Inspection on 04/12/07 for Rowan Garth

This inspection was carried out on 4th December 2007.

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

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

Other inspections for this house

Rowan Garth 26/07/06

Rowan Garth 09/01/06

Rowan Garth 02/06/05

Rowan Garth 07/02/05

Rowan Garth 13/07/04

Rowan Garth 10/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Rowan Garth 219 Lower Breck Road Liverpool Merseyside L6 0AE Lead Inspector Jeanette Fielding Key Unannounced Inspection 10:00 4th December 2007 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 Rowan Garth DS0000025187.V343491.R02.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. Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rowan Garth Address 219 Lower Breck Road Liverpool Merseyside L6 0AE 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) 0151 263 9111 0151 260 4511 www.bupa.com BUPA Care Homes (CFHCare) Limited Sharon Brennan Care Home 150 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (120) of places Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 150 Service users to include:*Up to 30 service users in the category of OP (Old age not falling into any other category) (PC - Beech House) *Up to 27 service users in the category of OP (Old age not falling into any other category) and 3 named male persons under 65 years of age. (N - Oak House). *Up to 11 service users in the category of OP (Old age not falling into any other category) and 5 named male persons aged under 65 years of age. (N-Clover House) 16 persons aged 55 years and over (N-Intermediate care - Clover House) within an overall total of 30 beds. *Up to 29 service users in the category of DE(E) (Dementia over 65 years of age) and 1 named male person DE (Dementia under 65 years of age). (PC- Moss House). *Up to 29 services users in the category of OP (Old age not falling into any other category) and one named male person under 65 years of age. (N-Heather House). The home may accommodate five named service users who are aged under 65 years. 26th July 2006 2. Date of last inspection Brief Description of the Service: Rowan Garth is a purpose built home and is registered to provide nursing and personal care for up to 150 older people. The home is divided into five separate houses, each providing specific care. The houses are generally laid out in a similar manner but each provides the facilities to meet the needs of the service users accommodated. The home has an acting manager and each house has a care manager. The home is located in well maintained grounds, in a residential area, close to shops and local amenities. The home is registered to provide care for 30 older people who have dementia and for 120 older people. An application to vary the conditions of registration is currently being processed by CSCI. Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted on two consecutive days over a period of 13 hours. This was the key unannounced inspection and was carried out as part of the regulatory process. As part of the inspection process, all areas of the home were viewed including many of the service users bedrooms. Assessments and care plans were inspected together with staff records and certification to ensure that health and safety legislation was complied with. Discussion took place with the registered manager, nurses, care staff, service users and visitors to the home. The manager had completed a pre-inspection questionnaire which gave further insight into the home. What the service does well: What has improved since the last inspection? What they could do better: The standard of décor and furnishings within the home has deteriorated since the last inspection. Plans are in place to address this, however, the time frame for work to be undertaken would benefit from review. The high number of maintenance issues highlighted indicates that some issues have not been identified by staff and reported to enable these to be addressed. Detailed information regarding medications would further inform staff. Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 6 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. Rowan Garth DS0000025187.V343491.R02.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 Rowan Garth DS0000025187.V343491.R02.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, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed pre admission assessments are undertaken on all service users who are accommodated for long term care to ensure that the home can meet their individual needs and preferences. EVIDENCE: The home has a comprehensive Statement of Purpose and Service User Guide to provide current and prospective service users with information regarding the services and facilities provided by the home. Copies are available from the home on request. All prospective service users for long term care are fully assessed prior to their admission. The assessments are undertaken by the house managers or one of the senior staff. Comprehensive details are obtained regarding the service Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 9 users’ social, health and medical history together with their individual preferences. Information is taken from the service user, their family and any other person involved in their care. The assessment also enables specialist equipment, necessary to meet the service users’ needs, to be identified and gives the home the opportunity to obtain this prior to their admission. The home is now using the specific ‘QUEST’ documentation which has been prepared for use in all BUPA care homes. Sufficient information is gathered to enable an initial plan of care to be prepared. The care files for service users recently admitted to the home were inspected in all houses and all were found to contain detailed pre-admission assessments. Assessments on service users who are accommodated for Intermediate care are usually undertaken by the Social Workers and are not as comprehensive as those prepared by the home’s staff. The staff at the home are not given the opportunity to assess these service users and it was evident that some service users were not suited for rehabilitation due to their cognitive impairment or their long term medical condition. Service users accommodated for intermediate care are accommodated within one designated area of Clover House but use the communal lounge and dining room with service users who are accommodated for long term care. Physiotherapists and Occupational Therapists provide specific care and advise to the staff on the therapies necessary to enable the service users to return home. All service users are encouraged to be as independent as possible and the care files reflect their abilities. Rowan Garth DS0000025187.V343491.R02.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 adequate This judgement has been made using available evidence including a visit to this service. The records in one house do not provide staff with sufficient information on how to meet service users individual needs, although records in all other houses are comprehensive and informative to ensure that service users needs and preferences are met. EVIDENCE: At the time of the inspection Heather house was closed for redecoration and refurbishment. The category of service users to be accommodated in this house is to change, enabling service users who require nursing care due to their dementia to be accommodated. Changes are being made to the home’s registration to reflect this is currently being processed by CSCI. A total of fifteen care files were inspected in the four houses inspected. Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 11 Moss House. A new unit manager has recently been appointed to this house. In the few weeks since her appointment, the majority of service users have had their care needs reviewed and the care files updated. All files inspected were found to contain detailed care plans and risk assessments. All files were up to date and provided sufficient information to enable staff to meet the needs of the service users. Beech House. The files were detailed and informative, including specific details such as the preference of gender of staff to provide personal care. Detailed records are held of discussions held with relatives. All files were informative and up to date. One service user had specific dietary needs and the records show that the staff were making every effort to obtain information regarding the diet to meet the service users needs and preferences. Oak House. The care files were extremely detailed and gave staff full information regarding nursing needs i.e. the size of hoist to be used when moving the service user. One service user is recorded as having had a number of falls within a short time frame. The GP had been contacted and appropriate risk management plans put in place to reduce the risk of falls. Clover House. Some of the care files inspected require to be updated and did not contain sufficient detail. One care plan stated clearly that a service user liked to sleep in bed with two pillows and a duvet, but in fact chose to spend the night in a recliner chair. The falls risk assessment for one service user had been reviewed in November, but was not accurate. More detail is required on the care plans for the management of wounds, together with a protocol to identify when the services of the Tissue Viability Nurse Specialist should be contacted. The care plan for one service user who is partially self caring states that they should be taught how to undertake one task, when in fact, they have been attending to this for a number of years. All service users should be fully reviewed and the care plans changed to reflect the abilities, needs, preferences and interventions required. The handwriting on some of the records held in this house proved difficult to read and has the potential for misinterpretation. The daily records completed by staff in all houses were detailed and provided evidence of the actual care given to service users. Medications were inspected in all houses. In Clover House, a count of one medication showed that the records were incorrect. The number of tablets administered and remaining, did not reflect the number of tablets entering the home, as recorded on the Medication Administration Record sheet (MAR). The audit of this medication as undertaken by the staff, could not therefore be deemed as accurate and appropriate measures should be taken to ensure that all medications are accurately recorded and audited. Two signatures are required to be entered on MAR sheets where entries are handwritten to ensure accuracy of the entry. Where the doctor prescribes one or two tablets, staff must clearly state the number of tablets that are given to the service user. Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 12 It was found that insulin, currently in use, was stored in the refrigerator. Only stock supplies of insulin should be refrigerated. It was of some concern that the detailed information leaflets for individual medications, as supplied by the makers, are not held in the home. The dispensing pharmacist should be requested to supply these as the information in the leaflets is more detailed than in the British National Formulary, copies of which are held in each house, to ensure that staff are fully aware of each individual medication. All service users are accommodated in single bedrooms. Personal care is given to service users in their bedroom or in the bathroom as appropriate to protect their privacy and dignity. Staff were observed to knock on bedroom doors prior to entering. Service users may meet with tie visitors or in one of the communal areas as they wish. Rowan Garth DS0000025187.V343491.R02.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. Menus provide evidence that service users are offered a choice of meals and that a well balanced diet is offered. EVIDENCE: The home employs three activities co-ordinators to provide activities and social stimulation to the service users. A planned programme of activities is prepared and details are displayed on notice boards throughout the home. Service users spoken to said that they enjoyed playing bingo, singing at the karaoke sessions and listening to DVD’s. Activities are provided on a one to one basis for those service users who are unable to participate in group activities. Arrangements have been made for a high number of activities to take place in the pre-Christmas period. Ministers of religion visit the home on a regular basis to provide services to meet the service users religious needs. Few service users maintain links with the local community to their age and frailty. Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 14 The garden areas have been improved over the summer months and all are provided with seating. These areas are not generally used during the cold winter months but provide a pleasant outlook for service users. Meals are prepared in the main kitchen and are transported to the units in heated trolleys. Meals are served from the trolleys in the satellite kitchens in each house by the staff to meet individual choices and meal size. The main kitchen was clean and organised and good supplies of food stocks are held. Fresh goods are used as much as possible in the preparation of meals with a supply of tinned and frozen goods to offer foods that are not in season. Service users are offered a choice of meals and special diets can be catered for on the advice of the GP, dietician or on the request of the service user. Meals can be taken in the dining room or in the service users own bedroom as appropriate. Dining tables are attractively laid to enhance the dining experience. The menus provide evidence that all service users are offered a choice of meals and that a varied and balanced diet is provided. Mealtimes in houses that provide care due to service users cognitive impairment are served within a protected environment. This system, by removing all background music and television and providing a calm atmosphere has proved extremely successful in ensuring that the service users enjoy their meals without distraction. One service user expressed concerns that the meals provided within the home did not suit his dietary needs or preferences. The chef, dietician and senior staff are all involved to ensure that the needs and preferences of this service user are being met. Other service users spoken to said that the meals were good and that there was always something good on the menu. One service user said that they often requested something that was not on the menu for that day and that every effort was made by the catering staff to meet that request. Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have been given training on adult protection and the action they should take in the event of it being suspected to ensure the protection of service users. EVIDENCE: The home has a robust complaints policy and procedure. Details on how to make a complaint are detailed in the service user guide and are also displayed on notice boards throughout the home. Training has been given to all staff on the various types of abuse during their induction training and has been reinforced with additional training. Staff spoken to during the inspection were able to demonstrate that they were aware of the procedure to be followed in the event of abuse being suspected. A small number of complaints have been made to the home since the last inspection and the records provide evidence that these have been addressed appropriately. Checks are made on all staff prior to their employment at the home to ensure that service users are protected. Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 16 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, 21, 22, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Repairs, redecoration and upgrade is required in some areas of the home to provide service users with a pleasant environment in which to live. EVIDENCE: One of the houses, Heather, was closed at the time of the inspection for redecoration and refurbishment to make it suitable to accommodate service users who require nursing care due to their dementia. All other houses were inspected. Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 17 Moss House. Attention is required to remove the mould from around the base of the shower unit in shower room 37. Some of the tiles around the WC are broken in this room and require replacement. Some of the extractors in bathrooms and WC’s were not working and require repair. The lighting in bathroom 16 is very poor. The diffusers on the fluorescent lights in the corridors require to be cleaned to remove debris and dirt. Beech House. A service user expressed concerns with regard to bathroom 32. He had raised this at a meeting with the social worker in September and had received written confirmation regarding this meeting in October 2007. It is not known if the home received a copy of this report. The nurse call alarm cord was not sufficiently long to enable a service user who had fallen to the floor to reach it. This requires to be extended. The flooring in this bathroom had begun to lift along a seam and presented as a tripping hazard. The lock on the door was not working and so a draw bolt had been fitted. Staff would not be able to access the bathroom in the event of an emergency and must be removed. The doors to the shower do not close properly resulting in water spilling on to the floor around the unit. These require repair or replacement. The lounge carpet is lifting by the kitchen and along the edges. This presents as a tripping hazard and requires attention. The carpet edge strip is missing at the doorway of bedroom 10 which now presents as a tripping hazard. One of the windows in the lounge is cracked and requires replacement. The WC in bathroom 5 is currently out of order and requires repair. Oak House. A risk assessment has been undertaken on one service user who smokes. A designated area has been provided but it was evident that smoking had place in the bedroom. An ash tray which had been used was near to the bed and a plastic bin with a plastic bin liner were in the room. This is presents as a risk and appropriate action must be taken to ensure the protection of all service users. The floor in bathroom 32 was extremely wet, although the room had not been used for a number of hours. The extractor fan in this room was not working and requires repair. The bath seat in bathroom 11 requires cleaning. Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 18 Clover House. The notice on the door of the electrical cupboard states ‘Keep locked at all times’. The door was neither locked nor closed. The extractor fan in WC 19 had been dismantled and requires replacement. The pillows in one bedroom were noted to be stained with bodily fluids and must be disposed of in accordance with the home’s health and safety policy. Tiles are missing from the wall in WC 30 and require replacement. The water at the sink in this room was excessively hot and presents as a scalding risk. This must be addressed. The paintwork is damaged on many of the door frames. The wall by the staff WC is damaged and requires repair. The planned programme of improvement has identified that Clover, Moss and Beech Houses will take place during the next twelve months, however it is evident that the home has deteriorated to an unacceptable level, with no short-term interventions planned. The home provides sufficient and suitable moving and handling aids to assist service users. Staff have all been trained in the use of the equipment to ensure that service users are moved comfortably and safely. Service users are accommodated in single bedrooms. Rooms have been personalised to reflect the lifestyle and preferences of the service user with pictures, photographs and items of memorabilia. All areas of the home were found to be clean. Housekeeping staff said that they worked hard to ensure that there were no unpleasant odours but were restricted due to the condition of some of the carpets. These are cleaned with great regularity but occasionally become malodorous. Rowan Garth DS0000025187.V343491.R02.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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Training opportunities are offered to all staff to further their knowledge and understanding to ensure that a high level of care is afforded to service users. EVIDENCE: Staff are employed in sufficient numbers to meet the needs of the service users. The home employs house managers, qualified nurses, care assistants together with housekeeping, catering, laundry and administration staff. A bank of staff are employed to cover vacancies, sickness and annual leave with the occasional need to employ staff from agencies. Staff rotas provide evidence of the numbers of staff on duty in each of the houses and these show that sufficient staff are on duty at all times. The home has a robust recruitment procedure in line with BUPA policy. Applicants are required to complete an application form prior to being called for interview. Two references are taken on all staff and checks are made with the Criminal Records Bureau and Protection of Vulnerable Adults register to ensure that service users are protected. Qualifications and training are required to be evidenced and gaps in employment are discussed. All new staff Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 20 undertake a comprehensive induction training programme, appropriate to the role for which they are employed. The induction training involves the completion of a workbook to provide evidence of training and competency, followed by foundation training. NVQ training is then offered as appropriate. At present, 54 of the care staff hold NVQ qualifications at level 2 or above with an additional 5 staff working towards these qualifications. All qualified nurses are required to continue with their professional development and training opportunities are offered on a regular basis. Records were inspected for new and established staff and all files were found to contain information as required. Detailed records are held of training undertaken and copies of certificates are held on files. Staff spoken to during the inspection confirmed that training was offered and that they were given opportunities to develop their knowledge and understanding. Catering staff hold appropriate qualifications and training opportunities are offered to housekeeping, catering, laundry and administrative staff. Rowan Garth DS0000025187.V343491.R02.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 and 38. 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 strong management structure to oversee the running of the home and the care of the service users. EVIDENCE: The registered manager of the home is a qualified nurse who has many years experience in the management of large homes for elderly people. The home is owned by BUPA Care Homes Ltd which provides a structured management support system for the registered manager. Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 22 Equality and diversity issues are given priority by the manager who is aware of the varying strands this involves. The home issues comment cards to service users to enable them to express their view of the home. Comments are always welcomed from relatives, healthcare professionals and other visitors to the home and the comment cards are available in the receptions areas. Annual questionnaires are sent to service users accommodated for general nursing or personal care, and to relatives of service users accommodated for care due to their dementia. Each house has a care manager who is responsible for overseeing the day to day running of that house and the care of service users. The managers are available to discuss issues with service users, relatives and staff at all times. The condition of parts of the premises do not indicate that the home is maintained in the best interests of the service users. Discussion with senior staff at the home confirmed that whilst improvements have been identified, there is little that can be done at local level to address these and requires financial input and management at a corporate level. Most service users have their finances dealt with by family members or advocates. Other service users have an individual bank account in a building society and are invoiced for any costs incurred i.e. hairdressing, chiropody and newspapers. Monthly visits are made to the home by the Responsible Individual, as required, and a report completed. Tests are made on the fire detection equipment as required and records held of the findings. Safety certificates were inspected and all found to be well maintained and up to date. Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 3 X 3 X 2 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 2 X 3 X X 3 Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 24 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 OP7 Regulation 15(2) Requirement The Registered Person must ensure that the care files on Clover House are kept under review. The Registered Person must ensure that all medications are stored at the appropriate temperature. The Registered Person must ensure that all tripping hazards are removed. The Registered Person must ensure that the extractor fans are maintained in a working condition. Timescale for action 31/01/08 2. OP9 13(2) 11/01/08 3. OP19 13(4) 11/01/08 4. OP19 23(2) 11/01/08 5. OP19 23(2) The Registered Person must 31/01/08 ensure that the shower doors are repaired or replaced as necessary. The Registered Person must ensure that the cracked window is replaced. The Registered Person must ensure that the electric cupboard DS0000025187.V343491.R02.S.doc 6. OP19 23(2) 31/01/08 7. OP19 13(4) 11/01/08 Rowan Garth Version 5.2 Page 25 is locked. 8. OP19 16(2) The Registered Person must ensure that all stained linens are removed. The Registered Person must ensure that broken tiles are replaced. The Registered Person must ensure that all damaged paintwork is repaired. 11/01/08 9. OP19 23(2) 31/01/08 10. OP19 23(2) 31/01/08 11. OP21 23(2) The Registered Person must 11/01/08 ensure that Bathroom 5 in Clover House is maintained in a working condition. The Registered Person must ensure that shower 37 in Beech House is maintained in a clean condition. The Registered Person must ensure that the bath seat in room 11 of Oak House is maintained in a clean condition. 11/01/08 12. OP26 23(2) 13. OP26 23(2) 11/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations Consideration should be given to obtaining information leaflets on all medications used in the home. Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North West Contact Team Unit 1. 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@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 Rowan Garth DS0000025187.V343491.R02.S.doc Version 5.2 Page 27 - 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!