Inspection on 01/05/08 for Qumran Rest Home

This inspection was carried out on 1st May 2008.

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

Qumran Rest Home 24/05/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Qumran Rest Home 7 Trevose Avenue Newquay Cornwall TR7 1NJ Lead Inspector Melanie Hutton Unannounced Inspection 1st May 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Qumran Rest Home DS0000067500.V362583.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. Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Qumran Rest Home Address 7 Trevose Avenue Newquay Cornwall TR7 1NJ 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) 01637 876699 01637 877060 qumranresthome@googlemail.com Mrs Memuna Khanum Ahmad Position Vacant Care Home 10 Category(ies) of Dementia - over 65 years of age (3), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (10) Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2006 Brief Description of the Service: Qumran is a small home in Newquay that provides care and accommodation for 10 older people, some of whom may have a history of mental disorder or dementia. Accommodation is provided on two floors which are linked by narrow stairs, one of which is fitted with a stairlift. There are changes in level along corridors and on entry to some bedrooms. The registered provider lives on the second floor. The communal areas are on the ground floor and comprise a large dining room where people eat together, a sitting room and a sun room in front of the house. There is a small courtyard, accessible to people who use the service, at the rear of the home. Car parking in the summer months can be difficult due to holiday traffic. The current fees range from £305 up to £395.00, this does not include personal toiletries, hairdressing. Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service potentially experience adequate quality outcomes. This key inspection of Qumran took place on 1 st May 2008 with one inspector spending 8.5 hours at the home. During this time we spoke to the registered provider, service users and staff. Records were inspected and the premises viewed. There were nine (9) service users in residence at the time of the inspection. While the home is registered to accommodate ten people, one double room is currently used as single accommodation. The registered provider, staff and people who use the service all refer to service users as residents. Therefore for the purpose of this inspection report we will use the same terminology. Prior to the inspection surveys we sent quality assurance surveys to the home for the residents and staff to complete. On the day of inspection we were provided with 3 completed surveys from the staff and 1 from a resident. Qumran offers a small homely environment. The registered provider lives on the premises so is on hand if needed. She is responsible for the day to day management of the home, including providing ‘hands on’ care and she cooks the main meal for the residents when needed. Other members of her family live in the home as well; her son provides assistance with administrative tasks. The home is suitable for its present service user group although it is limited in its provision for people with severe mobility problems. What the service does well: Redecoration has taken place in some rooms and the inspector was told that a plan to redecorate and refurbish the rest of the home where necessary had been prepared. Residents new to the home are welcomed, introduced to everybody and encouraged and assisted to socialise within the communal areas. Residents described Qumran as being friendly, warm and homely. Residents told us that their privacy was upheld and that the staff were very kind and respectful to them. Residents were observed to be addressed by their preferred names, in some cases this was a ‘nickname’. We regularly review views of residents to see how improvements can be made” Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 6 The completed and returned surveys were available at the inspection and residents told us that they feel involved in the running of the home. What has improved since the last inspection? What they could do better: Records were organised with a system where staff can access those of service users but some minor alterations are planned to keep these more secure. Limited information was available regarding individual risk assessments for residents. The registered provider reviews care plans on a monthly basis. Further assessments should be undertaken and the outcomes of the assessment be included within the care planning e.g. nutritional and continence assessments. The care plans do not always fully inform and direct staff as to the care that individual residents need regarding the promotion of continence and specific assistance required with personal care. No written menu was available that identified the planned meals. A record is kept of the meal provided each day but does not reflect which resident ate this main meal or who had an alternative. Most Residents told us that they were not informed in advance of the main meal of the day, most said that they did not find this a problem. In this area there are cleaning chemicals stored on an open ledge – these should be stored securely. Update and make bathrooms domestic in appearance currently quite clinical and some used for storage Keys to rooms if required and lockable storage space Not all radiators are fully guarded, surface temperatures were very hot to touch in some areas. In some rooms portable heaters were noted. Pipe work in some toilets and bathrooms were hot to the touch and not guarded. Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 7 The registered provider stated that that temperature valves were fitted to all hot water outlets in the home – these should be checked at regular intervals to ensure they are functioning properly. The water has not been tested for Legionella – the registered provider is aware that this must be carried out. No risk assessments were available regarding these risk factors on the day of inspection – the registered provider said that they had been undertaken. CRB checks for all staff 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. Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People need further information to make an informed choice regarding the care home. Further information should be recorded regarding people’s care needs to ensure that the home can meet their individual and sometimes specialised care needs. EVIDENCE: The registered provider told us that people enquiring about services and the current residents are provided with information in the statement of purpose and service users guide. This document is dated as being last reviewed on 1 March 2006. Further information should be included in this document to provide full information for residents. The registered provider has developed a care needs assessment recording tool that is completed before a resident is offered accommodation, to make sure Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 10 that their needs can be met at the home. It is recommended that this be developed so that further information can be recorded. Residents told us that they or a family member had visited the home before deciding to live there and that they had liked the atmosphere and the friendliness. The registered provider and residents told us that when residents come to live at the home they are welcome, introduced to everybody and encouraged to socialise within the communal areas. Staff told us how they strive to make people feel welcome at the home including residents and their visitors. Qumran does not provide intermediate care and for the past year has not had available accommodation to provide respite care. Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are treated with respect and their dignity is respected by the staff. Care plans do not always inform and direct staff as to the action they must take to meet peoples individual care needs. Decisions on how personal care is provided are not consistently recorded. Medication systems and procedures protect people including those who self administer their medication. EVIDENCE: Each resident has an individual plan of care. Limited information was available regarding individual risk assessments for residents. The registered provider reviews care plans on a monthly basis. Further assessments should be undertaken and the outcomes of the assessment be included within the care planning e.g. nutritional and continence assessments. The care plans do not always fully inform and direct staff as to the care that individual residents need regarding the promotion of continence and specific assistance required with personal care. Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 12 Residents are supported to obtain further medical assistance when needed e.g. from the GP, district nurse, chiropodist and optician. Detailed records are held of any visits from visiting professionals or when residents have attended appointments outside of the home. This was confirmed to us verbally by both residents and staff. A detailed medication policy and procedure has been developed to advise and inform staff – these are stored in the office. Staff told us that they access to the policies and procedures and have read and understood the medication policy. It is recommended that a list of homely remedies is held with consent to administer sought from the GP. Records are held of medications received within the home and returned to pharmacy. The majority of medication is undertaken by named staff for the residents with their consent. Records are maintained of all medication administered that are up to date and in good order. One resident self medicates – no risk assessment was seen regarding this and this person did not appear to have lockable storage facilities in their room for the medication. The registered provider has undertaken training with staff members who administer medication and stated that periodically training is provided from a local pharmacist. Medication is kept in the fridge in the kitchen. This was discussed with the registered provider who informed us that she has been told that this is acceptable to do provided it is kept in a separate and locked container. Residents told us that their privacy was upheld and that the staff were very kind and respectful to them. One person said “they are wonderful, so kind, they just cannot do enough for me”. Residents were observed to be addressed by their preferred names, in some cases this was a ‘nickname’ and some people confirmed this preferred form of address. The home has a mobile telephone handset which is available to residents for making and receiving telephone calls. Residents told us that their clothes are laundered well and promptly and available to them within 12 hours of sending to the laundry. Medical attention e.g. from the GP or district nurse is provided in their communal room – this was confirmed by residents. Policies and procedures are in place to guide staff regarding the care of the resident who is dying. Resident’s wishes concerning terminal care and arrangements after death are discussed and recorded within the care planning – relative’s views are also included in this process where appropriate. Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and enabled to make choices as to how they spend their day and are supported to receive visitors and access the community by the staff at the home. A varied diet is provided, but residents are not provided with the opportunity to always choose the content of their main meal of the day. EVIDENCE: Residents can choose whether to socialise within the home or remain in their own rooms. Several said they go out regularly, some alone, others accompanied by a member of staff or friends. Visitors are welcomed to the home, as confirmed by the visitor’s book. The residents were seen to have televisions, music facilities, books, that helped them continue with their interests. The home is developing the activities programme within the home and with that aim one member of staff has been provided with additional hours to achieve this. We were able to talk with the staff member about their plans and aims for this new role. One to one time is available for each person plus group activities. One resident told us that card games are popular at the moment. The activities co-coordinator plans to purchase a number of board Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 14 games e.g. Countdown as this is something the residents have expressed that they would like. Activities have been provided by people visiting the home e.g. Truro museum has come to the home and held a reminiscence day. The home provides a varied diet, with a mixture of fresh and frozen vegetables. Two people with a preference for vegetarian food said they were happy with the meals they received. No written menu was available that identified the planned meals. A record is kept of the meal provided each day but does not reflect which resident ate this main meal or who had an alternative. Most Residents told us that they were not informed in advance of the main meal of the day, most said that they did not find this a problem. One resident told us that while they knew what was for lunch on the day of inspection they did not like it but had not been offered an alternative. The registered provider and staff told us an alternative would always be available. The staff told us that frozen ready meals were offered to anyone not wanting the main meal. Fresh fruit is available within the home at all times. The kitchen is domestic in nature and the care staff on duty also take on the role of the cook both at mid day and at teatime. Staff told us that the registered provider is usually available to assist at these periods. Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents know how to make a complaint should they need to do so, further information to fully inform them on the investigation process should be available. Resident’s are protected from abuse by the policies, procedures and training provided for staff. EVIDENCE: There is a detailed policy and procedure regarding complaints available in the home. This should be developed to reflect the person (s) to refer complaints to within the home. The complaints procedure included in the service users guide and statement of purpose should be developed to inform people that complaints may be referred to the department of adult social care and the timescales for any subsequent investigation. This procedure should also be available, on request, in other formats e.g. large print and audio. All residents told us that they knew how to make a complaint should they need to do so. The home has received one complaint since the last inspection and detailed records of this were available for inspection that showed the complaint was not substantiated. Policies and procedures are in place regarding the safe guarding of adults. Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 16 The registered provider is aware of her responsibilities as a provider of referring staff to the POVA (protection of vulnerable adults) list should this be needed and also checking the POVA list prior to appointing staff. Staff are provided with safeguarding adults training either internally at induction – with the use of a video and worksheet or externally as provided by Cornwall County Council Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The accommodation provided at Qumran meets the current service users’ needs. Service users with limited mobility are likely to need assistance from the staff in accessing rooms on the first floor. EVIDENCE: Accommodation provided to residents is homely and comfortable. Residents expressed satisfaction with both their own bedrooms and the communal areas. There is a cosy sitting room, spacious dining room and seating available in the front porch. Several residents told us that they liked to sit in the front porch / sun room during the day and watch any activity in the street. There are changes in levels on landings and some bedrooms have a step to access them, therefore the home may not be suitable for somebody with considerable mobility issues. The first floor is accessible by a stair lift. Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 18 Handrails are provided throughout the home to assist residents moving around. The courtyard area accessible to residents is attractive and provides a seating area. Pot plants and shrubs help to make this a pleasant area. One resident told us they like to feed the birds and is supported to do this by the staff. A second courtyard area that houses the laundry and waste is accessible by steps. In this area there are cleaning chemicals stored on an open ledge – these should be stored securely. The registered provider does not maintain a formal maintenance plan, but it is obvious that care is taken and communal and private areas redecorated as necessary. Lighting throughout the home is domestic in nature. The bathrooms and toilets on the first floor are clinical in appearance. The residents and staff told us that the bathrooms on the first floor are not used as the preference is for the walk in shower that is located downstairs. One resident told us that they would prefer a bath. It is not clear when the bath hoist was last serviced – the registered provider told us that a service is due to be carried out although it is no longer used by anyone. We were also told that it is planned to update both bathrooms on the first floor. Most rooms are not ensuite, but do have access to toilets close by. Some residents choose to have a commode in their rooms. Bedrooms are personalised and showed that residents have their own possessions around them The home was clean, tidy and free from odours on the day of inspection. One resident has a key available to their room, but chooses not to use this. It is recommended that the resident’s bedrooms are fitted with locks suited to their capabilities and accessible to staff in emergencies. The registered provider stated that no other resident’s wishes to have a key – records should show that this facility has been offered to them. Lockable storage space should be available to all residents within their rooms. All rooms within the home are centrally heated and the temperature can be controlled in each room. Not all radiators are fully guarded, surface temperatures were very hot to touch in some areas. In some rooms portable heaters were noted. Pipe work in some toilets and bathrooms were hot to the touch and not guarded. The registered provider stated that that temperature valves were fitted to all hot water outlets in the home – these should be checked at regular intervals to ensure they are functioning properly. The water has not been tested for Legionella – the registered provider is aware that this must be carried out. No risk assessments were available regarding these risk factors on the day of inspection – the registered provider said that they had been undertaken. Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 19 The laundry has domestic size machines – 1 washing and 1 tumble drier and is sited in a shed near the backdoor. The registered provider says all laundry is taken to the laundry room via a door next to the dining room, so as not to pass through the kitchen. The registered provider said that the home has a system of different coloured baskets to keep clean & dirty laundry apart. Hand washing facilities are not available within the laundry, an outside tap provides water for soaking soiled laundry in buckets solely used for this purpose. Qumran Rest Home DS0000067500.V362583.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The present staff group hold qualifications that indicate their knowledge in care. The home has had a period of stability with this staff group and is investing in further training for them. Consideration must be given to ensure that resident’s needs are met during the night time period with the current arrangement of no waking night staff being on duty. EVIDENCE: There is a staff rota in place that identifies which staff are due to be on duty and in which role e.g. cooking or administering medication. Staff told us that the registered provider is usually available at busier times of the day to assist e.g. at teatime. All staff employed are over 18. The last inspection report indicates that there was previously one waking member of staff on duty at night. undertaking sleeping duties. The provider’s accommodation is on the second floor and is included in the call bell system and fire alarm. The present staff group all have relevant qualifications. Two are non-UK national’s with a nursing qualification. The staff that the inspector spoke with Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 21 said they enjoyed their work and felt they had time to spend with and provide care to the residents and were supported well by the registered provider. Staff files indicated that the home’s recruitment procedure included taking up references, Criminal Records Bureau & POVA checks. Two members of staff did not have a CRB check, the registered provider had relied upon the police check from their native country as provided by the recruitment agency. The registered provider is also awaiting a full CRB to be returned for one member of her family All staff have been provided with induction training, with records maintained to show the content. The registered provider is aware of the Skills for Care foundation standards. An on going training programme is in place for all staff, including the registered provider. Training records show that staff have received training regarding safe guarding adults, medication, moving and handling, first aid, food hygiene, health and safety. Further training is planned regarding Parkinson’s disease and the mental capacity act. Training is often provided in house by the registered provider with the use of video material and workbooks. Qumran Rest Home DS0000067500.V362583.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered provider has a proven record of dealing with service users and based on her previous record she provides good care. Further attention to the health, safety and welfare of service users and staff must be given including the availability of written risk assessments. EVIDENCE: The registered provider is a registered nurse with a current pin number from the NMC (Nurse and midwifery council) and holds a National Vocational Qualification level four, managerial qualifications. The AQAA (annual quality assurance assessment) completed by the home told us that “we conduct client assessment surveys to seek the views of residents and their friends / family. This allows everyone a further opportunity to make Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 23 any comments and suggestions to us and where practical we take up suggestions made. We regularly review views of residents to see how improvements can be made” The completed and returned surveys were available at the inspection and residents told us that they feel involved in the running of the home. Up to date insurance is in place in the home and the certificate is displayed in the hallway. The registered provider is assisted by her son to manage the homes accounts. Records are maintained on the premises of the financial transactions of the home and a chartered accountant audits the accounts annually. Residents are encouraged to manage their own finances, often with the support of friends / relatives. The registered provider holds money for one resident and a record is maintained of any transactions undertaken. Residents should all have access to secure facilities to store their money and valuables. Staff told us that the registered provider meets with them regularly and is always available to offer support and / or guidance. Records are held that show that regular supervision and annual appraisals take place. Records are generally well maintained and up to date. Attention must be paid to the storage of resident’s personal records. Food records should be kept to show the food provided for individual residents. Health and safety checks are made throughout the home. On the day of inspection all fire extinguishers in the home were checked by a fire safety company. Residents told us that regular checks are made on the fire alarms and fire drills take place regularly – this was confirmed by written records. Some fire training for staff now needs to be updated. A health and safety poster is situated in the central part of the house and provides information for staff and residents. The registered provider told us that maintenance and servicing takes place regularly for the stair lift, gas and electrical equipment. Records relating to these checks were not inspected. She also stated that the bath hoist is due to be serviced. As reported in other areas of this report the health, safety and welfare of service users and staff must be ensured, concerning the storage of COSHH substances, the use of window restrictors and hot surface temperatures, hot water, portable heaters and legionella testing. Where the risk relating to these areas has been assessed, this must be reflected within a written risk assessment and be available within the home at all times. Qumran Rest Home DS0000067500.V362583.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 2 X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 2 3 3 2 1 2 STAFFING Standard No Score 27 2 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 3 2 2 Qumran Rest Home DS0000067500.V362583.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. 1. Standard OP15 Regulation 16(2)(h) (i) Schedule 4(13) Requirement It is required that a record is kept of the food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutritional and otherwise, and of any special diets prepared for individual service users. It is required that menus are provided that allow service users to make food choices as stated in the statement of purpose. Timescale for action 20/06/08 2. OP25 OP38 13(4)(a) (c) It is required that the registered 20/06/08 person ensure that all parts of the home to which service users have access are so far as reasonable practicable free from hazards to their safety and that unnecessary risk to the health or safety of service users are identified and so far as possible eliminated. This should include safe storage of COSHH substances, use of window restrictors and risks from hot water / surfaces and the risk of legionella. DS0000067500.V362583.R01.S.doc Version 5.2 Page 26 Qumran Rest Home Risk assessments relating to these issues should be readily available in the home. 3. OP27 18(1)(a) The registered person must 20/06/08 ensure that at all times suitable qualified, competent and experienced persons are working at the care home in such numbers as are appropriate for the health and welfare of service users. This must include at night times. The registered provider must review and risk assess the arrangements for the night staff cover and inform the CSCI of any changes to the current arrangements. All person working or residing in 20/06/08 the home must have a CRB and POVA check in place. 4. OP29 19(1)(b) Schedule 2 (7) 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 DO1 Good Practice Recommendations It is recommended that the service users guide and statement of purpose be reviewed annually. It is recommended that further information should be included in this document to provide full information for residents e.g. updated staff list, include information regarding the department of adult social care in the complaints procedure, detail on how individual care plans will be reviewed and include the service users views of the home. It is recommended that the statement of purpose reflects the layout of the home and includes information on the DS0000067500.V362583.R01.S.doc Version 5.2 Page 27 Qumran Rest Home changes of level on landings and entering private bedrooms. 2. OP3 It is recommended that the registered provider reviews and develops the care needs assessment recording tool so that further information can be recorded e.g. oral health, foot care and any history of falls. It is recommended that the service users care plan sets out in detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service user are met e.g. including guidance for staff on specific assistance required with personal care and promoting continence. It is recommended that a list of homely remedies be held with consent to administer sought from the GP. It is recommended that a separate refrigerator be provided to store medication where necessary. Royal Pharmaceutical Society Guidelines – The handling of medicines in social care states that in residential care there should be a separate secure fridge that is used only for the storage of medicines. It is recommended that the complaints procedure included in the service users guide, should inform people that complaints may be referred to the department of adult social care and the timescales for any subsequent investigation. The complaints procedure should be available in other formats e.g. audio or large print. It is recommended that the resident’s bedrooms be fitted with locks suited to their capabilities and accessible to staff in emergencies. It is recommended that records are held to show that service users have been offered the opportunity of holding their own key or a risk assessment be in place to identify why this would not be practicable. It is recommended that lockable storage space be available to all residents within their rooms It is recommended that the registered provider review the laundry area particularly regarding the permeable floor and walls and lack of hand washing facilities for staff. 3. OP7 4. OP9 5. OP16 6. OP24 7. OP26 Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Qumran Rest Home DS0000067500.V362583.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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