Inspection on 24/06/09 for Phoenix House

This inspection was carried out on 24th June 2009.

CQC 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 CQC 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

Phoenix House 21/04/08

Phoenix House 09/07/07

Phoenix House 24/11/06

Phoenix House 03/02/06

Phoenix House 27/09/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Phoenix House 54 Andrews Lane Formby Liverpool Merseyside L37 2EW Lead Inspector Trish Thomas Key Un Announced Inspection 24 June 2009 11:00 DS0000064015.V376057.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Phoenix House DS0000064015.V376057.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Phoenix House DS0000064015.V376057.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Phoenix House Address 54 Andrews Lane Formby Liverpool Merseyside L37 2EW 01704 831866 01704 831866 phoenix_house@hotmail.co.uk 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) Total Care Homes Ltd Sandra Farrell Care Home 30 Category(ies) of Dementia (1), Old age, not falling within any registration, with number other category (30) of places Phoenix House DS0000064015.V376057.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 users 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 Dementia Code DE (maximum 1) The maximum number of service users who can be accommodated is: 30 Date of last inspection 22 December 2008 Brief Description of the Service: Phoenix House is a care home for thirty older people situated in a quiet residential street in Formby, close to a bus route and train station. The home is a converted and recently extended Victorian villa with a car park at the front of the building and a garden at the back. There are two communal lounges one having a dining area, there is also a separate dining room. Bedrooms are situated on ground and upper floors and there is a passenger lift for use by residents who are accommodated on upper floors. The home has assisted baths and shower rooms and does not have a hoist. Phoenix House is staffed throughout the day and night, providing personal care, home cooked meals and a laundry service. All residents are registered with a GP of their choice and are supported to receive the services of district nurses and paramedical services if needed. The weekly charge for this service is £398 - £420 with extra charges for chiropody and hairdressing. Phoenix House DS0000064015.V376057.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars. This means that people who use this service receive good quality outcomes. This visit was just one part of the inspection. We also looked at other information we had about Phoenix House. Before the visit the home manager was asked to complete a questionnaire called the annual quality assurance assessment (AQAA). This tells us what they thought they did well, what they need to do better and what they have improved upon since our last visit, giving us up to date information about the service provided. This helps us to determine if the management of the home see the service they provide in the same way we do and if our judgements are consistent with homeowners or managers. During the visit we looked at various records and walked round the home. We spoke with a number of people who live at Phoenix House as well as visitors who were there and staff and they gave us their views about the home. What the service does well: There is a good system to introduce people to Phoenix House with information provided and needs assessments done, so they know their needs can be met in the home. The staff team have worked with people who use the service, developing care plans and risk assessments that are unique to them so that they receive the right amount of support and care to meet their needs. This ensures that people using the service make their own decisions and have the right to take managed risks in their daily lives. People’s spiritual needs are recorded so they can be given the opportunity and any help they need, to follow their chosen faith. People said they were satisfied with the care they receive and that staff are helpful and answer call bells without delay. There are procedures in place so that people who live in Phoenix House are able to express their concerns and be listened to, their rights are protected and they are safeguarded from abuse. We found that there is a thorough recruitment procedure followed when employing new staff and that training is provided and updated. This helps to make sure that staff are suitable to work with the people who live at the home. During our visit, staff were able to discuss their roles and responsibilities in depth and showed awareness of the support needs of the people who live in the home and how these should be met. A training aid has been written by the provider to ensure that staff will be aware of how to make a deprivation of liberty safeguarding referral under local Phoenix House DS0000064015.V376057.R01.S.doc Version 5.2 Page 6 authority procedures if needed. This means that management are aware of people’s rights and the action they need to take if their rights are restricted in any way for their protection. What has improved since the last inspection? What they could do better: To protect their privacy and dignity, people need to be consulted about how their personal care should be given. This information should be included in their care plan to ensure that staff have the guidance they need to give care in the way people prefer. The medicines need to be checked each month to make sure they are correct and people will receive their medicines as prescribed. Although the building is safe and generally well maintained, three aspects of the environment need to be checked to make sure the home is safe throughout. These are the bedrails, the laundry and the doorway next to the dining room. Phoenix House DS0000064015.V376057.R01.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Phoenix House DS0000064015.V376057.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 Phoenix House DS0000064015.V376057.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have had their needs assessed and have up to date information about Phoenix House before they move in. This means they can make an informed choice about whether the home will be suitable and their needs can be met there. EVIDENCE: We looked at the care files of two people who have recently moved into Phoenix House. We found that there is a good system to introduce people to the home, with information provided and needs assessments done, so they know their needs can be met in the home. People are given up to date information about the service and are invited to visit Phoenix House before moving in to meet the others who live there and staff and view the Phoenix House DS0000064015.V376057.R01.S.doc Version 5.2 Page 10 accommodation. This is to help them to decide whether Phoenix House will be a suitable home for them. Phoenix House DS0000064015.V376057.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s personal and health care needs are recorded with staff providing support to make sure individual physical and healthcare needs are met. EVIDENCE: We looked at the care plans of two people who live in Phoenix House. This is part of what we call case tracking and is a way of inspecting that helps us to look at services from the point of view of some of the people who use the service. We found that there were care plans in place to guide staff about how to support the people with their health and personal care. Care plans had been regularly reviewed and changed if necessary to ensure that information was up to date and people were getting the support they needed. There were also risk assessments in place in aspects of need such as mobility, to ensure people were being supported properly and safely. Records showed us that Phoenix House DS0000064015.V376057.R01.S.doc Version 5.2 Page 12 people who live in Phoenix House are registered with local doctors and are helped to access all the medical services they need to keep them as healthy as possible. People told us they were satisfied with the support they receive and they said the staff are kind and answer call bells quickly. We found that people’s choices about how their personal care will be given are not always recorded. Some people said they are not asked about the gender of carer they prefer although they did have a preference. Another person said they had no preference in this as long as the care was what they needed. In giving people choices in care giving, the home will support their privacy, dignity and rights. We checked on how people’s medication is managed in the home by looking at records, storage and the monitoring measures in place to make sure the system is safe. We found that staff who give out medication receive training and have a procedure to follow for guidance to make sure they do this safely. There is a locked cupboard for medication and the keys are held securely. We found that there were stocks of the medication prescribed for the two people whose care was tracked and there were records of when this had been given to them. For one person, the records showed that an “as required” drug had not been given, as the person did not need it. However on checking the stocks we found that some tablets were missing from the container. There is a good system for checking in and returning unwanted medication to the pharmacy and it is recommended that a monthly audit of medication also be carried out so that all medication accepted into the home will be accounted for. Some people have been prescribed creams to be applied externally. Although this was written in daily care notes, there were no individual care plans in place to guide staff about applying the creams. In these instances, care plans are recommended to ensure that each person’s support needs are held in their individual files and staff are kept up to date about how to support them in accordance with pharmacy instructions. These care plans may be removed if the treatment is no longer needed. People’s privacy was being respected during the visit to Phoenix House and confidential information was secure. People we spoke with said that staff are respectful towards them and they had no concerns about staff conduct. People’s clothing was well looked after and they said laundered items are returned to them in good condition and without delay. Phoenix House DS0000064015.V376057.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in Phoenix House are provided with activities and a variety of home cooked meals to ensure that they are well nourished and have the lifestyle they choose. EVIDENCE: Staff have obtained information about the social, cultural and leisure needs of people living in Phoenix House. This means that people can be helped to follow their chosen lifestyle in the home. People told us they go out with their families, who are made welcome when they visit. Others said they like to spend time in their bedrooms and join the others in the dining room for meals. Others like to sit in the lounges reading or watching television. Some people said they like to have their meals in their bedrooms and staff respect their choice. Some people were sitting in the garden during the visit as the weather was fine. Thirteen people were taking part in a quiz during the afternoon. People said they were generally satisfied with the activities on offer; further Phoenix House DS0000064015.V376057.R01.S.doc Version 5.2 Page 14 suggestions for more music and bridge games were given during the visit. One person told us that entertainers visit the home from time to time and this is enjoyed very much. They told us there is bingo, regular quizzes and outings planned from time to time. A visitor was spending time with a relative in private. They told us they were satisfied with the service and that staff are very helpful and give good support. People told us that local religious ministers visit the home to support people who want to follow their chosen faith. Staff said religious support is arranged in accordance with the beliefs of people who live there and will change according to their needs and preferences. They confirmed that the rights of people who do not wish to take part in religious services will be respected also. We looked at the menus and the meal being served during the visit and asked people their opinions on the food served in their home. The menu records a variety of home cooked main dishes, desserts and breakfast choices. Steak, potatoes and vegetables was being served for the main meal at lunch time. One person told us the steak was very tender and the meal was hot when served, and tasty. The meal looked well presented and was served to residents in the two dining rooms which are comfortable and pleasant. One person said she gets lots to eat, “too much sometimes”. Another person said there could be more variety for the light evening meal as there are often sandwiches on offer. On the day of the visit there was a choice of a pasta meal and assorted sandwiches for tea. One person said they would like more fish in the diet. All those who were spoken with said plenty of drinks are served regularly throughout the day and on request at night. One person told us that the quality food has improved recently. There are two service hatches from the kitchen, one opening into the dining room in the old part of the building and another on to the corridor to serve the dining room in the new wing. The kitchen was clean and well organised. We were informed that all equipment was working well and we saw plenty of crockery and cutlery. There is a new storage area and food stocks were good with regular deliveries from suppliers. The home’s owner told us there are financial arrangements for catering staff to buy in food in addition to regular supplies when needed to avoid shortages in food stocks. Catering records were up to date and the home owner said there are arrangements in place for the cook to have access to all the forms needed to ensure these records are in the correct formats. Phoenix House DS0000064015.V376057.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints and safeguarding procedures are understood by staff so that people living at Phoenix House can be confident their concerns will be taken seriously and they are protected from abuse. EVIDENCE: Phoenix House has a complaints procedure which is given to people when they move in. This means they know about their right to complain and that their complaints will be taken seriously. We looked at the complaints records kept in the home, and the latest complaint was about the quality of food. The complainant said there was fish on the menu but not enough for everybody and it ran out before her meal was served. It was also said that the chips were not cooked properly. We were told during the visit by people living in the home that the food has improved recently and we received no concerns during our visit other than regarding limited choices for the evening meal. There are safeguarding and whistle blowing policies available at the home. These provide guidance for staff on how to make sure that people living at Phoenix House are protected from poor practice and abuse. They also give guidance on how staff can report any concerns they have about the way people Phoenix House DS0000064015.V376057.R01.S.doc Version 5.2 Page 16 living at the home are being treated. Records showed that staff have received training about safeguarding adults so they know how to recognise the signs of abuse and what to do to protect people living at the home from harm. We have not received any safeguarding referrals about this home since our last visit there. Phoenix House DS0000064015.V376057.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Phoenix House is well maintained so that people who live there have clean, comfortable, pleasant and safe surroundings. EVIDENCE: Phoenix House has recently been extended to provide twelve extra bedrooms, improved assisted bathing facilities and new passenger lift for those who have poor mobility. There is a second lounge with dining area with French doors to the garden to accommodate the increased numbers of people who may now move in to this home. There is also a new laundry. Some of the bedrooms in the original building have been refurbished also and the AQAA tells us this will continue as rooms become vacant. People told us they are comfortable in their Phoenix House DS0000064015.V376057.R01.S.doc Version 5.2 Page 18 home and they spend time in the lounges, their bedrooms or the garden as they please. We spoke with the manager about housekeeping arrangements this home and looked at the staff rosters. There are designated staff employed for domestic cover throughout the week. Ten people living in Phoenix House were asked if the cleanliness of their home was to their satisfaction. None expressed any concerns. Some said they like to tidy their own bedrooms and domestic staff clean the rooms and en suites and empty the bin. The areas we visited were clean and odour free and there were cleaning materials and protective clothing in store. Phoenix House DS0000064015.V376057.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Phoenix House are supported by a well trained staff team who have gone through a thorough recruitment process. This means that people’s needs are met and they are safe from possible harm or poor practice. EVIDENCE: We looked at the staff rosters to make sure that there is enough staff on duty throughout the day and night. On duty during the visit was the manager and two care assistants, (one being the deputy manager), one cook, one house keeper. The manager told us that the administrator has left since our last visit and a deputy manager has been employed since February 09. The deputy and manager are included in the care rota on some shifts as well as having allocated managerial duties. The manager said the arrangement is working well and that care staff numbers are altered in accordance with the number of people in residence at any time. The AQAA informs us that the activities officer is no longer included in the care roster which frees more time to arrange social events for people living in the home. Phoenix House DS0000064015.V376057.R01.S.doc Version 5.2 Page 20 There is a training programme in the home. Staff records showed us that they receive induction and mandatory training with updates and the majority of care staff have NVQ qualifications. We spoke with staff during our visit. They said they have plenty of training and one suggestion made was for training in behavioural management. The manager confirmed to us that a training aid for deprivation of liberties has been written by the provider so that staff will be aware of the rights of people who live in this home and how they should be supported in situations where their rights may be restricted for their protection. In discussion with the deputy and manager they showed awareness of the local authority procedures and contact person for Deprivation of Liberties safeguarding referrals if needed. To check how people who work in the home are recruited and vetted we looked at two staff files. These gave us evidence of the vetting and recruitment procedures in place. Staff files contained evidence such as criminal records bureau checks, two satisfactory references and employment history. We saw that staff have job descriptions, contracts of employment and induction training. The files also contained certificates for mandatory training and National Vocational Qualifications. These checks help to make sure that the staff are suitable to work with the people who live at Phoenix House. Phoenix House DS0000064015.V376057.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Phoenix House has an experienced management team and there are systems in place so the home is run effectively in the best interests of the people who live there. However more attention needs to be given to identifying and addressing environmental hazards which could cause risk or injury to people. EVIDENCE: The AQAA informs us that the registered provider and manager have National Vocational Qualification Level 4 in management and Registered Managers Award. During our visit we were told that a deputy manager is now in post to support the management team. There are good systems in place for running Phoenix House DS0000064015.V376057.R01.S.doc Version 5.2 Page 22 the home, such as for monitoring training, updating documents and managing the staff group. Annual quality assurance monitoring is carried out by a firm of consultants. Questionnaires are given to people living in the home and the outcomes monitored and used to influence service development. In addition we were told that weekly checks of home are carried out by a designated member of staff, who speaks with people who live in Phoenix House to find out if they are satisfied with the service. This means they have the opportunity to express any concerns or compliments regularly. Also complaints records are monitored and remedial action taken by management where complaints are upheld. There is a system in place whereby local authorities review the support given to people whom they are funding in Phoenix House, to ensure the service is meeting their preferences and expectations. We were informed by staff that the home does not take responsibility for people’s personal finances and they are billed for the service and any items charged for as extras. The AQAA informs us that contracts of residence are in place for people who live in the home and these are reviewed and updated. This means their financial rights are protected and they know what is included in the fees for the service. We saw up to date records and certificates for safety checks carried out by engineers on the equipment in the home, including the fire equipment and the gas and electrical systems. Staff carry out weekly checks on the fire alarm system and water temperatures to ensure these are satisfactory. To keep the home safe and suitable for people, more attention is needed regarding environmental hazards which could cause injury. We saw in the laundry that laundered items had been placed on top of the dryer, which could cause a fire hazard. The fire door into the hallway from the stairs opens directly into the path of people walking into the dining room in the old part of the building and could cause a risk of injury. A risk assessment regarding this door should be in place and action needs to be taken to alert people using this door and the dining room of the risks. In two of the new bedrooms, we saw bedrails fitted to divan style beds. Bedrails can cause injury or entrapment if they become loose and they need to be checked regularly with records kept of their condition. Their use should be assessed to ensure that they are the right option for the person. Temperature records showed us that the kitchen needs more ventilation as it is becoming very hot when cooking is in progress. It is advised that ways of controlling the temperature in the kitchen be considered to keep it safe and comfortable for people who work there. Also a fly screen will be needed on the back door, to avoid insects entering and contaminating food. A record of accidents is kept in the home. We looked at the records of one person who has had a number of falls and noted that the person was referred to the falls clinic. This means that people’s welfare will be protected by the action taken to avoid accidents and falls. Phoenix House DS0000064015.V376057.R01.S.doc Version 5.2 Page 23 Phoenix House DS0000064015.V376057.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 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 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 3 X 3 X 3 X X 2 Phoenix House DS0000064015.V376057.R01.S.doc Version 5.2 Page 25 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 OP38 Regulation 13(4) Timescale for action To keep people safe in the home, 14/08/09 unnecessary risks to their health and safety (such as from door openings, bedrails and fire hazards) should be identified and as far as possible eliminated. Requirement 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 OP9 Good Practice Recommendations A monthly audit of medication should be carried out to ensure safe management and that all medication accepted into the home will be accounted for. Individual care plans should be in place for the application of prescribed creams to ensure staff have the guidance they need to support people properly and safely and in accordance with pharmacy instructions. People should be consulted about how their personal care is to be given, particularly with regards to gender of carer. DS0000064015.V376057.R01.S.doc Version 5.2 Page 26 2 OP9 3 OP10 Phoenix House This will help ensure people’s privacy and dignity is respected. 4 OP30 To ensure that staff have the skills they need to support people properly and safely it is advised that training in behavioural management is provided. It is recommended that a fly screen be fitted to the kitchen door to avoid contamination of food by insects. It is recommended that consideration be given to controlling temperatures in the kitchen so that it is safe and comfortable for the people who work there. 5 6 OP38 OP38 Phoenix House DS0000064015.V376057.R01.S.doc Version 5.2 Page 27 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.north west@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Phoenix House DS0000064015.V376057.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!