Inspection on 16/03/07 for Northern Counties

This inspection was carried out on 16th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Northern Counties 16/02/06

Northern Counties 22/09/05

Northern Counties 23/11/04

Northern Counties 12/05/04

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 Northern Counties 36 Lancaster Road Birkdale Southport Merseyside PR8 2LE Lead Inspector Mrs Janet Marshall Key Unannounced Inspection 07:30 16th March 2007 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 Northern Counties DS0000005405.V318876.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. Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Northern Counties Address 36 Lancaster Road Birkdale Southport Merseyside PR8 2LE 01704 568019 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) mail@eventidehome.co.uk Northern Counties Management Committee David Swan Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 31 OP Date of last inspection 16th February 2006 Brief Description of the Service: Eventide is a voluntary run Home providing 31 registered places for both male and female Service Users with strong Christian faith. The Home provides personal care; nursing care is provided directly through the district nursing services when required. The Registered Manager is Mr David Swan. The Registered Provider is Northern Counties Management Committee. The Home is situated in Southport close to the town centre and with access to public transport on the Liverpool Road. Eventide is situated over 4 floors, the ground and upper floors accessible by stairs and a passenger lift (there are no bedrooms on the lower/basement floor). The Home has 2 spacious lounges, 1 small quiet lounge and 1 dining room. Single and double accommodation is provided though at present the double rooms are being used as single rooms. The gardens at the front and rear of the building are well maintained and accessible for wheelchair users. A ramp with handrails is in place at the main entrance to the Home. There is car parking space to the front of the premises where the Home’s minibus is parked when not in use. Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection visit (site visit) at the home this inspection year. The inspection was unannounced and took place over one day for a total of 9 hours. The inspection was carried out with the registered manager Mr David Swan. The Commission considers 22 standards for Care Homes for Older People as Key Standards, which have to be inspected at least once in a 12-month period. All Key standards, which are identified in bold within the main body of the report, were inspected during this inspection. The two requirements, which were given as part of the last inspection report, were checked during this inspection. There was evidence to show that they have both been met. A partial tour of the home was conducted. Care records and other required records were inspected, they included a selection of resident’s care plans, daily diaries, medical notes, staffing rotas and medication and associated records. Four residents were “case tracked”. Case tracking means that the Inspector concentrates on the care given and experiences of one or more residents to get an idea of what is like to live at the home and how that person’s needs are being met. A number of residents, the manager and two members of staff were spoken with during the inspection visit. A pre - inspection questionnaire sent to the home prior to the inspection was returned fully complete. The questionnaire provided the commission with up to date information about different aspects of the home such as the residents, staff, the premises, policies and procedures. Have your say about… surveys were sent out to a number of people including residents, their friends and relatives. The surveys, which are from the commission for Social Care Inspection (CSCI) included people’s views about the home. The report has been put together using evidence from a number of different sources including peoples comments, observations and records looked at during the inspection visit, the pre-inspection questionnaire and surveys. What the service does well: Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 6 The service ensures that prospective residents have all the information that they need about the home before they make a choice about living there. The information helps people to decide if it is the right place for them to live. The service carries out full needs assessments and obtain others from relevant social and healthcare services so that they can be sure of meeting the person’s needs. The service develops a care plan for each person which clearly sets out in detail their preferred routines and the action care staff need to take to ensure that all aspects of the persons health, personal and social care needs are met. The service is good at ensuring that residents live fulfilling and healthy lifestyles. They do this by providing each person with appropriate opportunities in relation to social activities and cultural interests, food, meals and mealtimes, relationships, routines of daily living and religious observance. The turn over of staff working at the home is low. Resident’s benefit from a stable and committed staff team. The majority of staff have worked there for a number of years so have a good understanding of residents needs. Staff receive a good level of training, which is linked to the aims, and objectives of the home and the needs of the residents. The home is well managed to the benefit of residents and staff. Residents are safeguarded by the homes policies and procedures and record keeping which were detailed, up to date and accurate. Below are examples of comments made about the home by residents, their relatives and friends. Other comments can be found in the main body of the report. “All the staff are very polite” “The staff are respectful” “Staff always talk to me and others politely” “Staff never come in my room without knocking first” “The staff will do anything for me” “The staff are always very helpful, respectful and polite” “Staff always treat residents well” “There are no restrictions placed on visiting times, I can visit my mum at any time” “The staff are always very welcoming” “We can sit in the lounge or in my mums bedroom” “Staff always offer me drinks” “Every effort is made to meet the varying needs of residents particularly in relation to their faith. ”My room is cleaned and my bin is emptied daily” “My room is always kept clean and tidy” “Staff are good at their jobs” “The staff are excellent, they are very caring” Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 7 “The manager runs the home very well” “The manager cares a lot for the residents” What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Northern Counties DS0000005405.V318876.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 Northern Counties DS0000005405.V318876.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 Key standard 6 does not apply, as the service does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are given information about the home and their needs are fully assessed before moving in so that they can be sure that it is the right place for them. EVIDENCE: The pre-inspection questionnaire and discussion with the manager evidenced that 5 residents have been admitted to the home since the last inspection. Discussion took place with a resident who has recently been admitted to the home, their comments included, “before moving in somebody from here came to see me in my home to talk about the help that I need”, “I was given information about the home before I moved in”. Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 10 Surveys showed that people received enough information about the home before they moved in so they could decide if it was the right place for them and that they have received a contract. The files for two newly admitted residents were looked at. They contained needs assessments, which were carried out by the home prior to the person being admitted to the home. The assessments were detailed and covered things such as personal care, likes and dislikes, mobility, communication religion and culture, medication and personal safety. Need assessments and care plans produced by other health and social care services were also available in resident’s files. Northern Counties DS0000005405.V318876.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 good. This judgement has been made using available evidence including a visit to this service. Residents health and personal care is well supported which ensures their physical well-being however medication procedures carried out by staff at the home undermine this and have the potential to put residents health and safety at risk. EVIDENCE: A care plan has been developed for each person. 6 care plans were looked at in detail as part of the case tracking process. Case tracking showed that the care plans were developed on the basis of need assessments carried out by the home and other health and social care services. The plans set out in detail residents preferred routines and the action to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the resident are met. Care plans that were looked at showed that they are reviewed and up dated at least once a month with the full involvement of residents and/or their representative. Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 12 During discussion a number of residents confirmed their knowledge and understanding of care plans. They made the following comments, which supported this: “Yes I have a care plan, it gives staff information about the help that I need” “I know about my care plan, I helped with it” “My care plan tells staff about me and how they can help me” During interview a member of staff said “Care plans are important as they tell us about the person and what we need to do for them”. All surveys completed by residents indicated that they always receive the medical support that they need. Records showed that residents have access to specialist medical, nursing, dental, chiropody and GP services. The pre-inspection questionnaire detailed the arrangements that are in place at the home to enable residents to access other specialist services such as speech therapists and dieticians. The pre-inspection questionnaire provides details of a number of policies and procedures, which are available at the home, which relate to the health care of residents. They include control, administration, recording, safe keeping, handling and disposal of medication. The administration of breakfast and lunchtime medication was observed during the inspection visit. All medication was administered and recorded correctly by a senior member of staff. Medication and Medication administration records were looked at as part of the inspection. This showed that medication procedures are not always carried out appropriately and in accordance with the homes policy, which has the potential to put resident’s health and safety at risk. This was discussed with the manager. Throughout the inspection visit staff were observed treating residents with respect. Staff respected resident’s rights to privacy. They were seen knocking on resident’s bedroom doors before entering and carrying out personal care in the privacy of bathrooms and residents own rooms. Staff were observed talking to residents in a polite manner. Residents spoken with said that staff always treat them well and respect their privacy and dignity. They made the following comments to support this: “All the staff are very polite” “The staff are respectful” “Staff always talk to me and others politely” “Staff never come in my room without knocking first” “The staff will do anything for me” A district nurse and a volunteer were spoken with during the visit and made the following comments: Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 13 “The staff are always very helpful, respectful and polite” “Staff always treat residents well” Northern Counties DS0000005405.V318876.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 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Activities and routines carried out at the home ensure that residents enjoy a fulfilling and healthy lifestyle. EVIDENCE: The homes statement of purpose provides information about the services and facilities, which are available at the home. Residents are provided with the opportunity to exercise their choice in relation to leisure and social activities and cultural interests, food, meals and mealtimes, relationships, routines of daily living and religious observance. A resident’s friend made the following comment, “every effort is made to meet the varying needs of residents particularly in relation to their faith”. Care plans which were looked detail residents preferences and support needs in relation to social contact and activities. The pre inspection questionnaire described the facilities/activities available for residents both inside the home and in the community. They include a weekly shop, daily devotions, occupational therapy classes, use of the local library, and visits to churches, weekly quiz and sightseeing trips in the homes minibus. Residents spoken with talked about the things that they take part in and said that they are happy with the range of activities available at the home. Residents made the following comments: Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 15 “I play bingo, I like bingo” “I attend church and church meetings each week” “We have a quiz every week”. Surveys completed by residents indicated that there are always activities arranged by the home that they can take part in. An activities programme was displayed on the notice board in the hallway. The programme included religious services, hairdressing, a quiz and hymn singing. A visitor’s book was in place at the home. This showed that residents receive visitors at various times during the day and night. A number of residents received visitors on the day of the inspection visit. They were made welcome and offered refreshments. Residents and visitors spoken with said: “My family visit me every week” “There are no restrictions placed on visiting times, I can visit my mum at any time” “The staff are always very welcoming” “We can sit in the lounge or in my mums bedroom” “Staff always offer me drinks” During the inspection visit residents were offered choices and supported to make decisions about such things as were to sit, what to do and what to eat. Observation of a number of bedrooms showed that residents have brought personal possessions with them. Furniture, ornaments, pictures and plants were amongst some personal items that residents said they had brought with them to the home. A newly admitted resident said, “I brought some personal possessions when I moved in and am having other things brought in. Having my own things around me has helped me settle in”. Residents can have a key to their own room, during the visit a number of residents were seen using keys. For safety reasons there are certain restrictions placed on residents for example, use of keys, access without support to certain parts of the home and the community, management of money and medication. There are also instances when some decisions and choices have to be made for residents by others. Restrictions placed upon people and choices, which need to be made by others and the reasons why, were recorded in each person’s plan of care. The quality and choice of the food at the home is excellent. This was supported by the following comments made by residents during the inspection visit: “The food is marvellous” “The food is beautiful, it is quickly served” “I can always have more” Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 16 “The food is very good” “The food is absolutely superb” “The food is beautiful, we have fresh salmon each week” “We get a proper roast dinner on a Sunday” “We have 3 course meals” “I have a choice of food each day” The menu for the day was displayed in the dining room and a weekly menu was displayed on the notice board in the hallway. Breakfast and lunch was sampled. The food was of good quality, tasty and well presented. Staff served residents individually with their meals. The dining room was decorated and furnished to a high standard and was bright and cheery. Dining tables were attractively laid with good quality cutlery and crockery. Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the homes procedures for responding to concerns and complaints and for ensuring that they are safe from abuse, harm or neglect. EVIDENCE: There has been no complaints received by the Commission about the home since the last inspection. Information provided in the pre-inspection questionnaire and discussion with the manager and staff showed that there have been no complaints made at the home in the last 12 months. There was a complaints procedure on display at the home. It is also available in the homes statement of purpose and resident guide. Residents and relatives spoken with during the inspection said that have the information that they need to make a complaint if they wish to and they would feel confident about making a complaint. The following comments supported this: “I know about the complaints procedure, I would complain if I needed to” “I would definitly complain if I needed to” “I am confidient about complaining and I know it would be dealt with in the right way”. Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 18 Surveys completed by residents indicated that they always know who to speak to if they were unhappy and that they know how to make a compalint. Surveys completed by relatives, friends and advocates included the following comments: Everything at the home is excellent, we have no complaints at all. Never had any Concerns. Discussion with staff and details provided in the pre-inspection questionaire showed that staff have received protection of vulnerable adults training. During discussion staff showed a good understanding about what they need to do if they evidenced abuse. A copy of the local authorities protection of vulnerable adults procedure was avaialbe at the home. Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 19 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 excellent. This judgement has been made using available evidence including a visit to this service. Residents live in an environment, which is maintained to a very high standard, clean, pleasant and hygienic in all parts. EVIDENCE: The home is located in a popular residential area of Birkdale, Southport close to public transport links. Community facilities including churches, shops, cafes and community health centres are within close distance of the home. Parking is available at the front of the building and on the road outside the home. There are attractive gardens to the front, side and rear of the house, which are planted out with various plants, shrubs and trees. Both the inside and the outside of the home were maintained to a very high standard. The home has a good amount of communal space for residents use. They include two large lounges and a dining area located on the ground floor and a Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 20 number of smaller sitting rooms/areas on other floors. All parts of the home were furnished and decorated to a very high standard. The pre-inspection questionnaire detailed a number of improvements carried out at the home since the last inspection. They include the refurbishment of 11 bedrooms, the main lounge, TV lounge and hallway. Carpets and furniture have also been replaced in these rooms. These areas were viewed during a tour of the home, which took place as part of the inspection visit. All the work has been carried out to a very high standard. All parts of the home were clean, peasant and hygienic. Residents spoken with said that their rooms and other parts of the home are always kept clean and tidy. They made the following comments: ”My room is cleaned and my bin is emptied daily” “My room is always kept clean and tidy” “The chairs in the lounge are wiped over daily, when we got in for meals” The laundry, which is located in the basement, was equipped with sufficient washing and drying machines and ironing facilities. The laundry was clean and well organised. One service user said, “my clothes are laundered daily” another resident said, “I never have to wait long for my clothes, take today for example, my clothing was returned to me clean and smelling fresh only a couple of hours after I put it in for washing”. Detailed in the pre-inspection questionnaire and available at the home were a number of policies and procedures, which aim to ensure a clean and safe environment, they include infection control and disposal of soiled waste. Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 21 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 excellent. This judgement has been made using available evidence including a visit to this service. The staff team have the competence and qualities to met the needs of the residents. EVIDENCE: The staffing rota, which was examined as part of the inspection showed that there are sufficient staff on duty throughout the day and the night. Two members of staff were interviewed during the inspection. General discussion also took place with a number of other staff at intervals throughout the visit. Staff interviewed showed a good understanding of their roles and responsibilities and were very knowledgeable about the needs of the residents. Residents spoken were confident about the staffs ability to do their jobs. They made the following comments, which supported this: “Don’t know what I would do without them, they are so good” “The staff are very good, they will do anything for me” “All the staff here are good at their jobs” “The staff are excellent, they are very caring” Surveys completed by relatives, friends and advocates indicated that the care staff always have the right skills and experience to look after the residents properly. Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 22 Available at the home was evidence to show that staff complete training to update their knowledge and skills and that the training is linked to the aims and objectives of the home and the needs of the residents. Staff spoken with said that they have completed a lot of training and gave the following examples, health and safety, medication awareness, first aid and lifting and handling. A training programme, which was displayed on the wall in the main office, showed that staff receive a good level of training. The pre-inspection questionnaire and staff training records held at the home evidenced that at least half of the staff team have achieved or are currently undertaking a National Vocational Qualification in care level 2 or above. Training planned for the future includes palliative care, eye care and further NVQ training. Staff made the following comments about training: “I have been on a lot of courses” “The training helps me in my work” There has been a low turn over of staff working at the home. Discussion with the manager and details provided in the pre-inspection questionnaire showed no new staff have started work at the home since the last inspection. The staff team is stable and has been for sometime. The homes recruitment and selection procedures were assessed as part of the last inspection and found to be in good order. Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 23 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed to the benefit of the residents and staff. EVIDENCE: In February 2006 David Swan was approved by the Commission as the Registered Manager of Northern Counties. The manager is experienced and has a number of relevant qualifications that are required to meet the stated purpose and aims and objectives of the Home. Information detailed in the pre-inspection questionnaire and examination of a selection of records during the inspection showed that records required by regulation are available, up to date and accurate. Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 24 Residents and staff spoken with during the inspection were complimentary of the manager and the way he runs the home, the following comments, which were made, supported this: “The “The “The “The “The manager manager manager manager manager is supportive and approachable” is well organised” has an open door policy” runs the home very well” cares a lot for the residents” The health safety and welfare of residents are well protected this was supported by a comprehensive set of policies and procedures, which were detailed in the pre-inspection questionnaire and available at the home. Information provided in the pre-inspection questionnaire and examination of a selection of health and safety records showed that the required health and safety checks have been carried out on the environment at the required intervals, for example fire system checks, gas and electricity checks and environmental risk assessments. Staff and residents spoken with confirmed that they hear the fire alarm system regularly being tested. Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 25 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Medication must be administered to residents in the correct way to fully ensure their health and safety. Timescale for action 23/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Northern Counties DS0000005405.V318876.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Northern Counties DS0000005405.V318876.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. Re-publishing this information is in breach of the terms of use of that website. 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