Inspection on 04/10/07 for Magnolia House

This inspection was carried out on 4th October 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

Magnolia House 08/09/09

Magnolia House 23/09/08

Magnolia House 08/08/06

Similar services:

Ravensworth Lodge

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Magnolia House 42 Hull Road Cottingham Hull East Yorkshire HU16 4PX Lead Inspector Diane Wilkinson Key Unannounced Inspection 4th October 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 DS0000066548.V352497.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. DS0000066548.V352497.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Magnolia House Address 42 Hull Road Cottingham Hull East Yorkshire HU16 4PX 01482 845038 01482 848271 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) Park Lane Healthcare (Magnolia House) Limited Mrs Susan Bottomley Care Home 74 Category(ies) of Dementia - over 65 years of age (74), Old age, registration, with number not falling within any other category (74) of places DS0000066548.V352497.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2006 Brief Description of the Service: Magnolia House is a care home that is operated by Park Lane Healthcare Limited, a privately owned company. The home has been adapted and extended to provide accommodation and care for up to 74 older people, including those with dementia. It is situated in Cottingham, close to the border between the East Riding of Yorkshire and the city of Hull. The home stands in extensive landscaped grounds that include mature trees, flowerbeds and various seating areas. Information about the home is provided to service users and others in the home’s Statement of Purpose and Service User’s guide. The registered manager informed the inspector on the day of the site visit that fees paid range from £345.00 to £600.00 per week, and that there is an additional charge for hairdressing and chiropody. Private and communal accommodation is located over two floors, primarily in the east wing and the west wing. There are various lounge and dining areas, some overlooking the landscaped gardens. Willow Court is an adjoining property where people are able to live slightly more independently than in the main part of home. All areas of the home, including the garden, are accessible to residents via the provision of passenger lifts and ramps. The home is on a bus route and is easily accessed via road; there is ample car parking space for visitors and staff. DS0000066548.V352497.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last Key Inspection of the home on the 22nd August 2006, including information gathered during a site visit to the home. The unannounced site visit was undertaken by one inspector over one day. It began at 10.00 am and ended at 5.30 pm. On the day of the site visit the inspector spoke on a one to one basis with three residents, a senior carer and the registered manager as well as chatting to other residents and staff. Inspection of the premises and close examination of a range of documentation, including four care plans, were also undertaken. The registered manager submitted information about the service in advance of the site visit by completing and returning an annual quality assurance assessment (AQAA). Survey forms were sent out prior to the inspection; two were returned by relatives and two were returned by health care professionals. Comments from returned surveys and from discussions with residents, staff and others were mainly positive, for example, ‘staff are dedicated and caring’. Comments from surveys and from discussions on the day of the site visit will be included, anonymously, throughout the report. The inspector would like to thank residents, staff and the registered manager for their assistance on the day of the site visit, and to everyone who completed a survey. What the service does well: People are only offered accommodation at the home if an assessment evidences that their needs can be met by staff. Care planning at the home is good and people are involved in developing their own plan of care. Regular reviews of peoples’ needs take place and this results in ‘up to date’ care plans being used by the home. Hourly checks are made on residents that choose to remain in their own room, and these checks are recorded; this is good practice. One health care professional recorded, ‘the home meets the needs of their residents well. Staff are dedicated and caring’. Meal provision at the home is good and people get a choice at every mealtime. Staff ensure that mealtimes are a social occasion. People living at the home are supported to maintain their chosen lifestyle, and are encouraged to take part in activities inside and outside of the home. DS0000066548.V352497.R01.S.doc Version 5.2 Page 6 The home provides people with attractive, comfortable, well-furnished and well-decorated accommodation. The home has sufficient staff to meet the needs of residents. One health care professional recorded in a survey, ‘there is always someone on the floor who is easily contactable’. Over 50 of care staff have achieved NVQ Level 2 or above in Care, and staff get additional pay in recognition of NVQ achievement. The home is well managed and there is a good quality assurance system in place that enables residents, relatives and others to affect the way in which the home is operated. What has improved since the last inspection? 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. DS0000066548.V352497.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 DS0000066548.V352497.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 was not assessed, as there is no intermediate care provision at the home. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are only offered accommodation at the home following a full assessment of their individual needs that evidences that these can be met by the home. EVIDENCE: Records at the home evidence that people are visited by the registered manager when they initially make enquiries about admission, and that the assessment process commences at this stage; the registered manager was due to visit a prospective resident on the day of the site visit. A full assessment of needs is completed and prospective residents are only offered accommodation at the home if this assessment evidences that their needs can be met by staff. Prospective residents and their relatives are invited to look around the home DS0000066548.V352497.R01.S.doc Version 5.2 Page 9 as part of the assessment process, and some people initially attend the home for respite care to assist them in making a decision about permanency. The registered manager told the inspector about a new resident that is moving into the home from another area of the country. Because they were unable to visit this person before they moved into the home, they contacted their GP and other health professionals to gather as much information about the person as possible prior to their admission; this is good practice. Community care assessments and care plans are obtained from Social Services for anyone who is placed at the home by them, and this information is used along with the assessment undertaken by the home to develop an individual care plan. DS0000066548.V352497.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of people are met in a way that respects their privacy and dignity. In most instances medication is administered, recorded and stored safely and this protects people from the risk of harm. EVIDENCE: The inspector examined four care plans; these included a copy of the home’s own assessment and a community care assessment and care plan undertaken by the local authority Social Services Department, where appropriate. Care records contained a detailed risk assessment for all areas of personal care; on completion this indicates the level of risk for each resident. Individual risk assessments are also undertaken for such topics as ‘using an electric blanket’ and ‘the incidence of falls’. The care plan records a person’s strengths and needs and a personal history. The registered manager told the inspector that relatives are asked to sign care plans if people are unable to sign and agree to their own. DS0000066548.V352497.R01.S.doc Version 5.2 Page 11 Key workers record two weekly reports in care plans, one on medical inputs and one on quality time spent with residents. In addition to this, a monthly review and a formal six monthly review of care plans takes place; these take place for people that are funded by the local authority and people who are selffunding. There is evidence that people attend their care reviews. A record is kept of all contact with health care professionals; this includes the reason for the contact and any outcome. There is evidence that specialist health professionals, such as community psychiatric nurses, are consulted about a persons care when this is appropriate. Accident reports are recorded in individual care plans and there is a system in place to monitor all accidents within the home. In addition to this, falls are recorded when this is an area of concern. The inspector noted that hourly checks are made on residents who choose to remain in their own room, and that these checks are recorded; this is good practice. One health care professional recorded, ‘the home meets the needs of their residents well. Staff are dedicated and caring’. A person’s individual needs regarding continence care and pressure care are recorded in assessments and care plans, and reviewed appropriately. Any areas of concern are clearly recorded in care plans, and some residents have been provided with special pressure care equipment such as mattresses and cushions. A person’s weight is monitored as part of nutritional screening. Medication is stored in locked medication trolleys, one in each wing. These are used to take the medication around the home and are then stored in medication rooms; these rooms are not always locked and the registered manager agreed to have the trolleys fixed to the walls to improve their security. There is a separate medication fridge and the inspector saw the record of fridge temperatures. The inspector observed medication being administered at lunchtime – people were provided with a drink with which to take their medication, and all were observed by staff to ensure that they actually took their medication. The inspector noted that one cabinet was not locked when left unattended; the registered manager reminded the member of staff that the medication trolley should be locked apart from when in use by staff. There are suitable arrangements in place for the storage and administration of controlled drugs; records were seen by the inspector and were found to be satisfactory. Administration records were examined by the inspector; medication administration records included a laminated photograph of the resident followed by medication records for that person. Records were found to have a small number of gaps in recording; these appeared to be when residents have refused their ‘as required’ medication; more care should be taken to complete DS0000066548.V352497.R01.S.doc Version 5.2 Page 12 medication administration records accurately. Records to confirm that staff that administer medication have undertaken accredited training were seen by the inspector, and sample signatures are held for staff that have undertaken accredited training to enable medication records to be checked. On the day of the site visit the inspector observed that staff treat people with respect and that their privacy is maintained as far as is possible; the inspector observed that people were assisted with eating their meals and with personal care in a sensitive manner, and people told the inspector that staff respect their privacy. DS0000066548.V352497.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported to take part in activities both inside and outside of the home and are encouraged to maintain relationships with family and friends. Visitors to the home are made welcome and meal provision at the home is excellent. EVIDENCE: Care plans record details of a person’s previous lifestyle, including leisure and social interests. Key workers record quality time spent with residents, as well as any visitors seen or visits taken out of the home. These record such things as ‘key worker did nails – cleaned and painted. Nice chat’ and ‘tidied out wardrobes with x’. An activities coordinator is employed each day, working three days in the west wing and two days in the east wing. Most organised activities take part in communal areas of the home and information about these activities is recorded on an activities board. The activities board also records hairdressing DS0000066548.V352497.R01.S.doc Version 5.2 Page 14 arrangements, details of clothes parties and entertainers. The registered manager told the inspector that they have held three barbeques this year – relatives were invited to attend and many did so. This gave residents the opportunity to spend time with their relatives in a social setting. Discussion with residents and information seen in care plans evidenced that people that have friends and relatives are supported to remain in contact with them. People told the inspector that their visitors are always made welcome by staff at the home, and this was observed by the inspector on the day of the site visit. Many residents have had a telephone installed in their room to enable them to keep in touch with friends and relatives easily. The inspector observed that people had personalised their bedrooms to the extent chosen by them; some people had brought small items of furniture into the home as well as pictures, ornaments and photographs. Information about advocacy services is made available to services users and visitors; it is displayed in the entrance hall. People told the inspector that they can choose what time to get up and what time to go to bed, whether or not to join in activities and where to take their meals. People told the inspector that this changes from day to day; they are not expected to have a set routine. There is a four-week seasonal menu in operation and the registered manager told the inspector that all residents have their own copy of the menu. There is a choice of main meal and dessert at both lunchtime and teatime; on the day of the site visit the choice at lunchtime was either liver and onions or minced beef and onion pie, followed by strawberries and cream or almond tart and custard. The meal was well presented and looked appetising. There is a dining room in each wing; one is situated in a large conservatory-style dining/living room. The inspector observed that there was a pleasant and relaxing atmosphere over lunch and that people were offered appropriate assistance with eating and drinking. The registered manager told the inspector that the cook prepares ‘afternoon tea’ once a week, and a cooked breakfast is prepared one a month; perhaps this could be extended to once a week to increase choice at breakfast time. People told the inspector that they enjoy the meals at the home. DS0000066548.V352497.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Most residents and relatives are aware of the complaints procedure and of how to make a complaint; there is evidence that complaints are dealt with effectively by the home. There are appropriate policies and procedures in place on safeguarding adults to alert staff to the importance of this issue. Staff should be better equipped to identify issues about abuse when they have undertaken the planned training. EVIDENCE: We have received two complaints about the home since the last key inspection. One complaint was investigated jointly by Social Services and the registered provider, and the other was investigated by the registered provider. One complainant made allegations about general care practices at the home and the lack of protective clothing, and the outcome following the investigation was that regulations were met by the home. The other complainant was dissatisfied with the care of their relative at the home. Again, the outcome of the investigation was that regulations were met. The complaints procedure was displayed at the home and this included the information that the CSCI could be contacted at any stage of the complaints process. A complaints log is held by the home and this records the details of DS0000066548.V352497.R01.S.doc Version 5.2 Page 16 the complaint, the investigation undertaken by the home and the outcome; this evidences that complaints are dealt with in a satisfactory manner. Another book records verbal complaints and concerns made by residents. Again, there is evidence that action is taken to resolve these issues. On the day of the site visit people told the inspector that they would speak to the manager if they had any concerns or complaints, but one relative that returned a survey recorded that they did not know how to make a complaint. One allegation of abuse has been received by the CSCI. Enquiries were made by Social Services and the Police and the investigation did not proceed, as there was no evidence that an incident had actually taken place. There is information about safeguarding adults from abuse in the medication rooms in both wings of the home. Some staff have already attended appropriate training and another training course has been arranged for staff on the 16th October; this should ensure that all staff at the home have undertaken training on safeguarding adults, which should be considered as mandatory training. The registered manager told the inspector that she has undertaken the safeguarding training designed specifically for managers of care services. DS0000066548.V352497.R01.S.doc Version 5.2 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 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides residents with clean, attractive, comfortable, well-furnished and well-maintained accommodation. EVIDENCE: The inspector toured the premises and observed that the home is well maintained. A new extension is being built in the west wing; the inspector observed that this area of the home had been made safe for residents and staff whilst the work was in progress. On the day of the site visit the passenger lift in the west wing was being replaced; the registered manager said that this was because it had broken down several times and inconvenienced residents. There is another passenger lift in the east wing so people are still able to access the first floor. DS0000066548.V352497.R01.S.doc Version 5.2 Page 18 The registered manager told the inspector that the west wing is due to be fully refurbished when the extension is completed. Plans include an enclosed garden that will allow people to spend time safely outdoors. A gardener and a handyman are employed at the home; there is a maintenance log in place and this is a thorough record of all repairs and refurbishment that have taken place. The AQAA completed by the registered manager records an extensive list of refurbishment including new laundry equipment, new kitchen equipment, a new heating system in Willow Court and a hoist assisted bath. The home has a large attractive landscaped garden that is enjoyed by residents and visitors; it includes mature trees, flowerbeds and various seating areas. There is a large conservatory-style room at the rear of the property that is used as a lounge and a dining room; this allows residents ample access to sunlight and fresh air. Laundry facilities at the home are good; there is a laundry room in both wings and a laundry assistant is employed. Several domestic staff are employed by the home and this results in a home that is maintained in a clean and hygienic state. There were no unpleasant odours on the day of the site visit and the inspector observed good hygiene practices being followed by staff throughout the day. The training programme evidences that a course on infection control was held at the home in July 2007 and a further four staff were attending a course at their ‘sister’ home on the day of the site visit. One health care professional recorded in a survey when asked how the home could improve, ‘to have wipes instead of face cloths’. This would enhance current systems in place to promote infection control. DS0000066548.V352497.R01.S.doc Version 5.2 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, 28, 29 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The staff rota evidences that sufficient staff are employed to meet the needs of residents. In most instances staff are recruited safely, and staff undertake Induction training, core training and more specialised training programmes to equip them to carry out their roles effectively. EVIDENCE: There are various staff rotas in place at the home; a care staff rota for each wing, a domestic staff rota, a kitchen staff rota and a night staff rota. The rotas evidence that there are sufficient staff on duty to meet the needs of those living at the home but rotas do not record the role in which each person is employed. One health care professional recorded in a survey, ‘there is always someone on the floor who is easily contactable’. The registered manager informed the inspector that no agency staff are used at the home, as they have their own ‘bank’ staff; this results in consistency for residents. Because domestic, laundry and catering staff are employed, care staff are able to concentrate on the personal and social care needs of residents; this reduces the risk of cross infection. There is a qualification audit in place that records details of achievement in NVQ qualifications. This evidences that 50 of care staff have achieved NVQ DS0000066548.V352497.R01.S.doc Version 5.2 Page 20 Level 2 or above in Care, and a further eleven staff are working towards this award. The registered manager told the inspector that staff get additional pay in recognition of NVQ achievement; this is good practice. Recruitment records for three staff were examined by the inspector. These included an application form that recorded details of the applicant’s employment history. In most instances, two written references and a satisfactory CRB check have been obtained prior to staff commencing work at the home. However, in one instance a member of staff had commenced work at the home prior to these safety checks being in place. The registered manager told the inspector that this was an oversight; the registered manager has since informed us that a CRB check has now been obtained in respect of this person, and that the person was asked to remain at home (on full pay) until their CRB check arrived. Staff records seen by the inspector included clear information about Induction training undertaken by staff. Each member of staff has an individual training record and there is also a training and development plan that records all training undertaken by staff. The training and development plan records the dates that staff have undertaken training; this assists with identifying when refresher training is needed. There is evidence that most staff have undertaken core health and safety training such as moving and handling, health and safety, fire safety and food hygiene, and that refresher training is undertaken on a regular basis. The home’s training programme results in a staff group that are skilled and trained to care for the people living in the home. DS0000066548.V352497.R01.S.doc Version 5.2 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): 31, 33, 35 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and the health, welfare and safety of service users and staff are protected. EVIDENCE: The registered manager is experienced and competent to manage the home. She has completed the NVQ Registered Managers award but still needs to complete NVQ Level 4 in Care; she has achieved NVQ Levels 2 and 3 in Care. She told the inspector that she plans to start this training this year. There are clear lines of accountability within the home; senior staff have been given areas of responsibility to assist the registered manager with day to day DS0000066548.V352497.R01.S.doc Version 5.2 Page 22 management tasks. Two senior staff are also planning to commence NVQ training at Level 4. The home has achieved QDS (the local authority quality assurance scheme) Parts 1 and 2 and there is a satisfactory quality assurance system in place. There is evidence that the registered manager is proactive in dealing with quality issues within the home; she explained to the inspector how any issues raised in quality surveys are dealt with on a one to one basis. Surveys are given to residents, relatives and others. Feedback on the outcome of quality surveys is fed back to relatives at meetings, in the twice yearly newsletter and in the information book that is held at reception. Residents are given their own copy of any feedback and this is also discussed at resident’s meetings. Staff meetings and resident meetings take place on a regular basis; relatives are invited to attend residents meetings. Quality audits take place on a different topic each month; topics include catering, communication, laundry and activities. No personal allowances are held on behalf of residents. Small amounts of money are held for some people in the safe; receipts are given to people that hand over money to staff at the home and when this money is handed to residents. Some people hold their own money – all bedrooms have a lockable drawer so that this money can be held securely. The registered manager told the inspector that they would ‘loan’ people money from their petty cash account if they requested this; relatives are sent an account once a month for any services or purchases paid for on behalf of residents, such as hairdressing and chiropody. The inspector examined health and safety documentation in place at the home. This evidenced that equipment and appliances are serviced regularly and are well maintained, including an annual test of the fire alarm system and a gas safety inspection. A new fire risk assessment was undertaken in August 2007; in-house fire tests take place every week and fire drills are held each month. Accident reports are recorded in individual care plans and there is a system in place to monitor all accidents within the home. The training programme for 2007/8 includes courses on Health and Safety (including COSHH), manual handling, infection control, fire safety awareness and basic food hygiene. DS0000066548.V352497.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 DS0000066548.V352497.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. 1. Standard OP29 Regulation 19 Requirement The registered manager must ensure that staff have appropriate safety checks in place before they start working at the home. Timescale for action 04/10/07 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. 2. 3. 4. Refer to Standard OP9 OP9 OP27 OP31 Good Practice Recommendations Extra care should be taken with recording when people have refused medication; there should be no gaps on medication administration records. Because medication rooms are not locked at all times, extra precautions should be taken to ensure the security of medication cabinets. Rotas should record the role of each member of staff included on the rota. The registered manager should continue with training so that NVQ Level 4 in Management and Care is achieved. DS0000066548.V352497.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000066548.V352497.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!