Inspection on 13/02/07 for Old Wall Cottage

This inspection was carried out on 13th February 2007.

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

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

Other inspections for this house

Old Wall Cottage 20/06/08

Old Wall Cottage 06/06/07

Old Wall Cottage 14/12/05

Old Wall Cottage 09/08/05

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Old Wall Cottage Old Reigate Road Betchworth Surrey RH3 7DR Lead Inspector Lesley Garrett Unannounced Inspection 13th February 2007 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 Old Wall Cottage DS0000064426.V327617.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. Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Old Wall Cottage Address Old Reigate Road Betchworth Surrey RH3 7DR 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) 01737 843029 01737 845223 European Healthcare Group plc Mrs Glenys E Scadden Care Home 43 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (20), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (32), Old age, not falling within any other category (6) Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may accommodate up to: 32 residents within MD(E), 20 within DE(E), 6 within OP and 2 within DE. The age range of residents accommodated will be: 65 years and over with 2 female residents being under the age of 65 years. Up to 2 (two) beds may be used for respite care. Date of last inspection 22nd August 2006 Brief Description of the Service: Old Wall Cottage is a care home providing care and accommodation for fortythree older persons some of whom have dementia. The home is located in Betchworth Village near to Dorking Town. The home provides accommodation in twenty-four single and nine double rooms on one floor except for the three rooms in the attic. There is communal space available, including a well maintained garden to the rear of the property. Electronic gates leading to a car park in the front of the home also secures the home. Old Wall Cottage is now part of European Health Care Group Ltd. since May 2005. The fees for the rooms are between £525 and £800 Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of a key inspection and took place over seven hours commencing at 0915 and finishing at 1625. Mrs L Garrett regulation inspector completed the visit. The registered manager assisted the inspector with the inspection process and members of staff were interviewed. During the site visit the operations manager joined the inspector for feed back along with the deputy manager. A tour of the premises took place and the inspector met some service users and viewed their bedrooms. Verbal feedback from service users was limited as a result of their mental health needs. A pre-inspection questionnaire has been completed by the service and the information provided will assist with this report. Feedback has also been received from ‘comment cards’ completed by service users and their relatives. Records were sampled as part of the inspection process including care plans, policies and procedures and employment records. The inspector would like to thank the service users and staff for their time, assistance and hospitality during this site visit. What the service does well: What has improved since the last inspection? The requirement that was made for the home to consult with other health care professionals for advice with tissue viability has now been met and it was reported by the manager that the district nurses visit and give advice. Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 6 What they could do better: There are still two outstanding requirements from the inspection in December 2005 and this includes representatives being involved and signing care plans. The shower is still not working and this remains unchanged since December 2005. With respect to home environment, requirements were made and can be seen in detail at the end of the report but the main areas for improvement relate to the maintenance, decoration and general upkeep of the building. This includes the garden where items of furniture and wheelchairs have been placed and need to be stored or disposed of. Improvements in these areas will ensure that the service users have a safe and well-maintained home to live in. Health and safety issues were also raised during this visit, which concerned the two rooms on the lower ground floor and the attic rooms. A requirement was made for the home to consult with the fire, health and safety or environmental health departments to check the safety and suitability of these rooms. This will ensure that service users’ welfare and safety are promoted and protected. There was a malodour in the two rooms, which the manager said came from the oil central heating boiler and this also needs to be checked for the welfare of the service users in those two rooms. Some items of equipment in use with potential safety and restraint implications had not been risk assessed and documented in care plans. For example, the use of bucket chairs and bedrails. One service user with behaviours that tested the service needs to have an improved care plan and risk assessment in place to ensure that their needs are appropriately met. Care plans were not generated from the assessed needs of the service user and therefore the home could not demonstrate that these needs will be met. The home should also develop an effective quality audit system, which seeks the views of the service users or their representatives and other stakeholders, and the outcomes form part of the home’s development plan. Please contact the provider for advice of actions taken in response to this Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 7 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. Old Wall Cottage DS0000064426.V327617.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 Old Wall Cottage DS0000064426.V327617.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): 3&6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While pre-admission assessments are undertaken it was not evident that care plans were generated from these and therefore service users or their representatives cannot be confident that their needs will be met. The home does not provide intermediate care. EVIDENCE: The manager stated that the deputy manager or a senior registered nurse carries out all the pre-admission assessments prior to service users moving into the home. The manager following a requirement at the last inspection has recently updated the assessment documentation used. The manager showed an example of a recent assessment undertaken and stated that these assessments are kept in the individual folders of the service users and care plans are generated from this document. Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 10 The inspector sampled three individual plans and there was no evidence of the pre-admission assessments in their folders and no evidence that the care plans were generated from this document. The files sampled related to service users who had been at the home for some years. The service user who was the subject of the recent assessment shown to the inspector had not been admitted to the home so this was not in an individual folder yet. The home does not provide intermediate care. Old Wall Cottage DS0000064426.V327617.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 poor. This judgement has been made using available evidence including a visit to this service. Service users have individual plans of care but they do not fully reflect the care and support that they require. Medication policies and procedures are in place and are used appropriately by staff to protect the service users and the privacy and dignity of the service users is respected. EVIDENCE: Three individual plans of care were sampled and the inspector found two different systems for documentation operating. The inspector spoke with the manager, deputy and the operations manger for the company who stated that new documentation was being developed but not in place yet. The plans that were sampled contained some individual care plans but very limited risk assessments. Two of the care plans had not been regularly reviewed and updated and for all three plans there was no evidence of service user or relative involvement. Two of the service users required bedrails and one a bucket seat but there was no risk assessment in place for these. Bedrails Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 12 and bucket chairs are potential forms of restraint and have safety implications if not used correctly. Appropriate risk assessments must be in place to protect the service users from harm. One service user was in her room and calling out ‘help me’ and ‘I want to go home to see my Mother’. The manager stated that this is the normal behaviour for that particular individual and that she had challenging behaviour. The manager also stated that the service user would often throw things at the staff and for that reason heavy objects are removed from her reach. The inspector observed a care plan in place for challenging behaviour but this did not indicate how to manage this behaviour or how often checks should be made when the service user was in her room. The care plan also did not demonstrate how adequate fluid intake would be achieved if drinks are not left within the service user’s reach. Due to the needs of this service user it was not possible to seek their views. The deputy manager told the inspector that the General Practitioner (G.P.) visits every week and is a good support to the home. The deputy also stated that he would also come whenever he is called and on the day of the site visit the G.P. came in the afternoon to visit three service users. The G.P. had returned a ‘comment card’ to assist the inspector with the site visit and this stated that staff demonstrated a clear understanding of the care needs of the service users. The manager stated that the home benefits from visits from the district nurses who will advise on wound care. The manager also told the inspector that the home’s registered nurses had all had training in wound care and used the district nurses for advice only. The deputy manager told the inspector that the home has recently changed their pharmacy and method of delivering service users medication. The home now uses the monitored dose system and the inspector looked at the medication charts of the three service users that the inspector had identified for sampling. It was observed that it was the beginning of the month and there was no gaps noted on the charts and no hand written entries. The clinical room is very small and is housed in the lounge and the medicine trolleys are kept separately in the lounge secured to the wall. The deputy manager told the inspector that there are no policies in place for collection of medication out of hours for example evenings and weekends and this will be a recommendation at the end of the report. Shared rooms are available at the home and during the tour of the building the inspector observed that privacy curtains had been fitted to ensure the privacy of service users during personal care. The inspector noted staff knocking on bedroom doors prior to entering and using service users preferred name. The inspector observed that in the individual plans of care the name that service users would prefer to be called was documented. Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a programme of activities, which could be further, developed to meet service users recreational needs and preferences. Contact is maintained with family and friends and service users are helped to exercise some choice over their lives. Service users receive a balanced diet but the dining room is one of the communal areas that need improving. EVIDENCE: The manager told the inspector that the home benefits from an activity organiser who works part time. She will organise a range of activities with groups or on a one to one basis and these include painting, cooking with the chef, quizzes and hand massages. The manager stated that an outside provider comes in once a week to provide exercises. On the day of the site visit the inspector observed service users joining in with an exercise class, which involved service users hitting a balloon with bats. The manager also stated that every month an entertainer comes to Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 14 the home to play the piano and that service users enjoy singing. The manager said communion is available every month provided by the local vicar. Due to the needs of the service users it was not possible to gain any feedback on the provision of activities within the home. For this reason the home should consider developing more activities during the week and for social care plans to be written with information gained from relatives or friends of the service users. A ‘comment card’ returned by a service user relative said that they thought the activities could be improved The manager stated that visitors are welcome at any time and if they would like to they can have a meal with their relative or friend. The manager stated that the home does not have any volunteers but a bible study group does visit the home every week. The manager said that no service user is able to handle their own money as a result of their needs. Choice is given where it is possible but for meal choices the manager stated that the staff would speak to relatives or friends to determine service users food preferences. The inspector observed that many of the bedrooms had been personalised and service users can bring in items of furniture from home. The inspector met the chef who stated that the environmental health department had visited the previous month and had made only one comment that the kitchen was a little small and cluttered. The chef showed the inspector the new storage containers that had been purchased to address this issue. The chef told the inspector that he has a five-week menu cycle. Cooked breakfasts are available and a range of fresh fruit and vegetables. He stated that food has a high calorie count and on the day of the site visit the morning coffee was made with whole hot milk instead of water. Service users eat their food in the communal dining room, which would benefit from decorating or refurbishment to improve the facilities for the service users. Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives can be sure that any complaint will be taken seriously and acted upon, and are protected from abuse as staff had good knowledge of the safeguarding procedures. EVIDENCE: The manager told the inspector that a log of all complaints is kept at the home. Three complaints were received last year and all resolved within the time scales. The inspector observed a complaints policy displayed which is also available to all service users representatives. The manager showed the inspector the homes safeguarding adult’s procedures and this matched the local authorities procedures. Staff receives training in these procedures and the inspector saw certificates. The inspector had the opportunity to speak with some staff members who demonstrated a good knowledge of the safeguarding adult’s procedures and what they understood abuse to be. Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The environment was generally clean but is not well maintained and some areas in the home are not safe. EVIDENCE: The inspector had a tour of the building, which included all communal areas, most of the bedroom and the kitchen and laundry. The gardens were also seen at this time. During the tour the inspector observed some health and safety issues, which will be reported in the outcome group under the heading management and administration. The inspector observed that some of the service users bedrooms had been decorated but the home does not have a programme of routine maintenance for the renewal of the fabric and decoration for the premises. Some of the carpets are worn and stained and some of the bedrooms floors are covered in Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 17 a waterproof covering not carpet. Some of the furniture in the bedrooms and communal areas are worn and there should be a programme of renewal as some bedrooms have only one chair for the use of the service user. One bedroom had an offensive odour the manager stated that the carpet is cleaned regularly but the carpet now needs replacing. The inspector observed that a large number of beds in the care home are the divan type. The service users at the home are increasingly frail and the manager should carry out a risk assessment on all beds to ensure that all service users have the appropriate equipment required for their needs. During the tour of the building most of the bathrooms had baths that were domestic in character making it difficult for service users to access with assistance. A previous requirement was made to repair the shower on the ground floor and this has still not been addressed. The manager needs to complete an assessment to seek the views of the staff team to see how baths are being carried out in the home and to organise for the shower to be properly maintained and repaired. There are many corridors in the home with steps leading to some bedrooms. There are no ramps available making movement around the home in wheelchairs difficult or when trying to move a hoist when necessary. Risk assessment must be carried out for the communal areas and ramps fitted where necessary in order to improve access and safety. Some of the bedrooms had extra radiators placed in them and the rooms felt cold. The manager stated these had been placed there, as they were colder rooms. Even though these rooms had the benefit of the extra heater, the heaters were not in use and the room felt cold. The heating system is discussed further under the management outcome group in the report. The inspector spoke with the laundry person who works full time and is assisted by another member of staff who works part time. The laundry is small and cluttered. The manager stated that this was an area that was planned for refurbishment. The laundry person said that she had received training in infection control and that the laundry was cleaned regularly. Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff are trained and competent to do their jobs, however staffing numbers are in need of review to ensure that they are sufficient to meet the needs of service users. There were some gaps in recruitment practices, which should to be addressed in order to ensure that service users are fully protected. EVIDENCE: Prior to the site visit ‘comment cards’ had been sent to relatives/visitors, the general practitioner and other health care professionals and all were complimentary about the staff. Thirteen relatives responded and only one ‘comment card’ said that they thought staff numbers were low at weekends. The inspector discussed staffing numbers with the manager and the ratios of care staff to service users must be determined according to the assessed needs of the service users. The manager stated that due to the client group many service users wake early and the night staff get these service users up washed and dressed. During a tour of the building the inspector observed that some service users were being nursed in bed and one was in isolation due to challenging behaviour. The manager must review the staff numbers, as the staff are also responsible for the stimulation and activities when the coordinator is not available. Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 19 The manager stated that over 50 of the carers have the national vocational qualification at level 2. Care staff told the inspector the qualifications they had prior to joining the home and that they undertook regular training whilst working there. The inspector sampled three employment records and although most of the checks were in place there were some shortfalls. References obtained for a registered nurse that works for another establishment in Surrey did not have a reference from her current manager at the other care home. A work permit did not match the home that the member of staff was working in. The administrator checked the legislation with the home office during the site visit and confirmed that care staff could work twenty hours at another establishment without the need for a further work permit. All folders should have proof of identity to include a recent photograph. The manager should review all employment records to ensure that they meet the current regulations. The manager and the operations manager stated that all training is provided in-house and that only manual handling is provided by outside providers. The operations manager said that the company has not got the training systems fully in place yet and that the company is in a transition period. She stated that a training grid is being developed but this has not been completed. The manager stated that mandatory training takes place and this includes safeguarding adults, fire safety and food hygiene. Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager is appropriately qualified and fit to be in charge of the home however the home is not run in the best interests of the service users. Service user’s financial interests are safeguarded, but health and safety arrangements in the home do not ensure that the health, safety and welfare of service users is promoted and protected. EVIDENCE: The manager told the inspector that she is about to retire and that interviews are taking place in order to replace her as soon as possible. She has been at the home for nearly two years and is supported by a deputy manager. Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 21 The manager has developed a regular audit system to improve the quality systems within the home and these include medication, care plans and maintenance. The manager said that no regular service user or relatives meetings take place. The manager said that she had completed a survey of the relative’s views last year but these were not available on the day of the site visit. The manager needs to develop an effective system to seek the views of service users their relatives or representatives and other stakeholders in order to incorporate this into the service development plan. The manager told the inspector that no service user personal money accounts are kept at the home. During the tour of the building the inspector observed some health and safety issues and these were discussed fully with the manager and the operations manager for the company. The operations manager said that the provider was visiting the home the next day and that some of the issues may be addressed. The inspector visited two rooms that are accessed by some steps. There are only two bedrooms on this lower ground floor and they share a corridor with the boiler room. The corridor door has to be closed at all times as this is a fire door but the inspector noticed a smell in the corridor that the manager confirmed was the smell of oil coming from the boiler. The inspector made a requirement that the home consults with the appropriate authority; health and safety or fire, for them to assess this area and to confirm it is suitable for use by service users. A steep and narrow staircase accesses the three attic rooms and service users can gain access to their rooms with the aid of a stair lift. The manager stated this had been serviced in July 2006 but was told that parts are no longer available so should it break down it would not be repairable. The inspector also advised the manager to discuss with the appropriate authority about rooms at this level and means of escape in the event of a fire. Service users on this floor are unable to use the bath and therefore have to take baths on the lower floor. The inspector had the assistance of a pre-inspection questionnaire to check compliance width some health and safety checks. There was no date given for the central heating check and the manager stated that this has never been carried out. The maintenance person has recently retired therefore some of the regular checks have not taken place for example fire alarms and emergency lighting. Flushing of the showerheads to comply with the Legionella guidelines has also not been carried out. The communal areas and bedrooms had poor lighting and this should be improved to enhance the health and safety of service users. The gardens were accessible and the manager stated that they were well used by the service Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 22 users during the summer. The inspector observed that under the veranda was old chairs, armchairs and wheelchairs and this area needs to be tidied and unused items disposed of where necessary or storage found for them. One ‘comment card’ returned to the inspector said that the garden often looked untidy. Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13(8) Requirement The registered persons must ensure that on any occasion on which a service user is subject to physical restraint the circumstances shall be recorded including the nature of the restraint. Risk assessments must be in place for the use of bed rails and bucket chairs. The registered persons must ensure that the service users assessed and identified needs are met and documented in the care plan and that the care plan is available for the service user or their representative and it is kept under regular review. The registered persons must ensure that they promote and make proper provision for the health and welfare of service users and that any service user with challenging behaviour has the appropriate risk assessments and care plans in place. The registered persons must ensure that all parts of the care home are kept clean and reasonably decorated. There DS0000064426.V327617.R01.S.doc Timescale for action 28/03/07 2 OP7 15 28/03/07 3 OP8 12(1)(a) 28/03/07 4 OP19 23(2)(d) 28/05/07 Old Wall Cottage Version 5.2 Page 25 5 OP22 16(2)(c) 6 OP22 23(2)(n) 7 OP26 16(2)(k) 8 OP27 18(1)(a) 9 OP33 24 10 OP38 13(4)(a) must be a programme for redecoration and replacement of carpets, curtains and furniture. The registered persons must ensure that rooms occupied by service users have adequate furniture, bedding, and other furnishings including curtains and floor coverings and equipment suitable to meet the needs of service users. The registered persons must ensure that suitable adaptations are made, regarding ramps in the home, for service users who are old and infirm or physically disabled in order to improve access and safety. The registered persons must ensure that all parts of the care home are free from offensive odours. The registered person must ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. A review must take place of the staffing numbers and arrangements in the home to ensure service users needs are met. The registered persons must ensure that the home develops an effective quality audit system, which seeks the views of the service users or their representatives and other stakeholders, and the outcomes form part of the home’s development plan. The registered persons must ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to DS0000064426.V327617.R01.S.doc 28/05/07 28/03/07 28/03/07 28/03/07 28/04/07 28/03/07 Old Wall Cottage Version 5.2 Page 26 11 OP38 16 12 OP38 23(2)(o) their safety and risk assessments must be obtained for the rooms on the lower ground floor and the attic. The registered persons must 28/03/07 ensure that they consult with other agencies for example fire and health and safety to ensure the suitability of the two rooms on the lower floor and the attic rooms. The registered persons must 28/03/07 ensure that external grounds are suitable, safe and appropriately maintained: the rubbish and furniture located under the veranda area must be removed or disposed of. 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 OP9 Good Practice Recommendations It is recommended that the home further develops the social contacts and activities in the home and that this is documented to reflect the needs of the service users. It is recommended that the person responsible for the recruitment folders review them to make sure all the necessary checks are in place. Old Wall Cottage DS0000064426.V327617.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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