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Inspection on 29/09/05 for Prestbury Court Residential Home

Also see our care home review for Prestbury Court Residential Home for more information

This inspection was carried out on 29th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

What the care home does well

The service provides a good level of personal care to residents with complex mental, physical and social needs. The home offers a range of social activities in the home and local community, which includes the use of a mini bus and staff welcome visitors to the home. This means that residents remain mentally and physically active and there is a pleasant busy atmosphere the communal areas of the home. It also means that residents can visit areas outside of the grounds of the home and that they maintain contact with families and friends.

What has improved since the last inspection?

The proprietor has made major improvements to the premises with the additional of a new wing to the home this has extended the accommodation, adding additional lounge and dining areas and more residents rooms. It has also improved the main part of the home as the proprietor has purchased new furnishing throughout the home and has changed some rooms so that the home has a new improved laundry area and a new sensory room. These changes have improved overall the living accommodation for all residents and an improved working environment for staff. The manager and proprietor have also extended some of the documentation in the home, such as improvements in how the home records the recruitment and selection of staff and the purchase of a controlled drugs book and a new returns of medicine book. These improvements demonstrate the service commitment to improvement and these documents make clear that the home are recruiting staff who should be working in care and that medicines are safely controlled in the home. The service has a complaints procedure that residents and their friends and families are confident in so that complaints are listened to and action is taken to address any areas of concern.

What the care home could do better:

Although the home have improved in some areas of record keeping their remains areas that need review and fully completing, such as ensuring any gaps in information were clearer marked "not available at the moment or refused". This will make clear that the home have tried to obtain this information, which is needed to ensure staff have a clear picture of residents needs and how to meet those needs. A consistent approach to fully completing all documentation including care plans and ongoing assessments of residents care must be developed to clearly demonstrate how residents changing needs are being met and to provide vital information to ensure care staff can provide individual care to residents. The accommodation while having been improved by the extension and purchases of equipments had several areas that impacted on the health and safety of residents this included windows on a first floor that opened wide enough for a resident to fall through and a kitchen area that was left unlocked, offering the opportunity for residents who may have some memory loss to wander in and hurt themselves on kitchen equipment. Risk assessments for the property were discussed with the homes manager who agreed to take immediate action to address the short falls the inspection had highlighted, and to extend risk assessments to show all areas of the home had been assessed and action taken to make sure residents were safe from any potential hazards. The service also needs to develop a quality assurance system, and as part of this system the proprietor must submit a monthly report to the Commission outlining the areas the proprietor had considered when visiting the home. This will help to keep the Commission informed of the day to day events in the home and how the home continues to progress.

CARE HOMES FOR OLDER PEOPLE Prestbury Court Residential Home Brimley Lane Bovey Tracey Newton Abbot, Devon TQ13 9JS Lead Inspector Andrea Peryer Announced 29th September 2005 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 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. Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Prestbury Court Residential Home Address Brimley Lane, Bovey Tracey, Newton Abbot, Devon, TQ13 9JS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01626 833246 01626 833236 prestburycourt@tesco.net Avens Care Homes Ltd. Mr Andrew James Avens, Mrs Samantha Avens Mrs Rosalyn Nolan Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (40), Old age, not falling within any other category (40) Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 20.05.05 Brief Description of the Service: Prestbury Court Care Home is registered as a Care Home providing Personal Care for forty elderly frail residents who may have additionally a degree of physical or mental disability. The home has two floors and had recently increased the accommodation of the property to include a large conservatory lounge on the ground floor, an additional dining area and an increase in residents private rooms/accommodation. This is additional to the exsisting lounge and dining areas so that the home has two lounges and two dining areas. The extension to the home has also increased the number of toilet and bathroom facilities aqnd has also increased the number of staff on duty at any one time. The home also has a sensory room. Three staff live on the premises on the top floor of the property opposite residents accommodation. Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out through the day, with the homes manager. The inspector spoke to staff and residents and the home had supplied the inspector a pre inspection questionnaire before the inspection started. The inspector also received feedback cards from residents and relatives. The inspector looked at a range of documentation choosing four residents to look at their specific needs and looked at their documentation, this included care plans and assessments. Staff records were also examined and the inspector toured the premises, entering all areas of the home. What the service does well: What has improved since the last inspection? The proprietor has made major improvements to the premises with the additional of a new wing to the home this has extended the accommodation, adding additional lounge and dining areas and more residents rooms. It has also improved the main part of the home as the proprietor has purchased new furnishing throughout the home and has changed some rooms so that the home has a new improved laundry area and a new sensory room. These changes have improved overall the living accommodation for all residents and an improved working environment for staff. The manager and proprietor have also extended some of the documentation in the home, such as improvements in how the home records the recruitment and selection of staff and the purchase of a controlled drugs book and a new returns of medicine book. These improvements demonstrate the service commitment to improvement and these documents make clear that the home are recruiting staff who should be working in care and that medicines are safely controlled in the home. The service has a complaints procedure that residents and their friends and families are confident in so that complaints are listened to and action is taken to address any areas of concern. Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 6 What they could do better: 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. Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 8 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 standard(s) 3,6 Residents do not move into the home without first having their needs assessed and been assured that these will be met. The home does not provide intermediate care. EVIDENCE: A random sample of residents files were examined and they included the homes assessment forms for residents needs, which the manager said was completed in discussion with the resident, the residents family and any professionals that had been involved with the resident while living in the community. A range of supporting documents which also provided information on residents needs were stored in a filing cabinet, these documents included weight charts and assessments carried out while a resident was in hospital, assessments from the placing authority and care plans completed by Social Services representatives or hospital staff. The home also completes an admission sheet and issues contracts to residents that gave information on the services and facilities available. Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 9 The documents examined varied in how well they had been completed, some were very detailed while others could not be found at all, for example weight charts were well completed for some, missing for others and some were not fully completed. This was also true for some of the initial assessments/admission forms. Discussion took place on ensuring any gaps in information were clearer marked “not available at the moment or refused”. This will make clear that the home have tried to obtain this information, which is needed to ensure staff have a clear picture of residents needs and how to meet those needs. The manager stated that the proprietor has invested in guidance from an outside company (Croners), which supplies up to date policies and guidance on all areas of care. This will enable the homes manager to ensure all the homes policies and procedures including initial assessments and admission procedures are up to date and in a clear easy to read format, which will also help staff understand and meet the resident’s needs. The inspector spoke to a new resident to the home and despite this residents memory loss, the resident was able to say that the home’s manager had spoken too him and his family about coming into the home and the sort of services he could expect. Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 10 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 standard(s) 7,8,9,10 The resident’s health, personal care, and social needs are set out in an individual plan of care and residents are treated with respect with their right to privacy upheld. The residents are protected by the homes policies and procedures on dealing with medication. Resident’s health care needs are partially met. EVIDENCE: A sample of residents care plans were examined and on the whole there had been some improvement in the detail of the care plan so that staff providing the care could easily see the care needs of the resident and how to meet those needs. The care plans examined were not consistently well recorded. Some care plans were very good, showing input from relatives, changes in care and taking into account manual handling and risk of falls information. Others lacked vital information, such as challenging behaviour (shouting and swearing at staff) and how this could be managed or affect the staff or other residents. In the same way although some care plans had been reviewed monthly others had not been reviewed monthly or gave very little information on any changes in care or significant changes such as a distressing incident, in which one Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 11 resident became tearful. The daily records of assessment or “daily review” was also inconsistently completed with some staff being very detailed in their recording of residents needs, how the resident had spent their day and how this linked to their care plan. While other staff were not completing daily records at all, with one resident’s records showing days with no records being made. These inconsistencies could indicate that staff may be unaware of resident’s needs or how to meet them, so they don’t write about them, it could also indicate that staff were unable to write about the care of the resident as no care was given. Consistent recording is important as it shows any changes in care for residents so that carers can respond to those changing needs. The manager assured me that all care needs were met and this was an error in recording rather than a lack of care. The manager confirmed that she would be taking immediate action to address this. Residents spoken too and who were able to respond said that they were pleased with the care provided. One relative also praised the care received by their partner and said that the care provided was “very good”. The home operates a monitored dosage system of medication administration so that medicines are stored, labelled and administered on an individual basis. Records of medicines given to residents were well maintained and this included a new controlled drugs book and a new returns of medicine book. The home has a medication policy, which includes controlled drugs and cover medication. This indicates that the home administers medications safely. The inspector observed staff throughout the day interacting with residents and they were observed to treat residents with politeness and dignity, knocking on doors and apologising when interrupting residents to ask them about what they preferred for supper. The residents seemed to enjoy the contact with members of staff and the members of staff were relaxed in the company of the inspector and happy to discuss how the home cared for residents. This indicates good relationships between the staff and the residents based on respect and dignity. Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12,13 Residents find the lifestyle in the home matches their preferences and satisfies their social and recreational needs, maintaining contact with family and friends and the local community as they wish. EVIDENCE: Residents who were able to speak to the inspector were pleased with the way home provided activities but did not force everyone to attend, so that residents had a choice about how they spent their time. Some residents preferred to remain for long periods in their rooms while others chose to sit in either of the homes lounges or in the dining rooms. On the day of the inspection there were several visitors to the home, and the inspector spent some time discussing a variety of topics with one relative who confirmed that the staff always made them welcome and that they could visit at any time. The manager supplied the inspector with a list of some of the activities planned for the next few months this list had previously been displayed on a notice board. The “entertainment plan” includes musical exercise, crafts, trips out and games, there was also listed themed months/activities such as October and “good old days music hall” and November “a day at the races” (a game). The manager also described one to one discussions with residents and some of these activities are detailed in daily records. Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 13 On the day of the inspection a musical entertainer was singing in the homes lounge to a number of residents. The home has a minibus. These things continue to maintain links for residents with the community and outside events. The new extension to the home has meant some changes to the accommodation previously used including one room being turned into a sensory room, with relaxing music, large soft chairs and a lighting system that stimulates and relaxes. The homes manager stated that this room is still being slowly introduced to residents and the home are exploring the best way to use this area. For residents this room could be an important opportunity to have one to one time with staff or have a gentle mental stimulation that they have not previously had. The changes to the accommodation had also resulted in a new laundry area and new equipment being purchased. Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 14 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 standard(s) 16,18 Residents and their friends and families are confident that their complaints will be listened too and acted upon and that residents are protected from abuse. EVIDENCE: The home has a complaints procedure, which is included in the service users guide, was displayed in the homes policy and procedure manual and is in the homes contract with residents. The residents spoken too said that they felt able to bring any concerns to the attention of the manager and they would be resolved. One relative give an example of this to the inspector detailing one area that needed attention and how this had been addressed. The home also has a policy on dealing with abuse issues and this includes reference to the NHS “No Secrets” guidance. The homes pre inspection questionnaire submitted to the Commission also details that the home has a range of policies in relation to abuse such as aggression towards staff and physical intervention/restraint. This document also lists the training completed by staff and on that list was adult protection/abuse training. Members of staff spoken too said that they were aware of possible abuse issues and would feel comfortable in bringing this to the attention of the manager or proprietor. By ensuring that members of staff receive training, documents are in place to remind staff and ensuring that residents feel able to express themselves protects residents and staff from harm/abuse. Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 15 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 standard(s) 19,20,24,26 Residents live in a clean, pleasant and hygienic home with comfortable indoor and outdoor communal areas and comfortable bedrooms that residents have furnished with some of their own possessions. Residents do not live in a safe environment. EVIDENCE: The inspector toured the premises entering every resident’s room, communal areas, toilets and bathrooms. The home presented as clean, and odour free, with lots of personal affects making the home comfortable and homely. The new extension adds to the home a large conservatory lounge and the proprietor had purchased new furniture of good quality throughout the home, such as new dining furniture and new lounge chairs. The home has enclosed patio areas that have also been furnished to enable residents to sit outside. Overall the home presents as providing a good standard of accommodation for residents. Two residents rooms are in need of new carpeting and one room in particular was in need of redecoration. This was discussed with the homes manager who Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 16 confirmed that this work was planned for the future, as the homes priority had been the completion of the new extension and the new furnishings. There were several areas of concern that the inspector discussed with the manager. On the first floor of the home is staff accommodation opposite and on the same corridor as resident’s rooms. The members of staff living on the premises have a kitchen area filled with kitchen equipment including a set of knives, which were clearly on view. It had been previously agreed that this room must be kept locked when not in use. On the day of the inspection this kitchen area was not being used and the door although fitted with a bolt had not been locked. Some of the residents who have memory problems are at serious risk of injury should they enter the kitchen unsupervised. The manager agreed to take action to address this with staff. One resident’s room did not have a fire/smoke detector fitted so that if there had been a fire in this room it would not have alerted the alarm, putting this resident and other residents at risk. One resident had bed rails protected by sheets tied around them to try and protect the resident from injury by knocking against the sides. Discussion took place on replacing this with bed rail protectors, which are available for purchase and will improve the way the bed looks and lower the risk of injury for the resident. One resident’s room on the first floor had a window that opened well over 12 inches and was easily large enough for the resident or any other resident to fall out of. The manager stated that the resident preferred lots of fresh air and discussion took place on achieving this while keeping the window restricted and making sure there is minimal risk to residents. Several radiators (in the new wing) were unguarded and residents are potentially at risk of injury from the radiators, for example if they fell and hit themselves on the radiators sharp edges. This was discussed with the homes manager and it was agreed that risk assessments would be carried out and radiators would be covered/guarded. The Inspector examined the homes risk assessments for the premises and the manager confirmed that these documents were to be updated including making sure they were dated, signed and extended to include each room in the home and covering guarding radiators, window restrictors and fire safety. These documents will highlight potential risks and show how the home have minimised risks keeping staff and residents from harm. The new corridor in the new part of the home has been fitted with a camera, the manager said that this to ensure no residents left the premises without staff being aware of there movements. Discussion took place on removing the camera as the camera took away some of the residents privacy. The manager agreed to do this. Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Resident’s needs are met by the number and skill mix of staff who are trained and competent to do their jobs. The homes recruitment procedures and practices protect residents from potential harm. EVIDENCE: The inspector examined a sample of staff files and this included staff induction, supervision and appraisal records. The home had recently developed a new application form and interviewing forms, which are a great improvement on the past documents in this area. The new forms clearly show that the home asks about previous employment and any disciplinary action and show that references are requested. There is also an interview format that show the questions asked at interview and how the employer responded. This helps to show how the home had recruited staff in an fair and even handed way. Police checks and references for staff were examined and the manager confirmed that police checks and references were obtained before staff worked unsupervised in the home. This protects residents from being cared for by staff who are not suitable to work with vulnerable adults. The proprietor confirmed that a range of training had taken place with most staff and that this included fire training, a basic induction and abuse training. The homes pre inspection questionnaire also details training for the future and confirms that 50 of staff have or are working towards NVQ Level 2 Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 18 qualifications in care. Records were available of staff training and copies of staff qualification certificates were also examined. The staff induction for new staff to the home is not detailed enough to match a recognised training organisations standards (TOPPS). The proprietor said that documents had been obtained but not implemented which would match these standards and confirmed that she would be re introducing these documents in the future. The numbers of staff employed at the home has been increased with the increased number of residents now living at the home. Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,38 Residents live in a home, which is run by a person who is fit to be in charge and which is run mainly in the best interests of the residents. The health, welfare and safety of residents and staff is protected in some areas, while in others there are areas of concern. EVIDENCE: The proprietor is a registered nurse who until last year had been employed in the health authority and has a past family history in the care industry. The manager of the home has been at the home for some time prior to the current proprietors purchase of the home and she confirmed that she has continued to obtain a range of qualifications within the care field and has now completed her NVQ4 in Care Management. The inspector examined a range of health and safety policies and procedures, which are stored in two homes files, these documents cover some key health and safety issues such as infection control and manual handling. Discussion took place on ensuring that members of staff sign to say they have read and Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 20 understood policies and procedures and the manager confirmed that, some staff sign policies at induction, while others are not signed for. Staff signing to confirm that they have understood documentation helps staff to feel valued, helps to keep them informed and accountable and helps to ensure that staff have access to them. The residents and resident’s families spoken too, said that the manager and staff tried their best to accommodate each residents individual interests and preferences. The managers and staff description of care and the care detailed in some of the care plans indicates that the home is run in the best interests of the residents. As the care described is in the best interests of the residents such as the use of rail guards, the opportunity to attend activities and for staff too reassure residents if concerned. There were a number of health and safety issues linked to the environment (please see standards 19-26 Environment), which the manager confirmed would be addressed and in the past the manager and proprietor have always acted on any areas of the home that need attention. Discussion also took place on developing a quality assurance system and as part of this system the proprietor to submit a monthly report to the Commission outlining the areas the proprietor had considered when visiting the home. This will help to keep the Commission informed of the day to day events in the home and how the home continues to progress. Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 2 x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 2 Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 22 yes Are there any outstanding requirements from the last inspection? 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 7,8 Regulation 14,15 Requirement all documentation including care plans, monthly and daily assessment must be fully and consistently completed, showing the needs of the resident and how those needs have been met. risk assessments for the premises must be extended to include, all areas of the home, identifying hazards and showing how the home have addressed these hazards. this must include window ristrictors, fire safety, radiator guards and hazards for those residents that may be confused or disorientated. window ristrictors must be fitted to all windows kitchen areas must be kept locked when not in use. a smoke dectctor must be fitted in one residents room two residents rooms must be refurbished radiators must be guarded develop a quality assurance system that includes a monthly report to the Commission. Timescale for action 12/12/05 2. 19, 12,13,23 12/11/05 3. 4. 5. 6. 7. 8. 19,25,38 38 19,25,38 24 19,25,38 33 12,13,23 12,13,23 12,13,23 16 12,13,23 24 12/11/05 12/11/05 12/11/05 01/02/06 12/11/05 1/02/06 Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 23 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 3 19.6 30 Good Practice Recommendations Review the current storage and completion of admission and assessment records to ensure that there are no gaps in information. remove the camera in the corridor as planned implement documents that match TOPPS standards on staff induction. Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection 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 Prestbury Court Residential Home D54-D07 S33222 Prestbury Court V237542 280905 Stage 4.doc Version 1.40 Page 25 - 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. 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