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Inspection on 18/12/07 for Park View (Ilfracombe)

Also see our care home review for Park View (Ilfracombe) for more information

This inspection was carried out on 18th December 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

Plans of care now include a section about the individual, their social history and preferred routines. This helps staff understand the needs and wishes of the individual so that they can provide care in a consistent way. Since the last inspection a new conservatory has been built onto the entrance of the home. There is now a slope leading into this entrance, with only a small ridge at the entrance door. This makes access into the home much easier for those people who use wheelchairs or who have mobility difficulties and use a frame to walk.

What the care home could do better:

Plans of care, although improved could be further enhanced by making sure that where possible the individual or their family are involved the development and review of the plans. This would ensure that care could be planned in a way the individual wishes and prefers. Where individuals have reddened areas that could develop into pressure areas, the staff team, must ensure that the district nurse team is called in good time.This will ensure that correct dressings and procedures can be adopted to prevent the pressure area developing. One person`s daily notes showed that a pressure area had developed, but the district nurse team were not called in until some 6 days later. The home must consider how it is going to ensure that the social needs of the people who live there are met. There are very few activities on offer and some people were sitting for quite long periods with no social engagement. Two family members said that this was their one concern about the home. One said `` the care is good, but there is very little stimulation for the residents.`` Several of the people spoken to said they would welcome more opportunity to take part in activities and two also said they would like to get out on trips occasionally. Staff spoken to said that they did try to get people engaged in activities when time permits, but that it was often difficult to motivate people to join in. Al radiators should be covered to reduce the risks of burns and any checks on hot water outlets should be recorded as part of the ongoing quality audit of the home. The home needs to ensure that the views of the residents and their carers/families are sought to help improve the quality of care provided.

CARE HOMES FOR OLDER PEOPLE Park View (Ilfracombe) Furze Hill Road Ilfracombe Devon EX34 8HQ Lead Inspector Jo Walsh Key Unannounced Inspection 18th December 2007 09:00 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 Park View (Ilfracombe) DS0000022148.V352760.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. Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Park View (Ilfracombe) Address Furze Hill Road Ilfracombe Devon EX34 8HQ 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) 01271 865657 Mr Andrew S Crowe Mrs Maria Crowe, Mr Geoffrey Crowe Shirley Ann Darling Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (22) of places Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The manager must obtain the Registered Manager’s Award by 2006 The Manager must undertake NVQ 4 in care Date of last inspection 26th April 2007 Brief Description of the Service: Park View is a care home providing personal care and accommodation for 22 service users in the categories of old age (OP) and dementia, over 65 years of age (DE [E]). The home is situated in a residential area of Ilfracombe, adjacent to, and with direct access to, Bicclescombe Park. The Crowe family have run the care home over 20 years and it consists of a two storey building with a large car park situated at the rear of the property. All the private rooms are single and have en-suite facilities. There is a stair lift giving access to all areas of the home. The home has a conservatory, which is sited overlooking the garden at the side of the property and a sun lounge sited to the front of the property. The home has a designated resident smoking room, separate from the main lounge. The range of fee is £281 to £392 per week. The CSCI report is kept in the manager’s office and she will put up a notice in the front lobby to inform people that they are welcome to look at inspection reports if requested. Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second key inspection carried out this year by CSCI. The inspection took place during a weekday in December and lasted approximately 6.5 hours. During this time seven people who live at the home were asked their views about what it was like to live in Parkview. Time was also spent observing care practices and talking to staff on duty about their role, training undertaken and what their understanding was of individuals needs. The registered manager was available throughout the inspection and assisted in ensuring that key documents were made available for inspection. Records seen during this inspection included, plans of care, staff files, training records, medication records, menus and staff rotas. As this was the second inspection completed this year, surveys were not used on this occasion however five relatives of people who live at the home were contacted following the inspection as was the district nurse team. Their views and comments are included throughout this report, together with the views of those people who live at Parkview. Prior to the inspection the home completed an Annual Quality Assurance Assessment (AQAA), which gives us information about how the home maintains a safe environment, what training has been completed and tells us how they are reviewing their services to improve the care and support provided. This information helps to inform the inspection process. What the service does well: People spoken to who live at Parkview said • The staff are lovely • We are well looked after here • You couldn’t wish for better • It’s alright here One relative said ‘’I am more impressed than I expected to be, the care is very good’’ another said ‘’the carers are excellent, they do a very difficult job.’’ Parkview provides people with a warm homely environment. All bedrooms are en suite giving people a degree of privacy. The communal areas were decorated for the Christmas period and looked bright and cheerful. Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 6 Care and support is provided by a staff team that have remained fairly consistent, enabling them to get to know individuals needs and provide care in a consistent way. Staff have a reasonable level of training that enables them to do their job effectively. The home offers a good range and choice of food. People who live at the home said • The food is good, very tasty • The food is excellent • The food is alright, I have put on weight since I have been here • I enjoy the roasts Individuals’ special requirements, likes and dislikes are taken into consideration when the menus are planned. What has improved since the last inspection? What they could do better: Plans of care, although improved could be further enhanced by making sure that where possible the individual or their family are involved the development and review of the plans. This would ensure that care could be planned in a way the individual wishes and prefers. Where individuals have reddened areas that could develop into pressure areas, the staff team, must ensure that the district nurse team is called in good time. Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 7 This will ensure that correct dressings and procedures can be adopted to prevent the pressure area developing. One person’s daily notes showed that a pressure area had developed, but the district nurse team were not called in until some 6 days later. The home must consider how it is going to ensure that the social needs of the people who live there are met. There are very few activities on offer and some people were sitting for quite long periods with no social engagement. Two family members said that this was their one concern about the home. One said ‘’ the care is good, but there is very little stimulation for the residents.’’ Several of the people spoken to said they would welcome more opportunity to take part in activities and two also said they would like to get out on trips occasionally. Staff spoken to said that they did try to get people engaged in activities when time permits, but that it was often difficult to motivate people to join in. Al radiators should be covered to reduce the risks of burns and any checks on hot water outlets should be recorded as part of the ongoing quality audit of the home. The home needs to ensure that the views of the residents and their carers/families are sought to help improve the quality of care provided. 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. Park View (Ilfracombe) DS0000022148.V352760.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 Park View (Ilfracombe) DS0000022148.V352760.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential new people have their needs assessed prior to moving in, to ensure that Parkview are able to provide the care and support needed EVIDENCE: Since the last inspection there has been no new admissions. Information held on the newer people at Parkview shows that the registered manager completes an assessment of the personal and health care needs of the individual. Where possible people are invited to visit the home prior to moving in and the manager said that she always ensures staff have the assessment information prior to a new person moving in so that they can plan for their care. Staff spoken to said that they usually discussed any new people moving in and any essential information is written on a white board in the staff room. Staff said that as it is a small home they quickly get to know new people, and try to Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 10 meet their needs within a routine that suits the individual. One staff member discussed that fact that a few people like to get up later so they leave them until last for their morning routines. Park View (Ilfracombe) DS0000022148.V352760.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): 7-10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although plans of care help to provide consistent personal care, some improvements are needed to ensure that health care needs are fully met in a timely fashion and that the medication procedures are more robust. EVIDENCE: People spoken to who live at Parkview said • The staff are lovely • We are well looked after here • You couldn’t wish for better • It’s alright here One relative said ‘’I am more impressed than I expe4cted to be, the care is very good’’ another said ‘’the carers are excellent, they do a very difficult job.’’ Three plans of care were looked at in some detail. The plans are now more detailed and include a personal history and preferred routines of individuals. This helps staff to provide care in a more consistent way and how the person Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 12 wishes. The plans are reviewed monthly, but usually this is simply an initial to say they have been reviewed. Good practice should include some comments about how the individual has been over the month, with a clear indication as to whether there have been any changes to their plan of care. It would also be helpful if plans were shared and developed with the individual and/or their family member. The registered manager says she has begun to do this for newer people. All plans should if possible include the views of the individual it concerns. People who live at the home said that their personal and health care needs were met, although one did say they had to wait a while sometimes for their call bell to be answered. One relative spoken to said that the staff team were good at keeping in touch and following up on health care needs. One plan of care looked at reported that an individual had developed a pressure area, which the staff team treated, but a district nurse was not called to assess the pressure area until six days after it was first reported. This was discussed with the registered manager. It is essential that the home ensure that health care professionals are called in good time so that the right treatment can be arranged. Medications are kept secure and records well maintained for the administration of medications. The home are advised however that where a medication is prescribed as needed (PRN), there should be clear directions in the plan of care for staff. This should include details of when and why a PRN medication should be considered. Whenever the medication states one or two tablets, the staff need to make clear on the medication records whether one or two have been given. One persons records states that their morning medication had been found in the downstairs toilet, and for staff to be aware that they need to ensure they swallow the medication. All staff should be aware that medications should only be signed on the medication records as administered once they have witnessed the person taking it. One person’s medication records had been altered in respect of the dose of medication they were taking. There was a record of why this was done in the person’s daily records, but any changes should be signed by two people as this helps to prevent errors occurring. A pot of cream prescribed for an individual who had died some months previously was found in the staff toilet. The home are reminded that all medications should be returned if the person leaves the home for any reason. During this inspection staff were observed interacting and providing support in a caring and respectful way. One person said ‘’they treat us really well, you couldn’t ask for better.’’ Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 13 Park View (Ilfracombe) DS0000022148.V352760.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): 12-15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Routines are flexible and contact with family and friends is encouraged and supported, but some improvements are needed to ensure social activities meet people’s expectations and preferences. EVIDENCE: Staff spoken to said that they ensure that individuals routines and preferences for getting up and going to bed are supported and gave examples of individuals who preferred to get up later, have their breakfast later and others who liked to be up early, have a morning cup of tea in bed. People who live at Parkview said they were able to choose when they got up , where they spent their day and what time they went to bed. One person said ‘’I go out with my family a few times a week and staff keep my meal for me if I need it.’’ There are only a limited number of planned activities offered, which include a prayer meeting, visits by the local victor and occasional entertainment. During Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 15 the Christmas period for example local school children had been in to give a carol concert and paid entertainers had preformed a play. Several people who live at the home they would like more activities to be offered. One person said ‘’ there’s just so little to do, it can be very boring.’’ Another said ‘’there should be a car available to take us out on trips occasionally’’ Four of the five relatives contacted said that they would like to see more activities offered. One said ‘’ they do not seem to offer much stimulation for people, despite the fact they advertise an activities programme is available, I have seen very little evidence of this.’’ All relatives spoken to said they were made welcome and could visit at any time they wished. Staff spoken to said that they do try, when time permits to get people involved in games and activities, but most people are reluctant to join in. This issue was discussed with the registered manager, and it was agreed this is an area the home needs to work at improving. The registered manager said she had been in contact with another home to see what activities they offered, but had been unable to resource any entertainers on a regular basis. The manager is looking at how she can involve family in helping her to look at a more regular activities programme for the coming year and is aware this is an area they need to concentrate on. The menus were looked at and the lunchtime meal was sampled with the people who live at the home. The registered provider continues to do much of the cooking and they plan menus around individuals’ likes and dislikes. A menu board is displayed in the main lounge and people are asked what their preferences are for tea time. People who live at the home said • The food is good, very tasty • The food is excellent • The food is alright, I have put on weight since I have been here • I enjoy the roasts • The food is still grim, they should employ a proper cook Overall the home appears to offer a good choice and range of meals, with individuals likes and dislikes taken into consideration. There is one option for the lunchtime meal, but the manager stated that they are aware of what people like or dislike and an alternative is offered if necessary. Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at Parkview, their family and friends can be confident their views and concerns will be listened to and acted upon. Good processes are in place to keep people safe. EVIDENCE: People spoken to who live at the home were mostly confident that their concerns would be listened to. One person said they had raised the same concerns over and over again and nothing was done about it. This issue was discussed with the registered manager and we are satisfied that all issues have been followed up. There have been no new complaints since the last inspection and only one issue raised with CSCI who passed this on to the registered provider and manager. The manager gave a full response to the issues and we are satisfied that this was dealt with in a fair and proper manner. The home has a robust recruitment process that ensures staff have all checks completed in order to protect residents. Staff also have training in looking out for abuse, and those spoken to appear aware of what they should do, if they suspected abuse. Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 17 Residents’ finances are appropriately managed and records seen showed they were accurate and kept up to date. This also further protects residents. Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 18 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 good. This judgement has been made using available evidence including a visit to this service. Parkview provides a clean homely and relatively safe environment for the people who live there. EVIDENCE: Since the last inspection a new conservatory has been built onto the main entrance, with a ramp into the building. This makes accessibility much easier for people with limited mobility and those needing to use wheelchairs. The home has a main lounge/dinning area where most people choose to spend their time. There is also seating in the conservatory, although this was very clod on the day of the inspection and consideration should be given to providing some form of heating so this area can be used during the winter months as clearly some people enjoy sitting in this area, where there is good natural light. Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 19 There is also seating in the entrance hall, a small room for smoking and a sun lounge off the main lounge, which again was very clod on the day of the inspection. The registered manager said that they are looking at improving the walkways around the house as several people enjoy going for walks around the home, but some of the pathways are uneven and could present as a risk. One relative said ‘’ I have seen some improvements in the building over the last year, they now have lovely garden furniture for people to sit out in the warmer weather.’’ Not all radiators are covered, so could present as a risk. The registered manager said they have risk assessed radiators and those in areas where staff are not often present such as bedrooms have been covered. Regular checks are made on all hot water outlets, but this is not recorded. The registered manager was advised to record all such checks. They have installed two thermostatic valves on taps in individuals’ en suites, where a risk was identified. All baths have similar valves fitted to ensure that risks form scalds form hot water is minimised. Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 20 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): 27-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff group are experienced and sufficiently trained and supported to ensure the needs of the people who live at the home are well met. EVIDENCE: The staffing levels are sufficient to ensure that the personal needs of the people who live at the home are met. Normally there is three staff on each morning shift and two for the afternoon staff with two waking night staff. The home also employs a cleaner five mornings per week and the registered provider does most of the cooking. Whilst this staffing level is sufficient to meet all care needs, consideration should be given to whether this needs to increase to ensure that individuals’ social needs are more fully met (see section on daily life and social activities) Staff spoken to said there were good opportunities for training, and the registered manager said that they have over 50 of staff having completed nationally recognised training in care practices (NVQ2 or above). Staff records show that staff have updated training in areas of health and safety to ensure they can do their job safely and effectively. Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 21 The staff files of the two newest members of staff were seen and relevant checks and references had been taken up to ensure that individuals were suitable to work with vulnerable adults. Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 22 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): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed although improvements are needed to show how Parkview is run in the best interests of the people who live there. EVIDENCE: The registered manager has now completed her registered managers award, and is awaiting the results of this. She will need to also complete NVQ4 in care. She has worked at the home for many years and has good knowledge and experience of individuals needs. She normally has one day where she is addition to the compliment of staff to complete any managerial tasks. This is an inadequate amount of time to ensure she can fully do her job to good Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 23 effect. She has been unable to ensure that all staff have regular recorded supervision sessions, where they are given the opportunity to discuss their roles and responsibilities. This is an important process to ensuring all staff have good support to do their job effectively and competently and the registered provider needs to look at ensuring the manager has more time to complete her duties to good effect. The registered manager has been unable, due to lack of time, progress any further with looking at ways they can ensure the views of the people who live at the home are used to improve the quality of care. Although the home has asked people who live there to complete questionnaires, these have been too vague and nothing has been done with this information. It was agreed that questionnaires need to be more focused on specific issues relating to care at the home and that the results of any surveys should be used to help improve the quality of care provided. The home should also ensure that monthly checks are recorded on such things as hot water outlets and these could form part of their quality assurance plan. The records for handling residents’ fiancés was checked and found to be accurate and up to date. This ensures residents are protected. Information provide by the home prior to the inspection shows that they have up to date policies and procedures in place for all safe working practices, staff have training in these areas to ensure both they and the people they support are safe. The registered manager and provider do need to make sure that any checks made on health and safety are recorded, such as checks to ensure hot water is at a temperature that would not pose a scalding risk. The fire logbook and accident and incident book were seen during this inspection and were well maintained and up to date. All new staff has an induction programme to ensure that they understand working safely. They use a company to provide this information, and should check that the induction programme is still in line with recommended national standards. Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 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 2 X 2 X 3 X X 3 Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 25 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 15 Requirement Care plans must include risk assessments and be developed and reviewed with the resident and/or their representative. (Previous date set for compliance 30/10/06 and 30/09/07) Timescale for action 30/03/08 2 OP9 13(2) 3 OP12 16(2)(m) 28/02/08 The home must ensure that robust procedures are in place for recording medications. This relates to ensuring staff record whether one or two tablets have been administered, where any changes to medication records are made two staff members sign and ensuring that individuals have taken their medications before recording that it has been administered. The home must provide a regular 30/03/08 programme of activities that suits the needs of the people who live there Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 26 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. Refer to Standard OP19 Good Practice Recommendations The home should replace some of the old worn furniture in the communal areas and refurbish the sun lounge area. The home should ensure that all radiators are covered or have guaranteed low temperature surfaces. The manager should ensure she completes her NVQ4 in care and be given adequate time to complete her managerial duties. The home should ensure that the results of any surveys completed are collated and results made available to residents and CSCI. The results should be used to improve the quality of care and support provided. The home should ensure staff receives training in infection control and the Mental Capacity Act. The home should ensure that where checks are made on health and safety issues to ensure a safe environment, these checks should be recorded. 2. 3. OP25 OP31 4. OP33 5. OP38 6. OP38 Park View (Ilfracombe) DS0000022148.V352760.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Park View (Ilfracombe) DS0000022148.V352760.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. 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