Inspection on 14/11/07 for Overton House

This inspection was carried out on 14th November 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

Overton House 15/11/06

Overton House 03/03/06

Overton House 08/06/05

Overton House 24/02/05

Overton House 19/08/04

Overton House 16/02/04

Similar services:

Dystlegh Grange

Thornton Lodge

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

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

CARE HOMES FOR OLDER PEOPLE Overton House 2 Newton Avenue Longsight Manchester M12 4EW Lead Inspector John Oliver Unannounced Inspection 15th November 2007 10:00 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 Overton House DS0000021573.V351282.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. Overton House DS0000021573.V351282.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Overton House Address 2 Newton Avenue Longsight Manchester M12 4EW 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) 0161 273 2555 Mrs Angela Asomaning Mrs Angela Asomaning Care Home 19 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (1), Old age, of places not falling within any other category (19), Physical disability (1) Overton House DS0000021573.V351282.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 service user of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Mental disorder - over 65 - Code MD(E) (maximum number of places 1) Physical disability - Code PD (maximum number of places 1) The maximum service users who can be accommodated is: 19 2. Date of last inspection 15th November 2006 Brief Description of the Service: Overton House is a privately owned residential care home providing personal care and accommodation for 19 older people. The home is located in the Longsight district of Manchester. Longsight is a multicultural residential area, which is close to the city centre and is within reach of good transport links to Stockport and surrounding areas. The home is a large Victorian style property. It is located on a corner plot by a busy junction of the A6. Bedroom accommodation is on the ground and first floors. There are 3 single and 8 shared bedrooms. All rooms have a wash hand basin and basic furnishings are provided. None of the rooms have en-suite facilities. There is a passenger lift. Accessible toilets and bathrooms are located on both floors near to bedrooms and living rooms. There are two lounge facilities on the ground floor, one of which is the designated smoking area. A separate dining room is available. Parking is limited to the roadway in front of the home. Fee charged by the home range from £357.53 to £500.00 Overton House DS0000021573.V351282.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken as part of a key inspection, which includes an analysis of any information received by us (the Commission for Social Care Inspection) in relation to the home prior to the site visit. This visit, which the home did not know was going to happen, took place over the course of 6.5 hours on Thursday 15 November 2007. During the course of the site visit we spent time talking to residents, the manager/owner, assistant manager and staff on duty to find out their view of the home. Before the site visit we sent the manager of the home an Annual Quality Assurance Assessment (AQAA) document for them to complete and return to us with information about the service they provide. This was returned to us before the visit took place and contained lots of information that helped us to assess the service being offered by the home. Again, before the site visit we sent questionnaires to residents, relatives, staff and other healthcare professionals such as doctors and district nurses for them to complete and return to us to tell us what they think of the service being provided. A number of these were returned before the visit took place and contained information that helped us to assess the service being offered by the home. We also spent time examining various files and written information and spent some time looking around the building. We were also provided with a copy of the Business Plan for the next twelve months. This document gave us information about the short, medium and long term plans for the home and the service. What the service does well: We found the atmosphere in the home to be relaxed, comfortable and informal and residents spoken to say that they could choose for themselves how they would like to spend their day. Staffing levels in the home were good and plenty of staff were available to make sure that supporting residents in meeting their individual needs was given priority. Staff told us, “(There are) always enough staff on duty and we never struggle”. Residents told us “There is always enough of them around (staff)”, “Staff help me whenever I need it” and “She (the manager) makes sure there is enough staff”. Overton House DS0000021573.V351282.R01.S.doc Version 5.2 Page 6 Information in care plans is very clear and a lot of time has been spent in making sure that individual residents get the support in the way that is most important to them. We saw from information in individual resident’s files that other healthcare professionals such as Community Psychiatric Nurses (CPN), District Nurses and General Practitioners (doctors) were all involved in supporting people to maintain a healthy life. We received some comments from healthcare professionals that included, “Good health care is given (including) regular psychiatric reviews (and) good personal care”, “…. These needs are very adequately met by the RMN (Registered Mental Nurse) Mrs Angela Asomaning and her staff”. We watched staff interacting with residents and this gave us a good indication of the staff’s commitment to supporting residents in meeting their needs and also showed that staff were respecting the privacy and dignity of individuals whilst providing that support. A good example of this was of a resident being encouraged to go to their room in order to get changed. The member of staff spoke gently to the individual whilst encouraging them to walk with them to their room without any other residents being made aware of what was happening. Residents told us that staff in the home were “Very good”, “They help me when I need it” and “I love living here because of the staff”. What has improved since the last inspection? What they could do better: It would be good if care plans and risk assessments were reviewed on a monthly basis to make sure information regarding any changes to the way in which a resident receives support and care is made available to all staff immediately. Overton House DS0000021573.V351282.R01.S.doc Version 5.2 Page 7 At present, no record is maintained by the cook of the food she prepares on a daily basis. Keeping such information would be good to support care staff in monitoring the nutritional intake for each resident. 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. Overton House DS0000021573.V351282.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 Overton House DS0000021573.V351282.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents’ needs were assessed prior to admission. EVIDENCE: Since our last inspection visit to the service there have been four new admissions into the home. We looked at the information contained within the files of those four people. All had relevant pre-admission assessments in place including comprehensive Nursing Needs Assessments and Multi-agency assessments. Two residents were on the Care Programme Approach (CPA) and relevant CPA review notes were in place. We were told that the registered manager and a senior staff member always visited a prospective resident in their own environment in order to carry out a Overton House DS0000021573.V351282.R01.S.doc Version 5.2 Page 10 full needs assessment to ensure that the home was suitable to meet the individuals’ needs. Copies of these assessments were seen to be on the files. We saw that arrangements had been made for one of these people to have regular visits and stays in the home before admission took place to help them make a positive choice about moving in. Overton House does not offer the service of intermediate care. Overton House DS0000021573.V351282.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 good. This judgement has been made using available evidence including a visit to this service. Care plans were in place that detailed the needs of the individual resident and supporting policies and procedures were in place to ensure the safe handling and administration of medication in the home. EVIDENCE: Care plans and risk assessments had been completed for each resident living in the home. These were comprehensive in content and gave clear guidelines to staff in how to support the person to meet their identified needs and goals. We saw that most care plans and risk assessments had been reviewed and updated where necessary however, the timing of the reviews was inconsistent and some had not been reviewed for a number of months which could result in people’s needs not being met in the most appropriate way. Staff told us that they were involved in the preparation and reviewing of the care plans and those spoken to were able to demonstrate a good knowledge and understanding of the individual needs of people living in the home. Overton House DS0000021573.V351282.R01.S.doc Version 5.2 Page 12 As part of the inspection process a number of survey questionnaires were sent to healthcare professionals and we asked them to comment on how they found the services offered by the home. They told us “Good health care is given (including) regular psychiatric reviews (and) good personal care” and “The clients are quite difficult to handle at times and some of them require skills of nurses rather than carers. These needs are very adequately met by the RMN (Registered Mental Nurse) Mrs Angela Asomaning and her staff”. During our visit a Community Psychiatric Nurse (CPN) and a District Nurse came to see particular residents, and from their conversation with the manager, it was very clear that the staff in the home were closely following any advice that had been given by the CPN and that there were good professional relationships. We spoke with a number of residents during our visit and they said that staff in the home were “Very good”, “They help me when I need it” and “I love living here because of the staff”. We were told that only managers and senior carers have the responsibility for administering medication in the home and all have had relevant training including Safe Handling of Medication via Manchester City Council. We checked Medication Administration Records (MAR) and found them to be appropriately signed and recorded. However, some entries of details of medication were hand written and we strongly recommend that where this needs to be done two members of staff complete this and sign to reduce the risk of errors in information occurring. All medication received into the home is recorded on the MAR and a spot check of some medication carried out by us confirmed that the balances were correct. Some medication such as Paracetamol (pain killers) is to be given as and when required in doses of 1 or 2 tablets. We saw that this medication had been administered appropriately but no record had been maintained of how many tablets had been given (1 or 2) making it difficult for us to track the balance of medication that should be left. It is important that balances can be checked to minimise the risk to residents from potential errors occurring. The manager told us that no resident was taking any type of Controlled Drug (CD) at the time we visited but she was aware that suitable storage facilities would need to be provided should anyone be prescribed this type of medication. Overton House DS0000021573.V351282.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had choice and support to meet their expectations and preferences regarding their daily lifestyle. EVIDENCE: On the day we visited the home the atmosphere was relaxed and informal. We saw staff assisting residents to get up and to have breakfast and we saw one resident enjoying breakfast in the dining room in his pyjamas and then went back to bed. The manager told us that various activities were available for people to participate in that included musical afternoons led by a member of the care staff team. One of the most popular activities is the ‘art class’ run by a visiting activities organiser. Various paintings done by the residents are displayed throughout the home. The residents are also entertained by visiting organisations to the home such as the Stockport Academy Theatre School who put on shows and other forms of entertainment. Overton House DS0000021573.V351282.R01.S.doc Version 5.2 Page 14 Residents are helped to maintain contact with people they wish to keep in touch with and visitors were welcomed into the home. A number of residents told us that they have regular visitors and that the staff make their visitors “very welcome”. Meals are planned over a 4-week period and include various choices as an alternative to the main meal of the day. On the day we visited the home the dinner time meal was roast pork, roast potatoes, fresh cauliflower, cabbage, swede and carrots and onion gravy or sausages and mashed potatoes with the vegetables and gravy. The cook told us that she asks the residents on a daily basis what they would like and then prepares meals accordingly and those residents we spoke to confirmed this. No record was maintained of the food prepared on a daily basis and although the cook told us that she probed food as it was cooking no record was kept of temperatures etc. It is important that such records are kept to minimise the risk to residents and staff. The cook told us that although she had completed a Basic Food Hygiene course this was over three years ago. It is important that any person with the responsibility for preparing or handling food has received the appropriate and up to date training to show that they can prepare and make food safely. It is also recommended that the registered manager contact the Food Standards Agency for further advice on this matter. All meats and vegetables are freshly purchased from the local community stores and ample stocks of tinned and fresh foods were available and the cook told us that she also purchased fresh foods that enabled her to prepare culturally appropriate meals for those residents who requested them. Residents told us about the food in the home and said “The food is good here”, “You can have what you want” and “I don’t like meat so I have fish”. Overton House DS0000021573.V351282.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had the relevant policies, procedures and systems in place to enable concerns to be raised and to protect residents from neglect and/or abuse. EVIDENCE: A clear complaints procedure was in place and a record of complaints was kept. On examining these records we noted that no complaints had been made to the manager since our last visit in November 2006 and the Commission for Social Care Inspection (CSCI) had received no complaints about the service. We received six completed staff survey questionnaires back and all indicated that staff understood what to do in the event of a complaint or concern being made. We received three completed relative/carers survey questionnaires back and again all indicated that they understood what to do should they need to raise a concern or complaint with the manager of the home. Residents told us “I would speak with Angela (manager)”, “I would talk with one of the girls or Angela” and “I would tell him (assistant manager)”. The home had a comprehensive policy for dealing with abuse including the Department of Health guidance “No Secrets”. The manager told us that since our last inspection visit no allegations had been made or referred to the Overton House DS0000021573.V351282.R01.S.doc Version 5.2 Page 16 Safeguarding Team. When we spoke with staff they confirmed they had received training in Abuse Awareness and had a clear understanding of the procedures to follow in the event of an allegation being made. Overton House DS0000021573.V351282.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall, the general environment of the home was clean, tidy and comfortable with systems in place to protect the safety of residents. EVIDENCE: On the day of our visit it was a very cold morning and we found all parts of the home were nice and warm and the home was found to be clean and tidy with no unpleasant odours detectable. We carried out a limited tour of the premises with the manager and we saw that a number of improvements had been made since our last visit in November 2006. Overton House DS0000021573.V351282.R01.S.doc Version 5.2 Page 18 New dining tables and chairs have been purchased and these had been chosen in consultation with the residents. This furniture improved the dining area and made it easier for residents to socialise during meal times. Whilst in the dining room we noticed that one pane of glass in the front window was cracked. This must be replaced in order to minimise any risk to residents or staff. We checked the lift, which had recently been fully serviced and has been upgraded to include sensors being fitted on the doors to minimise risk to residents. The lounge areas are comfortably furnished although some chairs are in need of replacement due to general wear and tear and this should be considered as part of the rolling programme of maintenance and refurbishment. The large lounge had recently been redecorated/repainted and was in the process of being further upgraded. The sash cords to the two windows identified to the manager must be replaced in order for the windows to stay open properly and to reduce any risk to residents or staff. A floor plate needed fitting to the edge of the carpet leading into the shower room near the office. This will help to prevent the potential risk to residents and staff from tripping. We viewed a number of bedrooms and found them to be comfortably furnished and the manager told us that some of the poorer quality furniture would be replaced as part of the rolling programme of maintenance and renewal. It is recommended that Room 8 is re-decorated and a new carpet laid as soon as possible as it was looking worn. New quilted bedspreads had been purchased for all beds. We noticed that in room 2 the radiator cover was damaged and in need of repair. This repair must be carried out to minimise any risk to the resident whose room it is. The upstairs bathroom was in the process of being fully refurbished and included a new bathroom suite with electric chair hoist, new toilet, tiling and flooring. New washing machines and dryers had been fitted in the laundry. Overton House DS0000021573.V351282.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff are employed in the home, with staff training and development helping to ensure staff are competent to carry out their jobs. A robust recruitment and selection process helps to protect residents from unsuitable people working in the home. EVIDENCE: The staff team in the home consisted of the registered manager, 2 assistant managers, senior care staff, care staff and ancillary staff. We saw that at least three week’s rotas were readily displayed in the home and examination of these rotas demonstrated to us that enough staff were on duty at any one time to meet the needs of the residents currently living in the home. Staff told us within the completed survey questionnaires that there is always enough staff on duty to meet the individual needs of all the people who use the service and staff we spoke to during the inspection visit confirmed this and told us that agency staff are never used to cover the rotas and that there is “Always enough staff on duty and we never struggle”. We were told by a number of residents that “There is always enough of them around (staff)”, “Staff help me whenever I need it” and “She (the manager) makes sure there is enough staff”. Since we last visited the home a number of new staff have been employed. We looked at the files of three of these staff and found that relevant preOverton House DS0000021573.V351282.R01.S.doc Version 5.2 Page 20 employment checks such as Criminal Record Bureau and POVA First checks had been carried out before the person started working in the home. However, it is recommended that further documentation such as a copy of a passport, birth certificate, work permit etc is obtained and put on file to further support a new employees application to work in the home. The manager told us that the majority of care staff has successfully completed National Vocational training Level 2 and we saw a number of certificates displayed in the hallway with a photograph of the member of staff. We saw that all staff had an individual training sheet but these were not up to date and so it was difficult to tell what individual training had taken place. We were told by the staff on duty that a lot of training takes place and comments received in questionnaires returned by staff included, “Up to date courses are on-going which gives us current information and experience needed to support residents efficiently and also makes us feel confident enough to face any needs arising in regard to race, ethnicity, faith etc” and “The service organises training courses for the staff to be more experienced and be more knowledgeable about the work we do so that we can give a better quality service to the residents”. The assistant manager told us that he had recently completed training in First Aid, Moving and Handling and Abuse Awareness. Overton House DS0000021573.V351282.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 good. This judgement has been made using available evidence including a visit to this service. Residents living in the home benefited from having the support of a manager with skills to provide and develop a good quality service and had procedures in place to promote and protect their interests. EVIDENCE: The registered manager of the home has completed various training courses and holds both the Certificate and Diploma in Management Studies. We were provided with a copy of the business plan (October 2007) and this identified many proposed developments for the home during the next twelve months. We were told that a chartered accountant maintains the business account to ensure financial viability of the home. We saw that appropriate insurance cover was in place and the certificate was prominently displayed. Overton House DS0000021573.V351282.R01.S.doc Version 5.2 Page 22 When we spoke with the manager about the services offered to people living in the home it was very clear that she was aware of the needs of people with varying degrees of disabilities including dementias. Both the manager and the staff team have developed good relationships with other healthcare professionals such as Community Psychiatric Nurses and Doctors and have used their knowledge and skills when necessary to meet some of the specific needs of some residents living in the home. We received a number of survey questionnaires back from healthcare professionals and comments included, “Angela (manager) and her staff will seek advice and help if they are unsure about an individuals’ healthcare needs” and “The clients are quite difficult to handle at times and some of them require skills of nurses rather than carers. These needs are very adequately met by the RMN manager – Mrs Angela Asomaning and her staff”. The manager told us within the Annual Quality Assurance Assessment (AQAA) returned to us that the maintenance and servicing of equipment used in the home had been carried out and a random selection taken from the service records during our visit indicated that all servicing and maintenance of equipment was up to date. The assistant manager had carried out a number of fire drills with various members of the staff team and the fire register indicated that the fire alarm system was tested on a weekly basis. The Fire Officer visited the home in June 2007 and the outcome of that visit was satisfactory with no issues of concern being recorded. Where the manager had responsibility for managing the personal allowance for any resident, individual records were kept and were available for examination on the day of our visit. All records were found to be appropriately kept and up to date. In order to measure the quality of the service being provided in the home, regular survey questionnaires are sent to both residents/relatives and visitors. Information received back in these questionnaires is then used to develop an action plan to address any particular issues raised. It would be good if the outcomes from such quality audits were published in the service user guide to inform potential residents of the results. Overton House DS0000021573.V351282.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Overton House DS0000021573.V351282.R01.S.doc Version 5.2 Page 24 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 OP19 Regulation 13 (4) (a)(b) & (c) (a) Requirement The cracked window pane in the dining room must be replaced. The sash cords to the two windows in the lounge identified to the manager must be replaced. A floor plate must be fitted to the edge of the carpet leading into the shower room near the office. The radiator cover in room 2 must be repaired. Timescale for action 20/12/07 (b) (c) (d) Overton House DS0000021573.V351282.R01.S.doc Version 5.2 Page 25 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 OP7 OP9 Good Practice Recommendations It is recommended that all care plans be reviewed on a monthly basis. Medicines prescribed as when required or, as a variable dose should have clear written criteria for staff to follow to ensure they are administered correctly. All handwritten medicine records should be an exact copy of the pharmacists dispensing label, which should be double-checked and counter signed, this should help prevent mistakes. 3. OP15 It is recommended that a record is kept of all food prepared and cooked in the home and that suitable training is arranged for all staff who are involved in any way in the preparation and handling of food and that advice is sought from the Food Standards Agency. It is recommended that room 8 be re-decorated and the carpet replaced as soon as possible as part of the rolling programme of routine maintenance and refurbishment. It is recommended that job application forms request a full work history from potential employees in order that any ‘gaps’ in employment could be further explored. It is recommended that training records for all staff are kept up to date. It is recommended that the results obtained from quality audits be published in the service user guide. 4. OP19 5. OP29 6. 7. OP30 OP33 Overton House DS0000021573.V351282.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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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