Inspection on 03/10/07 for Pretoria Court Complex Care Home

This inspection was carried out on 3rd October 2007.

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.

Other inspections for this house

Pretoria Court Complex Care Home 31/10/06

Pretoria Court Complex Care Home 19/12/05

Pretoria Court Complex Care Home 11/07/05

Pretoria Court Complex Care Home 03/11/04

Pretoria Court Complex Care Home 21/04/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Pretoria Court Complex Care Home Corbridge Road Medomsley Consett Durham DH8 6QY Lead Inspector Mrs Sue Lowther Unannounced Inspection 3rd October 2007 09:30 X10029.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 Pretoria Court Complex Care Home DS0000000741.V351861.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 and Care Homes for Adults 18 – 65*. 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. Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Pretoria Court Complex Care Home Address Corbridge Road Medomsley Consett Durham DH8 6QY 01207 561880 01207 563094 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) Alliance Care (Trendlewood) Limited (wholly owned subsidiary of Four Seasons) Mrs Christine Munro Marr Care Home 91 Category(ies) of Old age, not falling within any other category registration, with number (67), Physical disability (26) of places Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Physical disability - up to 24 persons with a physical disability (younger adults) may be accommodated in the Stanhope Suite only, commensurate with the home’s statement of purpose. The home may accommodate up to two persons with a Physical Disability in Edmundbyers House only. 31st October 2006 Date of last inspection Brief Description of the Service: Pretoria Court Complex is a large, partly purpose built establishment, located in a rural setting with spectacular views from many rooms overlooking the Derwent Valley. It is provided by the Four Seasons Health Care group. The care home complex provides accommodation for people with nursing or personal care needs. It is staffed with registered nurses and care staff, who are supported by a team of ancillary staff, including cooks, domestics and handyman. The home is divided into separate units to enable people with different care requirements to be catered for: Edmundbyers House (37 beds) and Blanchland House (30 beds) (currently vacant) are for older persons (over 65 years); Stanhope Suite (24 beds) is for younger adults with physical disabilities (18-65 years). All bedrooms are single rooms and there is a good range of sitting and dining areas for communal use. Most bedrooms are supplied with en suite toilet and wash hand basin. There are pleasant garden and patio areas around the home and ample parking space for visitors. The Registered Manager for the whole complex is Mrs Christine Munro Marr. A Deputy Site Manager, Mrs Anne Johnson, who is responsible for the Stanhope Suite, supports her in her duties. At the time of the inspection the fees charged were between £399:50 and £459:50 plus the cost of free nursing care. The cost of hairdressing, chiropody, newspapers, aromatherapy and holidays is not included. Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 3rd October 2007. During the inspection time was spent talking to people using the service, staff, relatives and management. A number of records were looked at and the grounds and building itself were inspected. The home was also asked to complete a self-assessment, which provided the inspector with information prior to the site visit. Information gathered throughout the inspection maybe included within the inspection report. The inspection focussed on key standard outcomes for people who live in the home and to check whether requirements from the previous report had been met. What the service does well: What has improved since the last inspection? What they could do better: The drug fridge contained medication that had a limited shelf life once opened. The date of opening was not identified on the label. This medication was still in date as it had only been dispensed a few days previously. However there was potential that out of date medication may be given in the future. The date of opening must be written on any bottle of medication that has a limited shelf once it is opened. Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 6 The programme of refurbishment should continue so that a high standard of accommodation is provided throughout the home. The remainder of windows must be replaced and the ventilation improved in all of the bathrooms. It is recommended that the thermostatic mixer valves to hand basins are maintained so that the hot water is delivered at no higher than 43 degrees. Staffing levels should be kept under review to ensure that they are in sufficient numbers to meet the changing needs of the people who live in the home. 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. Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): OP3 (YA2). The home does not provide intermediate care and therefore assessment of Standard 6(OP) is not applicable. ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. Admissions are well managed and people are provided with information about the home before moving in. EVIDENCE: The home provides a statement of purpose and service user guide, setting out its aims and objectives, the range of facilities and services it offers to people. This enables people to make fully informed choices about whether the home Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 9 can meet their indivdual needs. People are encouraged to visit the home unannounced and spend time there. They can have a meal and talk to people to help them make a decision as to whether they would like to live there. People are only admitted after a full assessment of need is carried out by an appropriately trained person. This is usually the registered manager or the unit manger of Stanhope suite. This is to make sure that the home can meet the care needs of the people who go to live there. The family of one person who had recently gone to live in the home confirmed that they had looked around the home and had been supplied with all of the information they needed to make a decision about whether or not their relative would like to live there. Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): OP7 (YA6 & 9), OP8 (YA19), OP9 (YA20) and OP10 (YA16 & 18). ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. People’s health care needs are well managed by the home. Systems to administer medication are in the main safe and people living at the home say that they are treated well and that the standard of care is good. EVIDENCE: Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 11 All of the people who live in the home have care plans so that staff know how to look after people on an individual basis. There was evidence within some of the plans to confirm that people had been consulted with regard to their care. There has been one complaint recently which indicated that people do not have plans to cover all of their social needs. Those examined on the day of inspection contained the relevant information. One healthcare professional from outside of the home has confirmed that the person she deals with has comprehensive care plans in place and that she is happy with the care delivered within the home. One of the relatives said “Since my relative arrived at Pretoria Court, she has been extremely well cared for. She is well fed and kept entertained”. Another said “I am extremely happy with the care my relative receives”. Records examined showed that people receive visits from other healthcare professionals. These include district nurses, doctors, and care managers. One person who lives in the home said “When I need the doctor the staff call him straight away. I have had to see him a few times lately as I haven’t been very well”. Medication is administered by qualified nurses and the home has a comprehensive medication policy. Accurate records of all medicines received, administered and those leaving the home are maintained. The drug fridge was checked. This contained medication that had a limited shelf life once opened. The date of opening was not identified on the label. This medication was still in date as it had only been dispensed a few days previously. However there was potential that out of date medication may be given in the future. The date of opening must be written on any bottle of medication that has a limited shelf once it is opened. People spoken to said that staff always treat them with dignity and respect. One of the relatives said “Since my relative arrived at Pretoria Court, she has been extremely well cared for. She is well fed and kept entertained”. Another said “I am extremely happy with the care my relative receives”. Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP12 (YA11, 12 & 14), OP13 (YA13 & 15), OP14 (YA7) and OP15 (YA17). ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. The home provides a range of activities with input from the people that live there. Relatives are made welcome and encouraged to visit the home. People living at the home said that they were able to make choices within all aspects of daily living. There is a varied menu and people likes and dislikes are well catered for. EVIDENCE: Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 13 Routines of daily living and activities are flexible and varied to suit individual expectations, preferences and capabilities. Personal choice is promoted at all times. People’s interests are recorded, there is a daily activity programme which is flexible. The home has in-house entertainers monthly and trips out when they can be arranged. Relatives are invited to all events. People can have visitors at any time and private visiting areas are available. People’s spiritual needs are respected. People are encouraged to make choices and decisions wherever possible and this was observed throughout the day. One person said “I can get up and go to bed when I want. I go to bed at 11:30 and get up really early”. Meals are varied, appealing, nutritious and based on individuals choice. The choice of menu is recorded daily but remains flexible. Special dietary needs are catered for and people are assisted to eat if necessary. One person who lives in the home said “The food is alright. We get a choice and there is definitely plenty”. Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP16 (YA22) and OP18 (YA23). ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. Complaints and adult protection matters are supported by clear guidance and training. EVIDENCE: The home has a complaints procedure in place, which is displayed throughout the home. As previously stated there has been one complaint since the last inspection. This was with regard to the implementation of the no smoking policy. The investigation has not as yet been concluded. However part of the complaint was that there was no internal area in which to smoke. The room had been completed on the day of the inspection and people were smoking in there. People who live in the home said that they would know how to make a complaint. One oerson said, “I would ask to see the manager and tell her off. I know she would put things right as soon as she could”. One visitor said “If I have a problem I just tell the manager and things are done promptly. I rarely have any problems”. Staff said that if they have a problem they feel that they can approach the manager and she tries her best to sort it out. Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 15 Staff are trained to recognise and prevent abuse of the people who live in the home. The home has a clear adult protection procedure which links with the local authority procedure for safeguarding adults. The home also has an active whistleblowing policy. All staff spoken with said that they would have no hesitation in whistle blowing (telling someone) if there was a problem. Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP19 (YA24) and OP26 (YA30). ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. The home is clean, well maintained and furnished and decorated to a good standard. EVIDENCE: Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 17 Parts of the home have been refurbished to provide a good environment for the people who live there. The programme of replacing the windows has commenced. Those which have been done make the home very attractiive. Many of the bedrooms have been personalised to individual choice and taste. There are a variety of lounge/dining areas for people to enjoy. There are bathrooms throughout the home which have adaptations to assist those who are less mobile. However the last inspection identified that the ventilation in bathrooms needed to be improved. This process has commenced but is not yet completed. The building complies with local fire and environmental health regulations. The premises were clean, hygenic and free from any odours. Policies for the control of infection are in place and adequate handwashing facilities are available. Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP27 (YA33), OP28 (YA32), OP29 (YA31 & 34) and OP30 (YA35). ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. Staffing numbers support people’s needs. The home has a commitment to staff training and recruitment practices protect people living in the home. EVIDENCE: The home had staff files in place, which provided evidence that the appointment of new members of staff is made through proper recruitment processes. This includes the vetting of staff through the use of Criminal Record Bureau (CRB) checks, Protection of Vulnerable Adult checks (POVA) and written references. The staffing rotas were examined during the inspection. Some staff felt there were not always sufficient numbers on duty to meet the needs of the people who live in the home. The unit manager of Stanhope Suite said that staffing Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 19 levels throughout the home are based on the dependency levels of the people who live there. These are reviewed on a regular basis as needs change. One person who lives in the home said, “There are enough staff most of the time. I sometimes have to wait a while for attention if they are busy. This tends to be during the morning time”. Training has recently taken place in fire safety, safe handling of medicines, infection control, equality and diversity, health and safety and person centred care. Certificates to confirm this were seen in staff files. Staff confirmed that there is plenty of training available. One said, “There is a lot of training for us to do. Sometimes there is too much”. Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP31 (YA37), OP33 (YA8 & 39), OP35 (YA23) and OP38 (YA42). ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. The home is well managed and relatives and people using the service are regularly consulted about the service they receive. Financial arrangements are good and health and safety systems and practices protect people. Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager is well qualified, with several years experience in working with older people. She is a qualified nurse and holds an appropriate management qualification. There are clear lines of accountability within the home. Staff, relatives and those living at Pretoria Court are actively involved in the decision making process of the home. The home has an annual plan for quality assurance which includes, meetings with people using the service, relatives and staff. These are held monthly and information from these are included in quality monitoring. The area manger completes a regulation 26 visit monthly. The administrator is responsible for the record keeping with regard to people’s financial interests. Transactions are recorded and receipts are kept. The company carry out an audit on a regular basis and the home have recently had a financial audit from Durham County Council. Health and safety systems were looked at. Safe working practices are maintained in line with current regulations and appropriate risk assessments are available. All safety checks for maintenance are carried out by external contractors as designated by law. However it is recommended that the thermostatic mixer valves to handbasins are maintained so that water is delivered at no higher than 43 degrees. Those which are fitted to baths are working correctly. All accidents are recorded and reported appropriately. Accident statistics are audited monthly and care plans amended where required. Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 22 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 X 2 X 3 3 4 X 5 X 6 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13(2) Requirement Medication that has a limited shelf life once opened must have the date of opening identified on the bottle. Ventilation to some bathrooms and shower rooms needs to improve in the interest of health, safety and welfare. (Outstanding requirement. Partially met since last inspection). The programme of window/window frame replacement needs to be completed, to ensure residents have full protection from the weather. (Outstanding requirement. Partially met since last inspection). Timescale for action 31/10/07 2. OP19 13 & 23 31/03/08 3. OP19 13 & 23 31/03/08 Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 24 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. Refer to Standard OP27 OP38 Good Practice Recommendations Staffing levels should be kept under review to ensure that they are in sufficient numbers to meet the changing needs of the people who live in the home. It is recommended that the thermostatic mixer valves to hand basins are maintained so that the hot water is delivered at no higher than 43 degrees. Pretoria Court Complex Care Home DS0000000741.V351861.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB 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. Pretoria Court Complex Care Home DS0000000741.V351861.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. 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