Inspection on 25/03/08 for Norfolk House

This inspection was carried out on 25th March 2008.

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

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

Norfolk House 10/11/08

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Norfolk House 34 Norfolk Street Wigan Lancashire WN6 7BJ Lead Inspector Judith Stanley Unannounced Inspection 25th March 2008 09:15 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 Norfolk House DS0000070363.V360678.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. Norfolk House DS0000070363.V360678.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norfolk House Address 34 Norfolk Street Wigan Lancashire WN6 7BJ 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) 01942 495777 Mr Megraj Jingree Mrs Premila Jingree Mrs Sharon Marie Makinson Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Norfolk House DS0000070363.V360678.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC To people of either gender, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP The maximum number of people who can be accommodated is: 18. Date of last inspection New Registration Brief Description of the Service: Norfolk House is a privately owned care home that offers personal care and support for 18 older people. Norfolk House is a large converted semi detached property situated in the Springfield area of Wigan and is a short drive away from Wigan and Standish town centres. Local amenities are close by including shops, local church, library and health centre. The home offers 10 single rooms and 4 shared rooms, there are no rooms with en suite facilities, however all rooms have a hand basin and bathrooms and toilets are within close proximity to bedrooms and communal areas. There are bedrooms on both floors; the first floor is accessible by passenger lift. There are car-parking facilities at the front of the Home and a large enclosed private garden to the rear. At the time of the inspection the weekly fee charged ranges from £322:65 to £360:51 there is no top up fee incurred. Additional charges were made for hairdressing, magazines and toiletries and private chiropody. Norfolk House DS0000070363.V360678.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 the service experience adequate outcomes. This inspection, which included a site visit that the home did not know was going to happen, was conducted over six hours on one day. Part of the time was spent in the office looking at information the home holds on residents (care plans) and other records the home needs to keep to ensure the home is being properly run. Prior to the inspection the manager was sent an Annual Quality Assurance Assessment form (AQAA), this is a self assessment form that informs the inspector how the home meets the National Minimum Standards (NMS), what the home does well at and in what areas they need to improve on. To find more out about the home comment cards were sent to residents, relatives and other people who visit the home such as doctors and district nurses. Sixteen residents, nine relatives and three health care professionals returned comment cards. One resident said, “I am very grateful for all the care given, I love the meals and I am very happy here”. Another said, “All the staff are friendly and courteous and make me feel safe and happy”. Other residents expressed their satisfaction about the care and the services provided. One relative said, “My mother is extremely happy at Norfolk House, she never complains. The carers look after her well. I was impressed by the homely, friendly atmosphere, the care is very good. I admire all the carers”. Another said, “ The home meets the needs of the residents. From what I have seen when visiting all the staff seems to exceed the requirements of a residential home”. One relative commented on the need for more activities and outings. This was discussed with the manager and is being addressed. Another comment made by a relative was the home needed better control of temperatures in individual rooms as the radiator in his mother’s room is always on even in summer. The homeowner has only recently taken over at Norfolk House and is aware that the heating system requires attention. Three doctors returned comments cards, one said,“ They respect patient dignity by ensuring that patients are in their room for my visit”. Another said, “ The staff appropriately and promptly request medical opinions about ill residents. They give excellent individual care to residents, I am not aware of any needs for improvements, it’s a lovely homely environment”. There have been no complaints made to the manager of the home and no complaints have been forwarded to the CSCI. Norfolk House DS0000070363.V360678.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: The home would benefit from the services of a handyman to carry out odd jobs such as replacing light bulbs in fittings that are to high for staff to reach. The broken microwave in the kitchen should be replaced or repaired. Staff must not commence work without a POVA first check or returned Criminal Records Bureau check regardless if the person is known to the manager or staff. The registered provider must in accordance with the Care Homes Regulations 2001 visit the home unannounced monthly and compile a written report which must be on site and available for inspection. There were only two reports from November and December 2007 available. The home would benefit from an activities budget to allow more trips and activities to be planned. Currently the home relies on the good will of the staff, residents and relatives for fund raising. Any controlled drugs kept in the home must be stored in a CD cupboard. The home should purchase an official Controlled Drugs Register to record the use of controlled drugs within the home. Norfolk House DS0000070363.V360678.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Norfolk House DS0000070363.V360678.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 Norfolk House DS0000070363.V360678.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): 1,2,3 and 4 were assessed. Standard 6 does not apply, as Norfolk House does not provide an intermediate care service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents and their supporters with up to date information about the services provided that helps them in making a decision about moving in to the home. A full pre-admission assessment is carried out prior to admission to ensure the home can meet the needs of the individual. EVIDENCE: Prior to the new owners being registered the statement of purpose and the service user guide is presented to the Central Registration team for approval. Copies of the documents were seen at the home and were available for inspection. Norfolk House DS0000070363.V360678.R01.S.doc Version 5.2 Page 10 We selected two care plans for inspection, one being the last person to move in to the home. Written contracts were available in both files, however both needed further details adding to them, for example the method of payment. This was discussed with the manager who confirmed that she had been waiting for paperwork from the funding authority and will complete the contracts as soon as possible. The manager needs to check that all contracts are correct and up to date for all residents to avoid any issues. A pre admission assessment is carried out by the manager at the most convenient place for the prospective resident, this could be in their own home or whilst in hospital. The purpose of the assessment is to ensure that the home and staff can meet the individual needs of the resident. A copy of the assessment was seen on both residents files and includes: all the residents details such as date of birth, next of kin, allergies, past medical history, routines of daily living for example diet, sleep patterns, hearing, sight, communication, health and personal care and social interests. There are some residents in the home that appear confused and possibly in the early stages of a dementia related illness. To ensure that staff have an understanding of the changes in some residents a group of staff are undertaking dementia training and on completion other staff will receive similar training. Norfolk House DS0000070363.V360678.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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are clear and concise and provide staff with the information they need to meet the needs of the residents. Personal care and support is offered in such a way as to promote and protect resident’s privacy and dignity. EVIDENCE: We continued to use the care plans chosen to check the pre admission assessments. The information contained in the care plans gave staff detailed information about the care each resident required. A social profile of the residents is included in the individual’s activity file, which informs staff of the life experiences of the resident’s, this helps staff to get to know them better and generate topics of conversation. The profile includes family background, work life experiences, hobbies and interests. Norfolk House DS0000070363.V360678.R01.S.doc Version 5.2 Page 12 Other information in the care plan includes risk assessment for example moving and handling, mobility, bathing and movement around the home to ensure the resident’s safety is maintained. There was evidence to demonstrate in the care plans that outside agencies, such as doctors, district nurse and the chiropodist are contacted and visit the home as required. On the day of the inspection staff were concerned about the well being of one resident and the doctor was called resulting in the resident being transferred to hospital. The resident’s family were informed and accompanied their relative. Staff at the home had contacted a dentist for one resident and accompanied her to the surgery. The district nurse is attending the home on a regular basis to attend to dressings etc. The home keeps a separate file for resident’s weights and bathing checks, to ensure both are done on a regular basis and any changes documented. The home would benefit from a better pairs of scales, which can be calibrated to ensure residents correct weight. The care plans had been up dated monthly as required by the manager. Observation throughout the inspection showed the personal care needs of the residents were being met. Attention was given to residents personal care grooming; residents were seen to be clean and nicely dressed in coordinated clothing. On the day of the inspection the hairdresser was visiting the home and most ladies had had their hair washed and set. Staff were tentative to the needs of the residents, it was noted that after lunch a couple of ladies needed their jumpers changing and this was promptly noted by the staff and addressed. Staff were observed maintaining residents privacy and dignity by ensuring toilet doors were closed when in use and knocking on bedroom doors and waiting for a response before entering. It was evident from conversations heard that good, respectful and friendly relationships had been formed between staff and residents. We inspected the medication of the residents whose files were inspected. The manager was asked to assist with the check. It was found in one case there was an error in medication. One of the morning tablets had been signed for as given but was still in the blister pack. As a matter of routine we checked the controlled drugs of another resident. An error was found in that there were 21 tablets left and there should have been 19. As with all controlled drugs, the records had been signed by two staff as required, as being correct. Some of the controlled drugs were in a box other than in the blister pack, it appeared that the box had not been finished and a tablet from the blister pack taken at random from the wrong place. The inspector suggested that the manager carries out a full medication audit to ensure there were no further discrepancies with resident’s medication. The manager should ensure that all staff even though they have undertaken Norfolk House DS0000070363.V360678.R01.S.doc Version 5.2 Page 13 training in medication are competent in the administration and recording of medicines and any errors noted are reported to the manager. There is a system in place for the recording of controlled drugs held in the home, however the inspector recommends a proper controlled drugs register be purchased. The home must have, for the safe storage of controlled drugs, a proper CD cupboard. Norfolk House DS0000070363.V360678.R01.S.doc Version 5.2 Page 14 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with well-cooked food, which they like, in good portions at time that suits them. EVIDENCE: The home offers residents a range of activities to suit their capabilities, these include gentle chair exercises, baking, gardening, crafts, bingo, reminiscence, dominoes, knitting, quizzes, sing- a-longs and films. Residents told the inspector about their trip out to Blackpool to the illuminations and how they enjoyed fish and chips after. One resident is an avid reader and said that staff took her to the library to choose her books. Other visits to garden centres, shopping and trips to the park are arranged, and the home has entertainers that visit the home during the year. Both staff and residents assist with fund raising activities, these include: raffles, bring and buys and selling cards that they have made. Each resident has an activities file, which records what they have done and whether it was enjoyable, these also include photographs of different events. Norfolk House DS0000070363.V360678.R01.S.doc Version 5.2 Page 15 It was discussed that the home would benefit from an activities budget to help subsidise planned activities and outings. The home tries to maintain links with the local community through visits to the library and shops. Children from the local school visit and sometimes sing for the residents. Residents have also attended the school for some events and have been welcomed in to the local church to take part in their social events. The home welcomes visits from the local clergy who visit the home and offer communion to those residents who wish to partake. Visitors are welcome to visit the home at any time; there are no restrictions as to when people can visit. Residents can meet their visitors in the lounge or conservatory or in the privacy of their own room. Two visitors were available to speak with the inspector and expressed their satisfaction about the home and the care their relative receives. The cook has worked at the home for several years and knows the likes and dislikes of the residents she is catering for. A flexible breakfast is available to allow residents to have a lie in if they wish. There is a choice of breakfast dishes including cereals, toast and preserves, tea and coffee. A cooked breakfast is available if requested. Lunch is the main meal of the day, on the day of the inspection residents were offered the main dish of steak pie, roast potatoes and carrots and swede and gravy, followed by banana cake and custard. One resident wanted a fried egg with bread and butter, which she got and another had sandwiches, which were cut in triangles and served with a salad garnish. A lighter afternoon tea is served, however on the day of the inspection residents were having a buffet tea to celebrate another residents birthday. Suppers are available before residents retire for the night. Hot and cold drinks and snacks are served during the day. The tables were nicely set with placemats, napkins and appropriate cutlery and condiments. After lunch the inspector sat with three residents who said the food was always good and there was plenty of it, they had no complaints. Norfolk House DS0000070363.V360678.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can have the confidence that residents will be protected from abuse and have their rights, including the right to complain protected by effective staff training and procedures. EVIDENCE: A complaints procedure exists and a copy of the complaints form was seen in the care plans looked at. There have been no complaints recorded in the complaints file and no complaints had been brought to the attention of the manager or to the CSCI. There have been no safeguarding issues reported by the home. All staff have had training in the protection of vulnerable adults and the home holds a copy of the local councils adults safeguarding procedure. Norfolk House DS0000070363.V360678.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): 19,24, 25 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Norfolk House is maintained to a good standard making it a homely, comfortable, clean and pleasant place for residents to live. EVIDENCE: From a tour of the premises, it was evident that the home is well maintained. The home had recently been given a grant from the council which has enabled them to replace most of the bedroom carpets, order some new furniture, bedding and curtains and replace some of the windows where the seals had gone. However there is a problem with some of the new windows and the handles, this needs to be addressed to allow the windows to be opened. Norfolk House DS0000070363.V360678.R01.S.doc Version 5.2 Page 18 Several of the resident’s bedrooms were looked at. These were seen to be clean and tidy, and residents had personalised them with their own possessions brought with them from home. The bathrooms are suitably decorated and toilets and bathrooms are available on both floors, however residents said they preferred the downstairs bath rather than the shower. It was noted that in one bedroom the light shade was missing resulting in just a bulb hanging, this looked unattractive. Part of the dining area was gloomy, as the staff cannot replace the bulb, as it is too high and unsafe for them to attempt this, even though the replacement fitting is there. One wall light in the main lounge was not working and a bulb in the main chandelier needs replacing. To keep on top of jobs like this and to allow the carers to get on with caring this is where the home would benefit from the services of a handyman. Previously staff had relied on the good will of the managers husband to do these types of jobs when he called at the home. The heater in the conservatory must be removed, as it was felt by both the inspector and the manager, that this could cause serious burns to residents, staff and visitors should they fall or catch themselves on it. Alternative heating must be arranged to ensure the conservatory is maintained to a comfortable temperature for residents to sit in. The manager immediately turned the heater off on realising how hot it was. The outside of the home was well maintained and the gardens were neat and tidy. The manager confirmed that staff and some residents enjoyed helping with the potting plants etc. Systems are in place for the control of cross infection. Staff were seen wearing protective clothing and gloves for different tasks. The home was clean and tidy with no offensive odours detected. The laundry is sited a way from food preparation and food storage areas and does not intrude on the residents. Norfolk House DS0000070363.V360678.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 and 30 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can be sure that their needs can be met by good staffing levels and with a competent, committed, experienced and well-trained staff team. EVIDENCE: The staff rotas showed that there are sufficient numbers of staff on duty each day and through the night. On the day of the inspection there were seventeen residents living at the home and the staff on duty included the manager, two carers, a cook and a domestic. There are two waking night staff on duty each night. The home does not use agency staff unless absolutely necessary and the staff if needed will cover shifts between them if required. The same staff had worked at the home for a number of years and work well as a team with a willingness to help one another out. From discussions with the staff and manager, staff showed they know the residents well and they demonstrated a strong commitment to providing a good standard of care. The staff group are all female and currently there are only ladies living at the home. Norfolk House DS0000070363.V360678.R01.S.doc Version 5.2 Page 20 Two staff files were looked at; there had been no care staff recently recruited. The only new member of staff was a domestic. There were application forms in the files, however, these need to contain more detailed information and need to be revised. References had been taken up and were kept on file. It was discussed with the manager that any new staff recruited must provide proof of identity, including a recent photograph, the person’s birth certificate, the person’s current passport (if any) and that staff must not commence work without a POVA first check or a full Criminal Records Bureau check (CRB). The new member of staff had been working without either of the checks as she was known to the home and staff could vouch for her. The CRB had been applied for but had not been returned. The manager was reminded that this was not the correct procedure and this must not occur again. The manager confirmed she would chase up the CRB immediately. Staff training is on going. All staff working at the home has NVQ level 2 and some have NVQ level 3. The training matrix showed that mandatory training is completed and refresher courses booked as required. Certificates were available for inspection. A group of staff have signed up for training in dementia care, other staff will do the same training when the first group have completed theirs. Staff undertakes a full induction programme on commencement of work. This induction programmed is set out by Skills for Care (formerly known as TOPSS). Norfolk House DS0000070363.V360678.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): 31,33,35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can be sure their best interests will be the central focus, with a positive and inclusive approach to making the service better. EVIDENCE: The home’s manager has a significant numbers of years experience in working with the elderly and is qualified to NVQ level 4 in care, and also has the Registered Manager’s Award. She is also an NVQ assessor. Norfolk House DS0000070363.V360678.R01.S.doc Version 5.2 Page 22 The homes manager is committed to her own training and that of her staff team and sees this as an essential element to delivering good quality care for residents. The way in which the home is managed, and run is open and transparent. The manager operates an ‘open door’ policy so that she may be approached at any time by staff, residents or their families. The office is well organised so that staff have access to all the paperwork they need during a shift. There were systems in place for self-monitoring in the home, which includes satisfaction and quality surveys and regular checks and auditing. The home holds residents meetings to which relatives are invited and staff meetings. The home is inspected annually by an external company, RDB (Residential and Domiciliary Benchmarking). RDB inspects the home and awards a star rating. RDB is an independent company and has no connection to CSCI. The registered provider, in accordance with the regulations must carry out an unannounced monthly visit to the home and complete a written report of his findings. There were only two reports from November and December 2007 available for inspection. Continuing to use the same two care plans we checked the residents money that the home holds for safekeeping for them against the record of transactions. Resident’s money was stored in separate wallets in a secure location and on checking each wallet against the balance sheets; no discrepancies were noted. The records showed that staff are trained in safe working practices and that training is updated at regular intervals. Equipment and systems used in the home are serviced and maintained, and records are well kept and easily accessible. The following checks have taken place and certificates were available to verify that: Electrical circuits serviced: 06.2007 Portable appliances: 06.2007 Lift serviced: 03.2008 Hoists serviced: 11.2007 Gas appliances: 04.2007 Regular fire checks were documented in the home fire assessment book and the last fire drill was carried out on 04.01.2008. Norfolk House DS0000070363.V360678.R01.S.doc Version 5.2 Page 23 Accidents, injuries and incidents are recorded properly in the homes accident book and reported to the CSCI as required. Norfolk House DS0000070363.V360678.R01.S.doc Version 5.2 Page 24 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 STAFFING Standard No 27 28 29 30 Score 3 2 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 9 10 11 3 x x x x 3 2 3 3 2 3 x 3 3 2 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 3 Norfolk House DS0000070363.V360678.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? New Registration 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 OP2 Regulation 5A (b) Requirement All contracts should clearly state the method of payment of the fees and the persons by whom the fees are payable. All medication must be correctly administered, accounted for and accurate recordings maintained. The home must have a CD cupboard for the safe storage of controlled drugs. The home must be suitably lit and bulbs replaced in all fittings in all parts of home, which is used by residents. The heater in the conservatory must be removed as this was extremely hot to touch and could result in people receiving severe burns. A suitable replacement is required to ensure the temperature in the conservatory is maintained to approximately 70°F. All staff must have a current Criminal Records Bureau check on commencement of work. The registered provider must carry out unannounced monthly visits to the home and compile a DS0000070363.V360678.R01.S.doc Timescale for action 30/04/08 2 3. 4 OP9 OP9 OP25 13 (2) 13 (2) 23 26/03/08 30/06/08 26/03/08 5 OP25 23 25/03/08 6 7 OP29 OP33 19 (1) Schedule 2, 7 (b) 26 26/03/08 30/04/08 Norfolk House Version 5.2 Page 26 written report of his findings. These must be on site and available for inspection. 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 OP12 OP27 Good Practice Recommendations Consideration should be given to an annual activities budget. The home would benefit from the regular services of a handyman to undertake general routine maintenance. 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