Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 13/09/06 for Plymbridge House

Also see our care home review for Plymbridge House for more information

This inspection was carried out on 13th September 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

Resident`s family said: "The staff are almost 100% kind" and "Anything my father wants he gets". A staff member said: "The home works brilliantly as a team" "As a young carer I feel I have been given good training and support" Residents benefit from staff who are competent and well trained, committed to resident well being and well supported and supervised by the registered manager. It is commendable that almost all care staff have achieved the National Vocational Qualification (NVQ) qualification in care.

What has improved since the last inspection?

The home was in need of much investment to upgrade the environment and keep equipment, fittings and furnishings in good repair. This investment is ongoing, but much has already been achieved, examples being new windows, laundry, heating, a bathroom, stair lift, bedroom redecoration and new garden furniture. These improve the comfort, safety and living conditions of residents. All documents, which should have been available for inspection at the last inspection but were not, are now kept at the home as they must be. This is necessary for the protection of residents from persons unsuitable to care for them.

What the care home could do better:

Staff are inclined to an out of date approach to the care of residents with dementia. They are caring and kind, but need to review their practice in line with training which they have already received. This training needs to be continued. Tensions exist where a residents or their family wish to make a complaint or comment which might be perceived as a criticism of the home. Complaints made have therefore not been accepted as such. The home therefore cannot demonstrate a desire towards continuing improvement in the best interests of residents. Residents would be better protected from abuse if staff can easily access the contact details for the Local Authority Adult Protection team. Residents must be supported as individuals and encouraged to maintain their independence; it should be considered why certain behaviour exists. As the environmental upgrading continues works planned should be in line with good practice in dementia care. The ongoing commitment toward privacy, dignity and independence for all residents should also be continued in this way, with more rooms having locks fitted suitable for residents` use. Lighting within the home should be reviewed, as in some areas it appeared insufficient, one area being the stairs. Systems for assessing hazards and risk should be improved so that potentially dangerous situations are not allowed to occur. These have included a trailing electrical cable, a scorched lamp-shade, loose light switch and an inadequate window restrictor in one of the first floor rooms. All bedrooms should have hand washing facilities for staff and the management of clean and soiled linen needs to be reviewed, so as to prevent cross infection from close contact. Recruitment needs to be fully robust, with Criminal Record Bureau (CRB) checks undertaken prior to employment in every case. This will further ensure that only staff suitable to work with vulnerable adults are employed to do so.

CARE HOMES FOR OLDER PEOPLE Plymbridge House Plymbridge Road Plympton Plymouth Devon PL7 4LD Lead Inspector Anita Sutcliffe Unannounced Inspection 13th September 2006 12:00 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 Plymbridge House DS0000041564.V305585.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. Plymbridge House DS0000041564.V305585.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Plymbridge House Address Plymbridge Road Plympton Plymouth Devon PL7 4LD 01752 345720 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) www.peninsularcarehomes.co.uk Peninsula Care Homes Ltd Kathleen Shopland Care Home 32 Category(ies) of Dementia - over 65 years of age (32), Old age, registration, with number not falling within any other category (32), of places Physical disability over 65 years of age (32) Plymbridge House DS0000041564.V305585.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users from the age of 60 may be admitted to the home. Date of last inspection 30th January 2006 Brief Description of the Service: Plymbridge House is a detached property situated in the residential area of Plympton. The Home is registered to provide residential accommodation and personal care, for a maximum of 32 persons over the age of 65 for reasons of old age who may also have dementia or physical disability. The home has 32 single bedrooms, 16 of which have en-suite facilities: 7 of these have en suite baths. There are 3 bathrooms, all fitted with bath hoists and one with a shower cubicle. On the ground floor there are 3 lounge rooms and a dining room. A stair lift provides access from the ground floor to both 1st and 2nd floor levels. There is a call bell system throughout the home. Residents are enabled to access any health or social care services they require and various social activities are arranged by the home. The garden is attractive, spacious and accessible to the Residents. Current fees: £300 - £375 Additional charges: chiropody, hairdressing, papers and magazines, toiletries and non-prescribed continence products. The report from the last CSCI inspection is found in the entrance hall of the home. Potential residents are shown this and also directed to the reports on the CSCI web site. Plymbridge House DS0000041564.V305585.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this key inspection was to assess the homes compliance with Key National Minimum Standards. The inspector also reviewed progress on previously set requirements and recommendations communicated following the homes last inspection in January 2006. Information about the home was gathered since April. The inspection itself took place over several weeks and included two unannounced visits to the home. Prior to those visits the organisation provided up to date information about the service at Plymbridge House. Comment cards were made available for the use of family and visitors. Staff views were surveyed confidentially. GP’s had the opportunity to give their views and a community psychiatric nurse and social worker were spoken with. For further information we telephoned some residents’ family. During the visits to the home the premises was toured and service users (residents) spoken with. Staff were observed and spoken with in the course of their daily duties. Care and management records were examined. The registered manager was involved in all inspection visits and a representative of the organisation in two of the visits. What the service does well: What has improved since the last inspection? The home was in need of much investment to upgrade the environment and keep equipment, fittings and furnishings in good repair. This investment is ongoing, but much has already been achieved, examples being new windows, laundry, heating, a bathroom, stair lift, bedroom redecoration and new garden furniture. These improve the comfort, safety and living conditions of residents. Plymbridge House DS0000041564.V305585.R01.S.doc Version 5.2 Page 6 All documents, which should have been available for inspection at the last inspection but were not, are now kept at the home as they must be. This is necessary for the protection of residents from persons unsuitable to care for them. What they could do better: Staff are inclined to an out of date approach to the care of residents with dementia. They are caring and kind, but need to review their practice in line with training which they have already received. This training needs to be continued. Tensions exist where a residents or their family wish to make a complaint or comment which might be perceived as a criticism of the home. Complaints made have therefore not been accepted as such. The home therefore cannot demonstrate a desire towards continuing improvement in the best interests of residents. Residents would be better protected from abuse if staff can easily access the contact details for the Local Authority Adult Protection team. Residents must be supported as individuals and encouraged to maintain their independence; it should be considered why certain behaviour exists. As the environmental upgrading continues works planned should be in line with good practice in dementia care. The ongoing commitment toward privacy, dignity and independence for all residents should also be continued in this way, with more rooms having locks fitted suitable for residents’ use. Lighting within the home should be reviewed, as in some areas it appeared insufficient, one area being the stairs. Systems for assessing hazards and risk should be improved so that potentially dangerous situations are not allowed to occur. These have included a trailing electrical cable, a scorched lamp-shade, loose light switch and an inadequate window restrictor in one of the first floor rooms. All bedrooms should have hand washing facilities for staff and the management of clean and soiled linen needs to be reviewed, so as to prevent cross infection from close contact. Recruitment needs to be fully robust, with Criminal Record Bureau (CRB) checks undertaken prior to employment in every case. This will further ensure that only staff suitable to work with vulnerable adults are employed to do so. Plymbridge House DS0000041564.V305585.R01.S.doc Version 5.2 Page 7 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. Plymbridge House DS0000041564.V305585.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 Plymbridge House DS0000041564.V305585.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 4 (Standard 6 does not apply to Plymbridge House) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care needs are met following thorough assessment and planning. The practice at the home is to protect residents with dementia rather than work with their strengths and abilities. Residents with a physical disability are enabled to be independent. EVIDENCE: The care of three residents was examined in detail. The needs of each had been assessed prior to admission. The assessments contained some excellent detail, such as falls risk assessment, and emotional well being. The assessment of daily care needs could be further expanded. A community psychiatric nurse says the home is providing the care she expects and staff are very caring. Staff have received some training in the care of residents with dementia and there have been some adaptations within Plymbridge House DS0000041564.V305585.R01.S.doc Version 5.2 Page 10 the home to help residents find their way around. (See also Standard 19). Staff engage well with residents who would become isolated if they did not. There is a maternalistic culture throughout the home. During the first visit staff were heard speaking to residents in a very kind, but childish way, one example being “good girl”. This was contrary to the training they have received. This was discussed with the manager and fed back to staff immediately. Further training in dementia care is planned. Adaptations are in place within the home for residents with physical disability so that independent movement within the home is not restricted. Plymbridge House DS0000041564.V305585.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care is well planned, based on residents wishes, and health and care needs are fully met by well informed staff. Medication at the home is very well managed. Residents dignity and privacy are respected but this could be more fully demonstrated. EVIDENCE: Those residents able to comment on the care they receive said they were well cared for. Others appeared so and there was attention to detail. Residents’ wore jewellery. Clothes were well laundered. Staff said: “Client care is exemplary. We could not do any better”. A GP who attends the home says she is satisfied with care provided and most family commented that they were satisfied with the care, one saying “extremely pleased” one saying “most of the time”. Plymbridge House DS0000041564.V305585.R01.S.doc Version 5.2 Page 12 Care plans were well organised, detailed and provide staff with the information from which to ensure care is delivered to a consistent standard. The handling of medication was found to be very good, with safeguards in place to ensure mistakes cannot be made. Residents said they were treated with respect by staff. (See also Standard 4). Plymbridge House DS0000041564.V305585.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported to lead a fulfilled life where staff believe they are able, but this could be further expanded. Residents receive a nutritious varied diet, which meets individual choice and health care requirements. EVIDENCE: A couple of residents have independent regular contact with social events outside the home and others go out on a regular basis with staff. A particular member of staff organises social events at the home. Residents are encouraged to ‘make their room their home’ and some have chosen to maintain their independence with a key to their door. This is commendable and should be expanded. (See also Standard 19). If there were increased information on personal interests, life history and important events, it would further help staff to support residents as individuals, especially those with dementia. This would also help them tailor the activities provided and understand patterns of behaviour, which might otherwise appear challenging. Staff should work with resident’s strengths as well as protect Plymbridge House DS0000041564.V305585.R01.S.doc Version 5.2 Page 14 them. Residents able to communicate their needs confirmed that they make daily lifestyle choices, such as when to get up and go to bed. Residents said they liked the food provided and there is choice available. During the inspection the manager was trying hard to provide the rabbit pie requested by some of the male residents. Diet is well monitored. Staff said: “Food is really good and well balanced” and “We monitor food taken really well”. Staff were observed assisting residents sensitively and it was confirmed that specialist diets, such as vegetarian, are handled in accordance with the resident’s wishes. Plymbridge House DS0000041564.V305585.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents do not benefit from the way complaints to the home are managed. Residents are protected from abuse but this could be further assured. EVIDENCE: The complaints policy is well displayed at the entrance of the home, included in the homes admissions information, and it contains contact details for the Commission. Three of the five surveys received from family towards the inspection commented that they have at one time complained to the manager. However, the manager says there have been no complaints “for years”. This inconsistency strongly suggests that the handling of complaints at the home is not benefiting residents. One family member said their parent had complained, but “had not been believed”. They also said the parent was now worried about ‘doing things wrong’ at the home. Policy and procedure on complaints need to be reviewed as a priority. The findings were discussed with the Registered Provider, as the Registered Manager could not accept the findings. The Commission have received no complaints about the home. Plymbridge House DS0000041564.V305585.R01.S.doc Version 5.2 Page 16 Staff have received training on how to protect residence from abuse, and the home’s whistle-blowing policy (what actions to take if they have a concern) was discussed with them in detail at a staff meeting in March. A resident confirmed that he felt safe at the home, but a discussion with a family member highlighted a concern that residents were “not expected to break the rules”. (See also Standard 32). The whistle-blowing policy is situated in the office. Should staff wish to disclose a concern outside the home they should be able to access this document discreetly. To this end it should be placed in a more accessible place. The manager said it would be included in the Staff Handbook, which is given to each new employee. Plymbridge House DS0000041564.V305585.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a pleasant, homely environment, which has been greatly improved for their benefit, but where safety needs additional improvement. Improvements in line with good practice in dementia care are ongoing. EVIDENCE: The provider has made significant changes toward improvement and upgrading which will add to the comfort and safety of residents. These include new windows, laundry, heating, a bathroom, stair lift, bedroom redecoration and new garden furniture. Maintenance concerns, once identified, are dealt with promptly. Plymbridge House DS0000041564.V305585.R01.S.doc Version 5.2 Page 18 The communal accommodation at Plymbridge House is spacious and furnished and decorated in a comfortable, domestic style. Individual bedrooms are very personalised with some excellent attention to detail. The home was clean and fresh throughout. However, there was no liquid soap in the staff lavatory (only bar soap) and during one of the three visits no hand drying towels in the laundry. No bedrooms have hand washing facilities for staff, who provide personal care and must therefore be able to leave each room having washed and dried their hands thoroughly to prevent cross infection. The newly refurbished laundry is thoroughly cleanable and had the appropriate standard of equipment needed. However, at one point drying clothes had been placed across the entrance to the sluice. This is unsatisfactory as clean and soiled linen/equipment must be kept separate at all times to prevent cross infection. The adequacy of lighting within the home needs reviewing. There were areas where it was insufficient, one being the stairwell. This may pose a danger and is a particularly disadvantage to those with failing sight or dementia. As upgrading continues consideration should always given to how the needs of residents with dementia might be better met. Residents benefit form a variety of sitting rooms and good internal space to walk. The gardens have been improved and contain new garden furniture. A resident confirmed that this is regularly used in the warmer weather. However, due to differing levels and steps unsupervised access to the garden would be hazardous. Residents who are deemed able to lock their room have this provided for them. This option should be available for all residents unless there is an identified risk in doing so. As rooms become available locks should be added so the option is in place. Some safety concerns were identified. This included some trailing electrical cables, water leaking from a toilet or bath, a lamp with faulty switch, a scorched lampshade and a bath hot tap running extremely hot at over 50C. Where a window restrictor was in place it was inadequate as it was very easily removed, the window was wide, low and swung open with little effort. This might lead to a fall. These concerns were dealt with promptly. The environment is checked for safety but this needs to be undertaken more thoroughly. (See also Standard 38). Plymbridge House DS0000041564.V305585.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from very competent and well trained staff, but staffing numbers and deployment are not always to their benefit. Recruitment is fairly robust, but this could be further assured. EVIDENCE: Three of the five family surveys returned say there are not enough staff on duty at Plymbridge so additional family were contacted for information. Not all agreed, but some said that staff are sometimes rushed, one comment being “staff are too busy to sit and talk to the residents”. A resident said that he hears staff “rushing from one bell to another” at night and staff commented that sometimes there weren’t sufficient numbers at certain times of the day, mentioning changes made to staffing arrangements at the beginning of the year. At no time during the inspection was it observed that residents’ needs were unmet, but during the tea time period, with the manager preparing food and the deputy serving and washing up, it was clear that staffing numbers and deployment at the home need to be reviewed. It is commendable that so many care staff have achieved the National Vocational Qualification (NVQ) in care qualification, as almost all have now Plymbridge House DS0000041564.V305585.R01.S.doc Version 5.2 Page 20 done so. Staff were very complimentary of the training they receive with comments including: “I was given all the support and training to enable me to achieve good quality standards”. Staff appeared competent and knowledgeable and a GP who attends the home said that staff usually demonstrate a clear understanding of the needs of residents. Recruitment records of two recently employed staff were examined. Recruitment is undertaken in a systematic and orderly way with good references received and identity checks. However, it had been decided that Criminal Record Bureau (CRB) checks did not need to be repeated having been recently done by a previous employer. Neither had there been checks on the list of persons unsuitable to work with vulnerable adults. These safety checks must always be made prior to employment commencing. Plymbridge House DS0000041564.V305585.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are disadvantaged by the inability of the manager to accept any comment which she perceives as a criticism of the home. She is therefore unable to work toward continuing improvement. Residents’ finances are safeguarded through the home’s practice. Health and safety are generally maintained at the home, but this could be further improved. EVIDENCE: Staff feel very supported by the manager, who is qualified and experienced in her work. There were many comments highlighting the good teamwork at the Plymbridge House DS0000041564.V305585.R01.S.doc Version 5.2 Page 22 home. Staff are well supervised in their work, and also benefit from regular meetings, training and support. The manager chose not to accept information received toward the inspection as factual. Inconsistencies (See Standard 16) were not accepted. A resident commented that they were frightened to make any mistake or “break the rules”. Family wanted comments they made to remain anonymous. Whilst the manager demonstrates her committed to high standards, and is experienced in her role, her approach is not always in the best interests of the residents. Money kept on behalf of residents was secure and correctly kept on behalf of residents. Staff meetings are regularly held at Plymbridge to provide and share information. Surveys are available for residents and family to comment on the home. However, evidence around complaints (see above and Standard 16) suggests that the quality assurance system in use is not working. This needs to be addressed by the organisation and registered manager. Health and safety requirements are met for the most part through knowledgeable staff and satisfactory servicing and upgrading of equipment and environment. Maintenance concerns, once identified, were dealt with promptly. However, the inspector highlighted concerns that should have been found as part of the safety audit within the home. They include, very hot water temperatures, trailing cable, faulty switch on a lamp and a scorched lampshade. There needs to be improved systems in place to assess risk within the home. Plymbridge House DS0000041564.V305585.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 4 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 X X X X 3 2 1 STAFFING Standard No Score 27 2 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 1 2 X 3 X X 2 Plymbridge House DS0000041564.V305585.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP16 Regulation 22 Requirement Complaints must be accepted, investigated and acted upon in the best interest of service users. Policy and procedure must be reviewed. Policy and procedure regarding infection control should be reviewed and changed made in line with good practice guidelines on infection control. All checks required to ensure the safety of service users, and in accordance with Schedule 2, must be done prior to the employment of new staff. Residents, and their representatives must feel confident in making their feelings known without the concern of recrimination. Unnecessary risks to the health or safety of service users must be identified and so far as possible eliminated. Timescale for action 31/10/06 2 OP26 13 (3) 30/11/06 3 OP29 19 30/09/06 4 OP32 12 31/10/06 5 OP38 13(4) 31/10/06 Plymbridge House DS0000041564.V305585.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP4 OP12 OP18 Good Practice Recommendations The home should continue to explore how to deliver appropriate, person centred care to service users with dementia. Service users should be supported to continue using skills and follow interests of importance to them. Staff should be able to read the whistle blowing policy without having to go into the office to find it. It should contain the contact details for the Local Authority Adult Protection team. As the environment is upgraded consideration should be given to further enabling independence for residents with dementia, in line with current, good practice guidelines. Door locks should be offered to newly admitted residents who occupy rooms where these are not already fitted. The adequacy of lighting should be reviewed throughout the home. Staff should be able to wash and dry their hands after providing personal care to service users, handling soiled laundry or equipment and available at all times in the staff toilet. Staffing numbers and deployment should be reviewed in light of comments received towards the inspection. Effective quality assurance and quality monitoring systems, based on seeking the views of service users, should be in place to monitor success in meeting the aims, objectives and statement of purpose. 4 5 6 7 OP19 OP24 OP25 OP26 8 9 OP27 OP33 Plymbridge House DS0000041564.V305585.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 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 Plymbridge House DS0000041564.V305585.R01.S.doc Version 5.2 Page 27 - 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!