Inspection on 22/05/08 for Pilton House

This inspection was carried out on 22nd May 2008.

CSCI found this care home to be providing an Excellent service.

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

Pilton House 14/06/06

Pilton House 08/02/06

Pilton House 01/08/05

Pilton House 10/01/05

Pilton House 12/07/04

Pilton House 13/02/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Pilton House Pilton Street Pilton Barnstaple Devon EX31 1PQ Lead Inspector Sue Dewis Unannounced Inspection 22nd May 2008 09:30 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 Pilton House DS0000022096.V365105.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. Pilton House DS0000022096.V365105.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pilton House Address Pilton Street Pilton Barnstaple Devon EX31 1PQ 01271 342188 0870 1219766 pilton.house@bigfoot.com 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) Barnstaple Old People`s Housing Association Limited Mrs Gina Helen Rogers Care Home 27 Category(ies) of Dementia - over 65 years of age (27), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (27), Old age, not falling within any other category (27) Pilton House DS0000022096.V365105.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2006 Brief Description of the Service: Pilton House is an extremely spacious and attractive listed Georgian manor house. It is situated in the Pilton area of Barnstaple. Barnstaple Old Peoples Association (BOPA) is the registered provider and a Committee play a regular and active part in the running of the home. The home is registered to provide care for up to 27 people in the categories of old age (OP), Mental Disorder - over 65 years of age (MD, E) and Dementia over 65 years of age (DE, E). The home is situated in large, attractive grounds in a residential area and is close to the local facilities, amenities and services of both Pilton and the centre of Barnstaple town. It has an extensive parking area. Bedrooms are mainly en-suite, of varying sizes and are situated on two floors. Residents can access all areas of the building by a lift or staircases. There are a variety of communal areas in the building, which include a welcoming reception area, large sitting room, dining room, quiet lounge and a small library. Current information about the service, including the CSCI inspection reports, are available from the manager. The cost of care ranges from £320-£410 per week at the time of inspection. Chiropody, hairdressing, personal toiletry items and newspapers/magazines are additional costs which are not included in the fees. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at http:/www.oft.gov.uk . Pilton House DS0000022096.V365105.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 3 star. This means the people who use this service experience excellent quality outcomes. This unannounced visit took place over 9 and a half hours, one day towards the end of May 2008. The home had been notified that a review of the home was due and had been asked to complete and return an AQAA (Annual Quality Assurance Assessment). This shows us how the home has managed the quality of the service provided over the previous year. It also confirms the dates of maintenance of equipment and what policies and procedures are in place. Information from this document was used to write this report. During the inspection 3 people were case tracked. This involves looking at peoples’ individual plans of care, and speaking with the person and staff who care for them. This enables the Commission to better understand the experience of everyone living at the home. During the inspection 3 people living at the home were spoken with individually and 6 in a group setting, as well as observing staff and people living at the home throughout the day. We also spoke with 3 staff, one relative and the manager. A full tour of the building was made and a sample of records was looked at, including medications, care plans and staff files. What the service does well: The home returned an AQAA (Annual Quality Assurance Assessment) when we asked for it that provided good evidence of the way the home has been managed since the last inspection. There are generally good assessment and admission procedures in place and people are encouraged to visit the home before they decide to move in. Care plans generally give good information about the health and personal care needs of individuals and how these should be met. There is evidence that the care plans are reviewed regularly and of involvement of the individual or their representative in drawing up the plans. Care plans showed good evidence of the involvement of health care professionals as necessary. Medication is stored and administered in a safe manner. Pilton House DS0000022096.V365105.R01.S.doc Version 5.2 Page 6 A variety of activities are provided and meals were seen to be well presented and nutritious. Visitors said that they were always made to feel welcome. People were treated with dignity and respect and were offered choices wherever possible. There is a simple complaints procedure that people were aware of. Recruitment procedures are generally robust and ensure people are protected from staff who may be unsuitable to work with vulnerable adults. Staff receive good levels of training and there are sufficient numbers on duty to ensure the needs of individual’s are met. The home is well managed and there are systems in place to protect the health, safety and well being of people living and working at the home. What has improved since the last inspection? What they could do better: The home must ensure that before anyone is admitted to the home a full assessment of their needs is obtained, and that they have confirmed in writing to the individual that the home can meet their needs. Any gaps in the employment history of prospective staff must be fully explored to ensure their suitability to work with vulnerable people. Care plans should include information on dealing with the needs of anyone whose behaviour may present a challenge to the home. Daily recordings made Pilton House DS0000022096.V365105.R01.S.doc Version 5.2 Page 7 on the care plans should be more useful and specific and describe exactly what happened during the day. The manager should continue to encourage everyone living at the home to express their views and to show they are being considered. The annual quality assurance programme would be improved by showing a clear line of consultation, identification of issues and any action taken to address the issue. The home should ensure the fire log book is maintained in accordance with the recommendations of Devon and Somerset Fire Service. 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. Pilton House DS0000022096.V365105.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 Pilton House DS0000022096.V365105.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. People have sufficient information on which to base a decision as to whether or not to move into the home. However, assessment procedures are not robust enough to ensure that their care needs can be met. EVIDENCE: Three people’s files were looked at, including that of the most recently admitted person. All of these contained some pre-admission assessments. However, one of these (that of the most recent admission) was incomplete with no written assessment, although the person had been informally assessed during their visit to the home. Pilton House DS0000022096.V365105.R01.S.doc Version 5.2 Page 10 There was no written confirmation on file, that the home can meet the needs of people thinking of moving into the home. This means that people may be at risk of not having their needs fully met. The person who had recently been admitted confirmed that they had spent some time at the home before they decided to live there. The home does not provide intermediate care. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to update their website and for all senior carers to be competent with the Mental Capacity Act assessment procedures. Pilton House DS0000022096.V365105.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 excellent. This judgement has been made using available evidence including a visit to this service. Care plans are well formulated and give clear information to enable staff to meet people’s health and personal care needs in an individual manner. However, behaviour risk assessments and management information could be improved. Medicines are stored securely and administered appropriately. EVIDENCE: Three people’s care files were looked at. Two had an individual plan of care in an easy to read and follow format. They also showed evidence of regular updating/reviewing and that the people themselves were involved in this. The third file was that of the person most recently admitted, and had not yet been fully completed. People’s preferences and choices were recorded. Staff said that they receive a good handover and looked at care plans each time they came on duty, so that they were aware of any changes to the care needed by individuals. Pilton House DS0000022096.V365105.R01.S.doc Version 5.2 Page 12 Risk assessments had been completed and regularly updated and generally preventing unnecessary risk to those living at the home. However, the care plan for the most recently admitted person stated that they ‘can have occasional aggressive outbursts’, but there was no assessment as to how these may present, how they are to be managed or how they may be avoided. This may present a risk to this person and others living at the home. The files showed that people’s health needs are regularly monitored and that the home contacts health professionals when needed, such as a CPN (a nurse specialising in caring for people with mental health issues), a nurse specialising in caring for people with diabetes, speech therapist and continence advisor. The care plan daily notes for each individual are written by the senior on duty, from notes made by care staff in the person’s room. The notes were not always very helpful and contained a lot of ‘fine’ and ‘had a good day’. Recording need to be more specific and useful specifying how the person had had a good day and what they had been doing. The home has a satisfactory medication policy and procedure, including a ‘homely remedies’ policy. All staff that administer medication receive the appropriate training. Three people’s Medication Administration Records (MAR) were looked at. These were now completed satisfactorily with all medications being given at the prescribed time. All changes in medication were now being recorded appropriately on the MAR chart with two signatures from staff. These improvements have reduced unnecessary risk to those who receive medication. Also, medication for external use, now has the date it was opened written on the pack which ensures its potency is maintained. One person looks after their own medication and there are procedures in place to ensure that medication is taken appropriately and stored securely. Staff demonstrated a good understanding of people’s needs and were able to describe good practice in relation to maintaining their privacy and dignity. They were seen offering personal care in a discreet manner, and spoke with people in a friendly and respectful way. People said that staff were very good and were always respectful towards them. All bedrooms, toilets and bathrooms have suitable locks fitted to the doors to ensure people’s privacy. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to liaise further with GPs and Boots and to hold more senior care officers meetings. Pilton House DS0000022096.V365105.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. The home generally offers a suitable range of activities and entertainments to stimulate and occupy people and links with visitors and the community are good, giving opportunities to support and enrich people’s social life. Meals were seen to be well presented, providing nutritious variety and choice for individuals. EVIDENCE: The home used to employ an activities organiser who provided 20 hours a week of various social and recreational activities. The previous organiser has left and has not yet been replace. However, care staff at the home do their best to ensure the level of interaction is maintained. Activities on offer range from the usual in house activities such as quizzes, bingo and musical entertainers to outings to local shops and displays. Pilton House DS0000022096.V365105.R01.S.doc Version 5.2 Page 14 On the morning of the visit several staff were in the main lounge with most of the people living at the home. One member of staff was reading a newspaper to an individual an offered to take them shopping later. Two other staff were asking people various quiz questions and there was much discussion and laughter during this time. People confirmed that they enjoyed the activities that were on offer, though one said that they missed the previous activity organiser who would regularly take them out on trips. The home’s mini bus is being sold as the manager said that they could not justify the expense with it being used so infrequently. People said that their visitors were always made very welcome and the relative that was spoken with said they thought the home was ‘fantastic’. They also said that the home keeps them fully informed of any changes in the health of their relative and that they also received a regular newsletter about what is going on in the home. People told us that they have as much choice and control over their lives in the home as possible. They told us they are free to come and go as they please, spend their day as they please and get up and go to bed when they like. There is a monthly newsletter produced called ‘Chit Chat’, which keeps everyone up to date with what is happening around the home. Regular meetings are held for everyone living at the home to air their views. However, one person told us that they felt there was no point in saying anything as nothing was ever done about it, but would not explain this further. We did discuss this with the manager, who said that they were aware of the individuals concerns and had been trying to address them. A new larger menu board has been provided so that everyone is able to see it. Menus show that the home provides a wide variety of nutritious food, with a choice for each meal. Following comments that some people thought breakfast and lunch were too close together, lunch is now slightly later. Special dietary needs are catered for and the cook said that they took people’s preferences into account when preparing the menus. People said that they always enjoyed the food and liked having a choice. Cups of tea or coffee and cold drinks are available on request. Lunch was unhurried and relaxed with people being given time to eat at their own pace, but with staff available to offer assistance if needed. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to ask each resident for their food likes and dislikes in order to further improve the menus, and to try to obtain funds to extend the dining room. Pilton House DS0000022096.V365105.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. People are confident that any complaints would be dealt with appropriately. People are protected by staff that are able to recognise abuse and know their duty to report poor practice. EVIDENCE: The home has a clear and simple complaints system and people who were spoken with confirmed that they knew who they should talk to if they were unhappy about anything at the home. All complaints received by the home are held securely in a file and contain details of a full investigation and any outcomes or changes in practice. One complaint has been received by the Commission since the last visit. The complaint was anonymous and concerned staff being employed before full Criminal Records Bureau (CRB) checks were received. This complaint was upheld as the manager stated that some staff had started work before their CRB checks had been received, due to a shortage of staff. The manager was reminded that this was unacceptable as it places people at risk from staff who Pilton House DS0000022096.V365105.R01.S.doc Version 5.2 Page 16 may be unsuitable to work with vulnerable adults. All staff now have satisfactory CRB checks returned before they start work. Two of the staff spoken with said that they had not yet received training in recognising and dealing with abuse, but were due to do this very soon. However all three staff were able to describe a variety of differing kinds of abuse, including shouting at people who may be hard of hearing, or ignoring someone who is asking for help. Staff were aware of the correct procedures for reporting any suspicions to someone within the home and said that they would involve other agencies such as the police if they felt they needed to. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to send out more questionnaires with the monthly ‘Chit Chat’ newsletter to encourage feedback from anyone connected with the home. Pilton House DS0000022096.V365105.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, 20, 22, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides people with a clean, safe, comfortable and homely place to live. EVIDENCE: We made a full tour of the communal areas of the home and saw that the home is safe, comfortable and well maintained. There are several communal areas around the home for the use of everyone and while some have their favourite areas, some do move between them. The communal areas are homely, with many ornaments and pictures around them. Pilton House DS0000022096.V365105.R01.S.doc Version 5.2 Page 18 They are decorated and furnished in a comfortable manner that meets the needs of individuals. The beautiful gardens are maintained by a gardener and are adjacent to a public area, which gives the people living there an even lovelier aspect. There is a wide terrace on which people can sit and look out onto the gardens. The manager told us that she was waiting for the hanging baskets to be delivered which make the space even more attractive. The terrace has a glass roof and the area can become very hot. Two parasols have been purchased to protect people from the sun and the glass is to be painted white to reflect the light. There is a programme of refurbishment at the home both for indoors and outdoors and the dining room is currently being redecorated. The type and colour of stair carpet has been chosen specifically to reduce the risk of falls and prevent unnecessary risk to people living at the home. When anyone leaves a room, the opportunity is taken to redecorate the room as necessary. The laundry is well equipped to deal with the washing from people living there. Cleaning fluids are now looked in a nearby cupboard so that they do not pose a health and safety risk to individuals (see also Standard 38). Staff confirmed that they have access to disposable gloves and aprons, and were aware of good basic hygiene procedures. Staff were seen to be wearing disposable gloves and aprons to maintain good hygiene practice. The home has a variety of hoists and moving and handling aids to enable staff meet the needs of those individuals with mobility difficulties. Examples of these were seen in the home in both communal and private areas and is stored out of the way when not being used. There is level access to the home via the rear of the building. Some bedrooms were looked at, each had personal possessions displayed and reflected the personalities of the occupant. The rooms contained all the items that the people require in order to have their needs satisfactorily met and had suitable locks fitted to the doors. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to purchase new furnishings and equipment and to lag heating pipework. Pilton House DS0000022096.V365105.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): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The deployment and numbers of well trained staff available throughout the day and night are sufficient to meet the needs and numbers of the people currently living at the home. The procedures for the recruitment of staff are generally robust and offer protection to people living at the home. EVIDENCE: During the visit there were 5 care staff on duty and a senior carer as well as the manager and ancillary staff. People spoken with and their representatives said that they felt there were always sufficient staff on duty to meet people’s needs. Positive comments were received from representatives about staff, including ‘the staff are very caring, mum gets excellent treatment’ The care staff said that they did not generally feel rushed and had time to meet the care needs of individuals, but that they would like more time to spend chatting with people. People told us that there were always staff Pilton House DS0000022096.V365105.R01.S.doc Version 5.2 Page 20 available if they wanted anything, and that they did not have to wait too long for help. There was a relaxed and unhurried atmosphere around the home, with staff meeting the needs of individuals in a quiet and competent manner. Staff were well aware of the individual care needs of people living at the home and were able to describe these and how they are met on a day to day basis. Staff spoke with enthusiasm about the individuals and their work with them. There has been quite a high turnover of staff since the last visit and several new staff have been recruited. Staff files were available for inspection and three staff files were looked at. All contained two written references, proof of identity and photographs of the staff member. They also contained evidence that satisfactory police checks had been obtained (see also Standard 18). However, one file did not contain an explanation of gaps in the staff member’s employment history. Staff told the inspector (certificates were seen where applicable) that they had received training in Moving and Handling, Basic Food Hygiene, infection control and Fire Precautions. Staff are encouraged to obtain an NVQ (National Vocational Qualification) level 2 or above. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to maintain current standards. Pilton House DS0000022096.V365105.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, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed resulting in practices that promote and safeguard the health, safety and welfare of people living and working at the home. EVIDENCE: The manager, Gina Rogers, is a qualified Registered General Nurse (RGN) and has other care and management qualifications to enable her to run and manage the home, including an NVQ level 5 in training and development. People that were spoken with generally had confidence in her, though one individual felt they could not speak with her (see also Standard 14). Visitors Pilton House DS0000022096.V365105.R01.S.doc Version 5.2 Page 22 that were spoken with commented ‘Gina is fantastic, we are lucky to have mum live here’. There is an annual programme for ensuring the quality of care provided at the home is maintained to a high level. This system allows for consultation with people living at the home and regular visits from the home’s committee. An annual development plan is produced and the AQAA (Annual Quality Assurance Assessment) that was submitted prior to the visit included good information on how the quality of care has been managed throughout the year. However, the plan does not show a clear line of consultation, identification of issues and any action to be taken. The home manages personal monies for some individuals and we looked at how these are kept. Each is kept secure and all records, receipts and accounts were in order. Staff said and records confirmed that regular supervision takes place with a senior member of staff every two months to discuss practice. An annual appraisal takes place for all staff which may identify any training needs. The AQAA (Annual Quality Assurance Assessment) provided evidence that Pilton House complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. The record of fire safety training and accident and incident records were found to be accurate and up to date. However, the Fire Log book was not being maintained in accordance with the advice of Devon and Somerset Fire Service. The manager told us so that the risk of burning from hot surfaces is minimised, radiators within the home are covered. They also said that all windows above ground floor level are fitted with restrictors, in order to minimise the risk of anyone falling from these windows. They also confirmed that so that the risk of burning from hot water is minimised temperature controls are fitted to bath taps. Policies and procedures are not always inspected during the visit but the information provided on the AQAA helps us form a judgement as to whether the home has the correct policies to keep people living and working at the home safe. Information provided by the home, showed that policies and procedures are in place and along with risk assessments are reviewed regularly and updated where necessary, in order to ensure they remain appropriate and reduce risks to people living and working at the home. Staff confirmed that they receive regular training in fire precautions as well as Health and Safety. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to delegate more tasks to senior staff and to continue to train staff through NVQ pathways. Pilton House DS0000022096.V365105.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 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 Pilton House DS0000022096.V365105.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. Standard 1. OP29 Regulation Requirement Timescale for action 31/07/08 19 sch 2(6) All gaps in employment history must be explored to ensure the person is fit to work with vulnerable adults. 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 OP33 Good Practice Recommendations You are recommended to ensure that the annual quality assurance process shows clearly how people are consulted with, issues are identified and any action that needs to be taken as a result. You are recommended to ensure that the fire log book is maintained in accordance with the recommendations of Devon and Somerset Fire Service. 2. OP38 Pilton House DS0000022096.V365105.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Pilton House DS0000022096.V365105.R01.S.doc Version 5.2 Page 26 - 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!