Inspection on 17/10/07 for Saffron House

This inspection was carried out on 17th October 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Saffron House 22/12/09

Saffron House 02/09/09

Saffron House 10/04/06

Saffron House 22/09/05

Saffron House 10/05/05

Saffron House 26/01/05

Saffron House 11/06/04

Saffron House 20/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Saffron House 2a High Street Barwell Leicestershire LE9 8DQ Lead Inspector Keith Charlton Unannounced Inspection 17th October 2007 09:40 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 Saffron House DS0000036290.V347620.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. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Saffron House Address 2a High Street Barwell Leicestershire LE9 8DQ 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) 01455 842222 01455 841222 saffronhouse@dsl.pipex.com Downing (Barwell) Limited Emma Sara Philpott Care Home 42 Category(ies) of Dementia (20), Dementia - over 65 years of age registration, with number (20), Old age, not falling within any other of places category (42), Physical disability (10), Physical disability over 65 years of age (10) Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons who fall within either category DE or DE(E) may only be accommodated within Saffron House on the ground floor No person under 55 years of age who falls within categories PD or DE may be accommodated in Saffron House Service User Categories PD & PD(E) No person who falls within categories PD or PD(E) may be admitted to Saffron House when 10 persons of those categories/combined categories are already accommodated within the home Service User Categories DE & DE(E) No person who falls within categories DE or DE(E) may be admitted to Saffron House when 20 persons of those categories/combined categories are already accommodated within the home To be able to admit to Saffron House the named person of category LD 55 named in variation application number 56181 dated 18th September 2003 10th April 2006 4. 5. Date of last inspection Brief Description of the Service: Saffron House is a purpose built care home situated in the centre of Barwell, Leicestershire. It is registered for forty-two service users within the categories of old age, dementia and physical disability. The home is not registered to provide nursing care. The home is situated on two floors and these are accessed by a passenger lift. The home has a dining room and lounge on each floor and a further five lounges throughout the home. The home has forty-two single bedrooms, which have ensuite facilities. Close to the home are a number of hotels and restaurants and is within close proximity of Mallory Park Race track and Market Bosworth. The home has a grassed area and flowerbeds at the back of the property and a circular walkway. The home has electric gates fitted to the exterior of the home for safety and to prevent intruders. The weekly fees are from £276 to £475 – this information was provided on the day of the inspection. There are additional costs for individual expenditure such as hairdressing, toiletries, etc. A Statement of Purpose and Service Users Guide to the services the home offers can be supplied to applicants and the last Inspection Report is available in reception, to enable prospective residents to make an informed choice as to whether they wish to live at the home. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 5 Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. The Commission for Social Care Inspection carried out a short focused inspection in September 2007 looking at the needs of residents with dementia on the ground floor of the home. This concluded that residents with dementia were supplied with a good service. This was an unannounced Inspection. The Registered Manager was on duty. Planning for the Inspection included reading the notifications of significant events sent to the Commission for Social Care Inspection and the last Inspection Report. The Annual Quality Assurance Assessment, at the time of inspection, still needs to be completed by the Company to provide information on the running of the home. The Inspection took place between 09.40 and 15.45. The inspection included a tour of the building, inspection of records and indirect observation of care practices. The Inspector spoke with eleven residents, three members of staff, a Community Nurse, the Registered Manager and Deputy Manager. It was completed the following day. What the service does well: There were a number of issues which covered residents needs –residents spoken to were very satisfied with the care they received from staff, they thought that the food was generally good, that there are a range of activities provided and that bedrooms were kept clean and tidy. The inspector also observed that staff were friendly and helpful in their dealings with residents. Residents said visitors are made welcome, and residents feel that the management would quickly act on any issue they raise. Residents needs are actively promoted. Staff were aware of how to promote residents independence and this was reflected in their Care Plans. Regular activities are provided and residents asked in Residents Meetings as to their preferred activities. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 7 Residents said that there were no rules so they could choose how they live their lives. The home was found to be clean and tidy and mostly odour free. Bedrooms were homely and personalised with residents stating they were happy with them and they could bring in their personal possessions. Staff training is encouraged so that staff carry out most essential training and they are encouraged to undertake National Vocational Qualification training to add to their care skills. Staff are asked to read residents Care Plans and the Policies and Procedures of the home so that they know what to do and are consistent in their work. What has improved since the last inspection? What they could do better: Residents needs would be more effectively covered by ensuring that: Assessments contain evidence of the last appointments with Medical Services – dentist, optician etc, that Care Plans contain more specific detail as to residents continence needs so that staff can offer the toilet before residents need to go, that staffing levels are increased to ensure that there are sufficient staff to cover residents needs at all times, to extend the training programme to include some more relevant issues regarding residents care so that staff to have knowledge of residents conditions, e.g. stroke management, diabetes, hearing and sight impairment etc. It is recommended that residents are encouraged to have a say in the running of the home in that a representative from the resident group can sit on staff recruitment interviews and in staff meetings. It is recommended that the Company policy to charge new staff for their Protection of Vulnerable Adults first/Criminal Records Bureau checks ceases as this is a condition required of the employer, it is not a good practice in terms of staff recruitment, and does not seem fair on staff being paid minimum wage rates. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 8 The Annual Quality Assurance Assessment needs to be returned within the timescale stipulated to ensure information can be used for inspection. 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. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 9 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 Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 10 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. This judgement has been made using available evidence including a visit to this service. The admission process is managed and meets the needs of residents. EVIDENCE: Some residents said that management visited them before their admission into the home and talked about their care needs. They had the option of visiting the home prior to their admission. The Inspector looked at residents files, which contained relevant information in terms of medical, physical and social needs of residents. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 11 The Registered Manager was asked to ensure that the form includes medical checks – last optical and dental checks, whether there is a need to refer to medical services regarding hearing tests etc. The Registered Provider does not provide intermediate care. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 12 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. This judgement has been made using available evidence including a visit to this service. Care plans identify most care needs and outline action to ensure their needs are met. Residents health needs are monitored but always need to be acted upon. Effective medication systems are generally in place. EVIDENCE: No residents said that they were aware of Care Plans. It is recommended that residents or relatives (with residents permission) are reminded that they can see Plans and ask for changes if they do not feel they are accurate. Care plans inspected were found to contain relevant information regarding residents needs. There are also Risk Assessments so as to manage any area of risk to residents. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 13 Some areas of need are not specific enough – e.g. there was no evidence of when appointments are needed regarding when checks are needed for the optician and dentist, the need for a hearing test etc though there was good information regarding residents appointments with medical services – the GP, District Nurse etc. There was a Care Plan which needed more detail as to a Risk Assessment for a resident who wandered and was at risk of falling and was subject to aggression from another resident. The Registered Manager said this would be followed up. There was a discussion with the Registered Manager regarding Care Plans being more specific as to the frequency residents with continence difficulties needing to be taken to the toilet based on their assessed needs. The Registered Manager said that she would update the plans. Care records were kept on a daily basis and were detailed as to residents care needs. There is a personal history section to ensure residents are seen as individuals with a valued past. Staff said they had been asked to read Care Plans, which helps to ensure that all relevant information is available for staff to meet residents needs, though not all Care Plans had been read. The Registered Manager said she would ask staff to read all the Plans and to sign to this effect. Monthly reviews of plans had been carried out to ensure they were still relevant to residents needs. Records show that medical services are contacted following illness to a resident. Accident records were viewed and it was found that incidents had been properly followed up with medical services where necessary, which was an improvement of the position in the 2006 Inspection Report. Medication records were found to be generally up to date. There were only a small number of gaps on records, which the Registered Manager said would be followed up. A comment has been received by the inspector that nighttime medication was given earlier than prescribed. This is also to be followed up by the Registered Manager. Staff members said they only staff who have received training administer medication. Information regarding this was on training records. Medication is kept in locked and properly secured trolleys and medication rooms. There is a proper register for the recording of controlled drugs. If safe to do so residents can choose to self medicate, as indicated on a resident’s Care Plan the inspector looked at. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 14 Staff were observed to be talking to the residents with respect and friendliness. Residents said that staff were ‘the best’, and that staff respected their privacy and dignity. The visiting relative also said staff were welcoming and friendly. This situation is commended. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 15 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. This judgement has been made using available evidence including a visit to this service. Residents have opportunities to have a stimulating lifestyle. EVIDENCE: Residents said that they were generally satisfied with the range of activities on offer and they liked it when staff had time to sit and chat with them, which was not often as staff were so busy. There is a full time Activities Organiser employed and a displayed weekly Activities Programme and residents meeting notes also recorded the choices put forward regarding activities. There is also a record on residents Care Plans as to the activities residents have participated in. Residents said they liked going outside sometimes and enjoying the well maintained garden, which they could do during warm weather. They have the opportunity to go on outings. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 16 Residents and the relative spoken to said that visitors were made welcome by staff. Residents again said that they thought there were no rules and they could please themselves about things – getting up and going to bed times, when to have a bath, ability to keep their own GP, have alcohol in their bedrooms etc and that staff encouraged them to retain their independence. Staff said that it was important that residents were able to do things for themselves, and confirmed this aim of the service. The Registered Manager said she would follow up residents being able to influence the running of the home by a representative being on staff recruitment panels and attending non confidential discussions in staff meetings. Residents said they thought the food was generally good and there were alternatives to all meals. There are choices for breakfast and tea as well. There was particular praise for the quality of the meat supply. There were some comments received as to making vegetables ‘taste’ properly by cooking vegetables in salted hot water. The Registered Manager said this would be followed up. Food records were generally full and recorded the variety of vegetables offered. Food preferences were found in Care Plans inspected. The food tasted was found to be of a satisfactory standard with two courses and choices of the main meal with two vegetables plus potatoes served. It was commended that the soup is home made. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 17 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. This judgement has been made using available evidence including a visit to this service. The current system generally protects residents from the possibility of abuse though the Complaints Procedure and Protection of Vulnerable Adults procedures need to be clearer, and staff awareness of the full abuse procedure needs to be increased. EVIDENCE: Residents said that they did not need to complain but if they did they thought the management would look into it properly if they ever needed to. The Complaints file was viewed where there were no recorded complaints since the last inspection. There has been one complaint made to the Commission for Social Care Inspection, which the Registered Manager investigated and found no evidence of the issues raised. However the Complaints Procedure needs to be altered to give the complainant the choice to go to the investigating body – the local Social Service Department - now the lead agency for investigating complaints - and to take out the reference to there needing to be a written complaint, as this could Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 18 prevent residents complaints being fully followed up. The Registered Manager said this would be changed. Staff members were asked about their understanding of the adult protection procedures, and demonstrated a generally good understanding of these. They said that they had attended Protection of Vulnerable Adults training held by the home. However not all staff knew which Agencies to contact if the in house procedure failed. This is not surprising, as the Company procedure does not give details of this procedure. The Registered Manager said this would be changed. There is a Residents Meeting held where all residents are invited to attend and share their views about the home. The Registered Manager keeps good detailed records of the Meetings. The Registered Manager said this Meeting would be held more regularly in the future to meet the National Minimum Standard of every two months, though at present it was poorly attended. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 19 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. This judgement has been made using available evidence including a visit to this service. A homely, generally clean and attractive environment is provided to residents. EVIDENCE: Residents all said that they liked the home’s facilities and that it was always clean and tidy with no odours. They said they could have their bedrooms in the way they wanted and could bring in their own furniture and other personal possessions. Bedrooms were observed to be personalised and homely by the inspector. Some residents said they like the garden, which has just been upgraded to create a sensory garden. Some residents are able to walk around the garden Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 20 with staff assistance as needed. The inspector recommended that the Registered Manager consider fitting rails to paths to provide assistance to residents and prevent possible falls. Facilities were found to be generally clean and odour free except for the ground floor lounge and corridor area near the lounge. The Registered Manager said that the lounge is to be redecorated and the carpet replaced in the near future. She will look into whether the corridor carpet needs replacement as well. Residents again praised domestic workers, and said that the laundry service was good; their clothes did not get lost and were always freshly laundered. There are single bedrooms for all residents. Facilities are generally well decorated. There were a number of areas, which were exceptionally hot – the first floor bathroom, medication room and staff station. The inspector said these areas need to be attended to as they could affect the health of residents and staff. The Registered Manager agreed to follow this up and confirm this had been done. A resident’s call bell was broken and needed to be repaired. The Registered Manager said this issue would be put in place. There is a maintenance person employed who can attend to issues that arise. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 21 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. This judgement has been made using available evidence including a visit to this service. Staffing levels may not meet residents needs. Recruitment processes are generally thorough to ensure the protection of residents from unsuitable staff. A staff training system is in place to ensure staff are aware of residents needs though this needs to be extended. EVIDENCE: Residents said that they usually did not have to wait too long if they needed help though there was sometimes a problem with staff shortages. There is a staffing ratio, which is three or four care staff on each floor until after lunch then three care staff until the three awake night staff members come on duty. There were other comments received by the inspector that staffing levels were not always sufficient. There was other information which supported this position – staff and residents meeting minutes and the Quality Assurance Survey in 2007. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 22 From the records inspected there is a high level of dependency needs – all residents on the ground floor have dementia, a number of residents on the first floor have dementia/were sick in bed/ needed two staff to one resident for personal care/and there was one resident who needed constant care as he was prone to wandering and at risk of falling. With this level of need there would appear to be a need to increase staffing ratios to having four care staff on each floor as a minimum for the busy morning period and to ensure residents are not left waiting for their lunch. Staff records were inspected and generally met expected standards with two references and Criminal Records Bureau checks obtained, copies of passport or similar ID. One file did not appear to have a reference from the last employer though the Registered Manager said this was due to there not being a updated Application form and that this would be followed up. The inspector noted that it was Company policy to charge new staff for their Protection of Vulnerable Adults first/Criminal Records Bureau check. As this is a condition required of the employer, it is not a good practice in terms of staff recruitment, and does not seem fair on staff being paid minimum wage, it is recommended that this practice cease. Staff said that training is provided and that there is encouragement to complete National Vocational Qualification level 2 training. There were training certificates on file to validate training. The Company has a core training programme for staff – e.g. for Food Hygiene, Health and Safety, Protection of Vulnerable Adults, First Aid, Dementia, Infection Control, Medication etc. The inspector looked at the staff file of a staff member – there was no evidence of training in First Aid or Infection Control. As discussed with the Registered Manager there is a need to extend core training topics to add other essential topics and adding knowledge of residents conditions, e.g. stroke management, diabetes, hearing and sight impairment etc, to the list of training issues. The Registered Manager said this was in process of being done with information obtained as to Parkinsons Disease. There is an induction programme, which covers relevant topics. A staff member said she had the induction booklet. The Registered Manager showed the inspector the induction information used from ‘Skills for Care’ organisation, which is the recommended method. The Registered Manager keeps a training matrix for staff to quickly identify training needs of individual staff, which she agreed to send to the inspector. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to protect the health and safety of residents. EVIDENCE: From information received from residents and staff there was a consistent message that the Registered Manager had a clear sense of direction and upheld residents welfare. The Registered Manager has a Registered Managers Award and said that she and the Deputy Manager were enrolled on the National Vocational Qualification Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 24 level 4 training course as well to increase their management awareness. This commitment is commended. There was information that staff receive supervision on a regular basis. It was recommended that this include an assessment from management regarding how well staff are performing with their tasks. Residents monies records are clear so that there is a record for each transaction and that two staff, or one staff plus a resident/ representative sign it. Monies were checked and found to be correct. There are Risk Assessments for safe working practices that have been carried out for issues that present risk for any issues that may present a danger to residents and staff, with Risk Assessments in place. There was evidence that a Quality Assurance survey had been carried out with residents and relatives. The Registered Manager said that issues raised in respect of obtaining more footstools, new towels and flannels, new plastic mugs, staff practice, more supervision of residents bathing and dressing, improved staff communication, improved meal presentation and meal service, better accompaniments to meals, more appropriate food to residents with dentures, the ability of residents to have more than one bath a week if they choose, more activities and having nail care had all been followed up. It is recommended that an Action Plan is drawn up to indicate how issues have been dealt with and this information is included in the Statement of Purpose. Staff meetings are held though not frequently. The Registered Manager said it was her intention to carry them out at two monthly intervals, as per the National Minimum Standard. Fire Precautions: fire drills had been not been carried out at three monthly intervals as there was a six month gap in 2007. Staff spoken to by the inspector were mostly aware of the proper fire procedure though one staff member was unsure regarding contacting the fire service. The Registered Manager said these issues would be followed up. There was a fire risk assessment for the home, to ensure that fire issues have been considered and residents protected from fire. The Registered Manager is revising this in line with more detailed government guidance. Emergency lighting testing was being carried out on the required monthly basis and fire bell testing was carried out on the required weekly basis. A hot water outlet in a first floor bathroom was found to be 42c, which met the National Minimum Standard of 43c, to prevent a scalding risk to residents. There are radiator covers to protect residents from burning. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 25 Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 26 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 3 8 2 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 1 28 X 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 27 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 OP27 Regulation 18 Requirement Care staffing levels in the morning period need to be reviewed and increased to ensure residents needs can always be met. Timescale for action 17/12/07 2. OP30 18 The staff training programme 17/04/08 needs to be extended to cover all relevant topics regarding residents care including residents conditions, e.g. stroke care, hearing and sight impairment etc . 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 OP8 Good Practice Recommendations There needs to be more specific information in residents Care Plans to ensure that residents are given the opportunity to go to the toilet when their needs indicate. DS0000036290.V347620.R01.S.doc Version 5.2 Page 28 Saffron House 2. OP18 The Vulnerable Adults policy needs to be more detailed and staff tested on their awareness of the full procedure. Saffron House DS0000036290.V347620.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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