Inspection on 14/04/08 for Rawalpindi House

This inspection was carried out on 14th April 2008.

CSCI found this care home to be providing an Good service.

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

Rawalpindi House 04/10/06

Rawalpindi House 13/12/05

Rawalpindi House 28/07/05

Rawalpindi House 09/08/04

Rawalpindi House 22/04/04

Rawalpindi House 10/03/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Rawalpindi House Rawalpindi House 81 Hermit Road Canning Town London E16 4HR Lead Inspector Sarah Greaves Unannounced Inspection 12:00 14 , 15 & 25th April 2008 th 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 Rawalpindi House DS0000032077.V364248.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. Rawalpindi House DS0000032077.V364248.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rawalpindi House Address Rawalpindi House 81 Hermit Road Canning Town London E16 4HR 0207 474 4500 0207 476 2225 mary.gavin@newham.gov.uk 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) London Borough of Newham Ms Mary Margaret Gavin Care Home 32 Category(ies) of Dementia - over 65 years of age (32), Old age, registration, with number not falling within any other category (32), of places Physical disability over 65 years of age (32) Rawalpindi House DS0000032077.V364248.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can admit persons over 60 years of age up to maximum number. Date of last inspection 4th October 2006 Brief Description of the Service: Rawalpindi House is a 32-bedded residential home for older people. The home is owned and managed by Newham Social Services. The purpose built premises are on the ground floor and located in Canning Town, within walking distance of the underground station, local amenities and frequent bus services. The home is divided into four separate units; two of these units provide care for older people with dementia and two units provide care for older people with general residential care needs. The home offers permanent and respite care. Rawalpindi House DS0000032077.V364248.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was conducted over two days at the care home. Information regarding the on-going development of the service was sought from the registered provider after the site visit to Rawalpindi House. We gathered information through speaking to residents and their families, talking to and observing staff, reading a random sample of the care plans and looking at other relevant documents (such as records of complaints and accidents, menu plans and the minutes for meetings). We toured the premises and checked upon the care home’s storage and administration of medication. The service had completed an Annual Quality Assurance Assessment (AQAA), which is a self-assessment tool; information from this document was also read. The quality rating for this service is 2 stars. This means that people who use the service experience good quality outcomes. What the service does well: What has improved since the last inspection? Rawalpindi House DS0000032077.V364248.R01.S.doc Version 5.2 Page 6 The main area of improvement is the management of medication. The service received a pharmacy inspection from a Commission for Social Care Inspection pharmacist inspector, which resulted in 13 requirements and 16 recommendations. These requirements and recommendations had been satisfactorily addressed at this inspection. A requirement for the service to ensure that all opened refrigerated items are marked with the date of opening was satisfactorily addressed and fungi in the garden had been dealt with. 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. Rawalpindi House DS0000032077.V364248.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 Rawalpindi House DS0000032077.V364248.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): 1 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents (and their representatives) are provided with satisfactory information about the service, including opportunities to visit prior to admission and a trial stay before choosing whether to remain at the care home as a permanent resident. The health and social care needs of people are properly identified by external health and social care professionals. EVIDENCE: We read the service’s Statement of Purpose and Service User’s Guide. It was noted that these items needed to be updated in order to reflect specific changes that have occurred since these documents were last reviewed (for example, the care home had now established an agreement with Age Concern Rawalpindi House DS0000032077.V364248.R01.S.doc Version 5.2 Page 9 to provide independent advocacy services). We advised the registered manager and the administrator to refer to the guidance within the National Minimum Standards and Regulations for Care Homes for Older People, which provides a comprehensive system for the clear presentation of both the Statement of Purpose and Service User’s Guide. All of the residents at this care home had been placed by Newham Social Services and were therefore provided with a pre-admission assessment that had been co-ordinated by their social worker. We noted that a significant number of residents were initially admitted to Rawalpindi House for a short period of respite care, which was then extended to a permanent placement, subject to appropriate social and health care assessments, and consultation with the individual and their representatives. A review meeting was held approximately six weeks after residents had moved into the care home to discuss whether the placement should be permanent. The registered manager stated that it was not feasible for herself or a senior member of staff to conduct their own assessment for some residents prior to their admission, as the admission was due to emergency circumstances. Standard 6 was not applicable for assessment, as the service does not provide a formally established intermediate care service. Rawalpindi House DS0000032077.V364248.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): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning process satisfactorily identifies the needs of residents, although the service should progress with the introduction of more detailed person-centred care plans. Health care needs are met well and medication practices have significantly improved, although there are still issues to be addressed with the application of prescribed topical medications. Residents receive a service that promotes their dignity. EVIDENCE: We read four randomly selected care plans during this inspection. One of the care plans had been updated using a more detailed care planning approach and was of a better quality than the other three care plans. The registered manager stated that the care home proposed to make these changes to all of Rawalpindi House DS0000032077.V364248.R01.S.doc Version 5.2 Page 11 the care plans within the next three months. The other care plans were satisfactory and evidenced that care plan objectives and risk assessments were regularly reviewed. We spoke to the service manager after this inspection, who confirmed that the service were investigating the use of other care planning models that would reflect the more complex and changing needs of older people that now require placement in residential care. We noted that there is a need for staff to be more vigilant regarding the need to record information. For example, we noted within a care plan that a resident should have been wearing a hearing aid but was not equipped with one. Through discussion with a care worker it emerged that a family member had removed the hearing aid for repair but this had not been recorded in the daily record sheet. We spoke to a visiting General Practitioner and district nurse regarding the care home’s ability to identify and address the health care needs of the residents. The feedback from both individuals was very good; it was stated that staff were prompt in their reporting of any significant changes or concerns, and any medical and health care instructions were correctly adhered to. We looked at the accidents book, which did not identify any patterns for concern. The service received an inspection by a CSCI pharmacist inspector following the previous key inspection in October 2006. We conducted the specialist pharmacy inspection as the key inspection had identified some concerns regarding the service’s management of prescribed medications. The pharmacist inspector issued 13 requirements and 16 recommendations for good practice; we checked upon the service’s compliance with these requirements and recommendations at this inspection visit. It was noted that the care home had addressed these issues and sought assistance from external community health care professionals in order to improve upon this aspect of the service. We observed two senior members of staff checking and recording new supplies of medication; staff were very clear about their responsibilities. A new medication policy was presented, which reflected published guidance recommended by the CSCI pharmacy inspector and a senior nurse from the local Primary Care Trust now regularly audits the medication systems. These requirements and recommendations have now been deleted. We found at this inspection visit that there was a noticeable pattern of staff not consistently signing the medication administration records when they applied topical creams and lotions. It was also observed that there were no specific instructions on pharmacy labels for the application of topical creams and lotions. We received a comment from a visitor at this inspection, expressing concerns that topical creams and lotions were not consistently applied to their relative. We found that residents reported that they were happy living at Rawalpindi House. Residents stated that they liked the staff and had formed good relationships with their key workers and other people involved in their care. Some of the residents were not able to clearly express their views or identify Rawalpindi House DS0000032077.V364248.R01.S.doc Version 5.2 Page 12 who was their key worker due to their memory loss; however, good interactions were observed between the residents and staff. We observed residents receiving their evening meal and medication on one of the units for people with dementia; there was a very relaxed and calm atmosphere and the care staff demonstrated an understanding of residents’ individual needs and preferences. A senior member of staff responded well to a resident who used unusual words to express their needs, due to the impact of dementia upon their communication skills. Rawalpindi House DS0000032077.V364248.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): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were offered fulfilling activities, although there is scope to develop a more individualised and varied programme. The importance of contact with the wider community and relationships with family members and friends was recognised and promoted. Residents benefited from a food service that offered consultation and homely, healthy choices. EVIDENCE: The care home does not employ an activities organiser, as there is an emphasis upon all care staff being involved in the provision of activities, entertainments and outings. Two care workers were undertaking activities training at the East Ham Care Centre (rehabilitation centre for older people); we reviewed the current activities programme with one of these care workers. It was noted that a varied programme was offered, which included Rawalpindi House DS0000032077.V364248.R01.S.doc Version 5.2 Page 14 contributions from external activities staff and volunteers. A number of residents enjoyed prize bingo, which was organised by volunteers from a community centre. An external therapist facilitated a weekly reminiscence group and a musician visited the care home for ‘sing-a-long’ sessions. Other activities included memory games, gentle exercise, baking, board games and tea dances. We noted that the service would benefit from possessing a wider range of reminiscence equipment; for example, the quiz cards were limited to famous celebrities from the past although different quizzes could be of interest, such as significant historical events in the past century. The care plans identified individual cultural and religious needs; the care home offered visits from different representatives of local places of worship on a weekly, fortnightly or monthly basis (the frequency of visits was determined by the representatives, in accordance to their own commitments). A hairdresser visited the care home every Saturday, which was noted to be a popular service. The care worker evidenced that staff also supported residents with pampering activities (such as manicures) and provided assistance with hair care that reflects cultural preferences. The care home used to provide ‘arts and crafts’ through a visiting art teacher. Via discussion with the service manager, we were informed that this activity would resume through the appointment of permanent specialist staff to visit Rawalpindi House and the other services for older people within the same directorate. The service evidenced an on-going working relationship with the Age Exchange Theatre Trust (specialist organisation for activities for older people, including older people with dementia). We were informed that the service would be working with this organisation to produce ‘life history’ assessments (to be known as individual memory cards), which would assist staff to offer personalised and meaningful activities to residents that were not able to fully express their former interests and hobbies. We noted that two of the residents attended day centres in the community. One of the residents used to visit a weekly luncheon club for older people that shared his cultural heritage but has now chosen not to attend. The service offered outings to places of interest in the community (such as pub lunches and picnics) and a lively programme of activities was devised for the Christmas period. The service had purchased a computer for residents to use; we were informed that residents would be supported to use the computer to contact relatives and discussions had already commenced with relatives that were interested in using this form of communication. The service offered flexible visiting hours and relatives confirmed that they were invited to entertainments. One visitor stated that they were participating in the delivery of activities. We found through speaking to residents and relatives that staff sought information regarding the individual preferences of the residents regarding their personal care needs, daily routines (for example, preferred time to get up and go to bed), food choices, and cultural wishes and interests. The care plans indicated some of this information but required more details. An independent organisation (Age Concern) organised the monthly meetings for residents and Rawalpindi House DS0000032077.V364248.R01.S.doc Version 5.2 Page 15 recommendations from these meetings were forwarded to the registered manager. Although these meetings were relatively new within the care home, we found that the registered manager was keen to positively act upon the views of the residents to promote improvements. We noted that residents were now formally involved in monthly menu planning meetings with the chef. We spoke to the chef and looked at the menu plans for one month. We also joined residents for their evening meal on the first day of the inspection and looked at the choice of food within the main kitchen and the small kitchens on each unit. The menu plan appeared varied, with healthy choices and an emphasis on fresh foods and home-baked cakes (the cakes were being prepared when we met with the chef). Residents were offered choices at both lunch and suppertime, and the chosen options of each resident were documented. There was also a range of choices available for breakfast. We found that there was good evidence of consultation with residents and staff, which included a request for daily comments, positive or critical, to be documented and returned to the chef. Residents and visitors commented upon the improvement in the food service. Fresh fruit was delivered once a week; however, we observed that fruit supplies were running low on some of the units. A recommendation has been made in this report for the service to review its arrangements for supplying fruit; for example, twice weekly deliveries might resolve this issue. Rawalpindi House DS0000032077.V364248.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives are made aware of their entitlement to express concerns and complaints, which are addressed in accordance to the complaints procedure for the service and Newham Council. Residents are protected through good training and policies for safeguarding vulnerable older people. EVIDENCE: We looked at the complaints procedure, which was clearly written and made available to residents and their representatives. It was noted that there had been two complaints since the last inspection; we spoke to both complainants (representatives of residents) during the course of this inspection. One of the complainants confirmed that their complaint had been appropriately managed by the service. The second complainant expressed several concerns regarding the quality of care provided to a family member and issues related to staff conduct towards the family. The complainant was not satisfied with the management of the complaint, which was being dealt with through Newham Council’s complaints department. In addition to a lengthy discussion with the registered manager Rawalpindi House DS0000032077.V364248.R01.S.doc Version 5.2 Page 17 during the inspection, we also spoke to the service manager at a later date with a specific focus upon incidents that indicate some staff have not observed professional boundaries. It has been noted that the care home has provided the CSCI with the minutes of investigations and resolution meetings that have been held to address the complaint, which had not been resolved at the time of this inspection. The service has upheld elements of the complaint and taken actions to improve upon outcomes for all residents. The service produced an appropriate Safeguarding Adults policy and staff received regular training regarding the protection of vulnerable adults. Rawalpindi House DS0000032077.V364248.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a comfortable and pleasant home. EVIDENCE: The care home occupies a purpose built ground floor building, which is divided into four separate living units. There are two units for older people with dementia; Belafonte Unit has nine bedrooms and Monroe Unit has eight bedrooms. The other two units accommodate older people with general residential care needs; Bassey Unit has eight bedrooms and Sinatra Unit has seven bedrooms. There is a large communal lounge that is used for activities and entertainments; some residents also choose to watch television or relax in Rawalpindi House DS0000032077.V364248.R01.S.doc Version 5.2 Page 19 this area. A requirement was issued in the previous inspection report for the service to ensure that hazardous items were safely stored. We observed that a trolley with cleaning fluids had been left unattended in an unlocked staff changing room on the first day of the inspection. The registered manager stated that this was an error as there is a designated lockable storage area for this trolley. A requirement has been issued for the service to install a safe system (such as a key pad) so that the staff changing room cannot be accessed by residents, taking into account potential risks to the safety of residents with dementia. It was noted that a few of the residents smoked in their bedrooms, in accordance to their own choice. The need for the care home to comply with current legislation by signposting that smoking was authorised in these rooms was discussed with registered manager and was addressed during the course of the inspection. The premises were found to be clean and well maintained, with homely and comfortable bedrooms and communal areas. The service had undertaken work in both the front and rear gardens to produce a relaxing and pleasant facility for residents. No offensive odours were detected. Rawalpindi House DS0000032077.V364248.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): 27,28 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The health and social care needs of residents were addressed through receiving care from sufficient staff with appropriate training for their responsibilities. EVIDENCE: We looked at the staffing rotas and observed staff working on the separate units, and found that the staffing levels were appropriate for the needs of the residents. All permanent staff (apart from a few members of staff due to retire soon) had achieved National Vocational Qualifications in Care at level 2 or 3. We reviewed the training programme for staff, which included mandatory training (such as moving and handling, protecting vulnerable adults, infection control and fire safety). The service demonstrated that it responded to current social care issues, such as the provision of training to understand the Mental Capacity Act. This was delivered as a half- day course for care staff and a full Rawalpindi House DS0000032077.V364248.R01.S.doc Version 5.2 Page 21 day for senior staff. One of the senior staff had achieved ‘train the trainer’ status as a dementia care trainer and this training had been delivered to staff. All senior staff had undertaken medication training and held valid qualifications in first aid. The registered manager stated that senior staff would be receiving further training regarding medication this year. Although general records were maintained for staff training, the care home is recommended to produce individual training records for each member of staff. We found that staff were not routinely provided with basic food hygiene training, although all care staff participated in serving food, making drinks and preparing light snacks. A requirement has been issued in this report. Standard 29 was not inspected at this inspection. Rawalpindi House DS0000032077.V364248.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): 31,33,35,36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefited from a well managed and safe service that took account of their views, although this service could be improved through more frequent individualised staff support. EVIDENCE: The registered manager has been in post for several years, having previously worked as a deputy and acting manager at Rawalpindi House. She has Rawalpindi House DS0000032077.V364248.R01.S.doc Version 5.2 Page 23 qualifications in general and mental health nursing, a management certificate and a specialist certificate in the health care needs of older people. We observed that good progress had been achieved in meeting the requirements and recommendations from the previous key inspection and the pharmacy inspection. Although the service had appropriately sought external guidance to address medication issues, the registered manager demonstrated her understanding and involvement with the significant positive changes to the storage and administration of medications. Evidence obtained at this inspection has identified areas that the registered manager has achieved good outcomes for residents, such as supporting people with their health care needs, the food service and the activities programme, and also identified areas that require improvement (care planning, management of topically applied medications and formal staff supervision). We found that the service was committed to listening to the views of the residents, as evidenced through the independently organised residents’ meetings and the menu planning meetings. The views of the residents were sought in other ways, such as statutory reviews and through the monthlyunannounced person-in –charge monitoring visits. We reviewed the system for managing the personal spending allowances for residents that required this support. No concerns were identified with the sample of records and receipts viewed. Although the service evidenced that regular staff meetings were conducted and the minutes demonstrated that relevant issues to improve the quality of care were discussed, it was acknowledged by the registered manager that staff were not receiving formal one-to-one supervision at the frequency stipulated by the National Minimum Standards for Care Homes for Older People. The importance of regular supervision was discussed, with particular regard to issues detected at this inspection (such as care staff not consistently signing medication administration records for the application of topical creams and lotions, and staff understanding of professional boundaries). We checked a sample of the health and safety records, which were satisfactorily maintained. The records looked at were (1) portable electrical appliances testing (2) landlord’s gas safety (3) weekly fire alarm testing (4) weekly water temperatures (5) testing of the emergency doors and emergency lighting (6) fire drills and (7) weekly testing of the residents’ call bell system. Rawalpindi House DS0000032077.V364248.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Rawalpindi House DS0000032077.V364248.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 OP9 Regulation 13 (2) Requirement The registered manager must ensure the safe management of prescribed topical medications. (a) Care staff must sign the medication administration records after each application (b) The instructions for application must be recorded on the pharmacy label, recorded on the medication administration records or written in the care plan. The registered manager must ensure that all staff handling food receive basic food hygiene training. The registered manager must ensure that staff receive a minimum of six formal one-toone supervisions each year. The registered manager must ensure that arrangements are made to secure the staff changing room. Timescale for action 30/06/08 2 OP30 18 30/11/08 3 OP36 18 30/11/08 4 OP19 13 (3) 31/07/08 Rawalpindi House DS0000032077.V364248.R01.S.doc Version 5.2 Page 26 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 OP15 Good Practice Recommendations The home should provide an adequate supply of fresh fruit at all time. Rawalpindi House DS0000032077.V364248.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Contact Team 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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