Inspection on 03/08/06 for Maesknoll

This inspection was carried out on 3rd August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Maesknoll 01/12/08

Maesknoll 18/12/07

Maesknoll 30/07/07

Maesknoll 14/01/06

Maesknoll 21/07/05

Maesknoll 28/03/05

Maesknoll 05/10/04

Maesknoll 25/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

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 Maesknoll 101 Bamfield Whitchurch Bristol BS14 0SA Lead Inspector Jon Clarke Key Unannounced Inspection 3rd & 18th August 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 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. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Maesknoll Address 101 Bamfield Whitchurch Bristol BS14 0SA 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) 0117 3772690 0117 3772691 Bristol City Council Mrs Diane Cecelia Bennett Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate one named service user aged 58 years of age. Home will revert when named person leaves. 14th January 2006 Date of last inspection Brief Description of the Service: Maesknoll is a care home registered with the Commission for Social Care Inspection to provide accommodation and personal care to forty residents aged 65 years and over. The home is owned by Bristol City Council Social Services & Health (SS&H) and situated in the residential area of Whitchurch. Maesknoll is arranged over two floors with lift access. There is a small patio and large areas of lawn surrounding the outside of the home. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days; the manager was present on the second day of the inspection. As part of this inspection a number of documents were looked at including pre-admission assessments, care plans, daily care records, training, supervision, staffing arrangements and those relating to health and safety practice in the home. There was an opportunity to discuss with residents and staff their experience of living and working in the home. Before this inspection a representative of the CSCI visited the home and completed Have Your Say questionnaires with 12 residents. This provided views from residents about a range of issues including availability of staff, activities arranged in the home, meals, whether residents receive the care and support they need including medical support. A quality assurance survey was undertaken by an independent body to obtain feedback from residents and others who have an interest in the quality of care provided at Maesknoll. A copy of their conclusions was obtained and has been used to inform this inspection. Any comments referred to in this report from this survey will be acknowledged. Since the last inspection the home has undergone staff changes with a new manager and the loss of permanent and long serving staff. These changes have impacted upon both the residents and staff. Some staff demonstrated a resistance to the new staff coming to the home as they have brought with them differing approaches. The arising difficulties were openly acknowledged by the staff team and there is a sense that, whilst this has been a difficult period, staff are now adjusting to these changes. However, in the process staff morale has clearly been affected. This has been further compounded by other areas such as staffing budget restraints, staff sickness and increasing dependency of residents. Discussions with the office staff confirmed that there is a strong willingness to move forward and address the areas of poor practice identified from this inspection. The current position held by Bristol City Council on the staffing policy and budget restraints hinder their ability to achieve the necessary changes. It was evident from the inspection that residents will not be provided with a service that meets their needs unless there is a commitment from the Local Authority to provide the home with sufficient resources. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 6 Moreover there needs to be a strenuous effort and commitment to address low morale and place a greater sense of value on the staff of the home. This can be addressed individually at supervision sessions examining working practises. The current practise of care staff undertaking domestic duties needs to be reviewed as it reduces the time that staff can give to the residents to meet their care needs. In addition this practice devalues the professionalism and commitment of staff impacting on the efficient use of already pressured resources. The introduction of structured key-time would address not only the lack of time staff are able to spend with resident’s, but also re-enforce the value and importance of staff spending “time with residents”. “We don’t have enough time to do it as we would want and spending time with residents” (staff member); “They (staff) can’t stop to listen and you don’t get time with your key-worker”; “…hardly ever see staff they have too much to do”, “Staff all very good, but have a lot to do; bit more entertainment would be good” (comments from residents). “More staff are needed, then, perhaps, residents will receive more one-to-one care, conversation and general contact” (relative comment from Mackintosh Rose survey). These comments reflect the level of dissatisfaction around the demands on staff and the implications for the quality of care provided. What the service does well: What has improved since the last inspection? A number of requirements were made at the previous inspection, particularly about care planning, recording of care needs, reviewing of care plans and training. Improvements have been made with regard to care planning; however, practice remains inconsistent. Training has been provided in person centred care planning and staff commented that this was helpful and has reenforced their practice. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The quality rating in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. The home undertakes full and comprehensive assessment of prospective residents so that they are able to make a decision about the capacity of the home to meet health and social care needs. However improvements in establishing overall capacity of the home could be made which would lead to a more informed and accurate view of the home’s ability to meet assessed need. EVIDENCE: A number of pre-admission assessments were seen and showed good practice in identifying the health and social care needs of prospective residents. Generally assessments are undertaken by the local authority and include views of the prospective individual and carers. Where there are mental health difficulties the involvement of the mental health team ensures that this area of care need can be clearly identified. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 10 Although pre admission assessments are good, they are not well used in that when complex needs are identified there is no system to establish whether current staffing levels are sufficient to meet need. It is recommended that this is reviewed to ensure that the mix and needs of service users can be met before committing to a new admission. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality rating in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. Care Planning and arrangements for meeting health care require improving so that there is more consistent practice and up to date information is provided to care staff so that the health and social care needs of residents can be met. The practice of the home helps to make sure that resident’s health needs are protected. The practice of staff and policies of the home help to make sure that residents are treated with respect and their dignity is upheld EVIDENCE: A number of care plans (7) were looked at and showed that there were significant gaps in the recording of information about resident’s care needs. Moving and Handling assessments are completed though not always updated and reviewed in one instance reflecting changed mobility of a resident following a fall requiring a different approach from staff than previously. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 12 Reviews of care plans were not completed regularly in three instances since 6/12/05,12/10/05 and 7/02/06. Personal profiles were completed, giving good information about the social needs, daily routines, family history, likes and dislikes of the individual. In a number of instances there was no evidence of the individual’s involvement in the completion of their care plans. Risk assessments are undertaken where necessary. Residents are seen by community health services, i.e. chiropodist (8 weekly), optician and dentist. Where able, residents are encouraged to visit these services in the community though some will provide a service in the home. District nurses visit the home if there is a medical and nursing need such as ulcers that require dressing. District nurses are also involved in undertaking continence assessments where the home has concerns about an individual and have also provided training to care staff. Daily records gave a good outline of individual’s routines and abilities and importantly highlighted any health concerns that were then followed up by referral to individual’s GP. It is the practice of staff to monitor weight. In one instance they had identified potential concerns about weight loss and staff had been instructed to “monitor regularly”. The last entry on the care plan was made on 28/07/06. In response to pre-inspection questionnaires about receiving the medical attention they need, all respondents replied, yes. The homes medication procedures, storage and recording were examined. Storage arrangements are good with secure facilities including separate storage for controlled drugs. Administering records showed accurate records of medication given to residents. Returns was also examined and provided satisfactory evidence of drugs returned to the pharmacist. Residents confirmed that they felt staff treated them, “as I would want to be treated”; when asked about their privacy being respected, a number said, yes, “always”. Staff were observed assisting residents with sensitivity particularly in one instance when helping an individual to the toilet. Another resident who was relatively new to the home said how she had felt “awkward at first” (this was in relation to being assisted to wash and dress), “but now I feel fine, not embarrassed at all”. Residents also confirmed that they could see their GP in private and when they have visitors can always go to “my room”. Staff were observed interacting with residents in an appropriate and respectful manner. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The quality rating in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. The arrangements for making sure there are opportunities for meaningful activities need to be improved so that resident’s social needs are met. The home makes a good effort to ensure that residents are able to maintain links with family, friends and the local community. The home’s practice and routines are flexible and enable residents to exercise choice and have control over their lives. The home provides meals, which are balanced and meet the dietary needs of individuals in the home. EVIDENCE: In discussing with residents activities arranged in the home there was evidence that there was “definitely not enough going on”, needing “a bit more entertainment”. There are no structured activities and at a residents meeting the minutes recorded that, “residents have noticed that entertainment has stopped”. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 14 The home’s notice board advertised outside entertainers who been invited into the home and Bingo was being organised; however, there was no indication of other activities being organised on a regular basis. The pre-inspection questionnaire also indicated dissatisfaction with the level of activities provided in the home. In response to the question, “Are there activities arranged by the home that you can take part in?” 6 responded always, 2 usually and 3 never. A relative who was visiting the home at the time of this inspection commented, “basic care is very good, but residents need more stimulation and activity, one to one”. Staff also acknowledged that they didn’t feel there was enough time to undertake activities with residents; “We just don’t get the time, always very busy”, was a typical comment. Staff related this to the high dependency of some residents, further compounded by use of agency staff who are not familiar with residents and routines of the home. This was a theme of comments made by residents, namely the lack of staff time, “The staff have a lot to put up with here, they have a lot of work”, “Staff all very good, but have a lot to do”, “Certainly need more staff” and, “There’s not enough staff”. This area was discussed with the manager who acknowledged that improvements are needed and outlined how it was hoped to provide a specific room in the home where activities could take place. There was a strong sense of the welcoming nature of the home and this was confirmed by a number of residents who commented how their visitors were always made “to feel welcome”, “Staff all very friendly”. A visitor commented to the inspector that they had “always been made to feel welcome”. Relatives’ comments in the independent survey included, ”friendly atmosphere”, “open and welcoming to visitors” and, “staff always been very kind and helpful when we visit or phone”. The attitude and friendly welcoming environment is certainly a real strength of Maesknoll and is to be commended. In talking with residents about the meals provided in the home there were positive comments made about the variety and quality; “Meals very good, very changeable good variety”, “I can have what I want and we get plenty”, “…can’t fault the food” and, “…always two thing to choose from”. The menu for the day was displayed and offered a good choice. In talking with the cook they had a good understanding of the likes and dislikes of residents in the home and clearly makes a good effort to provide meals, which are attractive and wholesome, and the meals on the day of this inspection were well presented and appetising. The home is able to cater for any specialist diets such as vegetarian or diabetic. Residents had made a number of suggestions about meals at the last residents meeting and these had been acted upon. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 15 There has been a real effort to offer flexibility and choice in respect of the meals arrangements in the home with two sittings for the main meal of the day and the option to have tea served in resident’s room. The inspector joined residents for lunch; there was an unhurried atmosphere and staff were observed offering assistance and support to residents in a sensitive and unobtrusive way. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality rating in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The home has clear procedures in place enabling residents to make a complaint and voice their views about the service they receive and to know that they will be listened to and actions taken where necessary. The home makes sure that, as far as possible, residents are protected from harm by having policy and procedure about the Protection of Vulnerable Adults and providing training to all staff in this area. EVIDENCE: Residents were aware of the home’s complaints procedure and when asked said that, “I would always say if something was wrong”, “…speak to one of the staff” if worried or had a concern. A number of residents commented that they felt that staff would listen to what, “I had to say” and importantly, “something would be done”. No complaints have been made since the previous inspection. There is a clear Protecting Vulnerable Adults policy and procedure, and training records showed that staff have completed Adult Protection training. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The quality rating in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The home provides a safe, well-maintained and hygienic environment for the residents and staff. EVIDENCE: All areas of the home were clean and free from offensive odours at the time of the inspection. Residents commented positively on the cleanliness of the home: “its always lovely and clean” and, “always fresh and clean”. The previous inspection identified concerns about the arrangements for smokers in the home and how this impacts on the non-smoking residents. This remains an area which needs addressing in that currently smokers use the bar area at all times which is next to and opening up to a well-used lounge area. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 18 There is no means of filtering or extracting the air and whilst residents did not directly comment about smokers when asked, there is in reality no other option which has been put in place to ensure that smokers do not affect those who choose not to smoke or use the lounge area. An alternative lounge area could be made available to smokers and with agreement of residents restrict the use of the bar area as a smoking area outside of opening times. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,30 The quality rating in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. Staffing arrangements in the home are generally satisfactory so that the needs of residents can be met in an efficient way with care being provided by skilled and competent staff. However, the use of agency staff impacts on staff morale and leads to inconsistency of care. EVIDENCE: Staffing rotas were looked at and showed that there are generally 4 staff on duty in the morning, 2/3 in the afternoon, 3 in the evenings and 2 waking night. As referred to elsewhere in this report there was a strong sense of real pressures on staff and high workload leading to low morale and lack of care for residents. This was referred to by a high number of residents, though there was real praise for the “caring and helpful staff”; “they are wonderful and work so hard”, “very efficient” and, “staff are lovely, can’t say nothing against them”. A relative commented, “…can’t fault the staff all very good, have cared for my relative really well”. A relative comment from the independent survey highlighted the use of agency staff, “I think over the years the home has dropped in its overall running standard and I think agency staff is not a help. They don’t know the job and residents as well as permanent staff“. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 20 One resident spoke of her, “reluctance to call for help” and this was because of their view that staff were so busy. Other residents commented when asked about availability of staff, “sometimes its all right, other times have to wait” and, “certainly need more staff”. A district nurse visiting the home stated that, “staff are very stretched, very busy” and found that some tasks not completed yet described staff as, “good and committed”. The use of agency staff is an area of concern, placing further pressures on staff and affecting the continuity of care. Over a period of one month, out of 27 shifts, 13 had agency staff on duty. There were 20 different individuals only 3 of who worked more then one shift. On one morning shift, out of 4 staff on duty, 3 were agency; only one previously had worked at the home. There were 7 shifts with two staff on duty where one of which was agency. There is currently a 19-hour domestic vacancy, a 15-hour Care Assistant, with one Full Time night staff on permanent sick. There is only one employed relief staff. Training records for all night staff (5) were looked at and showed that all had completed the mandatory areas of training: Moving & Handling, POVA, fire and first aid. All staff have NVQ professional qualification. Additional training has been provided about Dementia Awareness and Person Centred Care; the manager advised that it is hoped all staff will complete the latter over the next 3 months. A positive development is the providing of training by district nurse to senior staff around basic dressings in the event of a resident sustaining an injury. This has enabled a more immediate response to any such injury rather than a reliance on emergency services or the calling out of a nurse. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,36,38 The quality rating in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. Opportunities are provided for residents and others to comment on the quality of the care at Maesknoll and make suggestions as to how the service could be improved. The practices of the home help to make sure that the financial interests of residents are protected. The home fails to fully undertake the necessary safeguards so that the health, safety and welfare of residents and safe is protected. EVIDENCE: Bristol City Council commissioned an independent quality assurance survey that involved residents and relatives, and this has provided valuable feedback about a number of areas relating to the quality of care at Maesknoll. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 22 This survey is, the inspector understands, a public document and made available to residents and others, i.e. prospective residents. Some extracts have been included in this report. The home has regular residents’ meetings that again provide an opportunity for residents to comment and make suggestions about the care they receive. Minutes were referred to as part of this inspection and actions have taken specifically about the meals available to residents. The home assists residents with the management of their financial affairs, specifically their personal allowance. Records were seen showing resident’s accounts and these accurately recorded where money has been given to residents with their signature. Supervision records were looked at for 8 members of staff. They showed in four instances no supervision had taken place since January/February 2006 four had taken place in August 2006 but before this there was no evidence of regular sessions. Records relating to health and safety practice in the home were looked at including fire alarms weekly tests as required, emergency lighting monthly tests as required. Fire system and equipment serviced 7/03/06, Alarm call bells serviced June 06. Lift servicing 06/06. Servicing of equipment used with residents, i.e. hoists, parker bath, took place 09/03/06. The homes Gas Safety certificate dated 16/05/06. An environmental health inspection took place in July 06; no requirements were made and the outcome was good. Fire Drill records showed that staff had not received the required fire drills; there was no record of any drills taking place, only of two incidents where there had been false alarms. An Immediate Requirement was made that all staff undertake a fire drill within seven days of this inspection. The inspector returned to the home after this period and the requirement had been met. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 1 X 2 Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 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. 1. Standard OP7 Regulation 15 (b) Requirement Ensure all elements of resident’s care plans are kept under review and accurately reflect the health and social care needs of the individual. Timescale for action 03/08/06 2. OP7 15 (1) Ensure individual or their 03/08/06 representative is consulted about their care plan and evidence their involvement and agreement to the identified health and welfare needs. Ensure where monitoring of health need, i.e. weight is required the necessary action is taken to make sure the health and welfare of the individual is protected. Ensure there are sufficient opportunities for residents to undertake meaningful activities. Review smoking arrangements and take steps to eliminate as far as possible unnecessary risks to residents health and safety 03/08/06 3. OP8 12 (1) 4 OP12 12 (1b) 16 (m.n) 13 (4)(c) 01/12/06 5 OP19 03/08/06 Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 25 6 OP27 12 (1) 18 (1b) Undertake review of use of agency staff and ensure that as far as possible the continuity of care is maintained. CSCI to be provided with outcome report of review. Ensure that staff are appropriately supervised. NMS 36.2 formal supervision at least 6 times a year. Ensure by means of fire drills and practices as required that all staff are aware of procedures to follow in the event of a fire. 01/12/06 7 OP36 18 (2) 03/08/06 8 OP38 23 (4e) 03/08/06 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 OP3 Good Practice Recommendations Establish method of measuring level of dependency for all residents and prospective residents to inform capacity of home to meet identified care needs and that there are the necessary staffing arrangements in place. Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 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 Maesknoll DS0000035910.V294444.R01.S.doc Version 5.1 Page 27 - 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!