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Inspection on 07/09/09 for Saxilby House Residential Care Home

Also see our care home review for Saxilby House Residential Care Home for more information

This inspection was carried out on 7th September 2009.

CQC 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 CQC judgement.

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

There are generally good assessments in place to make sure that people’s needs and wishes are identified and met in the way they want them to be, however, these could be improved to include how people are able to make decisions and choices and the action needed if they are not able. Some people told us they are able to make their own choices and decisions and are able to be as independent as they can be. One person told us he is able to go out on his scooter whenever he wants and another person said she prefers her own company and is quite happy in her room. There are good systems in place to make sure that people are protected, including robust recruitment procedures.

What has improved since the last inspection?

Saxilby House Residential Care HomeDS0000059111.V377100.R01.S.docVersion 5.2Since the last inspection a new manager has been recruited and she has begun to make changes to the assessment process and some care plans. New people commencing work in the home have been recruited using robust safe procedures. During the last inspection we said that there must be opportunities for people to take part in activities and leisure appropriate to their individual needs. The manager has started to write life histories for people which include their hobbies and interests. She has identified in the AQAA plans to improve the service include appointing an activity co-ordinator. However, this must be made a priority to make sure this requirement is fully met. A representative for the provider visits the home at least once a month to monitor the quality of care and writes a report of her findings.

What the care home could do better:

Pre-admission assessments must contain more information to ensure all aspects of care are considered and take into account people’s preferences. They should also show who provided the information. The manager must have sufficient time to continue to make improvements to all care plans to make sure they contain sufficient detail to ensure that people’s needs are met. They must also show that people are actively involved in their care plans and subsequent reviews. The manager must have sufficient time to monitor the quality of the service to ensure people living in the home receive good standard of care. She must also have sufficient time to make sure staff are appropriately supervised and have the necessary skills to care for people living in the home. Training relating to safeguarding vulnerable adults must be given to all staff. Training must be provided about the Mental Capacity Act and the manager should obtain relevant legislation about this subject. The provider must appoint a manager who must then be supported to apply for registration with the Commission. Improvements must continue regarding the provision of activities and leisure interests. The complaints policy should be updated to include our new name, address and telephone number, so that people can contact us if they need to.

Key inspection report CARE HOMES FOR OLDER PEOPLE Saxilby House Residential Care Home Highfield Road Saxilby Lincoln Lincolnshire LN1 2QP Lead Inspector Elisabeth Pinder Key Unannounced Inspection 07th September 2009 09:00a DS0000059111.V377100.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Saxilby House Residential Care Home DS0000059111.V377100.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Saxilby House Residential Care Home DS0000059111.V377100.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Saxilby House Residential Care Home Address Highfield Road Saxilby Lincoln Lincolnshire LN1 2QP 01522 704025 01522 704025 triskelion@btinternet.com 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) Mr Colin Roy Hayes Vacant Care Home 10 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (10), of places Physical disability (1) Saxilby House Residential Care Home DS0000059111.V377100.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories: Old Age, not falling within any other category (OP) - 10 Physical disability (PD) - 1 Dementia - Over 65 years of age (DE(E) - 2 The maximum number of service users to be accommodated is 10 2. Date of last inspection 20th August 2008 Brief Description of the Service: Saxilby House cares for older people in a family environment in a detached property situated in the village of Saxilby. The home is approximately six miles from the historic city of Lincoln. Facilities include a post office, pubs, shops, a chemist and a village hall. The home is a two-storey converted farmhouse standing in its own grounds and gardens with car parking facilities to the rear. There is a stair lift to the bedrooms on the first floor and there are adaptations and aids around the building to allow residents to move around the home more independently. All of the bedrooms are single. There are five communal toilets and two communal bathrooms. On the day of our visit eight people were living in the home. The current scale of charges at this home is from £360.00 to £427.00. Additional costs are made for hairdressing, chiropody, transport to personal appointments other than hospital or doctors and personal toiletries. These are all private arrangements and costs are met by the individual. Saxilby House Residential Care Home DS0000059111.V377100.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means that the people who use the service receive poor outcomes. This was an unannounced visit and it formed part of a key inspection, focusing on key standards which have the potential to affect the health, safety and welfare of people who use the service. Throughout this report the terms ‘we’ and ‘us’ refer to the Care Quality Commission (CQC). The visit lasted just over six hours and took into account previous information held by us including the previous inspection report, their service history and records of any incidents that we have been notified of since our last visit. Before we made our visit the manager had returned the Annual Quality Assurance Assessment (AQAA). This gave us information about their own assessment of how well they are meeting standards and their plans to improve aspects of the service. The main method used to carry out the inspection is called ‘case tracking’, this includes following the care of a sample of people through their care records and assessing their care. We spoke to people who use the service and saw rooms of those who said we could and to two members of staff. The inspector issued what is called a Code B Notice, under the Police and Criminal Evidence Act. This is a legal document allowing the Commission to either take evidence away with us or search the premises or photocopy documents, which are deemed relevant to our inspection. What the service does well: There are generally good assessments in place to make sure that people’s needs and wishes are identified and met in the way they want them to be, however, these could be improved to include how people are able to make decisions and choices and the action needed if they are not able. Some people told us they are able to make their own choices and decisions and are able to be as independent as they can be. One person told us he is able to go out on his scooter whenever he wants and another person said she prefers her own company and is quite happy in her room. There are good systems in place to make sure that people are protected, including robust recruitment procedures. What has improved since the last inspection? Saxilby House Residential Care Home DS0000059111.V377100.R01.S.doc Version 5.2 Page 6 Since the last inspection a new manager has been recruited and she has begun to make changes to the assessment process and some care plans. New people commencing work in the home have been recruited using robust safe procedures. During the last inspection we said that there must be opportunities for people to take part in activities and leisure appropriate to their individual needs. The manager has started to write life histories for people which include their hobbies and interests. She has identified in the AQAA plans to improve the service include appointing an activity co-ordinator. However, this must be made a priority to make sure this requirement is fully met. A representative for the provider visits the home at least once a month to monitor the quality of care and writes a report of her findings. What they could do better: If you want to know what action the person responsible for this care home is Saxilby House Residential Care Home DS0000059111.V377100.R01.S.doc Version 5.2 Page 7 taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Saxilby House Residential Care Home DS0000059111.V377100.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 Saxilby House Residential Care Home DS0000059111.V377100.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standard 6 is not applicable People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assured that their needs can be met due to a clear introduction and assessment process. EVIDENCE: Information sent to us prior to the inspection told us that people have access to a range of information about the service and are able to visit the home and spend time there before making a decision about moving in. A copy of our last report was available in the home and the manager has information about the current fee rates. During the previous inspection a requirement had been given regarding people having a full needs assessment prior to their admission and we looked at the records of one person who had recently been admitted and these showed that a needs assessment had been carried out by the manager prior to their Saxilby House Residential Care Home DS0000059111.V377100.R01.S.doc Version 5.2 Page 10 admission. The assessment gave staff information about how the person wanted their care to be delivered, however, further improvements are needed to ensure all aspects of care are considered including how people are able to make decisions and choices and the action needed if they are not able. The manager told us that the home had been struck by lightening in July of this year and a number of computerised documents had been lost and although a letter confirming that after the assessment the service could meet needs was not on file, a reply to the letter from the person’s social worker was available. The service does not cater for people with intermediate care needs. Saxilby House Residential Care Home DS0000059111.V377100.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some care plans do not record enough detail to show that individual needs and wishes will be met in a respectful way. EVIDENCE: During the previous inspection a requirement had been given that care plans must be in more detail to make sure people’s needs are met. We looked at six care plans and four of these did not show that they had been reviewed in the last twelve months. The manager told us she is working so many hours on care and finds it difficult to have time to review and up date care plans. Please also see the management section of this report. Care plans looked at did not give clear information for staff to follow, for example two read ‘to maintain privacy and dignity’ but did not tell staff how to do this, and, during our visit we saw a member of staff helping to dress a person in the dining room and when asked about this said ‘…. doesn’t mind, Saxilby House Residential Care Home DS0000059111.V377100.R01.S.doc Version 5.2 Page 12 he’s not quite with it, he’s very amenable’. Another record contained a care plan for wound care, however, this was not signed or dated and when we asked the manager about this she told us the person did not have any wounds. Care plans did not make reference to the new laws about how people make decisions and neither staff had an understanding of the Mental Capacity Act. None of the care plans looked at showed that people had been involved in their care planning or any subsequent reviews or had agreed with any changes made to their care. We spoke to four people who were very satisfied with their care, none of them knew they had a care plan but told us they felt their needs were being met and when asked how the service could improve one person told us ‘they couldn’t’ and another person said ‘have more staff’. Please also refer to the staffing section of this report. Since the last inspection medication policies and procedures have been written specifically for the service, a new medication trolley has been purchased and medicines are now being stored safely and were being given to people by care staff who have completed relevant training. Records looked at showed that medication procedures were being followed in a satisfactory way. Saxilby House Residential Care Home DS0000059111.V377100.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Activities are limited and do not take into account individuals interests and capabilities. Meals provided are well balanced and take into account personal preferences and dietary requirements. EVIDENCE: A requirement was given during the previous inspection that appropriate activities and leisure opportunities must be provided to meet individual needs. Information taken from the AQAA told us that people’s independence is promoted and they are encouraged to continue with hobbies and interests. However, the service acknowledges the need to improve by developing an activity programme for each person and appoint an activity person. During our visit no activities were taking place and whilst some people told us they didn’t really want to do anything apart from watch television or read, others told us there is nothing to do. One person told us he is able to go out when he wants on his scooter and another person told us she prefers her own company and is Saxilby House Residential Care Home DS0000059111.V377100.R01.S.doc Version 5.2 Page 14 quite happy in her room. However, not everyone living in the home were able to express their wishes and their care plans did not tell staff how they could ensure social stimulation was to be given, or record detailed information about personal interests, life styles or daily routines. The manager told us she is planning to develop life histories and individual plans for people but as already highlighted is mainly working as a carer. People told us they receive regular visitors and that they are always welcomed into the home and offered a drink. However, not everyone has visitors and the manager told us she is currently arranging advocacy for people. People told us that the food is home for many years and has dislikes. Menus showed that a people being asked what they ‘very good’, the cook has been working in the a good understanding of peoples’ likes and varied, nutritious diet is offered and we saw wanted for lunch. Saxilby House Residential Care Home DS0000059111.V377100.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are protected by the procedures in place for handling complaints, however, the failure to train all staff in safeguarding adult protection procedures does place people at risk. EVIDENCE: Information taken from the AQAA tells us that people are made aware of the complaints procedure and support is given to anyone wishing to make a complaint. The complaints policy is included in the Statement of Purpose and Service User Guide and needs updating to include our new contact details. People told us that they feel safe living here and they felt confident to raise any issues with the manager or any staff. Records showed us that one complaint had been made since our last visit and this had been dealt with appropriately. One member of staff spoken to had a good understanding of abuse and the action to take should an allegation be made although she had not had any recent training whilst working in the home. However, the other staff member told us she had received training many years ago and told us she would not report any issues. Saxilby House Residential Care Home DS0000059111.V377100.R01.S.doc Version 5.2 Page 16 The manager told us she has received a training pack from Lincolnshire County Council which includes a CD and workbook and she is planning to make sure all staff work through this programme. The home has a copy of the Local Authority guidance on safeguarding adults and we know from our records that since our last inspection there has not been any alerts made to the Local Authority Safeguarding Adults Team. Saxilby House Residential Care Home DS0000059111.V377100.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a well-maintained, clean, comfortable and homely environment. EVIDENCE: No concerns were raised regarding the environment of the home, people told us they were happy with their rooms, they were kept clean and people had been able to personalise them as they wished with pictures, photographs and ornaments. One person told us she loves her room, she feels very comfortable and chooses to stay there all the time. Jugs of water or juice and baskets of sweets and fruit were available in the lounge and emergency call bells were within reach. Saxilby House Residential Care Home DS0000059111.V377100.R01.S.doc Version 5.2 Page 18 Information provided in the AQAA told us that an action plan is in place for infection control and the manager is developing an action plan for redecoration and refurbishment of the home. The service received a 5 star award for food safety from the Environmental Health Officer in January of this year. Staff were observed wearing protective aprons and gloves where needed. Saxilby House Residential Care Home DS0000059111.V377100.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are placed at risk due to a lack of staff at certain times of the day and inadequate staff training. People are protected by the homes robust employment procedures. EVIDENCE: There are currently eight people living at Saxilby House. We looked at rotas for the period between 01 August 2009 and 07 September 2009 and these showed that there are normally two members of staff on duty between the hours of 07:00 and 20:00. However, there are gaps between 2pm and 3pm where only one member of staff is on shift and we were told that the manager is usually on the premises. The manager’s hours are included on the rota and show that on numerous occasions she has worked from 3pm until 7am the following morning. The rota shows that there is one wakeful night staff and another person on call. However, the rota does not show who is on call throughout the night and staff told us that when the manager is not on call a person living in the village is on call who can be in the home within five to ten minutes. Staff told us they feel that there are not enough of them on duty to meet all the needs of people living at the home. Both said they had recently had their hours reduced and felt that had an impact on completing care records. One Saxilby House Residential Care Home DS0000059111.V377100.R01.S.doc Version 5.2 Page 20 person said ‘at the moment we can’t do our job 100 , we are not always able to meet needs and will have to ask people to hang on while we finish one task’. There was a mixed view from people living at the home, people who were fairly independent felt there was enough staff around, whilst others who needed more support told us they sometimes have to wait for a member of staff to attend to their requests. Training records looked at showed that there has not been any training since September 2008, however, over 50 of staff hold a nationally recognised care qualification and the manager told us she is currently arranging further training to a higher level. Staff spoken to had no understanding of the Mental Capacity Act and said they had not heard of the Deprivation of Liberty Act. The manager told us that she did not have the Code of Practice for this legislation. We looked at two staff records and these showed that application forms, criminal record bureau checks, identification and written references had all been completed before the person started work. One member of staff told us she had completed induction training although records to confirm this could not be located. Saxilby House Residential Care Home DS0000059111.V377100.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There has not been consistent management of this home to ensure its smooth running or the safety of people. Accurate accounts are kept of peoples’ monies and valuables. EVIDENCE: There has not been a registered manager in this service since June 2007. Information we have about the service shows that since this time there has been two unregistered managers at this home. The current manager has not yet applied for to be registered, having been in post since October 2008. She has completed the Registered Managers Award and is aware of her Saxilby House Residential Care Home DS0000059111.V377100.R01.S.doc Version 5.2 Page 22 responsibility to register with us. However, she expressed that she is mainly working care shifts and does not feel supported by the provider to manage the service. During our visit no concerns were raised about the manager, people told us they liked her and felt she was caring, always around and spoke with them everyday. Staff told us they felt the manager was supportive to them but raised concern about the number of hours she worked. We looked at two staff files and found that they had not received supervision from the manager since January of this year. They had not received any training since September 2008 and no staff meetings have taken place. The AQAA told us that the views and opinions of people are sought, however, there was little evidence to support this. The manager told us quality assurance questionnaires were left in the entrance area of the home in January for relatives/visitors to complete, however, only one was returned. Questionnaires had not been sent to GP’s (general practitioners), district nurses or social workers and no meetings are held for residents and/or their representatives, however, a representative for the provider had visited the home once a month to monitor and evaluate how the home is running and reports were available of their findings. The AQAA told us that there is a range of policies and procedures and the majority of these had been reviewed and updated in July 2008. We were also told of equipment maintenance and service date. Health and safety audits are carried out by an external company and their certificate of compliance was on display. The manager told us that finances are only held for one person and their records were looked at and were found to be up to date and accurate. Saxilby House Residential Care Home DS0000059111.V377100.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 2 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 2 X 3 Saxilby House Residential Care Home DS0000059111.V377100.R01.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 Requirement Care plans must be in more detail to ensure that peoples’ needs are met. Care plans must take into consideration the Mental Capacity Act 2007. This requirement has been met in part, a further timescale is given for compliance. The privacy and dignity of people living in the home must be respected at all times. Appropriate activities and leisure opportunities for residents to participate in must be provided to meet individual needs. This requirement has been met in part, a further timescale is given for compliance. All staff must have sufficient knowledge about safeguarding adults and report any concerns to prevent people from being placed at risk of harm or abuse. There must be sufficient staff on duty at all times to meet the needs of people living in the DS0000059111.V377100.R01.S.doc Timescale for action 01/11/09 2. 3. OP10 OP12 12 16 01/11/09 01/11/09 4. OP18 13 01/11/09 5. OP27 18 01/11/09 Saxilby House Residential Care Home Version 5.2 Page 25 6. OP30 18 7. 8. OP31 OP36 8 12 home. All staff must receive training appropriate to the work they are to perform to ensure the needs of people living in the home will be met. The provider must appoint a manager who must register with the Commission. The manager must have sufficient time to monitor the quality of the service to ensure people living in the home receive good standards of care. This requirement has not been met. A Code B Notice was given under the Police and Criminal Evidence Act. All staff must be appropriately supervised to ensure they have the necessary skills to care for residents. This requirement has been met in part, a further timescale is given for compliance. 01/11/09 01/11/09 01/11/09 9. OP36 18 01/11/09 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 OP3 Good Practice Recommendations Pre – admission assessments should ensure all aspects of care are considered including how people are able to make decisions and choices and the action needed if they are not able. It is again recommended that regular residents meetings are held and minutes are taken to ensure people are able to have their say about the running of the home. 2. OP33 Saxilby House Residential Care Home DS0000059111.V377100.R01.S.doc Version 5.2 Page 26 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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