Inspection on 11/04/08 for Milton Ernest Hall

This inspection was carried out on 11th April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Milton Ernest Hall 28/04/09

Milton Ernest Hall 07/04/09

Milton Ernest Hall 14/10/05

Milton Ernest Hall 08/06/05

Milton Ernest Hall 10/08/04

Milton Ernest Hall 20/05/04

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 Milton Ernest Hall Milton Ernest Bedford Bedfordshire MK44 1RJ Lead Inspector Katrina Derbyshire Unannounced Inspection 11th April 2008 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 DS0000017681.V362239.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. DS0000017681.V362239.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Milton Ernest Hall Address Milton Ernest Bedford Bedfordshire MK44 1RJ 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) 01234 825305 01234 826830 miltonernesthall@majesticare.co.uk Ross Healthcare Ltd Mrs Barbara Nomsa Mkosi Care Home with Nursing 29 Category(ies) of Old age, not falling within any other category registration, with number (29), Physical disability over 65 years of age of places (29) DS0000017681.V362239.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Adults (26 -64) (10) Date of last inspection 22nd September 2006 Brief Description of the Service: Milton Ernest Hall is a converted 1850’s manor house. The house, a grade 1 listed building, is in a good state of repair and retains many of its original architectural features making it an interesting property with a ‘stately’ feel. The property retains it original character and the safety of the people who live at the home is reviewed by the risk assessments undertaken by the staff at the home. The accommodation is spread over three floors linked by passenger lifts or staircases. All the communal areas are on the ground floor. Each bedroom has en-suite facilities, some with baths. The home is registered to provide nursing care for up to 29 people, ten of who can be under 65 years of age with conditions and needs similar to the majority. Four of the rooms are registered as double rooms but are currently used for single occupancy. The property stands in approximately 16 acres of land with uninterrupted views of the countryside of North Bedfordshire. There is ample staff and visitor parking; the home is on a local bus route to Bedford and Northampton. Fees are between £780.00 and £975.00 per week depending on the individual needs of the person and the room provided. DS0000017681.V362239.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. An Annual Service Review was undertaken about this home on 7th March 2008; we used written information that had been supplied by the home and feedback from eleven people living there and staff to help us when we did this. The Commission for Social Care Inspection was then passed information in April 2008 that had been sent to Bedfordshire Social Services and in addition further information had been sent directly to us; on reviewing the information a decision was taken to carryout a Key inspection. Two Regulation Inspectors carried out this unannounced visit on 11th April 2008, the duration of the site visit was 9 inspection hours. Alternative management arrangements of the home were in place when this inspection was carried out. Another manager of a home owned by the company had been in charge for two weeks and had been supported by the Area Manager who had attended at least three times a week. The Deputy Manager had recently returned from a period of leave and was going to ‘act up’ for as a temporary measure. During the visit the communal areas of the home were seen alongside twenty of the individual rooms. One of the inspectors spent time with many of the people who live at the home in their rooms. Meeting eighteen of the people living at the home. Management and staffing records were examined. The care of four people was looked at in detail. Evidence used and judgements made within the main body of the report include information from this visit, feedback from people who live at the home and the management’s submission of documentation. Feedback from people who use the service and staff was also received through returned comment cards. Observations of care practice and communication between the people living at the home and staff was also made at the inspection. The focus of this inspection was to look at the key standards and to follow up on previous requirements. DS0000017681.V362239.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Acknowledgement is given to senior managers in the company as they had already identified several shortfalls in the standard of care at the home and had started to work towards making things better. There are several areas that the home needs to look at to make things better for the people living there. Some examples are as follows. Management need to improve in the way they manage medication. Inconsistent practice amongst staff when administering medication where some staff signing to say that they have administered a medication when they have not and no system in place to enable a full audit of medication in place. DS0000017681.V362239.R01.S.doc Version 5.2 Page 7 The balances of some medication were not correct, or there were too many signatures on a chart for the amount of tablets for a person. This is unsafe for the people living at the home. The majority of individual rooms are not clean. Skirting boards, electrical sockets, legs of tables and chairs, carpets and en suite facilities were stained and contained a build up of dirt. Two of the rooms had an odour of urine. This does not provide a pleasant environment for the people to live in. Management need to look at the way they care for people with dementia and be clear in how they approach this, all the staff must know how they should be supporting people in living a fulfilling life providing stimulation and emotional support and how they can support a persons choices. We noticed that only one person used any of the communal facilities until lunchtime, everyone else stayed in their individual room and this happens everyday. Also they must look at meeting the equality and diversity of people at the home, English was not a language spoken by one person for example, yet the guidance to staff on how to communicate stated they should use signs where possible and encourage their family to visit, this is inadequate. There were no specific measures in place for this person to be able to communicate their needs to staff. The standard of care documents is inconsistent. All the files we looked at had information missing. One person had a wound on their admission to the home and was assessed by home staff as being ‘necrotic’; the treatment of this wound had not been documented. Another person had been assessed as being at high risk of pressure sores; the two pages named the ‘prevention of pressure damage’ were missing. Many people in the home feel that the amount of time that they have to wait for their call bell to be answered at certain times in the day is not acceptable. One person said, “If l call in the morning, at mealtimes or the evening I can sometimes have to wait up to 40 minutes before they come”. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000017681.V362239.R01.S.doc Version 5.2 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 DS0000017681.V362239.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 & 6 Quality in this outcome area is adequate. We have made this judgement using a range of evidence including a visit to this service. Pre admission information on the home is sufficient to ensure people can make an informed choice as to whether to move into the home or not. Although the standard of assessments is inconsistent so some people may not receive the care that they need. EVIDENCE: The care files examined included pre-admission assessment. Assessments included information from visiting the person at the hospital, or wherever he or she was living prior to admission and information from any referring social worker or health professional. There were sections covering the social, psychological and physical needs of the person although not all areas had been completed, one example was one person had no entry made in the dying, motivation or adapting to change and loss sections. Linkage to care plans was DS0000017681.V362239.R01.S.doc Version 5.2 Page 10 also inconsistent; one person identified at being at risk of falls had no plan in place for this. Although audits and action plans were seen in the files of reviews that had been undertaken to rectify missing information, the actual shortfalls had not been acted upon at the time of this inspection. The statement of purpose was seen to be displayed in the home. The document provided information on the staffing, accommodation and services available at the home. All comment cards returned to the Commission for Social Care Inspection from people using the service indicated that they felt they had been given enough information, before they decided to move into the home. It was observed that until the lunchtime meal was served, only one person living at the home used the communal spaces. People were on their own in their own rooms and had been so since the previous evening. Staff advised that this was the resident’s choice. However several people diagnosed with dementia, from information within their records were assessed as having very limited capacity to make decisions in their lives. The care of people with dementia must be based on current guidance and a requirement is made in this area. Intermediate care is not provided at the home. DS0000017681.V362239.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. We have made this judgement using a range of evidence including a visit to this service. Good access to medical support by staff ensures peoples healthcare needs are met. However inconsistencies in the management of care planning and medication place people at risk of not receiving the care that they need. EVIDENCE: The care documentation seen in most instances for the person gave sufficient detail to show some of the individual needs, although they were inconsistent in their standard. Examples included one person not having documentation relating to the treatment of a pressure wound, although staff stated that it was now healed. Another person assessed as being at high risk of pressure sores had documentation missing relating to this. Audits were seen on the files examined, however the actions detailed within them to improve had not yet been acted upon. The standard of entries made in documents was not DS0000017681.V362239.R01.S.doc Version 5.2 Page 12 adequate, following the catheterisation of one person and subsequent admission to hospital the records did not make clear why, what was done or follow up. It is acknowledged that senior management is undertaking a change in the care documentation however this area must be addressed and a requirement has been made. Medication storage in the home was noted to be satisfactory as was the ordering of medicines. However the recording of medication stocks and balances were insufficient so an audit of the medication systems was not possible and therefore no internal audits had been carried out. One person within the current 28-day cycle had a balance of 30 tablets written, 18 signatures had been entered onto the medication record, so the balance should have been 12 tablets but there was actually 22. The Deputy Manager showed another boxed course to show that this was correct, however from this 7 day, twice daily course of antibiotics there were 15 signatures in place. A requirement has been made. People through their comment cards said that staff treated them with respect and maintained their privacy. However one person at this inspection spoke of staff speaking to them in an abrupt manner, when they raised this with the manager they were not satisfied with their response. A requirement is made to look into this. Several people spoke of the length of time that they had to wait until their call bell was answered, one person stated that everyday especially in the evenings that they had to wait between 10 to 30 minutes, and another person stated that at times it could be 40 minutes. Of the 11 people spoken with regarding this at the visit, 7 stated that it was too long to wait to be answered. People spoken with confirmed that if needed they would receive a visit from a General Practitioner or District Nurse. Records of these visits and assistance given were seen. In addition letters from Bedford Hospital were also seen demonstrating people’s attendance at specialist clinics when required. Staff were interviewed and described the need to contact medical professionals if a person became unwell. DS0000017681.V362239.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are able to continue personal relationships with opportunities to see relatives in private however resticted opportunities and participation in social activities and social contact does not meet peoples individual prefrences and needs. EVIDENCE: With the exception of one person, all other people spoken to stated that they enjoyed their meals. An observation of the midday meal was undertaken, people were offered fish and chips or potatoes and a pudding. People spoken to said that following recent meetings held in the home they had been consulted on their food options and menus had been changed to reflect these. Feedback received from 11 comment cards also confirmed that they found the standard of catering at the home good. As previously assessed staff had made arrangements for daily activities and had until the activities co coordinator absence, maintained a record that DS0000017681.V362239.R01.S.doc Version 5.2 Page 14 included activities including, board games, reminisce and quizzes. As previously detailed within the Choice of Home section, the amount of social and recreational support and stimulation offered to the people living at the home was time limited. Only one person used the communal areas in the home up until the lunchtime meal was served, all others remained in their rooms. On speaking with three of these people they confirmed that they had retired the previous night between 7pm and 8pm, so for them they were spending 16 hours on their own in their bedrooms although they did have the facility of a call bell to ask for assistance. On speaking to people who lived in the home, they confirmed that their relatives and friends visited them. None of the people spoken with were aware of any restrictions on visiting and all confirmed that they could meet with their friends and family within the privacy of their own rooms. Daily records also contained entries by staff to indicate when people had received visitors. Information was also available so staff would know whom to contact if a person had a change in circumstance. One relative spoken to who had been visiting for two years said, “staff have always been lovely l have got to know many of them over time, they are always so helpful”. DS0000017681.V362239.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The training of staff is sufficent to ensure they have a satisfactory level of understanding of the safeguarding protocols to protect the people living at the home. However the systems in place for receiving, investigating and responding to complaints is inconsistent so people are not assured that their concerns will be listened to and acted upon. EVIDENCE: The complaints procedure policy of the home on examination showed that it was clear in its guidance to management and staff and included timescales that the complainant should be responded to if they had raised a concern. Bedfordshire Social Services and the Commission for Social Care Inspection had received anonymous complaints that highlighted a concern that complaints were not responded to in accordance with the homes procedure. Documents at this visit and information from senior management demonstrated that not all complaints had in fact been responded to in accordance with the homes own guidelines. In addition one person spoken to said, “ I wasn’t happy about something and spoke to the manager, there was no point as nothing was done about it”. Information relating to this comment was shared with the Operations Manager, who was asked to look into this matter and respond to the person. DS0000017681.V362239.R01.S.doc Version 5.2 Page 16 Records supplied by the home to the Commission for Social Care Inspection show that staff had undertaken training in the safeguarding of vulnerable adults, certification of this was seen at this visit. On interviewing staff they demonstrated a sufficient level of knowledge on the types of abuse including physical and psychological. In addition the homes procedure in this area was examined, it’s reflected the local guidance. The management had sought a copy of the local protocols and these were seen. The management and staff in place at the time of this visit did demonstrate through discussion an understanding of the need to refer any allegation or suspected abuse. DS0000017681.V362239.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Inconsitences in the level of cleanliness of individual rooms means some people do not have a pleasant enviornment in which to live. EVIDENCE: The communal areas on the ground floor were observed to be furnished in keeping with the style of the building. In addition to a large lounge/diner people could use a library. As previously reported a feature of the home was the large staircase and the wide hallways. Extensive grounds could be used by people and their visitors and provided a pleasant view from many of the windows of the home. The ground floor communal rooms were clean and tidy and free of any odours when this visit took place. DS0000017681.V362239.R01.S.doc Version 5.2 Page 18 In response to concerns raised to the Commission for Social Care Inspection on the standard of cleanliness, twenty individual rooms were seen at this visit. Two of the twenty rooms had an odour of urine. Six of the twenty rooms seen had an acceptable level of cleanliness, with flooring, skirting boards and walls being clean and free from stains or dirt. However the remaining rooms were of varying levels of cleanliness. Three particularly were of an unacceptable standard. Skirting boards in these rooms had thick dirt along them, carpets were stained and the en suite facilities were dirty and untidy. Wheelchairs and tables in these areas also were dirty around the legs and the level suggested that they had not been cleaned for some time. Bathrooms and toilets were clean and tidy and the people had the choice of a number of mechanical aids to assist them with bathing. DS0000017681.V362239.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The systems for reruiting and training staff is good although the numbers and depolyment of thoes staff are not sufficent to provide the care and support needed by the people living at the home. EVIDENCE: Information received by Bedfordshire Social Services following their receipt of three anonymous complaints that they passed to the Commission for Social Care Inspection and anonymous complaints made directly to the Commission for Social Care Inspection raised concerns on the number of staff on duty being insufficient. During the inspection many people in the home felt that the amount of time that they have to wait for their call bell to be answered at certain times in the day is not acceptable. One person said, “If l call in the morning, at mealtimes or the evening I can sometimes have to wait up to 40 minutes before they come”. Other people spoken to felt that the number of staff on duty at different times during the day was not enough one person said, “ evenings are the worst you have to wait ages for anyone to answer you and when they do they just say I’ll be back in a minute and sometimes that’s just not good enough”. Observation undertaken at this visit showed that sometimes staff were not readily available when people required their DS0000017681.V362239.R01.S.doc Version 5.2 Page 20 assistance. An example of this was when a person in their room required assistance, the inspector waited with the person as they had used their call bell, 5 minutes passed and no one had answered so the inspector then asked the Deputy manager to seek assistance and then someone came. A review of the number and deployment of staff must be carried out. The induction and training of staff was recorded in the individual records of all employees. Staff through interviewing confirmed that they had undertaken a variety of courses these included health and safety, moving and handling and national vocational qualifications in care. The homes recruitment policy and procedures as previously assessed are clear and comprehensive, documents submitted by the home to the Commission for Social Care Inspection show that no change has taken place to these policies. References are taken prior to staffs’ commencement and the relevant Criminal Records Bureau check is also carried out and evidence of this having been undertaken was seen. Certificates of qualifications are present within staff files alongside checks to the Nursing and Midwifery Council to check the registration status of nurses. Registered Nurses, care assistants, catering and housekeeping staff are employed at the home. Several of the people living at the home made positive comments on the skills of the staff team, one person said “they always seem to know what they are doing”. Training records examined that were supplied by the home show that staff had undertaken statutory training, including moving and handling, fire safety and food hygiene. In addition staff confirmed that they had attended a variety of courses including wound management. People living at the home who were spoken with felt that the staff had a satisfactory level of knowledge and felt confident in their abilities to meet their needs. Staff were questioned on the individual needs of some of the people who live at the home, through this they demonstrated a good level of understanding of the needs of the person. DS0000017681.V362239.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health and safety systems are sufficent to reduce the risks associated with this area for the people living at the home. However management of the service has not ensured that acceptable standards of care have been available to all people to meet their individual needs. EVIDENCE: Temporary management arrangements were in place at the time of this inspection. Senior staff advised that a review was being undertaken, as a result cover for the two weeks prior to this visit had been provided by another Home Manager employed by the company, until the Deputy Manager had DS0000017681.V362239.R01.S.doc Version 5.2 Page 22 returned from leave. Evidence gained at this inspection through complaints received, documents examined, observation and speaking to people that use this service shows that there has been a deterioration in certain areas of care at the home since the previous inspection. The evidence of this has been described within this report. Although acknowledgement is given that the company has arranged for a senior manager to directly oversee the operation of the home and review practice and make any required changes to improve the standard of care. An audit that had been carried out was seen and did demonstrate that senior managers in the company had a commitment to improve standards. As assessed previously the policy on health and safety was noted to be clear in its guidance to staff and comprehensive. Records were seen that evidenced that required safety checks had been carried out relating to fire, gas and electrical equipment. Approved contractors had undertaken servicing of equipment and site visit paperwork to evidence that theses had been carried out were seen. Maintenance staff carried out the regular checks relating to water temperature checks for example and recorded the temperature on charts. An inspector also undertook random water temperature checks at this visit; all were to the required level. Stocks of aprons and gloves were noted to be available for staff to use, in relation to infection control. No staff at this visit were seen to use these items inappropriately, their use was only seen to be made in the area where they were needed, for example at the lunchtime meal to reduce the risk of cross infection. Following the receipt of complaints near the end of 2007 management of the service had held relatives meetings at the home. Management advised that this was to seek the views of the relatives and to respond and act upon information that they would give. Information received anonymously to the Commission for Social Care Inspection stated that there were some relatives that found these meetings insufficient; they felt their concerns were not listened to or acted upon. Two other relatives were spoken with at the visit, they felt that the home did seek their views and they felt satisfied with the service that had been provided. DS0000017681.V362239.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 3 X 2 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 3 3 X X X X X X 1 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 2 X 3 DS0000017681.V362239.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 OP3 Regulation 14 Requirement Timescale for action 10/05/08 2 OP4 12,16 & 23 3 OP7 15 4. OP9 13(2) Assessments of peoples needs must be completed in full and linked to the care plans to make sure that their needs are met in full. Management must demonstrate 10/05/08 the home’s capacity to meet the assessed needs (including specialist needs) of all individuals admitted to the home. In the case of people with dementia, the service provided must be based on current good practice and reflect relevant specialist and clinical guidance so that people receive sufficient stimulation and emotional support in their lives. A care plan containing sufficient 10/05/08 information that is clear must be in place for each assessed need, to ensure people receive the care and support that they require. Medication systems must be 10/05/08 changed to allow for medication audits to be carried out to identify any shortage of stock, invalid entries being made on to records and checking people DS0000017681.V362239.R01.S.doc Version 5.2 Page 25 have actually received their medication. Then action taken must be recorded and reported by staff. 5. OP10 12(4)(a) & (5) People must be addressed by staff in a respectful manner to ensure people are treated with dignity. Follow up must be made relating to the person that raised an issue at this inspection. 12(1)(b) A review of the length of time people have to wait for their call bells to be answered must be undertaken. Action must then be taken and measures maintained so people do not wait excessive amounts of time for staff assistance. In waiting so long this places people at risk, as they may require emergency assistance. 12(1)(a),1 People must be provided with 2(4)(b)16 stimulation and social and emotional support to enable (2)(m) &(n) them to receive sufficient human contact to maintain a satisfactory level of personal wellbeing. 22(3) All complaints received must be &(4) responded to in accordance with the homes own policy. This is to ensure people and their relatives are listened to and their concerns are acted upon. 16(2)(j) All areas of the home must be &(k) & clean and free of odours so that 23(2)(d) people have a pleasant environment in which to live. 18(1)(a) The number of staff and their deployment within the home must be sufficient to meet the individual needs of the people living in the home in a timely manner. 9(1), Management of the home must (2)(b)(i) be effective and sufficient to ensure people receive the care DS0000017681.V362239.R01.S.doc 30/04/08 6 OP10 30/04/08 7 OP12 30/04/08 8 OP16 30/04/08 9 OP26 30/04/08 10 OP27 30/04/08 11 OP31 30/04/08 Version 5.2 Page 26 12 OP36 18(2) and support required to meet their individual needs. Staff must have a minimum of 11/04/08 six supervision sessions per year. (This requirement had a timescale of 30/11/06, which has not been met. This must now be met without exception). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000017681.V362239.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 DS0000017681.V362239.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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