Inspection on 21/06/05 for Netherhayes

This inspection was carried out on 21st June 2005.

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

Netherhayes 08/11/06

Netherhayes 06/12/05

Netherhayes 25/11/04

Netherhayes 02/06/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Netherhayes 13 Fore Street Seaton Devon EX12 2LE Lead Inspector Vivien Stephens Announced 21 June 2005 st The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Netherhayes Address 13 Fore Street, Seaton, Devon, EX12 2LE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01297 21646 01297 24921 adelaidelodgecarehome@btopenworld.com Adelaide Lodge Care Home LLP Mrs Shirley Elizabeth Fitter Care Home 28 Category(ies) of DE(E) Dementia over 65 [28] registration, with number PD(E) Physical Disability over 65 [28] of places OP Old age [28] Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 25/11/2004 Brief Description of the Service: Netherhayes is a large 3-storey house situated in the main shopping area of Seaton. It is close to the seafront and very convenient to all local amenities. In order to provide good security the front door is kept locked and the entrance to the home is via a pedestrian ‘tunnel’ from the main shopping area. Despite the close proximity to shops and seafront the home is surprisingly quiet and the gardens tranquil with lawned areas, flower beds, trees and duck pond. There are some parking spaces on site, or alternatively there is a Pay and Display car park at the rear of the home. Accommodation and personal care is provided for up to 28 service users. Bedrooms are on the ground, first and second floors. The home has 2 stair lifts for those people with poor mobility. 16 rooms have en suite facilities and 1 room is a double. The home accommodates elderly people who have needs associated with old age, who may have dementia type illnesses and/or who have physical disabilities. Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began at 9.30am and finished at 6.15pm. Two inspectors spent the day touring the home, talking to residents, relatives, staff and managers. Files were selected for inspection. The administration of medicines was inspected. Shirley Fitter, Iris Larcombe, Terry Lewis and Robert Cross were present for the inspection. At the time of this inspection 28 residents were accommodated. Seven comment cards were received by the Commission from residents, relatives and visitors What the service does well: Good assessment procedures are carried out on prospective new residents to ensure their needs can be met. Residents and relatives said they felt they had been given good information before moving in, and were satisfied they had made the right choice. Care plans are detailed and have been regularly reviewed. Residents and relatives praised the staff and confirmed that care and health needs have been met. Comments included “Their care for the residents is excellent. They make time for them as individuals and have time to sit and chat with them when necessary” and “We are lucky to have such kind people looking after us”. Medicines are stored and administered safely. The home provides a good range of activities and entertainments to suit all interests and abilities. On the day of the inspection there was musical entertainment and relatives and friends were invited to attend a strawberry cream tea party in the garden. Relatives said they felt welcomed whenever they visit the home. The menus are balanced and varied and provide a good standard of nutrition. Dining rooms are attractive and comfortable and provide pleasant surroundings at mealtimes. Good standards of maintenance and cleaning have been carried out in the kitchen. Residents and relatives said they were confident that any concerns or complaints they had would be listened to and acted upon satisfactorily. Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 6 The home demonstrated a determination to safeguard residents from any form of abuse or harm. Safe systems are in place to ensure the health and safety of residents, staff and visitors. The garden looked particularly attractive, with neat lawns, attractive flowerbeds, duck pond and shaded sitting areas. The inside of the home has been well maintained, decorated and furnished and looked comfortable and homely. All areas were spotlessly clean and the home was fresh and odourfree throughout. Records have been well maintained. What has improved since the last inspection? What they could do better: While the home has good recruitment procedures in place including at least two satisfactory references and a thorough induction procedure, some staff had started work before a satisfactory CRB and POVA checks had been received. The management gave firm assurance that procedures will be changed to ensure this does not happen in future. Medicine storage and administration was found to be good. However, in order to improve the audit trail it is recommended that the number of tablets received into the home is recorded on the MAR sheets. While the overall level of induction and on-going training for staff on the protection of vulnerable adults is good, during discussion with the management some areas need to clarified. The management team said they will review their policies and procedures and ensure all staff are aware of the most up-to-date guidance on this subject. Many of the radiators have already been covered and the home has an ongoing programme to provide low-surface temperature covers for all remaining radiators. Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 7 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. Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 5 Residents and their representatives have received good information about the home before deciding to move in. The home carries out thorough assessments and obtains good information before agreeing to admit new residents. EVIDENCE: Residents and relatives talked about how they chose Netherhayes. Some said the home had been recommended to them, and although they had looked at other homes they had still come to the conclusion that Netherhayes was the right home for them. They confirmed that they had been given good written and verbal information about the home before they decided to move in. Files are held for each resident containing detailed assessments, care plans, risk assessments, reviews and daily reports. Copies of Shared Assessment Schedules and nursing assessments have been obtained for those residents who have been publicly funded, and information from these contributed towards the care plans. Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 10 Residents said they were able to visit the home before moving in. Where they were unable to visit due to ill health or frailty they said their family or friends had visited on their behalf. The home does not provide intermediate care. Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 9, 10 Care plans provide good information to care staff about the personal and health care needs of each resident. Safe systems of medicine administration are in place. Staff treat residents with kindness and respect and in a manner that upholds their privacy and dignity. EVIDENCE: A sample of care plans were seen and these contained a range of details about residents’ personal and health care needs. Manual handling assessments, risk assessments, nutritional and dietary needs were held in the files. The layout and content of the plans were discussed with the managers and some suggestions were made for some minor improvements including clearer instruction to staff in the manual handling plans, and for the streamlining of some documents such as the day and night care plans. Iris Larcombe and Shirley Fitter said the staff are used to these documents and know where to find relevant care instructions and therefore it was agreed that no major Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 12 changes should be made, but the home will continue to adjust the plans as and when needed. The plans have been reviewed regularly. Individual daily reports have been completed for each resident. These relate to the care needs and provide a record of all incidents and events and give an overall picture of residents’ well being. In addition to the care plan files there are care instructions for staff held in residents’ bedrooms. The home has recently revised the Administration of Medicines policy to ensure it covers all aspects of the receipt, storage, administration and disposal of medicines. Medicine storage cupboards and trolley were locked and keys held securely. The home uses a monitored dosage system. Staff were observed administering medicines following agreed procedures. Records of medicines ordered, received, administered and disposed of were inspected. Staff were able to demonstrate careful recording and safe systems of work. To further improve the audit systems it was recommended that the quantity of medicines received into the home should be recorded and signed for on the medicines administration record. Staff were seen treating residents kindly and in a manner that upheld their privacy. Staff were seen knocking on bedroom doors before entering. One resident said, “We are lucky to have such kind people looking after us”. All residents are accommodated in single bedrooms unless they have requested to share. At the time of this inspection two married couple were accommodated in double bedrooms (a second room will be provided if requested for married couples). Personal care is provided in the privacy of their bedrooms or in a manner that respects their privacy in one of the bathrooms. Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 15 The home provides a good range of activities and entertainments to suit all interests and abilities. Residents are fully consulted over the level of activities and their preferences and requests are acted upon wherever possible. Relatives feel welcomed and involved in all aspects of the daily life at Netherhayes. The menus are balanced and varied and provide a good standard of nutrition. Dining rooms are attractive and comfortable and provide pleasant surroundings at mealtimes. Good standards of maintenance and cleaning have been maintained in the kitchen. EVIDENCE: The day of the inspection was warm and sunny, and on arrival at the home at 10am some of the residents were already sat outside in friendly groups chatting. The gardens are sheltered and provide various sitting areas. In the afternoon there was musical entertainment and friends and relatives were invited to attend for a strawberry cream tea. Inside the home there are two lounges and two sitting rooms and these can been used in various ways for socialising and group activities. Each week the Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 14 home provides a regular musical entertainment session, and exercise sessions. Further entertainers are employed on average once a month. The home has a regular newsletter, and forthcoming activities are publicised on the notice board in the hallway. These include details of shopping and day trips, outings for coffee, shows at the local town hall, church services and events, and Age Concern activities. Residents’ Meetings are held regularly and these give residents an opportunity to discuss the activities and outings and make suggestions. Seven relatives contributed towards the inspection by completing comment cards. In addition a number of relatives and friends attended for the cream tea and entertainments in the afternoon. Relatives said they are always made welcome, and are kept well informed. Comments included “The staff at Netherhayes always make us feel welcome and she is loved and cared for by them.” One comment related to the level of communication with relatives after a recent incident occurred. The event occurred when Shirley Fitter was off duty. Iris Larcombe and Shirley Fitter agreed to look at this matter again and if necessary they will amend their procedures to ensure families are satisfied with the information they receive following events and incidents. There is a 4 weekly rotating menu. These are displayed in the dining room. The home caters for all dietary needs including vegetarian and diabetics. Homemade cakes are cooked daily. Fresh vegetables are used as often as possible. Fresh fruit is provided daily. Residents said they always enjoy the meals provided. The menus are discussed with residents at the residents’ meetings and adjusted according to residents’ requests. Residents said they enjoy the meals. Dining rooms have been decorated and furnished to a good standard. Dining tables have been laid with co-ordinating tablecloths and attractive cutlery and crockery. The kitchen has been equipped with modern stainless steel work surfaces. All equipment was well maintained and up-to-date. The kitchen was bright and clean and records showed cleaning and temperature-monitoring routines were satisfactory. Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 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 standard(s) 16, 18 Residents and relatives know how to make a complaint. The management of the home take complaints seriously and have good procedures in place to ensure complaints are acted upon promptly. The home has recognised the importance of having robust policies and procedures in place to protect vulnerable residents from abuse. These should be reviewed to ensure they are in line with the guidance provided by Devon County Council on this subject. Satisfactory plans are in place to ensure that all staff receive adequate training on the protection of vulnerable abuse. EVIDENCE: No complaints have been received by the Commission or by the home since the last inspection. A record of compliments and complaints was seen during the inspection – this contained lots of letters and cards thanking the home for the good care provided, and very few complaints. The complaints procedure is displayed in the hallway, and residents and their representatives are given a copy of this in the Service User Guide. In 2004 the home sent out questionnaires to residents and relatives. Responses showed that people felt confident that they could approach any of the management team at any time and that their concerns would be taken seriously and acted upon appropriately. The protection of vulnerable adults was discussed in detail with the Management of the home. Policies and procedures are in place and these Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 16 demonstrated that the home has recognised the importance of this subject. The Assistant Manager has recently completed a ‘Train the Trainer’ course on the Protection of Vulnerable adults. All new staff have received basic training on this subject during induction and have watched the ‘No Secrets’ video. Some staff have received thorough training in this subject, but there are still a number of staff that have yet to attend. Procedures for acting upon allegations or suspicion of abuse were discussed and the management team agreed to amend their policies and procedures in line with Devon County Councils’ Alerter’s Guidance. Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 23, 24, 25, 26, The home has been well maintained and decorated throughout to provide a good standard of comfortable and homely accommodation. The staff have worked hard to provide a high level of cleanliness and to ensure all areas are free from unpleasant odours. Equipment has been provided to enable those residents with poor mobility to get around safely. Bedrooms are of a good size, attractively decorated and furnished. comfortable and homely in style. EVIDENCE: In a tour of the home all areas were found to be in good decorative order, comfortable and homely. The gardens are secluded and attractive, with lawns, flower beds, trees, level paths and a duck pond. The home employs a full time maintenance man who ensures that all repairs and maintenance are carried Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 18 out promptly. Plans have been drawn up to enlarge the home and further improve the facilities. There are 2 lounges (one of which is on the first floor) and 2 dining rooms. Communal areas have been redecorated and refurbished in the last year. Security of the home has recently been considered, and as a result there are plans in place to provide a new entrance gate. There are 16 single bedrooms with en suite toilets and washbasins. 10 further single bedrooms and one double bedroom have washbasins in the rooms and toilets and bathrooms in close proximity. At the time of this inspection one double bedroom was occupied by a married couple. This room is of a good size. Another married couple living at the home have 2 rooms, one of which they have chosen to use as a bedroom and the other as a private lounge. All bedrooms were bright, attractively decorated and furnished, and personalised to suit the occupant. Residents are encouraged to bring items of furniture and belongings in order to make their rooms feel homely. The home has a room specially equipped to provide hairdressing facilities. There are 2 stair lifts providing assistance between floors for those with poor mobility. Some radiators have been covered to eliminate the risk of burns. There are plans to replace the remaining radiators in the future. These have been risk assessed. It is recommended that the risk assessments are continuously reassessed, and that the timescales for all radiators to be covered are brought forward wherever possible. All areas of the home were found to be clean, bright, well ventilated and free from any unpleasant odours. The cleaning staff talked about how they act promptly to deal with stains or odours. Residents and relatives said how much they appreciated the cleanliness of the home, and how nice it is to visit the home and find it is always clean and fresh. The laundry is equipped with modern industrial washing machines, sluicing facilities and tumble driers. Night staff deal with most of the washing as part of their duties. The room was clean, tidy and in good order. Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 Staffing levels were sufficient to meet the needs of the residents. Overall the home has good recruitment procedures in place. Care is taken to ensure new staff have the right aptitude and caring manner. However, failure to obtain satisfactory CRB and POVA checks before new staff begin work could place vulnerable residents at risk. EVIDENCE: Evidence seen during the inspection showed that staffing levels at the home are normally Mornings – 1 manager, 3 carers, 2 cleaners, 1 maintenance person, 1 cook and 1 kitchen assistant Afternoons – 1 manager, 3 carers, 1 maintenance person. In addition, during the daytimes Robert Cross, Terry Lewis and Iris Larcombe are on duty – they share their time with another home owned by the company. Evenings – 3 care staff until 10pm At night there are 2 waking care assistants. Staffing levels in the evenings have been increased since the last inspection. Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 20 One relative said they thought the staffing levels have been low in the evenings, but they were satisfied when they heard that the levels have recently been increased. The number of care staff employed during the day is low in comparison with other homes in the East Devon area of similar size and category. However, residents and relatives were generally satisfied with the number of staff employed and the home was found to be running smoothly. Additional support from the senior managers and other staff in the home during the day enables Shirley Fitter to spend more time working directly with residents and providing supervision to staff. A sample of staff recruitment files were seen. These contained application forms, proof of identity, copies of qualifications and training certificates, at least two satisfactory references. CRB and POVA checks have been carried out for all staff. The home normally sends an e mail to the CRB requesting a POVA First check, and responses are normally received quickly. However, on a couple of occasions, staff have started work before a satisfactory POVA check has been received. The home must ensure that in future no staff are confirmed in post unless a satisfactory POVA check has been received. The managers agreed to comply with this requirement from now on. Evidence supplied for this inspection showed that only 2 of the 15 care staff employed at the home have NVQ level 2 or above. More staff are currently undertaking NVQ’s. Training records showed that staff have received regular updates on all health and safety related topics. Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 37, 38 The home has good methods in place to ensure the quality of the service is regularly reviewed. These methods would be further improved by ensuring surveys are carried out at least annually and the results published. Records have been well maintained. Good systems are in place to safeguard residents’ money and valuables. Satisfactory measures are in place to protect the health and safety of residents and staff. EVIDENCE: The home has a range of methods of checking the quality of the service provided including regular management meetings, staff meetings and residents’ meetings. Questionnaires were given to residents over a year ago and they plan to send more out in the near future. It is recommended that the Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 22 results of the survey is summarised and provided to residents and their families and friends. The results should also be included in the Service User Guide, Records of cash or valuables held by the home were seen and found to be satisfactory. The home has agreed to hold small amounts of cash on behalf of those residents who are unable or unwilling to hold this themselves. Cash is held securely, and only managers have access. The home does not have overall responsibility for the finances of any resident. Records seen during the inspection included * * * * * * * * Assessments, care plans, risk assessments, reviews and daily reports Staff recruitment files Menus Administration of medicines Policies and procedures Accident book Records of cash held on behalf of residents Fire log book These records were found to be well maintained. Health and safety policies and procedures are in place. Risk assessments have been carried out on the environment. Most radiators have been covered to reduce the risk of burns. Baths have thermostatic valves to prevent the risk of scalds and in each bathroom there is a bathing policy and thermometer for staff to double check the water temperature. COSHH policies and procedures are in place. Information provided for this inspection showed that equipment has been regularly maintained and serviced. Staff have received training in health and safety related topics. Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 4 3 3 3 3 3 2 4 STAFFING Standard No Score 27 3 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x 3 x 3 3 Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 24 No 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 OP9 Regulation 13 (2) 17 (1) (a) sch 3 (3) (i) 19 sch 2 Requirement The registered person must make arrangements for the recording of medicines received into the care home. New staff must not be confirmed in post until satisfactory Protection of Vulnerable Adults checks have been received. Timescale for action 1.7.05 2. OP29 1.7.05 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 OP18 OP18 Good Practice Recommendations All staff should receive updated training on the protection of vulnerable adults. Policies and procedures on the protection of vulnerable adults to be amended in accordance with the recommendations laid down in the Devon County Council document entitled Alerters Guidance. The programme of covering radiators to be continued in order to eliminate the risk of burns and scalds. 3. 4. OP25 Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Exeter Office, Suites 1 & 7 Renslade House Bonhay Road EXETER, EX4 3AY 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 Netherhayes D54-D06 45371 Netherhayes 223714 210605 Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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