Inspection on 28/06/06 for Queen Elizabeth House

This inspection was carried out on 28th June 2006.

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

Other inspections for this house

Queen Elizabeth House 25/01/06

Queen Elizabeth House 04/08/05

Queen Elizabeth House 19/01/05

Queen Elizabeth House 06/09/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Queen Elizabeth House Queen Elizabeth Road Eastmoor Wakefield WF1 4AA Lead Inspector Elizabeth Hendry Key Unannounced Inspection 28th June 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Queen Elizabeth House DS0000034425.V296206.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. Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Queen Elizabeth House Address Queen Elizabeth Road Eastmoor Wakefield WF1 4AA 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) 01924 302395 01924 307792 Wakefield MDC Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 25th January 2006 Brief Description of the Service: Queen Elizabeth House is a purpose built, short stay rehabilitation unit for older people operated by the Social Care Dept of Wakefield Metropolitan District Council. The home has 25 beds, seven of which are for existing long stay residents, plus communal areas including dining room, smokers’ lounge and non-smokers’ lounge. The rear garden is mainly grassed with shrubs and borders as well as a greenhouse. To the front of the home is a car parking area and grassed areas. A regular bus route is within short walking distance of the home. At the time of this inspection, no weekly fees were payable by those temporary residents who are in receipt of rehabilitation services. The home has hairdressing and laundry facilities. The home does not provide nursing care but is supported by local Health Centres and the GPs and Primary Care Teams visit as required. Queen Elizabeth House has a service user guide which provides information about the range of services for existing and prospective residents. Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s annual inspection, which took place on an unannounced basis between 09.30 am and 1.00 pm. As part of this inspection, CSCI have had contact with the following people residents, their relatives, the service provider, staff members, social workers and GPs. During the site visit records, observations and discussions with both residents and staff, were undertaken. Seven resident questionnaires were sent out. At the time of writing this report four had been returned. In writing this report, information and evidence was not only obtained by way of visiting and looking around the home but information and evidence was obtained from notifications sent to the CSCI since the last key inspection in January 2006, questionnaires, and the last inspection report. The inspection has concluded that residents’ needs, both personal and recreational, are fully met. Residents reside in a relaxed and informal homely environment. The inspector would like to thank the residents, manager, assistant manager and staff for their hospitality and patient co-operation throughout the inspection. What the service does well: Of those residents spoken with all spoke highly of all members of staff commenting that nothing is ever too much trouble. Staff spoken with had a sound understanding of each resident’s personal needs and abilities, and are able to communicate effectively with all in their care. Individual care plans and resident records seen are kept in good order with frequent reviews thus ensuring that any changing needs are always met. Support systems in place within the home ensure that both residents and members of staff have access to either a member of the care team or management to discuss any concerns as they may arise. Residents live in a welcoming, relaxed and homely environment, which is well maintained and furnished to a high standard. Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 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 the following standard(s): 3 and 6 The Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. Service users move into the home knowing that their needs will be fully met. Service users who are referred to the home for intermediate care are helped to maximise their independence. EVIDENCE: The home has seven permanent residents who resided at Queen Elizabeth House prior to the refurbishment. All of these service users have a contract of residence which clearly states what is and is not included within the weekly bed fee. Information regarding the trial period, notice of termination of contract and services available within the home is also included within this contract. The remaining service users reside at Queen Elizabeth House on a temporary basis to undergo rehabilitation and access therapeutic services prior to returning home. Although these service users do not have a formal contract of permanent residence, each service user gives written consent to their Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 9 admission into the home within individual care plans and assessments. Each resident has a copy of the home’s service user guide within their individual bedrooms. A sample of four care plans were viewed, all were found to identify the personal care needs and abilities of each resident, and the methods in which care staff can meet these needs. The Manager and assistant manager spoken to during the site visit confirmed that service user care plans are developed based on the pre-admission assessment undertaken by care management. Within forty eight hours of admission into the home each service user has a detailed plan of care. This care plan is compiled by a member of the management team or a senior carer and is reviewed on a weekly basis. The home only admits those individuals who are deemed suitable and has a definite need for rehabilitation. The manager explained that the care manager’s assessment focuses on the following areas - personal care, mobility, communication, family involvement, medication, medical treatment, social and recreational interests. Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 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 the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. Detailed information of residents’ health, personal and social care needs are set out in an individual plan of care. Residents are protected by the home’s medication policies and procedures. Records viewed identified that residents’ health care needs are met. Residents are always cared for in a manner that maintains their dignity and affords respect. EVIDENCE: A sample of service user care plans were viewed, all were found to contain details relating to the circumstances surrounding their admission into the home, personal and social care needs, rehabilitation needs and goals. The Manager spoke of holding weekly multi-disciplinary meetings with consultants, physiotherapists, occupational therapists and social workers to ensure that service users are receiving the level of support needed to aid their return home. Staff were observed clearly displaying knowledge of each individual resident’s needs. Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 11 Of all the residents spoken with on the day of the visit, all had an awareness as to the contents of their care plan and confirmed that, should they wish to see the plan, staff would provide assistance. All of the service user questionnaires returned to CSCI indicated that they always receive the care and support required, and that staff are either always or usually available when they are needed. Daily records contain sufficient information and are consistently completed detailing the individual’s activities for the day and staff observations. All of the residents spoken to at the site visit complimented the dedication of the care staff, commenting that “they are always smiling” and “ if I need anything I just have to ask”. One service user said that he has been made to feel at home. A sample of medication administration records were viewed and checked against drugs held within the home. Medication was found to be stored and labelled correctly in accordance with the Royal Pharmaceutical Guidelines of Great Britain. A discussion took place with the manager regarding the forms currently used for the recording of drugs entering and leaving the home and the problems that may arise. While no errors have occurred, these forms do give the possibility of being interpreted differently and, as a result, could cause errors to occur. The home’s manager confirmed that, since the last unannounced inspection, there has been an overhaul to the home’s medication procedures and storage arrangements. A dedicated medication and treatment room is located on the ground floor away from communal lounges in order to promote and ensure the privacy of any service user wishing to meet with a doctor or visiting health practitioner. The manager also explained that everyone involved in the management of service users’ medication is currently undertaking extensive training in the safe handling and management of medication. Only senior members of staff on duty have access to any medication. During the visit, district nurses were in attendance. Of those spoken with, positive comments were given surrounding the standard of care given by members of staff and the positive and homely atmosphere within the home. Individual care plans and medical notes viewed indicated that any problems identified are quickly addressed. A consultant visits on a weekly basis to review individual rehabilitation strategies and ensure only those suitable for rehabilitation are admitted into the home. Throughout the site visit, staff were observed treating service users with respect and dignity whilst remaining positive and supportive. Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 12 Queen Elizabeth House DS0000034425.V296206.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): 11,12,13,14 and 15 Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. Residents’ daily life and activities generally meet the needs of both the long term residents and short stay admissions. Discussions with residents described how, on the whole, the lifestyle they experienced within the home met their expectations and preferences and satisfied their social and religious interests and needs. Service users maintained contact with family and friends and members of the local community as they wished. Family and friends feel welcome and know that they can visit the home at any time Service users are encouraged and supported to exercise choice and control over their lives. Service users receive a varied and nutritious diet within a pleasant dining environment. EVIDENCE: The majority of service users are admitted into the home on a short term basis to receive rehabilitation in order to aid their return home, therefore activities Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 14 are scheduled around these individual therapy sessions. There are a wide variety of activities available but, because of the short time service users are in the home, it is sometimes difficult to ensure that everyone’s choices can be fully accommodated. Discussions with residents described how, on the whole, the lifestyle they experienced within the home met their expectations and preferences and satisfied their social and religious interests and needs. Of those permanent residents spoken with, all said that they are very pleased with the activities available. One resident said “I have all I need here. If I fancied doing something different I just need to ask and, as long as they have enough staff cover, they will arrange for me to do it.” At the time of the site visit, service users were participating in movement to music, watching television and chatting with one another. The Assistant Manager spoke of staff assisting service users to participate in regular daily activities. Evidence of service users’ personal preferences being sought in relation to activities and interests were clearly documented within each individual care plan. Within those care plans sampled, individual interests had been clearly recorded. Within daily records, reference had been made to what activities had been undertaken. Of the four service user questionnaires returned, one stated that there were always activities arranged in the home that they can participate in, one said there were usually activities and two said sometimes. Many service users were sitting within the communal lounges chatting to one another. Staff members were very busy on the day of the site visit, however they were observed being very responsive to residents when anything was asked of them. Throughout the site visit, service users’ family and friends were visiting. No relative surveys had been returned to CSCI at the time of writing this report, however service users confirmed that their family is always made to feel very welcome within the home and that they can come at any time. Discussions with service users were very complimentary about the food, confirming a wide range of choice, with all meals being tasty and of a good quality. Staff confirmed that snacks and drinks are available throughout the day. Menus showed careful planning and indicated choices available for each meal. Of the four questionnaires returned, service users identified meals were always or usually to their taste. The dining room has benefited from recent redecoration and extension and now provides a welcoming and pleasing environment in which service users can enjoy a leisurely meal. Fixtures and fittings are of good quality and domestic in nature. Dining tables had been arranged in a layout that Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 15 encourages small groups of service users to converse during mealtimes. Due to the nature of the service, service users are encouraged to eat all meals within the dining room, however, should service users express a wish to eat elsewhere, this is can be arranged. Staff were observed offering the same level of choices to each service user regardless of their ability or levels of need. Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 16 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 and 18 Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. Service users and relatives can be confident that their complaints would be listened to and acted upon. The service has a complaints policy that is up to date, clearly written and is easy to understand. Staff’s knowledge of adult protection is good, the home provides all staff with adequate adult protection training and staff are made aware of the in house procedures to follow should they suspect any abuse at the home. EVIDENCE: The home uses the Wakefield Metropolitan District Council complaints policy and procedure. The procedure is clearly written, easy to understand and is available in a number of different formats. Each service user is given a copy of this procedure upon admission into the home within their service user guide. Of the four service user questionnaires returned to CSCI, all stated that they were fully aware of the home’s complaints procedure should they wish to use it. Information received prior to the site visit identified that there had been no formal complaints made to the home since it reopened in May 2006, the home’s complaints book viewed during the site visit confirmed this. Staff training files indicated that all staff are given basic training in adult protection on commencement of their employment, additional training is available once this has been identified within individual development plans. Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 17 The manager confirmed that there is a senior member of staff on at all times to provide support should this be required. Of those staff spoken to, all were aware of the procedure to follow and how to contact Social Care Direct should they need report possible incidences. At the time of writing this report, the home did not have any ongoing adult protection alerts. Enhanced criminal records and POVA checks were in place within all of the staff files sampled during the site visit. Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. The standard of the environment within the home is good providing service users with an attractive and homely place to live. Infection control measures are in place which promote the wellbeing and health of both service users and staff. EVIDENCE: On the day of the visit, a tour of the home was undertaken. A good standard of decoration and furnishing was found throughout the home. The majority of fixtures and fittings were domestic in nature and of a good quality. To the rear and sides of the property there are large garden areas, which are laid mainly to lawn; this provides additional seating and leisure space for residents during the summer months. The manager explained that, since the home has undergone major renovation and a change in the primary use of the building, Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 19 there is now a need to expand the car parking facilities and, as a result, some of the garden to the side of the property is going to be used for car parking. Due to the size of the existing gardens, this should not cause any negative effects for the service users as there will be considerable outside space still remaining. The assistant manager explained that all service users are given the choice of where to sit when not taking part in therapies, the home has three good sized communal non smoking lounges and a smoking lounge. On the day of the site visit, the smoking lounge door had been propped open and, as a result, a definite smell of tobacco was present within the corridor and hallway. The manager explained that it is mainly the permanent service users who sit in there and that they prefer to sit with the door open to see what’s going on. The home has an ongoing programme of maintenance and redecoration. All service users spoken to said that their bedrooms were comfortable and that they had everything they needed. Feedback from four questionnaires identified the home as being “always” or “usually” fresh and clean. On the day of the site visit the home was found to be clean and tidy, no offensive odours were present. Staff training records sampled indicated that all staff receive infection control training as part of the induction programme. Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. Service users’ needs are sufficiently met by the numbers and skill mix of staff. Service users’ health and safety is protected. Service users are fully protected by the home’s recruitment policy and practices. Staff are sufficiently trained and competent to do their jobs. EVIDENCE: Good levels of staff were on duty during the site visit, staff rotas sent to CSCI indicated that good levels of staff were on duty at all times to ensure service users’ needs could be fully met. All of the service users spoken to commented on the staff’s patience and understanding and were very complimentary of all members of the care and management teams. Service user questionnaires returned to CSCI indicated that staff always listen and act on what they say and that they always or usually are available when they are needed. Staff were observed interacting well with all service users and, despite being very busy, were seen to take a proactive role with regards to meeting individual requests in both personal care and leisure activities. Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 21 A copy of the home’s recruitment policy was viewed and found to contain methods for ensuring equal opportunities during the recruitment process. The home stores all recruitment information electronically, all the required documentation was found to be in place relating to the references and checks on staff working within the home. The manager and assistant manager spoke of the home’s recruitment procedure and induction process. Records viewed confirmed that these policies are always adhered to. Four staff files were inspected on a sample basis. Enhanced criminal records bureau checks and POVA First checks were in place for all four members of staff. Information received prior to the site visit indicates that 72 of all care staff hold an NVQ level 2 in Care. Throughout the site visit, staff were observed approaching residents in a respectful manner. Of those staff files sampled, all contained evidence that regular supervision is undertaken. Details of identified training needs and personal development requirements are also formally discussed and recorded on a regular basis. A wide variety of training courses are accessed on a regular basis to ensure the changing needs of service users are fully met. Qualified health care professionals based within the home are not employed directly by WMDC but by the Health Trust and therefore no records relating to them were seen. Staff spoken to said that they just need to ask and additional support is given from both the management team and colleagues. The assistant manager explained that, since the merger of staff from another resource centre, one of the main priorities has been to ensure a good working environment for staff. Feedback received from staff on the day of the site visit was positive and confirmed that, although there may be a few small issues, generally everything is running well. Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 22 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): 31,33,35 and 38 Quality in this outcome area is good. This judgement is based on evidence gathered both during and before the visit to this service. Quality assurance procedures within the home ensure the home runs in the best interests of the service users. The management of the home is good and records are well managed. The manager is supported well by the assistant manager in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The home places a high priority on ensuring quality care for all residents. In addition to the annual inspection from CSCI, the home undertakes monthly quality audits. Each service user who undergoes residential rehabilitation Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 23 within the home is asked to complete a questionnaire to say how they have found their stay and what they thought of the overall service that they received. The manager said that the findings are then used to help improve the overall service residents receive by discussing them at team meetings and one to one supervisions. The manager is supported by two assistant managers who play an active role within the home. They are aware of the in house procedures and how the home runs on a daily basis. Should the need arise, they are able to act up in the manager’s absence. The manager has a clear understanding as to the goings on within the home, service users spoke of the manager being a very friendly and approachable person who likes to get involved. The manager spoke of having an open door policy for staff and service users to discuss personal issues and worries. Staff confirmed that the manager and assistant managers are approachable, understanding and that they actively encourage their personal development. Records are generally well maintained, accurate and regularly reviewed. No financial records relating to both the home and the residents’ finances were inspected on this occasion, however no incidents surrounding the management of residents’ monies has been reported to CSCI. Health and safety certificates viewed identified a consistent and responsible outlook being placed upon service users’ well being within the home by the management team. Records viewed, and information received prior to the site visit, indicated that regular fire safety checks are carried out and electrical appliances are tested annually. Training certificates viewed identified all staff undertake health and safety training as part of their induction process, with updates as required. Service user risk assessments are clear and concise, giving staff clear instructions to ensure the safety of the individual and themselves. Of those sampled, all showed evidence of weekly review with any changes being recorded. The home has made adequate provision for the removal of clinical waste from the home. Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations To review the home’s form for recording drugs entering and leaving the home. Queen Elizabeth House DS0000034425.V296206.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Queen Elizabeth House DS0000034425.V296206.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. 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