Inspection on 05/11/07 for Randolph House Care Centre

This inspection was carried out on 5th November 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 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

Randolph House Care Centre 29/11/06

Randolph House Care Centre 12/12/05

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Randolph House Care Centre Ferry Road West Scunthorpe North Lincolnshire DN15 8EA Lead Inspector Theresa Bryson Key Unannounced Inspection 09:30 5 and 9th November 2007 th 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 Randolph House Care Centre DS0000066375.V354533.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. Randolph House Care Centre DS0000066375.V354533.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Randolph House Care Centre Address Ferry Road West Scunthorpe North Lincolnshire DN15 8EA 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) 01724 272500 01724 272505 www.fshc.co.uk Four Seasons (DFK) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Vacant post Care Home 70 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (51), of places Physical disability (41), Physical disability over 65 years of age (41) Randolph House Care Centre DS0000066375.V354533.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is able to accept two named service users with Learning Disability and should revert to the original registration as they leave the home. 29th November 2006 Date of last inspection Brief Description of the Service: Randolph House is a dual registered home for residential, and nursing care for older people. The home was pleasantly decorated and furnished, and provided a homely atmosphere. The accommodation is provided over two floors, and has a unit on the first floor, which provides specific care for those with Dementia. The first floor is accessible by a lift, and stairs There are good parking facilities to the front of the building, and there are enclosed gardens to the rear and sides of the home. These were well maintained. The home is close to local amenities, including a post office, and general shops. It also has close links to the M180 motorway. The range of fees at the time of inspection was £312 - £535 per week. Additional charges were made for hairdressing, chiropody and newspapers etc for which separate invoices are raised. The Service Users Guide and Statement of Purpose are given to each prospective service user and were also on display in the main entrance and available at each nurses’ station. Randolph House Care Centre DS0000066375.V354533.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit took place over two days in November 2007. Prior to the visit surveys were sent out to relatives and staff working in the home. Members of the local Social Services Team were also contacted by telephone. The home submitted their AQAA documentation prior to the visit, with supplementary documentation. The event history kept by CSCI was also checked. During the site visit records and other documents were checked and a number of people using the service, relatives and staff interviewed. The Acting Manager was present through out the site visit and was accompanied at one point by the Company’s area manager. What the service does well: What has improved since the last inspection? Randolph House Care Centre DS0000066375.V354533.R01.S.doc Version 5.2 Page 6 The documentation on the Service users Guide and Statement of Purpose has been reviewed since the last inspection and now contains accurate details to enable people to make informed choice about staying in the home. All documentation regarding the care delivered to people living in the home has been reviewed and now reflects current needs and is updated when required. Checks are made by senior staff to ensure what is written has taken place and people are satisfied with the care received. A full review of the services the kitchen supplies to the home has taken place. A new cook employed, better monitoring systems for cleanliness and safety put in place. The menus have been reviewed and individuals assessed for their specific needs and tastes, with records being kept by both care staff and kitchen staff. The cleanliness has improved in the kitchen area to ensure all food is prepared in a safe environment and the menu gives choices to meet needs. The Company has completed an audit of the home to see what work is required to maintain the environment to an acceptable standard. A lot of work has taken place including the buying of easy chairs, carpets and some bedroom furniture. Many areas of the home have been redecorated and safety measures put in place such as replacing fire doors to the smoke room. The dementia wing now has more appropriate furniture in place and is decorated to ensure the atmosphere remains calm and friendly. This ensures people are living in an environment suited to their needs, which is pleasant and safe. The staff files have been checked to ensure that each staff member has received adequate checks to ensure they are safe to work in the home and people are free from harm. 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. The summary of this inspection report can be made available in other formats on request. Randolph House Care Centre DS0000066375.V354533.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 Randolph House Care Centre DS0000066375.V354533.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. Comprehensive information is available about the service to ensure prospective service users can make informed decision about the home meeting their needs. EVIDENCE: During the course of this visit Standards 1, 3 and 6 were checked. Since the last inspection the Company has reviewed the Statement of Purpose and Service Users Guide and copies were given to the inspector to keep on CSCI files. These now give a good reflection of the services available and will inform prospective service users about the home and help them make informed decision about staying in the home. Randolph House Care Centre DS0000066375.V354533.R01.S.doc Version 5.2 Page 9 Both documents were on display in the main reception area and relatives stated they had found them useful when helping their loved ones to make decisions about staying in a care home. Prior to admission to the home the Acting Manager completes an holistic assessment on each person who wishes to come to stay. This was seen to be a comprehensive document and looked at all aspects of a person’s needs plus details were taken of their families contact details in case of emergencies. At the moment the Acting Manger only is completing these preadmission assessments to ensure that the mix of people occupying the home is correct and the home does not contravene the categories it is registered for. If she is not available the area manger or other home managers will assist in this process, accompanied by a senior member of the homes staff. The deputy manager and team leader for the dementia wing are being trained in this process to assist the Acting Manager in the future. This assists staff in preparing for a person’s admission and to help them to settle into the home. The home does not have intermediate care and therefore Standard 6 is not applicable. Randolph House Care Centre DS0000066375.V354533.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. Comprehensive information is kept on each person living in the home and records kept up to date to reflect current needs and how they are being met. EVIDENCE: During the course of this visit Standards 7,8,9 and 10 were checked. The Company and local Home Management team have worked very hard since the last inspection and since concerns were raised earlier this year, in ensuring that all documentation is up to date and reflect the current needs of people living in the home. Audits which had been completed by the local team and regional Company personnel were given to the inspector to show what work had taken place since the CSCI visit in March of this year. This had included ensuring that all staff now use the very comprehensive documentation supplied by the Company to record events and the delivery of care and the training given to staff. Randolph House Care Centre DS0000066375.V354533.R01.S.doc Version 5.2 Page 11 6 care plans were tracked as part of the site visit, which ranged from low dependency, high nursing dependency and 2 from the dementia wing. Staff appear now to be following the Company procudre for completing these records to ensure there is accurate recording of the delivery of care. This will ensure that current needs are being met and can be accurately recorded. The Company has recognised that care staff still need to expand their daily report sheet writing to ensure all details are transferred from other parts of the documentation, such as visits by health professionals and families. Staff spoken to state they felt they now had a better understanding of why they need to accurately record the care delivered and felt more confident in writing the care plans. This will ensure all service users needs are being met as the staff have a better understanding of identifying needs. The storage problem on the first floor has now been resolved and all care documentation is kept in a secure office and filing cabinets and accessed on a need to know basis only to ensure peoples confidentially is maintained. Prior to the site visit survey forms were sent out to relatives but only a small number returned. Generally the comments were very positive about the delivery of care, but concerns were raised about Agency staff being employed which was felt did not help the consistence of care in the home. This matter has largely been addressed now as more permanent staff have been recruited. During the course of the site visit days 9 service users were spoken to in depth and 2 relatives. Individual concerns were passed directly to the Acting Manager. Again the comments were very positive with people making such comments as “staff are always very welcoming” and “I get everything done I want” and “brilliant, I am well looked after”. Over a two-day period we were able to observe staff giving personal care to people living in the home, also assisting at meal times, giving medication and helping people take part in activities. This they did in a calm and relaxed manner, taking care to be dignified in their approach to people and respecting individual wishes and addressing individual needs such as assisting with special diets. The medication records were tracked in each area of the home as the home has three separate areas. All records now appeared to be accurate and the staff who assisted us in checking these records were very knowledgeable about the systems in place and the medication each individual person was requiring to take. There appeared to be safe systems in place to ensure people are free from harm and the home has good relationships with all health professionals who, it Randolph House Care Centre DS0000066375.V354533.R01.S.doc Version 5.2 Page 12 was recorded in the care plan notes support the home with advice and suggestions to aid each individuals care needs. Randolph House Care Centre DS0000066375.V354533.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): Quality in this outcome area is adequate. People who use the service experience adequate quality outcomes in this area. Limited activities are available to meet people’s expectations, but a nutritional menu is in place, which is prepared in a clean environment. EVIDENCE: During the course of this visit Standards 12,13,14 and 15 were checked. The Company provides very comprehensive documentation to help staff record events people have taken part in. On tracking these through the care plans there appeared to be very limited choices on offer. The records showed very repetitive events taking place such as hand massage, moisturising legs, and entertainers. On reading the care plans, talking to relatives and people living in the home and on the surveys returned, people’s needs appeared to be more diverse and they felt very limited in what was on offer. The home must ensure that all peoples expectations can be met and the system, which is in place is checked more thoroughly to ensure those particular needs can and are being met. Randolph House Care Centre DS0000066375.V354533.R01.S.doc Version 5.2 Page 14 The Company needs to look into the reasons why so few people can attend events outside the home, although some stated they do go out with families, which they always look forward too. The contact with the outside community coming into the home has improved and there had been visits made by local schools and churches. Extensive work has been made in the dementia wing with a themed corridor in the process of being displayed, themed booklets provided on a variety of topics, with pictures. Redecoration of the wing has ensured that the people living there do so in a calm environment suited to their particular needs and staff are allocated daily to observe and ensure individual social needs are being addressed. There was ample evidence in other parts of the home that individual needs are met with how people’s personal environment has been adapted to suit their tastes and needs. One person stated “my room has been decorated in the last few months and staff have helped me display my pictures” and in another area a person stated “I like my display cabinets and help dust them as it reminds me of my previous homes”. Care has also been taken to establish a room for those who wish to smoke and it has been tastefully decorated and receptacles provided for safe disposal of cigarettes or cigars. It was in constant use during our stay with people chatting and watching television. Good improvements had been made in the kitchen area since the last inspection. Grave concern had been made at that time because of the poor state of cleanliness and disorganisation in this area. Since then the Company peripatetic cook has been overseeing the running of the kitchen and the Company has employed a new cook. A recent environmental health officer’s visit highlighted a couple of minor improvements which could be seen to have been completed on this CSCI visit. Food is now prepared in a clean and well-maintained environment and the last internal audit for catering and nutrition showed a much-improved score. 4week menus are now set and the home were also catering for some specialist diets at the time of our visit. People who live in the home made many positive comments about the provision of meals. Such as “portions are big enough” and “the food is very good” and “I don’t eat a lot but they give me what I want if it is different than the menu”. A food comments book has been put in place where people living in the home, relatives and other visitors and staff can make comments. This has been viewed as a positive move by the service users and assists in ensuring people’s views are taken into consideration and their needs are being met. Randolph House Care Centre DS0000066375.V354533.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 good. People who use the service experience good quality outcomes in this area. A robust system is in place to ensure people are protected from abuse and the complaints process allows for open and transparent discussion about peoples possible concerns. EVIDENCE: During the course of this visit Standards 16 and 18 were checked. Since the random inspection in March 2007 2 concerns had been made directly to CSCI and 2 other referrals made through the safe guarding adults’ team of North Lincolnshire. All are now closed and any improvements and suggestions actioned by the Company. Staff stated they had been “ashamed” this had happened to the home but felt supported by all parts of the Company who came to the home to assist them through that time. Staff also acknowledged they did not ask for support because of a lack of knowledge base, but felt more confident to move the home forward. The documentation supplied by the home for us to look at showed the home had dealt internally with 6 complaints, of which 50 had been dealt with in 28days, with satisfactory outcomes for the parties concerned. The documented evidence was seen and appeared to be accurate. Randolph House Care Centre DS0000066375.V354533.R01.S.doc Version 5.2 Page 16 Relatives stated they now had more confidence in the management team and thought everyone was approachable, friendly and would deal with their concerns in confidence. The Company has also ensured that all staff have now attended updatetraining sessions in the safe guarding of adults, which took place in May and November. Staff spoken to stated these sessions had helped them understand more how to protect people form harm and how to refer issues should the need arise. There was evidence displayed around the home about how to complain, with updated information for people to access and this had also now been changed in the Statement of Purpose and Service Users Guide. Randolph House Care Centre DS0000066375.V354533.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): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. People are living in a safe and secure environment adapted to their needs. EVIDENCE: During the course of this visit Standards 19 and 26 were checked. Since the last inspection the Company team and local management team have been working very hard to ensure the environment both inside and outside the home is brought up to an acceptable standard. During the course of the site visit an outside company was repainting the outside of the building. The gardens were neat and tidy with quiet areas to sit. Some relatives expressed in surveys that a couple of exits were not usable for those needing a Zimmer frame to aid their mobility, but when all formal exits were checked there were safe methods of exit such as ramps, which were Randolph House Care Centre DS0000066375.V354533.R01.S.doc Version 5.2 Page 18 hazard free. All fire exit signs were in place to ensure everyone in side the home was aware of safe exit routes in the case of an emergency. Inside the building an extensive redecoration and refurbishment programme has been put into place. This has included replacement carpets down stairs and some bedrooms. The downstairs lounge, dining room and kitchenette had been redecorated. New easy chairs had been purchased and new fire doors fitted to the smokers’ sitting room. The upstairs corridor had also been redecorated and in the dementia wing bathroom and toilet areas entry points painted a different colour for ease of identification by those service users. All communal areas, toilets and bathrooms were inspected plus a selection of bedrooms. The home has received a Capital Grant award of £5000, which is being used to completely refurbish bedroom areas with new furniture and a redecoration programme. The effort put in by the Company and local team plus outside contractors has made the home feel more cared for, lighter to live and work in and care taken to ensure service users individual tastes can be accommodated. Staff spoken to were able to give account of how they contribute to the up keep of the home and safety of the people living there. People living in the home stated how they had been bale to contribute to their personnel living space by bringing in furniture from home, having a say on the decor in the room and where they wished treasured items to be placed. Randolph House Care Centre DS0000066375.V354533.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience good quality outcomes in this area. Robust systems are in place to ensure staff are safe to work with people living in the home and are then trained to do their job. EVIDENCE: During the course of this visit Standards 27,28,29 and 30 were checked. Concerns had been raised during the last inspection and at safe guarding adults’ referrals earlier in the year that not enough staff were on duty through a 24-hour period. Concerns were also raised in recent relatives surveys that too many Agency staff were being used. Written evidence was produced at this inspection to show how staffing levels are maintained, the criteria for judging staff numbers required and Company accounts information showing where agency staff had been used. On the last point the written information showed that numbers of Agency staff had been reduced in the last couple of months due to more staff being vetted and employed. Some vacancies still need to be filled, but prospective staff had been interviewed and were now going through the vetting process, according to written information seen. Randolph House Care Centre DS0000066375.V354533.R01.S.doc Version 5.2 Page 20 Staff spoken to did not indicate any problems with staffing levels and stated they could complete the tasks allocated to them and felt they could meet people needs. This was also stated by the people them selves with such comments as “they come immediately when I call at night” and “they do everything for me” and “staff immediately do any thing I ask them to do”. There is also a new system in place to ensure someone in the building seven days a week takes responsibility for ensuring that overall there are enough staff in the building to meet peoples needs. This is because the three units work separate staffing levels, because of different needs and an overall picture was asked for by CSCI. 4 staff personal files were also checked to ensure that adequate information was on file that all safety checks had been made prior to a person being employed. They all appeared to be accurate. The details of all those requiring a work permit were also checked and the checking mechanism for those professionally trained nurses who have a “live” registration with the Nursing and Midwifery Council. This ensures that staff are safe to work with the people who live in the home. The training of staff has improved at this home. An internal audit had been completed and evidence was given to us. Areas needing urgent attention such as care planning, safe guarding adults’. Health and safety and wound management have now been completed. This was recorded on individual staff files, a Company training matrix and on certificates seen in personal files and on display. As most mandatory training has now taken place the Company needs to now concentrate on individual staff needs and more service specific training to ensure staff have updated knowledge to enable them to effectively look after people in the home. Randolph House Care Centre DS0000066375.V354533.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People who use the service experience adequate quality outcomes in this area. Adequate checks are made to ensure that the home is safe to live and work in. EVIDENCE: During the course of this visit Standards 31,33,35,36 and 38 were checked. The home now has a new Acting Manager who is yet to be vetted by CSCI but is working very closely with The Commission and the Company to ensure that Standards are maintained at all levels within the home. The home appears to be more organised and Company personal ensure that audits are completed to ensure policies are being maintained and the home is run for the benefit of the people living there. This has included keeping Randolph House Care Centre DS0000066375.V354533.R01.S.doc Version 5.2 Page 22 accurate records of peoples personal allowance accounts and ensuring there are no bad debtors bills on the accounting system. This has allowed the local management team to ensure money is available to keep up the maintenance of the building, that staff have equipment to ensure safety of the people living there and the home has sufficient staff employed to meet peoples needs. Records were seen to show that the home is being well maintained and all safety certificates were in place. Specific staff had now been tasked with ensuring that parts of the quality systems are maintained such as daily and weekly task sheets and that all risk assessments for individual people and general risk assessments are updated on a regular basis. This ensures that everyone’s specific needs are met and that the home is safe. Monitoring of staff work has also improved. Regular checks are made by senior staff on a daily basis and any issues documented, which were seen. This is coupled with a more robust supervision system, which is checking staff knowledge basis, their training and other specific needs and practical application of their role by observational supervision. This ensures they can do their jobs and people are free from harm. A recent customer survey showed that 80 had completed questionnaires with 30 stating the service was very good and 40 stating it was good. The surveys sent by CSCI prior to the site visit had a poor return but with positive comments made by the relatives. This was also stated in the comments gathered at interviews, whilst we were at the home, of relatives, people living there and staff. The home is being more proactive by having staff meetings, relatives and service users meetings and auditing their systems. This is fed to the Company on a weekly basis and the Acting manger can be challenged on the outcomes recorded. This events all feed into a remedial action plan, which was seen, to ensure people are safe, the service is run for them and all needs of those people are being met. Randolph House Care Centre DS0000066375.V354533.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 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 2 X 3 X 3 3 X 3 Randolph House Care Centre DS0000066375.V354533.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP12 Regulation 16.2.m. Requirement People’s expectations regarding their social and cultural needs must be met and a variety of activities offered to ensure all needs are met. The Company must ensure that the application for the manager’s post is submitted as soon as possible to ensure a Registered person is in post. Timescale for action 30/03/08 2 OP31 18.1. 28/02/08 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 OP9 OP30 Good Practice Recommendations Senior staff should be able to verify that the disposal system for controlled drugs is used correctly. To ensure they are disposed of safely. Senior staff will need to concentrate on more service specific training when all mandatory training has been completed to ensure staff can adequately do their jobs. Randolph House Care Centre DS0000066375.V354533.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Randolph House Care Centre DS0000066375.V354533.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!