Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 Page 14 It was further acknowledged that where residents refused medication that had been taken out of sealed packaging, the medication was inappropriately disposed of, which clearly places residents at a very high risk of coming across medication not prescribed for them and a potential accident taking place. Advice was given and the matter reported to the manager, who informed the inspector that medication training would be readdressed immediately, as would the policies and procedures around medication, and in the meantime the head of care and the manager would revisit medication training. Evidence found during the inspection with regard to the lack of regular reviews of care, risk assessments and the content and quality of the files viewed, led the inspectors to believe that presently the residents are at risk of not having their needs fully met. Furthermore, the home is not working in the best interests of the residents regarding their health, safety and welfare. Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 The meals offered to residents in this home are very good, offering choice and variety and catering for special dietary needs. There is a very good daily activities programme provided at the home offering variety, choice and stimulation. The home supports residents to maintain contact with family, friends and the local community, as they require. EVIDENCE: Residents spoken to during the inspection were very positive about the daily activities and the inspectors noted a very high attendance to those taking place during their visit. Activities offered include karaoke, keep fit, sing-a-longs, art and crafts and lucky dip. Much of the work produced by the residents during the activities is on show in the home. A great deal of effort goes into working on a one to one basis with the residents in order to ascertain lifetime ambitions that have not been achieved yet would like to be undertaken, and the activities co-ordinator works with the resident, wherever possible, to try and attain this where feasible.
Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 Page 16 Besides a programme of daily activities, the home organises trips and outings which residents spoke about enthusiastically. One forthcoming trip, advertised within the home on the noticeboard so as to keep residents informed, is that of a trip to a local inn situated by the river. The trip is to involve two hours of entertainment, a sing-a-long and a two course meal. The home has a hairdressing salon, which is fully equipped to meet the residents’ required needs. Residents can arrange appointments with the visiting hairdresser who visits the home three days a week. The salon presented as clean and tidy. Products and utensils were sterilised and stored appropriately and the hairdresser informed the inspectors that all necessary health and safety checks on electrical appliances are undertaken. It was noted that residents were making use of the service on the day of inspection and feedback from residents around the service were very positive. One resident said, ‘I like it here, it is beautiful.’ During the inspection residents were taking lunch and spoke highly of the meals offered in the home, stating that, ‘It is always very tasty and enjoyable’. Residents were seen to be taking their meals in a calm, relaxed atmosphere and staff were observed to be at hand helping those who needed help in an unhurried, discreet and supportive manner. The inspectors spoke to the cook and viewed the kitchen and varied menus that are produced for the residents. The kitchen was very spacious and clean throughout, food was stored appropriately and the general impression gained was one of a well-managed kitchen with staff who were enthusiastic and took pride in their work. During the inspection the inspectors were informed that visitors are made to feel very welcome and can visit at any reasonable time. One resident’s visitors made a point of informing the inspectors how pleased they were with the care their mother has been receiving at the home, during a period of terminal illness, that they have been welcomed to visit the home at any period and the home has been very accommodating in making arrangements for family members to stay with the resident day and night. ‘The care has been wonderful, we couldn’t fault it. They’ve looked after us all through this very difficult period of terminal illness’. Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 Page 17 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 17 There is a clear complaints procedure which is on view in the home for residents and visitors to the home to access if the need arises. Residents have access to an independent advocacy service. EVIDENCE: Residents spoken to on the day of inspection were aware of the complaints procedure and felt that if they had any concerns they would be taken seriously and acted upon appropriately. Residents have access to an independent advocacy service, provided by Age Concern, Oxfordshire, at no cost to themselves or the home. The service is confidential and one in which an advocate will work with and support residents to get their voices heard and their rights upheld when required to do so. All residents are enabled to take part in the electoral process. Residents can choose to take part either by postal vote or can be supported to attend the local polling station where required. Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 22, 23, 24, 25 and 26 The home provides comfortable surroundings that are equipped to meet the residents’ differing needs. Health and safety was not observed regarding the storage of hazardous substances in some areas of the home EVIDENCE: Madley Park is a spacious, newly built home which is built in semi contained care wings, all of which have their own lounge areas, dining room and bedrooms. The large central area on the ground floor, known as the ‘heart of the home’, is an area in which residents gather for social activities, entertainment and general socialisation with fellow residents and visitors. Whilst the home is a relatively large building and one which is very new, the inspectors commend the manager in having attained a warm, welcoming, homely and inclusive atmosphere in such a short space of time. Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 Page 19 Residents’ bedrooms viewed on the day of inspection were all wheelchair accessible, and contained en-suite facilities which included a wash basin, shower and WC. Grab rails were seen to be fitted in both the bedroom and en-suite to aid residents where needed. Residents spoken to during the inspection were very happy with their rooms, finding them spacious, furnished to a good standard and meeting their needs. The sluice on the first floor was not observed to be locked and hazardous substances were located there. Further hazardous substances were found in the kitchenette on the ground floor. Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 The home provides adequate staffing to meet the needs of the residents and ensure their safety. Recruitment at the home is sound. However, photographs are not held on all staff personnel files. EVIDENCE: Retention of staff since moving to the home has proved difficult, resulting in the loss of a few staff members. Moving to a larger environment and travelling issues have played a large part in this. The manager has been actively recruiting staff members to replace those who left and anticipates a full complement of staff once the relevant criminal records bureau checks have been returned. The staff members who remain at Madley Park are an enthusiastic team who have worked positively with the residents during their first three months at their new home. They have offered a consistency of care to those using the service and worked very well as a team, ensuring that the needs of the residents are met. Of four staff personnel files checked, only two contained a photograph. Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 37 and 38 The management of the home is generally good and this was clearly reinforced by staff and residents. Medication issues must be addressed immediately and care plan records be addressed so as to not place the residents at possible risk. (See section on Health and Personal Care). The manager has yet to enrol on NVQ4. EVIDENCE: The acting manager has many years experience working with older people in the care sector and was previously a care services manager with The Orders of St John Care Trust. Whilst she is presently undergoing registration with the Commission, it is expected that, if registration proves successful, she would register for the NVQ Level 4 in Care within three months and complete the qualification within two years, in order to meet the standard. Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 Page 22 Both residents and staff informed the inspectors that the manager is very approachable and feel that she values their opinions and suggestions. It was felt that she runs the home in an open, transparent manner. Evidence found with regard to the assessment and reviewing processes needs to be addressed in order to remove the risk factors to the residents’ health, safety and welfare that are clearly evident at present. Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 x 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x 2 3 3 x x x 3 2 Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 Page 24 N/A Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 3 7 and 8 Regulation 14 15(1)(2) 24 Requirement All future residents admitted to the home must have their needs fully assessed All residents needs must be fully addressed in a formal care plan, they must be risk assessed and reviewed as prescribed by the regulations. Medication must be stored and disposed of. All hazardous substances held in the home must be stored safely. Information held on all staff files must be as outlined in Schedule 2 of the Care Homes Regulations 2001 Timescale for action Immediate and henceforth By 9/9/05 3. 4. 5. 9 38 29 13(2) 13(4) 13(4) 19(1)(b) Schedule 2 Immediate and henceforth Immediate and henceforth Immediate and henceforth 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 7 Good Practice Recommendations All care plans should be transferred to the new format Madley Park House H57-H08 S62634 Madley Park House V232294 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Burgner House, Cascade Way Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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