Inspection on 30/11/06 for Regents View Nursing Home

This inspection was carried out on 30th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Regents View Nursing Home 25/11/08

Regents View Nursing Home 24/01/06

Regents View Nursing Home 12/07/05

Regents View Nursing Home 24/02/05

Regents View Nursing Home 30/06/04

Regents View Nursing Home 19/02/04

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

CARE HOMES FOR OLDER PEOPLE Regents View Nursing Home Francis Way Hetton Le Hole Houghton Le Spring Tyne & Wear DH5 9EQ Lead Inspector Sam Doku Key Unannounced Inspection 30 November & 4 December 2006 12:05 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 DS0000018204.V309235.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. DS0000018204.V309235.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Regents View Nursing Home Address Francis Way Hetton Le Hole Houghton Le Spring Tyne & Wear DH5 9EQ 0191 526 6776 0191 526 6882 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) www.fshc.co.uk Tamaris Healthcare (England) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Caralyn Janice Bowman Care Home 50 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (50), Mental disorder, excluding learning of places disability or dementia (5) DS0000018204.V309235.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2006 Brief Description of the Service: Regents View is a purpose built home in 1995 to provide both nursing and personal care places for 50 older people who have mental health care needs. It stands in grounds that are shared with another care home belonging to the same company. The home is located in a village, in a rural area, among a residential estate and there are local facilities close to the home including shops, post office, bank and public houses. The city centre of Sunderland and the town centre of Houghton-le-Spring is within a short direct bus route from the home. The home itself is constructed in a traditional style of brick and tile and has two floors with passenger lift access to the first floor. The access is level from the ground floor entrance. The car park is located to the front of the building. Bathrooms and communal WCs have handrails and appropriate lifting equipment for disabled service users. The internal space is generous and there are a variety of lounges and dining areas. Audio and television facilities are provided in these lounges. The grounds are well kept and there is a protected safe area to the rear of the home, in the form of a small sensory garden with a bird stand, enabling service users to meander in relative safety, weather conditions permitting. The scale of charges for the service users range from £379.00 to £460.00 per week. DS0000018204.V309235.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them to make choices. The information included the service user’s guide (sometimes called a brochure or prospectus), statement of terms and conditions (also known as contracts of care) and the complaints procedure. These findings will be used as part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. The inspection was carried out over two days and involved one inspector. Before the inspection date, pre-inspection questionnaires were sent to the manager to supply some information about the home. Questionnaires were also sent to service users and relatives for their comments on the quality of the service. Six responses were received from relatives. The responses were complimentary of the home and the quality of care provided by the staff. The inspection involved talking to service users, sitting in the lounge and observing staff interaction with the service users. It also involved discussions with the manager and care staff, tour of the home, examination of health and safety records and service users personal files including care plans. The final report takes account of the observations, discussions and responses from the questionnaires. Service users and relatives who were spoken with were complimentary of the service and the respect and dignity that the staff show to them. What the service does well: A designated staff member has responsibility for fire instructions and training. Through his activities, the home has continued to maintain regular fire instructions and training to all staff. Service users needs assessments are thorough and include detailed information received by the home and also from the social worker or nurse assessor. DS0000018204.V309235.R01.S.doc Version 5.2 Page 6 All care staff and nurses receive regular supervision. Records of these are maintained on individual personal files. The relatives commented positively on the communication between the home and themselves. Relatives commented that the staff keep them in informed about issues relating to the loved ones. Some relatives commented on their involvement in reviews and how they contributed to care plans. The role of the activities organiser is seen by staff, service users and relatives as essential in maintaining service users interests and enhancing the social and recreational opportunities available to them. The home is well managed and run for the benefit of the service users. The manager and the staff regularly consult with relatives and take into account their views in the planning of activities and other care practices. What has improved since the last inspection? What they could do better: The teapots are heavily stained and unsightly. The registered person should consult with the kitchen staff to determine the best ways of keeping the teapots in better condition. The oven in the kitchen for keeping cooked food warm is defective and must be repaired in order to keep cooked food at the right temperature to avoid food poisoning. The kitchen staff indicated that the temperature control on the equipment is faulty and only heats up to 40 degrees centigrade instead of 60. The dishwasher in the kitchen is leaking and need to be repaired. The leaked water on the kitchen floor is a safety hazard to those who work in the kitchen. DS0000018204.V309235.R01.S.doc Version 5.2 Page 7 A number of bedroom doors were wedged open with chairs and tables. If bedroom doors had to be wedged-open for practical reasons, then a risk management strategy put in place identifying such doors in the event of a fire. One of the shower rooms on the top floor has an unpleasant smell and this could be unpleasant for those who use it. The Registered person should investigate this and address it accordingly. 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. DS0000018204.V309235.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 DS0000018204.V309235.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The company has good information about the home in the form of a service user guide. This provides useful information about the service, including information about the terms and conditions of residence to prospective service users, which enable them to make decisions about the home. Prospective service users or their relatives are invited to visit the home before making their decisions about coming to live in the home. This gives them the opportunity to assess the home for themselves, thus giving them the means to make informed choice about the home. DS0000018204.V309235.R01.S.doc Version 5.2 Page 10 EVIDENCE: All service users and or their relatives receive a copy of the service user guide. The service user guide provides good information about the facilities in the home. Visiting relatives confirmed that they found the service user guide useful, and one particular relative described how the family used the information in the guide to make comparisons with other homes before deciding on choosing Regent View for their mother. Terms and conditions of residence are provided to all new service users either before or shortly after their arrival in the home. Copies of terms and conditions of residence are kept on individual files, which had been appropriately signed by service users or their representatives. These provide useful information for all the service users about the service and also about their obligations under the terms and conditions of residence. Under the terms and conditions, the first six weeks of residence is classed as trail period. This allows service users and their relatives sufficient time to decide if the Regent View is the right place for them. One relative stated that she found the six-week trail period helpful as it gave the family sufficient time to make sure that their mother settled well in the home. The policy of the home is that prospective service users would have their needs assessed by their social worker/PCT Nurse Assessor and also by the home before admission is agreed. This allows the individual’s care needs to be established and decide if the person’s care needs can be adequately met with the available resources within the home. Copies of pre-admission assessments by social workers/nurse assessors and also assessments that had been carried by the nursing staff of the home were available in the home. This assures the prospective service users and their families that proper steps are being taken which ensured that the needs of the person have been properly identified and plans put in place to meet them. Relatives described the arrangements made by the home for them to visit and meet with staff and other service users before making their decisions about coming to live at the home. They confirmed that they found these visits very helpful in allaying their anxieties about moving into a nursing home. DS0000018204.V309235.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personal and healthcare needs are clearly set out in the individual care plans and shared with all the carers. This ensured a consistent approach by all staff to the needs of the individuals. The service users are treated with respect and dignity by all staff, thus promoting their psychological wellbeing. EVIDENCE: The service users care plans set out their healthcare needs and the action plans for meeting them. The plans are regularly reviewed and updated to reflect changing healthcare needs and how they are be met. Records show that the healthcare needs of the service users are fully met. The home continues to maintain a record of contacts with healthcare professionals, including GPs, psychiatrist, chiropody service, dentist, optician and other healthcare services. DS0000018204.V309235.R01.S.doc Version 5.2 Page 12 This ensured that the service users rights to proper healthcare are being safeguarded by the home. The service users and their relatives confirmed that their healthcare needs are met through these arrangements. Service user records contained evidence of regular checks on their weights and nutritional assessments being carried out which ensured that all the service users receive adequate and nutritious diet that maintains their health and wellbeing. Risk assessments have also been carried out for those service users for whom it is thought necessary. These include falls, nutrition, moving and handling and pressure area risk assessments. These are documented and provide evidence of the care that individuals receive. None of the service users self medicate. However, there are suitable arrangements in service users room to allow this to happen if it is deemed safe for an individual to manage their own medication in order to maintain their independence. There are also suitable arrangements in place for the storage and administration of medicines in the home. The trained nurses are responsible for the administration of medicines. The drugs administration system was examined and there were no discrepancies found. The nurses carry regular drugs checks and the records indicated a regular audit of medicines. This promotes the health and welfare of the service users through the good drug administration system operated by the home. Practices observed on the days of the inspection and discussions with service users and relatives indicated that the service users are treated with respect and their privacy is respected. Staff were observed to speak to service users in a respectful manner and also knocked on service users doors before making entry. This promoted the self-esteem of the service users and gave them a sense of worth. DS0000018204.V309235.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans, including information from family members, identified individual’s interest and preferences, and social and recreational needs are carried out meet those needs. This promotes the service users social and recreational wellbeing. The home encourages and supports families and friends to visit the service users thus maintaining family and community contacts. The service users are assisted and supported by staff to exercise as much choice as they are able to, thus allowing them to maintain some level of independence in decision making. Service users receive nutritious meal, which promotes their nutrition and health. DS0000018204.V309235.R01.S.doc Version 5.2 Page 14 EVIDENCE: In the case of the service users whose files were examined, it was noticed that their care needs are clearly identified in the care plans including some aspects of their social and religious care needs. Service users confirmed that they enjoy the activities organised for them by the activities coordinator. They also confirmed that they are free to join in social activities if they wish and that they are not made to join in activities if they did not wish to. A number of art and craft materials and board games are available for service users to use, which has enhanced the recreational opportunities available to them. The relatives who were spoken with also confirmed the role of the activities coordinator. They described the activities that she organises for the service users, including going out for walks with individuals on occasions when the weather permits. Relatives who were spoken with stated that the flexible visiting times allow them to continue visit at times that is convenient for them. Service users confirmed that their relatives and friends are able to visit at anytime convenient to them and were very appreciative of this level of flexibility. Two relatives described how they are able to visit on daily basis to ensure that they remain involved in the care of his wives. The daily routines are organised flexibly to take account of individual likes and dislikes. This allows individual service users to make choices about some aspects of their routines. A four-week rotational menu remains is operation in the home. The service users and their relatives commented positively on the quality and quantity of the meals provided. Examination of past menus indicate that the home provides wholesome and nutritious meals for the service users thus promoting good health. DS0000018204.V309235.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a clear and easy to understand complaints policy, which is accessible to the service users and relatives. This provides the opportunity for service users or relatives to raise concerns and in so doing exercise their rights. Suitable arrangements are in place, which ensured that service users are protected from all forms of abuse and to protect their rights. EVIDENCE: The home continues to have in place a satisfactory policy and procedural guidance on abuse. A number of staff were spoken with during the inspection. They all confirmed that they are aware of how to instigate the ‘Whistle Blowing’ policy should this become necessary. The majority of staff have also received training on protection of vulnerable adults (POVA). The staff showed understanding of the POVA procedures and also showed an awareness of the need to protect service users from all forms of abuse, thus promoting the safety and welfare of the service users. DS0000018204.V309235.R01.S.doc Version 5.2 Page 16 The service user guide and statement of purpose have summaries of the complaints procedure. Copies of these are available to service users and their relatives and therefore provide the opportunity for them to complain if they wish. It also reassures service users and their relatives that any concerns or complaints would be treated seriously with the view to safeguarding the welfare of the service users. One complaint was received in August 2006. This was appropriately dealt with in accordance with the company’s complaints procedures. The complainant was happy with the outcome of the complaint investigation, thus providing further confidence in the process. DS0000018204.V309235.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 25, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides accommodation of a good standard. It is a safe, clean and comfortable environment, and promotes the service users’ privacy, independence and welfare. EVIDENCE: The positive comments made about the environment in the last inspection report had been maintained. Regent View is a home designed to accommodate older people, some of whom may have mobility and mental health problems. The corridors are wide and allow easier access for people with wheelchairs or other walking aids thus promoting free access and independence for the service users. DS0000018204.V309235.R01.S.doc Version 5.2 Page 18 All rooms are single occupancy with en-suite facility. Individual rooms have good ventilation and natural lighting. These ensured comfortable surroundings for the service users. Window restrictors have been fixed to all windows and all radiators have suitable covering. Checks of hot water at randomly selected bathing outlets confirmed that hot water did not exceed 43°c. thus protecting the service from accidental injuries. The home has written policies and procedures relating to safe handling of hazardous materials for staff to follow. The manager indicated that staff have had training in health and safety, infection control and food hygiene. At the time of the inspection the home was noted to be clean and free from offensive odour. The laundry machines have facilities for sluicing and washing foul linen at very high temperature to avoid the spread of infection, thus protecting the service users from harm. The above safety measures, practices and policies ensured that service users live in safe and comfortable environment. The kitchen was clean and all cookers and cooking utensils were clean and well maintained, thus promoting the welfare of the service user. However, the state of some of the kitchen equipment requires attention as highlighted in the summary of this report under “What they could better”. Addressing these issues would enhance the dignity of the service users and promote safety standards in the kitchen. DS0000018204.V309235.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides sufficient staffing which meet the needs of the service users. Suitable arrangements for staff training and supervision are in place, which ensured that staff are equipped to provide good quality service that benefits the service users. Staff recruitment and training procedures promote the welfare of the service users. EVIDENCE: Recent past staff rotas indicate that the home consistently maintains adequate staffing levels and these meet the needs of the service users. The home continues to maintain a staff training programme. The staff training records included moving and handling, first aid, protection of vulnerable adults, health and safety, fire safety, food hygiene, nutrition, dementia care training. The staff who were interviewed confirmed the training they had received and felt that this had equipped them to do their jobs better. DS0000018204.V309235.R01.S.doc Version 5.2 Page 20 The manager confirmed that the company is committed to training all care staff to NVQ Level 2 or above. Staff who have already acquired this training indicated that they found the training useful and had equipped them to provide better care for the service users. They also indicated that the training had boosted their confidence and are therefore confident in their care practices for the benefit of the service users. The home’s recruitment procedures ensured protection of service users from possible abuse by applicants who would be deemed as unsuitable to work with vulnerable people. Examination of staff records showed that the manager had consistently adhered to the company’s policy on recruitment, including appropriate references, CRB checks, and obtaining Home Office work permits for those who require it, thus protecting the service users from possible abuse. Relatives commented that the staff are properly trained and therefore are able to provide them with good quality care. DS0000018204.V309235.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager provides good leadership to the staff. This ensured that the service is run for the benefit of the service users. This promotes and safeguards the rights and welfare of the service users. The system for managing the service users monies is good and protects them from financial abuse. The detailed organisational policies and procedures on health and safety are adhered to by the staff, which protects the welfare of the service users. DS0000018204.V309235.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager is a Registered Mental Nurse and has the registered managers award. She has long experience of working nursing homes and with older people with mental health problems. Staff indicated that the manager runs the service for the benefit of the service users and has positive relations with them. All staff and relatives commented on the professionalism and positive leadership shown by the manager. The personal allowance records were examined and these were found to be in order and appropriately accounted for. Receipts are available for all transactions that have been made on behalf of service users. This ensured that service users are protected from any form of financial abuse. Relatives have been consulted on the methods of holding monies for the service users using a single bank account for that purpose. Relatives have the option of managing such monies for their relatives or agree for the home to manage this using a single bank account in the name of the home. The manager confirmed that most relatives have agreed for service users monies to be placed in a ‘pooled’ account and have signed an agreement to that effect. All care staff receive regular supervision from the trained nurses. The nurses also regular receive their personal supervision from the manager. In discussions with the manager, it was evident that also she receives good management support from her line-manager, however, she does not receive formal supervision from him. Arrangements for formal supervision would be helpful in enhancing the support she receives and promote her personal development for the benefit of the service and the people who use the service. The nursing staff commented that they are well supported by the manager and her deputy and that they are always available to provide the necessary professional support and guidance when needed. The company’s Health and Safety policies remain in place and these were made available for inspection. These cover policy areas such as fire prevention and Care of Substances Hazardous to Health (COSHH). The training provided for the staff ensured that the staff maintained safe working practices, which safeguard the safety and wellbeing of the service users. Servicing records were examined and it was noted that all portable appliances have been tested. A record is maintained of regular water temperature tests in the home. There is evidence of regular servicing of fire equipment, gas and electrical appliances being carried out by the contracted companies. All the servicing records that were examined were up to date. These included lift servicing, servicing of hoists, water treatment, electrical installation and gas servicing. Up to date servicing and maintenance of these services and DS0000018204.V309235.R01.S.doc Version 5.2 Page 23 equipments ensured a safe environment for the service users and the staff who work there. DS0000018204.V309235.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 3 3 3 3 X X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 DS0000018204.V309235.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP38 Regulation 16(2)(i) Requirement The oven for keeping hot food heated at the right temperature must be repaired to ensure that the temperature controls are working. The dishwasher in the kitchen must be repaired to avoid any accident to the staff who work there. Risk management strategies must be put in place for those bedroom doors that have been wedged open with tables and chairs. Timescale for action 28/01/07 2 OP38 16(2)(g) 28/01/07 3 OP38 13(4)(c) 31/12/06 DS0000018204.V309235.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 2 Refer to Standard OP15 OP36 Good Practice Recommendations The manager should consult with the kitchen domestic staff to ensure that appropriate cleaning materials are available to them for the cleaning of the teapots. The manager should receive personal supervision for her line manager. DS0000018204.V309235.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South of Tyne Area Office St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000018204.V309235.R01.S.doc Version 5.2 Page 28 - 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. 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