Inspection on 29/08/06 for Melrose House

This inspection was carried out on 29th 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

Melrose House 10/06/10

Melrose House 28/09/09

Melrose House 15/10/08

Melrose House 05/11/07

Melrose House 23/04/07

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Melrose House 95 Alexander Road Southend-on-Sea Essex SS1 1HD Lead Inspector Mr Trevor Davey Key Unannounced Inspection 29th 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 Melrose House DS0000066956.V309775.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. Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Melrose House Address 95 Alexander Road Southend-on-Sea Essex SS1 1HD 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) 01702 340682 01702 436551 Mr Masood Rashid Manager post vacant Care Home 31 Category(ies) of Dementia - over 65 years of age (31), Old age, registration, with number not falling within any other category (31) of places Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. To operate as a care home only. To provide care to 31 older people (OP) over the age of 65 years. To provide care to 31 Older People with Dementia (OP(DE(E)) over the age of 65 years. Maximum number of registered places 31 (both sexes). Date of last inspection 15/02/06 Brief Description of service: Melrose House is a detached property, which is currently registered for 31 older people to provide accommodation and personal care. The registration category includes older people with dementia. Bedrooms are situated on the ground, first and second floors and a passenger lift provides access to all floor levels. There are three communal lounges and dining room on the ground floor. Bathroom and toilet facilities are provided throughout the building. There is limited car parking for visitors at the front of the property. There are gardens at the rear of the house and patio area. The premises are situated in a residential area within a short walking distance of Southend shopping centre and seafront. The home is also in close proximity to mainline railway stations and numerous bus routes. The current rate of fees is between £375 and £425 per week. Additional charges are made for hairdressing, chiropody, clothing, toiletries, papers, magazines and taxes. Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Key Inspection site visit took place over a period of 10.50 hours. The visit mainly focused on the progress the home had made since the last inspection and covered all key standards. The home has also had a new Registered Provider who took ownership of the property on 30thJune 2006. A tour of the home took place. This included a closer inspection of one part of the premises on the first and second floors, which had been affected by water leakage, which had occurred over the weekend. The Registered Provider, staff, residents and visitors were spoken with during the site visit who were helpful in their contributions and the assistance they gave to the Inspector. In addition, case tracking took place using some of the personal care records and other official records within the home were also assessed. Letters had also been sent out to health care professionals requesting feedback of the service provided by the home. Survey forms were also available in the home which residents and visitors had completed. From the responses received, these were complimentary and positive regarding the standard of care provided. The inspection also took into account information submitted by the previous registered manager including the completed pre- inspection questionnaire. What the service does well: The management and staff team have a good rapport with residents, visitors and health care professionals. The overall response and feedback from surveys which the home itself had conducted with residents and families, was positive regarding the care provided, politeness of staff as well appreciating the opportunity of being involved with the care planning process. Visitors were made to feel welcome at the home. In addition, where concerns had been raised, these had been dealt with promptly e.g. a greater choice and variety of meals is now available. This is a useful tool for looking at quality assurance issues in the home. Questionnaires returned by local doctors to the Commission for Social Care Inspection also confirmed that so far as they were concerned, staff communicate clearly and work in partnership with them. The home is also good at taking account of different cultural needs and respecting the wishes of individual residents and their families. Staff stated that the new Register Provider is approachable and he is providing opportunities for families and residents to meet him on an individual basis to encourage open and effective communication in order to bring about improvements to the service. On going training courses for staff are arranged to take account of specific needs/conditions regarding resident care with a view to further improving staff skills in the delivery of care. Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 6 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. Melrose House DS0000066956.V309775.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 Melrose House DS0000066956.V309775.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): 1&3 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The Statement of Purpose and Service user Guide omits specific information which residents and prospective users of the service require to enable them to make an informed choice about living in the home. Pre- admission assessment details for care/health needs had been completed to give staff suitable information to determine whether the needs of potential residents could be met by the home. EVIDENCE: The Inspector was advised that the Statement of Purpose was currently being updated. This document together with the Service User Guide must be amended to include all details as required by regulation, including information relating to the new Registered Provider and manager when appointed. Once completed, copies should be made available to residents and/or their representatives. Copies of these updated documents must also be sent to the Commission for Social Care Inspection. Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 9 Samples of pre-admission assessments were made available for inspection, which included information relating to mobility, washing, hearing as well as health, personality and mental condition. One of the assistant managers had obtained this information by visiting the local hospital to assess prospective residents and in some cases, information had been obtained as a result of residents and relatives visiting the home prior to admission. The Inspector had conversations with residents who had been recently admitted and they confirmed that management had previously discussed with them individual needs and the support required. It is recommended that the pre-assessment process should include more information regarding background history and personal interests. The home does not provide intermediate care. Melrose House DS0000066956.V309775.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 & 10 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The care and health needs of residents were being met appropriately, which included the added support of other health care professionals as required. Residents are treated with respect and individual privacy is upheld. Care records were inadequately maintained. EVIDENCE: Case tracking took place in respect of three residents and other personal care records were also looked at, including recent admissions. Residents spoken to, were positive and complimentary regarding the assistance staff offered with bathing, washing and other personal care whilst at the same time, allowing independence to provide self-help wherever possible. Staff were observed to be interacting sensitively and dealing appropriately with residents who needed reassurance as well as support with toileting and their mobility. Appropriate use was being made by staff of disposable gloves and aprons in accordance with infection control procedures. Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 11 Staff took into account the cultural and diverse needs of residents and particular requests, which had been made by families. This included specific arrangements where serious illness and death of residents had occurred which was handled with dignity and propriety during the course of the inspection. Responses to survey forms sent out by the C.S.C.I. to local doctors who are involved the home, were positive. These confirmed that management and staff take appropriate decisions when they can no longer manage the care needs of residents. In addition, staff were said to demonstrate a clear understanding regarding the care residents required and the home communicated effectively with the G.P. practices. The home had also prepared its own questionnaire and a number of these had been completed by residents (some with assistance), and visitors/relatives. Staff were said to respect the privacy of residents and that relatives were kept informed and encouraged to be involved in the planning of care, although there had been some occasions when they had not always been kept fully informed of the condition of residents. Residents confirmed that commodes were emptied regularly although there was one comment from the questionnaire to say that this did not always happen promptly after use. A sample check was made of the medication administrative records and entries had been properly recorded with signatures of staff. Where residents were able to self-medicate, protocols were in place together with the signatures of the residents concerned. Where medication had been discontinued and returned to the pharmacist, copies of the record sheets were available. Various information had been included within the personal care records of residents together with care plans and risk assessments. Information was available which included risk assessments for pressure areas/waterlow dated April 2005 and the body chart was last updated August 2005. There was no clear evidence that this information had been reviewed or updated. Similarly, a falls risk assessment had been completed for one resident in April 2005 and was assessed as high risk but there was no record to show that a review had been carried out since. This places residents at potential risk. Medical notes were available to show visits and treatment provided by other health care professionals including medication/monitoring cards but these had not always been dated. In some cases, monthly reviews had been documented and regularly dated but although care plans provided space to record the problems/need, aim and action, there was not always specific details or instructions included for staff to follow. Liquidised meals had been introduced for one resident in relation to eating and drinking but no date had been recorded as to when this change had taken place. Reference had also been made to behavioural issues and difficulties with communication but no instructions or guidance as to how staff should interact with residents. A risk assessment for moving and handling had been carried out in July 2005 setting out the transfer arrangements for manoeuvring a resident from floor to bed and to chair with two care assistants. However, this resident is now fully Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 12 mobile and the risk assessment no longer applies. Risk assessments were not always in place for residents who were wheelchair dependent. The assistant manager advised the inspector that the format of care plans/risk assessments and recording procedures is to be reviewed and updated. A more simplified and consistent recording system, which clearly identifies the up- to- date care needs of residents and how these are to be met, is required for the home. Melrose House DS0000066956.V309775.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 & 15 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. The home provides an activities/recreational programme but appropriate signage/ symbols or occupational activity were not available to take account of residents with dementia and other sensory impairments. Meals take account of residents choice. Relatives and friends are encouraged to have regular contact with the home. EVIDENCE: Some of the residents spoken to confirmed that the home provided various social and recreational activities. This included quizzes and musical entertainers. A number of residents choose not to join in these activities and armchair exercises, which were being provided every week, now, occur less frequently at the request of residents. One of the residents said that some of the elderly people in the home were not able to take part in all of these activities because of confusion. A number of care staff have attended courses of training relating to dementia and provision should be made for appropriate occupational activities/interaction to take place specifically with this group of residents in mind. Appropriate symbols and signage must also be provided in rooms and areas of the home to assist residents with direction and recognition, Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 14 particularly those who may be confused or have sensory impairments. Some residents prefer to spend time in their rooms involving themselves in various pastimes such as watching television, completing crosswords or seeing visitors. According to the completed pre-inspection questionnaire, library services are available but one of the residents said that this was rather limited and more books need to be provided with large print. Residents were positive about the variety of food provided and that they were given the opportunity of selecting meals of their choice. This included a choice of cereals, cooked breakfast if required, and toast. One of the residents stated they were allergic to dairy products and alternative food was provided by the home. Residents confirmed that plenty of drinks were offered during the day and in particular, during the previous month of July which was very warm. Records of meals provided to residents were available for inspection. A visitor commented to the inspector they were very impressed with the meals and particularly the choice of breakfasts provided to residents. The new Registered Provider stated that he was in the process of meeting with individual families and residents to introduce himself and a special evening is to be arranged shortly for everybody. The home had carried out their own residents/visitors survey and the feedback confirmed that there was good nutritional choice and meals were well presented. Melrose House DS0000066956.V309775.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 & 18 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. There is an established complaints procedure in place. Staff had an adequate understanding of the reporting procedure for the prevention of harm of vulnerable adults, ensuring that the safety of residents in the home is of paramount importance. EVIDENCE: The complaints procedure is set out in the Statement of Purpose and the management are approachable enabling residents and visitors to raise any concerns, which are dealt with promptly. In a questionnaire sent to the home by Southend Social Care Department, some residents indicated they knew whom to approach when making a complaint. No complaints had been recorded by the home since 2005. Staff spoken to had an adequate understanding and knowledge of prevention of vulnerable adult reporting procedures and according to the home s training records, a number of staff had attended courses. The Inspector gave the assistant manager further information regarding telephone contacts who should be approached regarding incidents of this nature. Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is poor. This judgment has been made using available evidence including a visit to the service. Areas of the home were clean and hygienic. Ongoing maintenance and improvements to the building need to take place to ensure residents can continue to live in a safe and well maintained environment. The reason this judgment is poor, is because inappropriate emergency measures were in place, which placed residents at risk. EVIDENCE: Areas within the home were seen to be clean and hygienic and one of the domestic staff explained to the Inspector their routine for cleaning during the course of the week which included bedrooms, floors, lounges and bathrooms. Although staff have an awareness of the control of substances hazardous to health safety procedures, some cleaning materials had been left unattended in one of the resident s bedrooms. During the site visit, it was explained to the Inspector that water had leaked from the roof during the weekend and through Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 17 the ceiling of one of the bedrooms on the second floor. In addition, water had overflowed from the wash hand basin on to the floor and through to the ceiling of the bedroom immediately below on the first floor. On advice from the fire brigade who attended the home, the electrics in this room and the immediate vicinity were disconnected. A temporary means of alternative lighting had been installed in this bedroom by the home, which was unsafe and could have posed a serious risk to the resident concerned. The device had not been safely wired into the multi socket extension or fixed in a stable position. The Inspector removed the temporary lighting arrangement and returned this to the office on the ground floor. At the request of the Inspector, immediate arrangements were made for alternative secondary lighting to be purchased by the home, which included table lamps, which could be used safely for a temporary period. These were available and ready for positioning at the end of the inspection. The Registered Provider undertook to make urgent arrangements for the leak to the roof to be repaired and for the ceilings to be repaired/renewed. Since carrying out this site visit, the Registered Provider has notified the Inspector that these works have been completed and the electrics reconnected. Monitoring arrangements must be in place to ensure that at all times the health and safety of residents in the home is safeguarded. In addition, any alternative contingency arrangements, which are made for emergency situations, must be safe and risk assessed for residents including areas of the building and facilities affected (O.P.38 also refers). A rolling programme of upkeep and maintenance to the building/ facilities must be drawn up to ensure the premises to be used are of sound construction and kept in a good state of repair externally and internally. Some internal decoration had taken place since the last inspection and there were parts of the home, which were comfortable and suitably furnished including lounges and dining areas. Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. The number of staff on duty together with supporting supervision, was not always sufficient to meet the needs of residents. Not all staff recruitment records were complete so as to ensure residents are supported and protected by the home s recruitment policy and practices. EVIDENCE: Currently, the manager s post in the home is vacant. Two assistant managers are responsible for the day-to-day operation of the home and the Registered Provider visits on a regular basis. An up -to -date rota was available and the normal pattern of working is for one person to be in charge plus three or four care staff on the early shift but only two for the late shift. Three staff are on awake duty at night. Domestic staff and cooks are employed in addition as well as a gardener/handyman. Newly appointed staff work in addition to the rota as they are supervised by permanent staff during their induction period. The Inspector spoke to one of the newly appointed staff who had commenced employment the previous day and they confirmed this arrangement. Recruitment records were inspected and some documentation had not been completed to show that checks had been made regarding Criminal Record Bureau disclosures and P.O.V.A. First checks. In some cases, written references were not available neither was there evidence or proof of identification in respect of staff who had been employed recently. Advice was Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 19 given to the Registered Provider and one of the assistant managers on these issues. Staff training records were available which included nine staff who had attended training on dementia. Certificates were also available confirming the attendance of staff for courses completed. Records were also available of induction topics completed by new staff. According to the Pre-inspection questionnaire, 44 of care staff have obtained N.V.Q. Level 2 or above. At least one resident in the home is diagnosed with Parkinsons disease and it is recommended that staff have training to give them greater awareness of this condition and how to respond appropriately to their needs. Staffing levels must be reviewed to ensure that there are sufficient personnel to engage in occupational activities with residents who have specific needs e.g. dementia. This applies particularly to the late shift where only two care assistants are rostered for duty plus the person in charge of the shift for a home which is registered for thirty- one residents. Appropriate levels of suitably qualified, competent and experienced staff must be available at all times to ensure the safety, health and welfare of residents are met. Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to the service. Although there is no current registered manager in post, the Registered Provider and assistant managers operate the home in the best interests of residents. Although the management respond robustly to rectify urgent matters regarding repairs and maintenance , contingency/emergency arrangements are not always monitored effectively to ensure the health and safety of residents at all times. EVIDENCE: The new Registered Provider took ownership of the home on 30th June 2006 and the post of registered manager is currently vacant. The Registered Provider is regularly in the home and works closely with the assistant managers. It is understood that arrangements are in place to recruit a new manager as soon as possible after which, application will be made to the Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 21 C.S.C.I. for registration. The assistant managers have both been in post for some time and are following procedures already in place. The Registered Provider is in the process of meeting relatives on an individual basis to find out what they think about the home and to explain the improvements he is hoping to achieve. Staff spoken to, commented that the Registered Provider is approachable, puts forwards ideas and listens to staff. Reference has already been made in this report to the surveys that the home itself has conducted to obtain views and feedback from residents and visitors. Questionnaires have also been completed by the staff team. The premises need considerable maintenance work and improvements and a rolling programme needs to be in place in order to prioritise essential work particularly relating to the health, safety and well-being of residents. Reference has already been made in this report under the section for Environment Standard O.P. 19 regarding the need to monitor health and safety issues. Current electricity/gas safety certificates were in place and regular servicing takes place of other equipment in the home, which had been recorded in the Pre- inspection questionnaire. Records were available showing that hot water temperatures had been regularly checked for the safety of residents. They homes health and safety policy is available which is included as part of staff induction. All the staff had a responsibility to report and record any concerns for safety and maintenance which may be required in the building. This record book was available for inspection. Notifications under Regulation 37 of the Care Homes Regulations have not always been completed and sent to the Commission for Social Care Inspection. The lift had broken down on the 24th of July and was not repaired and working until the 27th July but this was only made known to the Inspector during the site visit. Records of risk assessments were shown to the Inspector, which had been completed in May 2005 for a safe working environment. It is recommended that these be reviewed annually or sooner if required. The Registered Provider must arrange to visit the home at least once a month (unannounced), for the purpose of monitoring the care and service provided in accordance with Regulation 26 of the Care Homes regulations. Copies of the written report must be sent to the C.S.C.I. and to the registered manager when appointed. Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 22 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 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 1 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 1 Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 23 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 Standard OP1 Regulation 6 Requirement The Registered Person shall keep under review and, where appropriate, revise the Statement of Purpose and the Service User’s Guide and submit copies to the Commission for Social Care Inspection. The Registered Person shall ensure that care plans/risk assessments are updated and regularly reviewed, after consultation with the service user, or representative, as to how needs in respect of health and welfare are to be met. The Registered Person must ensure that the physical design and layout of the premises to be used as the care home, meet the needs of service users by supplying appropriate signage/orientation aids. The Register Person Shall, having regard to the size of the care home, the Statement of Purpose and the number and needs of service users, ensure that at all times suitably qualified, competent and DS0000066956.V309775.R01.S.doc Timescale for action 30/11/06 2 OP7 15 31/10/06 3 OP12 23(2)(a) 30/11/06 4 OP27 18(1) 30/10/06 Melrose House Version 5.2 Page 24 5 OP29 19 6 OP31 8 7 OP38 23(2) 7 OP38 13(4) 8 OP38 37 experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. The Registered Person shall ensure that the homes recruitment records contain evidence of C.R.B. checks, references and proof of identification. (Schedule 2 also refers). The Registered Person shall arrange for a completed application form for registration to be submitted to the C.S.C.I. in respect of the new manager, once appointed. The Registered Person shall, having regard to the number and needs of the service users, continue the rolling improvement programme to ensure that the premises to be used as the care home, are of sound construction and kept in a good state of repair externally and internally. The Registered Person shall ensure that all parts of the home to which service users have access are, so far as reasonably practicable, free from hazards to their safety. Any unnecessary risks to the health or safety of service users must be identified and so far as possible, eliminated. The Registered Person shall give notice to the Commission without delay of the occurrence off any event in the care home, which adversely affects the wellbeing or safety of any service user and of all other incidents covered by this regulation. 30/10/06 01/11/06 31/12/06 15/10/06 20/09/06 Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 25 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 Refer to Standard OP3 Good Practice Recommendations The Registered Provider should include more background & social history information when carrying out pre-admission assessments. The Registered Provider should look at alternative ways to engage and interact with residents in occupational activities, particularly those who have dementia, cognitive impairments or sensory needs. The Registered Provider should arrange training for staff to have a greater awareness of Parkinson’s disease & possible side affects. The Registered Provider should arrange for risk assessments covering ‘safe working environment’, to be reviewed at least annually, or sooner if necessary. OP12 3 4 OP30 OP38 Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Melrose House DS0000066956.V309775.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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