CARE HOMES FOR OLDER PEOPLE
Raymond House 7-9 Clifton Terrace Southend On Sea Essex SS1 1DT Lead Inspector
Trevor Davey Unannounced Inspection 13th April 2007 09:50 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 Raymond House DS0000015464.V332350.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. Raymond House DS0000015464.V332350.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Raymond House Address 7-9 Clifton Terrace Southend On Sea Essex SS1 1DT 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) 01702 352956 01702 435027 Jewish Care Jacqueline Michelle Shuttleworth Care Home 39 Category(ies) of Dementia - over 65 years of age (9), Old age, registration, with number not falling within any other category (39) of places Raymond House DS0000015464.V332350.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. Personal care to be provided to up to thirty-nine (39) older people. Old age not falling within any other category (OP) Care Home only Personal care to be provided to up to nine older people who have dementia. Dementia, over 65 years of age (DE(E)) The maximum number to be cared for shall not exceed thirty-nine (39). 26th. June 2006. Date of last inspection Brief Description of the Service: Raymond House provides care and accommodation for thirty-nine older people of whom up to nine may have dementia. It is owned and managed by Jewish Care. It provides specialised care for people of the Jewish faith and caters for all their cultural, religious and dietary needs. The building consists of four floors. Residents use the first three and each can be accessed by way of a passenger lift. Thirty-seven rooms are single and one double room is used as single occupancy. All the rooms have a wash hand basin. None of the rooms have en-suite facilities. There is a lounge and separate dining room on the ground floor and a lounge/diner on the first floor. Raymond House is a lively, active home with a large team of volunteers who support a range of activities. The home has access to three vehicles, which are shared with a nearby day centre, which is also run for people of the Jewish faith. The home is situated on the cliffs overlooking Southend sea front and has a large parking area to the rear of the property. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplies them with up to date information on the home. Fees range from £652.00 to £725.00 and there are additional charges for hairdressing, chiropodist, taxi’s, toiletries and sundries. There is a decked area to the front of the home that provides seating with sea views. Raymond House DS0000015464.V332350.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The key Inspection site visit covered a period of 7.50 hours. The visit focused on the progress the home had made since the last inspection and covered all key standards. A tour of the premises also took place. The Registered Manager, Service Manager together with a selection of other staff, residents and relatives were spoken with during the site visit. Their comments and contributions received were helpful in assisting the Inspector to compile this report. As part of the site visit, case tracking took place using some of the personal care records and other official records within the home were also assessed. The management of the home had also conducted their own survey and quality assurance exercise with residents, staff and relatives. Other healthcare professionals/stakeholders were invited to contribute to the survey but no responses were received. A summary of the feedback received was made available to the Inspector together with a copy of the action plan which had been implemented by the home. Overall, the responses received by the Inspector and other information gathered by the home was complimentary and positive regarding the standard of care and services provided. The inspection also took into account previous information submitted by the home including the completed Pre-inspection questionnaire. The home is planning to extend the service provision of dementia care it offers to residents and these proposals were briefly discussed with the Inspector. What the service does well:
As well as meeting the care needs of residents, the home has been successful in recognising and practising the cultural and religious needs of residents who are from the Jewish faith and tradition. From conversations with residents, relatives and staff as well as feedback from surveys conducted by the home, residents generally felt well cared for, supported and appreciated the service provided. The management have increasingly recognised the importance of giving residents the opportunity of expressing their views and individual preferences for daily routines. Relatives are also made welcome and invited by the home to visit and discuss the care being provided and any concerns they may have with opportunities to discuss
Raymond House DS0000015464.V332350.R01.S.doc Version 5.2 Page 6 care plans. Comments made to the Inspector from relatives were positive regarding how well residents had settled into the home which had been due to the support and understanding of the staff team. They felt that the quality of life for some residents had considerably improved since being admitted to the home and the values of independence, privacy, choice and dignity were respected. Staff were said to be approachable and helpful if there were any issues of concern. There was a recognition from some of the conversations with the Inspector, that some residents were highly dependent and could express challenging behaviour but that staff were able to care and communicate effectively in meeting these needs. From observation during inspection, staff were seen to be competent, sensitive as well as responding appropriately in the support provided to residents. A variety of social activities is provided which is overseen by the social care coordinator. As well as group activities, information is gathered to ascertain how individual social/recreational needs can be met more effectively. The home provides regular courses of training and members of the staff team spoken to, confirmed that this included moving and handling, ongoing sessions in dementia care and prevention of harm to vulnerable adults /reporting procedures. The management are also good at encouraging staff to use previous experience/skills and are willing to provide additional training to enable hand/foot massage and reflexology therapy to be provided to residents. Staff spoken to, were positive regarding the support and supervision provided by management. Regular monitoring visits on behalf of the Registered Provider are made on a monthly basis and copies of these reports ( as required under Regulation 26), were available together with records of action taken. There is evidence to show that the home is good at regularly assessing its own performance and looking at how the quality of care and service provision can be improved for residents. What has improved since the last inspection?
Since the last inspection, requirements and recommendations have been met including improvements to the recording of information on care plans and reviews, medication administration and the documentation of complaint investigations. The home has also focused on improving the quality assurance policy which includes taking into account the views of residents, relatives and stakeholders as well as providing an action plan for implementation as a result of surveys and information received. Raymond House DS0000015464.V332350.R01.S.doc Version 5.2 Page 7 The corridors of the home have been redecorated and flooring has been renewed in two of the bedrooms. Unsafe storage cupboards have been removed from all the corridors. The Registered Provider has initiated additional training sessions to enable staff to have a greater awareness of dementia care and how to respond to these needs. This takes into account managing aggressive behaviour, guidance on colour schemes, signage and the use of appropriate symbols to enhance the quality of life for residents. Three key staff have been identified who will have a lead role in training and assisting staff in this area. 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. Raymond House DS0000015464.V332350.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 Raymond House DS0000015464.V332350.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): 3&6 Quality in this outcome area is good. Pre- admission assessment details for care/health needs had been completed to give staff suitable information to assure potential residents that their needs could be met. Intermediate care is not provided by the home. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Client profile sheets had being completed by a senior member of staff which is part of the pre-admission procedure. Potential residents are also visited by the manager in their homes or in hospital and in some cases, families make appointments to bring relatives to Raymond house. Information recorded
Raymond House DS0000015464.V332350.R01.S.doc Version 5.2 Page 10 included choices and preferences of residents as well as details relating to cultural and special needs, hobbies and interests. Once admission has taken place, Getting to know you life history forms are completed by residents with the assistance of members of the staff team. A holistic approach is taken which takes into consideration social aspects, behavioural problems and general dependency level charts to determining staffing levels and input required. Where social workers have been involved, these assessments are also taken into account along with other information provided. Some residents come into the home for respite care and there was evidence of reviews which had taken place during these periods. Community care assessment forms had also been completed by social workers. Visitors spoken to, expressed their satisfaction of the standard of care and the positive input provided by staff which had contributed to significant improvements in the quality of life and health of their relatives. Staff were said to be available to assist with any concerns and to answer questions. During the site visit, the Inspector had the opportunity of meeting with the Project Manager who is responsible for developing dementia care on behalf of the Registered Provider. Proposals are being considered to apply for a variation in registration to increase the home’s existing capacity to provide additional dementia care places. Raymond House DS0000015464.V332350.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, & 10 Quality in this outcome area is good. The personal care and health needs of residents were being met appropriately. Care records were clearly documented and person centred which reflected the involvement of residents in the decision-making process. Medication administrative procedures were being followed to ensure the safety and protection of residents. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A selection of care plans and other case records were looked at which involved case tracking and the sampling of other information. Care plan information was clear and easy to follow which included descriptions of needs and causes, the goals of care short/long-term/potential as well as care instructions with the
Raymond House DS0000015464.V332350.R01.S.doc Version 5.2 Page 12 steps to be taken. Monthly reviews had been carried out and dated by the member of staff concerned. Following a survey involving relatives, the home now send out a letter at the beginning of each new year asking all relatives to visit in order to check and sign the care plans . Many of the relatives have taken up this offer and others have been spoken with over the telephone. However, some relatives have not taken up this request. Risk assessments had also been completed which included moving and handling, nutritional risk score and dependency level audit. As part of the monitoring process, the Manager audits two care plans each week to ensure these are up-to-date and that reviews have been carried out as planned. Other senior staff also have responsibility for overseeing care plans on a regular basis. Staff were also observed completing daily log reports which included relevant detail of care and support provided to residents following each shift. The home enjoys a good working relationship with other health care professionals and appointments are arranged as required. Some relatives spoken to, also confirmed that the home responds promptly in arranging hospital and other health care appointments through local doctors. During the inspection, staff were observed to be competent and sensitive in the way they respected individual dignity as they communicated with residents when moving and handling which included the use of hoisting equipment and transferring to wheelchairs. A sample check was made of the medication administrative records and since the last inspection, protocols had been put in place for handling P.R.N.(to be taken as required) medication. Entries on the M.A.R. charts had been properly completed and where changes in medication had taken place, this had been subsequently verified by printed labels issued by the pharmacist as approved by the doctor. The Inspector advised staff that where transcribing takes place, any written entries on the M.A.R. sheets should be supported by two staff signatures or written confirmation by the G.P. concerned (e.g. fax from the surgery). Raymond House DS0000015464.V332350.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 & 15 Quality in this outcome area is good. The home provides an activities/recreational programme to meet residents preferences, social, cultural and spiritual needs. Meals are provided which take into consideration residents choice, cultural and faith traditions. Relatives and friends are encouraged to have regular contact with the home. This judgement has been made using available evidence including a visit to the service. EVIDENCE: In the resident’s survey carried out by the home in January 2007, fourteen completed the questionnaires. Of these, over 37 felt that the home maintained the Jewish atmosphere particularly on important days. There was also a positive response regarding the way special festivals were celebrated although it was thought these could be improved upon. The action plan
Raymond House DS0000015464.V332350.R01.S.doc Version 5.2 Page 14 produced by the management of the home in response to these comments, recognises that this is important to residents but they greatly rely on volunteers from the Jewish community to assist with the arrangements. Residents have also been encouraged to share ideas for promoting the Jewishness of the home and the new social care co-ordinator is also aiming to take this into account as part of her role for arranging social and recreational activities. Over 58 of the questionnaires returned were positive regarding entertainment and activities in the home. The home mentions in their action plan that regular outings for residents to various venues are arranged particularly in the summer months. The management of the home are also in the process of collating and arranging specific activities to further improve and meet the individual interests of residents as well as providing group activities. One of the visitors spoken with by the Inspector was very complimentary and pleased with the way staff had provided social stimulation for their relative which included visits to the shops and involving them in indoor games which she enjoyed. Other comments from residents were positive such as being able to go out for walks each morning and of being taken to the day centre regularly. Some of the staff also provide hand and foot massage as well as reflexology. It was appreciated that the home gave opportunity for residents to exercise independence and to be self caring but that assistance was available from staff if required. Other comments were positive regarding the cleanliness of the home, regular laundering arrangements and the standard of food. Members of the staff team showed the Inspector records of meals which had been given to residents based on their preferred choice. Samples of menus had also been submitted with the pre -inspection questionnaire. Responses from the home’s survey confirmed that snacks and drinks can be provided at any time but this is to be reinforced at the next residents meeting. Generally speaking, residents were satisfied with the variety and choice of meals available. The home is to start new Food Forum meetings from April 2007. The management of the home were able to demonstrate that as a result of increased discussions and feedback from residents and relatives, they are prepared to take on board comments made in order to improve communication and the quality of the service provided. Raymond House DS0000015464.V332350.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): 16 & 18 Quality in this outcome area is good. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents and relatives spoken with, were aware of the complaints procedure and to whom they should approach should they have any concerns. The Inspector was made aware of some issues which had been raised with the management relating to the conduct of an agency member of staff. Management were said to be approachable and responsive to relatives who had confidence that they could approach them any time with any problems. The care manager stated that two issues of concern had been raised since the last Key Inspection. Documentation was made available which included records of interviews and letters to evidence that the complaints had been investigated thoroughly and the outcomes recorded. Up to date policies relating to the prevention of harm to vulnerable adults and reporting procedures were in place and staff spoken with, had an
Raymond House DS0000015464.V332350.R01.S.doc Version 5.2 Page 16 understanding of the procedures they should follow should there be any cases of abuse or suspected abuse. Regular training to update staff takes place. Raymond House DS0000015464.V332350.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 & 26 Quality in this outcome area is good. The premises are well maintained to enable people who use the service to live in a safe, comfortable and well maintained environment. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The premises of the home were clean and hygienic and residents spoken with, confirmed that they liked their rooms which were kept tidy and clean. Residents are able to personalise their rooms and these are decorated to their individual taste. Since the last inspection, all corridors have been redecorated including new wallpaper with suitable colour schemes which take into account the needs of residents who may be partially sighted or have dementia. New
Raymond House DS0000015464.V332350.R01.S.doc Version 5.2 Page 18 non-slip flooring has been provided in two of the bedrooms and similar work/re-carpeting is to take place shortly in other bedrooms. Communal areas are pleasant, suitably furnished with quiet seating areas around the home. Toilet and bathroom areas which were seen on the day of the inspection, were clean and supplies of liquid soap/paper towels and disposable gloves were available. There were no unpleasant odours present in the home at the time of inspection. Following a resident’s survey, staff have been asked to ensure that windows are opened and ventilation is at an optimum. Raymond House DS0000015464.V332350.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): 27,28,29, & 30 Quality in this outcome area is adequate. Staff in the home are trained, skilled and in sufficient numbers to support people who use the service. Some areas of the home’s recruitment practice are not robust. This judgement has been made using available evidence including a visit to the service. EVIDENCE: At the time of inspection, staffing levels were adequate to meet the needs of residents. As well as the Registered Manager, there is an assistant manager and team leaders who have responsibility for a team of residential care workers. Staffing levels are usually six carers (including the Manager), from 8 a.m. to 4 p.m., five carers (including shift leader), from 5 p.m. to 8 p.m. and three night staff on awake duty from 8 p.m. to 8 p.m. In addition, a social care co-ordinator is part of the permanent staff team and a group of volunteer workers are regularly involved in the home and its activities. Domestic and catering staff are provided by an external contractor in addition to care staff. Raymond House DS0000015464.V332350.R01.S.doc Version 5.2 Page 20 Staff spoken with, enjoyed their work and felt well supported by management with supervision taking place on a regular basis. Records of supervision were available. It was noted from the staff survey carried out, that it was recognised that staff members need to feel their contributions will be listened to in regard to ideas for the home. The action plan subsequently prepared by the management, identified senior staff who would have the responsibility for ensuring that staff members would always feel supported as well as encouraging them to raise their concerns and that team meetings need to be held more regularly. Key staff have delegated roles in the home including supervision, medication and health and safety. Staff confirmed that they had attended various training courses including infection control, moving and handling as well as dementia training which takes place on a regular basis. Records were available showing courses and training completed by staff. One of the housekeeping staff employed by the contract cleaners was also spoken with who had a clear understanding of her duties within the home which included making beds, hoovering and cleaning bathroom areas. Recruitment records for all current staff who are employed directly by the home were in place and if required, a risk assessment is also completed if this is felt to be appropriate. Two other care staff are awaiting to commence duty once the Criminal Record Bureau checks have been completed. It is recommended that the Registered Provider includes a question on staff application forms requesting applicants to disclose any cautions received as well as criminal convictions. Evidence of recruitment checks completed by an employment agency were available covering agency staff. However, there was no evidence to show that two written references had been taken up for domestic and catering staff which are provided by an external contractor. Evidence must also be made available to show that Criminal Record Bureau checks have been completed by the contractor concerned. Because of staff vacancies, a number of agency care staff are used in the home. Comments from residents and relatives have highlighted difficulties where residents do not enjoy the same personal working relationship with agency staff as they do permanent staff. Other comments expressed concern that some agency staff are not so caring neither do they give the same time to residents as regular staff who are more familiar with their needs. Feedback from the relatives survey showed that some relatives think that the management of agency staff is not so effective as it should be. The action plan produced by the home, shows that the management are seeking to address this issue. Raymond House DS0000015464.V332350.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): 31,33,35 & 38 Quality in this outcome area is good. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent Manager. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The Manager has successfully completed the N.V.Q. Level 4 Registered Manager’s Award, has considerable experience and is competent in discharging her responsibilities for the day-to-day running of the home. The Manager is
Raymond House DS0000015464.V332350.R01.S.doc Version 5.2 Page 22 also undertaking additional study in pursuit of a further management qualification. The Registered Provider has, in conjunction with a consultant, developed positive quality assurance procedures for the home involving regular survey questionnaires involving residents, relatives and stakeholders. These were made available for inspection and included the homes action plan for improving the service provided. A member of staff from the Registered Provider’s head office is responsible for overseeing quality control for Jewish Care and staff in the home are anxious to receive further advice and explanation as to how this works in practice and the time involved. Residents are regularly consulted through meetings and on a ‘one-to-one basis’ regarding their preferences, comments and ideas. Listening forms are also completed on a monthly basis with all residents who sign following the responses they have given. Where the home was taking responsibility for personal finances of residents, records were available showing documented transactions which included receipts where required. Copies of summaries in relation to expenditure, are sent to relatives where they act as power of attorney. These accounts are audited by staff from the head office of the Registered Provider. Health and safety meetings take place every quarter of which minutes are available. The Environmental Health Department visited the home in November 2006 and there were no serious issues raised. Work place risk assessments are available for duties and equipment operated by care workers but it is recommended that this be extended to cover domestic duties and kitchen staff who are employed by the outside contractor. Hoisting equipment, beds, showers and hot water temperatures are regularly checked, serviced and records are available. Although care staff have attended training on infection control, it is recommended that this be extended to housekeeping and kitchen staff. Raymond House DS0000015464.V332350.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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 4 x 3 x x 3 Raymond House DS0000015464.V332350.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 OP29 Regulation 19(Sched 2) Requirement The Registered Person shall not employ a person to work at the care home until evidence has been obtained in respect of recruiting procedures. This refers to references & CRB checks for domestic and kitchen staff employed by outside contractors. Timescale for action 01/06/07 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. 3. Refer to Standard OP26 OP29 OP38 Good Practice Recommendations Domestic and kitchen staff should be offered training on infection control. Staff application forms should request information regarding cautions which have been issued. Risk assessments for safe working practices should be extended to cover kitchen areas & domestic duties in liaison with outside contractors who provide these staff. Raymond House DS0000015464.V332350.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Raymond House DS0000015464.V332350.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!
