Inspection on 03/10/06 for Shalom

This inspection was carried out on 3rd October 2006.

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

The inspector 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

Shalom 29/05/07

Shalom 16/05/06

Shalom 07/12/05

Shalom 25/07/05

Shalom 31/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Shalom 8 Carew Road Eastbourne East Sussex BN21 2BE Lead Inspector Kevin Whatley Unannounced Inspection 3rd October 2006 10:00 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 Shalom DS0000021210.V314166.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. Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shalom Address 8 Carew Road Eastbourne East Sussex BN21 2BE 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) 01323 410926 Mr David McMeekin Mrs Sandra McMeekin Mr David McMeekin Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of residents to be accommodated is eighteen (18). Residents must be older people aged sixty-five (65) years or over on admission. 16th May 2006 Date of last inspection Brief Description of the Service: Shalom is a three storey detached property in a quiet residential area of Eastbourne. It is situated close to the town centre and is within walking distance of the shops, train station and local bus routes. There is a garden surrounding the home. The home is registered to provide care and accommodation to eighteen older people and is an established family run business. There are eighteen single bedrooms, all with en-suite facilities. There is a communal lounge and dining area on the ground and first floors, in addition to an adequate number of communal bath and toilet facilities. The home have recently added a stair-lift to allow ease of access for residents to the upper floors of the building. As of 3rd October 2006 fees at the home ranged from £312 to £422 per week with additional costs for hairdressing, chiropody, personal toiletries and newspapers and magazines. The home do not currently have a website and information regarding the service is accessed via direct telephone contact with the home, whilst enquirers to the service can view the last inspection report which is available at the home. Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Shalom will be referred to as ‘residents’. This unannounced inspection took place in response to the poor findings of the previous inspection that occurred in May this year. Following the May inspection the proprietor/manager attended a meeting at the CSCI where a timescale for improvement in key areas of care provision was agreed. This inspection therefore focused primarily on whether satisfactory improvement and progress had been made in meeting a number of outstanding requirements, though all key National Minimum Standards (NMS) were assessed. The inspection visit took place on a weekday in October and lasted for approximately four hours. At the time of the inspection the home was accommodating 15 residents. The Inspection visit included a tour of the premises, both inside and out, and its facilities including viewing several bedrooms. The Inspector spoke with the proprietor/manager, the deputy manager and two members of care staff. Five residents were spoken with during the inspection, whilst care staff were observed carrying out their duties. Documents seen included 4 residents care plans, the accident book, fire safety log and medicine administration records. In preparing this report it was also necessary to assess and consider additional information concerning Shalom. Such information was gathered from a number of sources including service history information held at CSCI offices. Telephone contact was also made with a number of relatives/next of kin and with other care professionals who visit or who have contact with residents living at the home, such as Social Workers and the Community Psychiatric Nurse service. This report should be read in conjunction with the previous inspection report dated 16th May 2006. What the service does well: Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 6 Shalom offers residents a home that suitably furnished in a manner that is both homely and comfortable. Residents benefit from having their medication needs met and are supported and assisted to attend health care appointments. Residents are able to engage in their chosen religious observance and have opportunities to participate in outings and activities. Care staff are caring, committed and patient and residents continue to comment positively on the manner that they are cared for. What has improved since the last inspection? What they could do better: The home must ensure that residents are continually reminded not to prop open their bedroom doors, and should consider fitting alarm activated door stops to residents who wish their door to remain open to ensure they are safe at all times. The home should continue to improve it’s quality assurance and monitoring procedures to ensure that they assess their own care standards on a regular basis with a view to maintaining and improving care provision. Please contact the provider for advice of actions taken in response to this Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shalom DS0000021210.V314166.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 Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements to care needs assessment and planning indicate that residents will be suitably assessed prior to admission. EVIDENCE: The last inspection report highlighted a concern that a resident had been admitted without first having their care needs fully assessed and recorded into a suitable plan of care. Since the last inspection no resident has been admitted to the home, therefore it is somewhat difficult to make a clear assessment in regard whether the home follows suitable assessment and admission procedures etc. However as evidenced throughout the following report considerable improvements have been made in respect of care needs assessment and care planning. The deputy manager provided evidence of a new format for recording care needs assessments and outlined how the home would assess prospective residents Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 10 and how the admission procedure would occur. The home does not offer intermediate care. Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements made to the overall care planning process now ensures that each resident benefits from having their individual needs suitably addressed and recorded into robust care plans that outline how their needs must be met. The homes medication procedures ensure that residents have their medical needs met, whilst staff treat residents with respect, care and kindness. EVIDENCE: The last inspection report noted that care planning procedures at the home were poor and a number of requirements were made as a result. Since the last inspection the home have adopted a new format for recording the assessed care needs of residents and each resident now has a care plan that clearly outlines their physical, emotional, social and health care needs. Four care plans were viewed in particular and these evidenced that the care plan represented a clear picture of the individual needs of residents with clear guidance as to how such needs will be met by care staff and any risks that may be apparent including the risk of falls and lack of mobility etc. Each care Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 12 plan is robust and allows for care needs to be reviewed monthly or when required depending on the changing needs of each resident. Each resident now has a ‘record of care delivery’ that outlines the level of care support they should receive and is completed daily by care staff to ensure a consistent approach is taken in addressing the provision of care. The record of care delivery allows for comments to be added by care staff should the residents care needs change and will be subsequently considered when care plan reviews occur. Each care plan has a space for residents/next of kin to sign, though as this system has only just been completed none had yet been shared with residents. One member of staff stated that the new system of care planning ‘is really clear and useful’ and allows the needs of each resident to be considered ‘more closely than before’. Both the proprietor/manager and deputy manager confirmed that the current level of care needs among residents is relatively low, with care plans evidencing that most residents are fairly able to meet many of their own personal care needs themselves. There was clear evidence of the health care needs of residents being met with clear medical histories and current medical needs being recorded with appointments being kept and planned for including good liaison with the district nurse service and community psychiatric nursing service. All residents are registered with local GP’s. The home’s medicine administration and storage system was viewed. Medicines are stored in a suitable locked cupboard in the office and were found to be adequately labelled and separated. The homes medicine administration records were seen and were found to be accurate, up to date and clear. One medicine was found to have not been signed for, though on closer inspection it was confirmed that the resident had received their medication with the member of staff seemingly forgetting to enter their initial on the record. The proprietor/manager and deputy manager were able to quickly identify the member of care staff in question, through the signature, and stated they will be taking up the error with them as part of supervision. It was clear that care staff treat residents with care and respect and all residents spoken with spoke positively on the way they are cared for at Shalom. One resident stated that the staff are ‘really lovely and caring’, whilst another said ‘staff are very nice indeed’. Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered opportunities to engage in activities and events and are able to pursue their own interests and benefit from suitable daily routines that are relaxed and unhurried. Residents have their dietary needs met and benefit from meal choices and varied and nutritious home cooked food. EVIDENCE: As noted in the previous report the daily routines at the home appear to be reasonable and relaxed and residents can chose to have their meals in their rooms or in one of two dinning room/lounges, one on the second floor and one on the ground floor. Residents stated that they can ‘join in games and music’ if they wish. The home continue to employ the services of an activities coordinator who facilitates games and exercise events on a weekly basis, whist musical entertainment is arranged occasionally. Several residents continue to be able to venture out from the home on a regular basis to visit local shops or pubs. One resident recently ventured out to go fishing at the nearby pier and was lucky enough to catch a mackerel which the cook subsequently prepared for their tea. Residents continue to have opportunities to be taken out in a member of staffs car to visit local sites of Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 14 interest. A number of residents receive regular visitors and the home operate a relaxed visitors policy. A friend of one resident noted that she can visit whenever she wishes within reason and stated that she is ‘always made to feel very welcome’ by care staff when she visits. A number of residents continue to take ‘holy communion’ in their own rooms with a visiting priest, whilst services are held at the home for all who wish to attend them on a 6 weekly basis. The proprietor/manager ensures that fresh meat and vegetables are bought regularly in relation to the planned menu. The menu was seen and indicated that residents have a balanced, nutritious and varied diet, whilst two residents have special dietary needs and subsequently have their diets altered to meet their needs. One resident also has dietary requirements in relation to their religious preference and this was seen to be suitably managed with appropriate alternative meals being provided when necessary. Residents commented positively on the meals they receive. The cook explained her system of recording the wishes of each resident every day in relation to what they wish to eat and noted that although there is a daily menu residents can choose what they wish to have. The cook noted that the proprietor/manager shops daily and is therefore able to purchase different foods for residents when they request it. The cook stated that the home ensure they provide this resident with a drink supplement, whilst the residents niece brings them a vitamin drink. Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home enables residents and others the opportunity to make complaints should they wish, whilst residents are protected from the risk of harm, neglect or abuse. EVIDENCE: The home has a suitable complaints policy, although this was not displayed in the home the proprietor/manager was in the process of placing a copy in the entrance hall of the home as the Inspector completed his inspection. The complaints file confirmed that no complaints had been received by the home since the last inspection; no complaints had been made to the CSCI since the last inspection. Residents noted that they were aware of the procedure in the event of wishing to make a complaint, as did relatives. The previous report made a requirement that staff undertake appropriate adult protection training. All care staff had recently undertaken the Protection Of Vulnerable Adults (POVA) training provided by an outside care industry training agency. The format for the training was viewed and was seen to have provided staff with a comprehensive course that included all key aspects of adult protection awareness including definitions of abuse, how to reduce the risk of abuse occurring and procedures to follow in the event of suspecting abuse in the home. The home have suitable adult protection policies and procedures that include a policy on ‘whistle blowing’. No adult protection concerns have been expressed to the CSCI since the last inspection. Shalom DS0000021210.V314166.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements have been made to assist residents to gain easy access around the home. Residents benefit from an environment that is reasonably well maintained and furnished in a suitable and homely manner. The health and safety of all who live, work and visit Shalom is suitably addressed. EVIDENCE: A tour of the premises both inside and out confirmed that in general the home is structurally well maintained and decorated with residents bedrooms being individualised with personal effects such as pictures, ornaments and photographs. All bedrooms have a television, en-suite toilet facilities and the option of having a private telephone installed. Bedrooms are situated on the ground, first and second floors of the building. The last inspection report highlighted concerns that some residents may have had their option to use different areas of the home compromised by the lack of Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 17 a lift or stair-lift. Since the last inspection the home have had a suitable stairlift fitted the whole length of the stairs and this now allows for greater ease of movement. One resident recently celebrated their 100th birthday and care staff stated that the stair-lift encouraged most residents, who may have felt the stairs were too much of an obstacle, to venture downstairs to participate in the birthday celebrations. All areas of the home were found to be clean and hygienic with no noticeable offensive odours or smells. The communal areas of the home consist of a lounge/dining room downstairs and a lounge/dining room on the first floor. The front of the home offers residents the opportunity to enjoy a pleasantly arranged garden and porch area. The rear of the building has been tidied up since the last inspection and although not being large enough to offer any suitable outside amenities, now looks much more presentable. One resident stated that Shalom was ‘a lovely place to live’ whilst another said they ‘had all they needed here’. Records confirmed that a recent Environmental Health Officer carried out a routine inspection of the home’s kitchen area. The inspection found that the home were maintaining a ‘satisfactory level of hygiene’ in respect of the preparation, storage and handling of food stuffs, whilst the cleanliness of the kitchen area was seen as being satisfactory to meet health and safety requirements. During the tour of the building two bedroom doors were seen to have been propped open by wedges. On closer inspection it was found that residents had propped the doors open themselves and one had devised a means of keeping their door open by bending bits of plastic to create a wedge. Both of these bedrooms were on the ground floor and were situated next to the main corridor. The proprietor/manager explained that these two residents keep wedging their own doors open and although both rooms are in close proximity to the kitchen and office accepted that staff should remove such wedges at all times. The proprietor/manager stated that he would seek to have automatic door closures fitted to these rooms as they are the only two residents that continually refuse to close their doors. Records required to be kept in regard health and safety in the home confirmed that fire safety equipment was serviced and indeed replaced with new extinguishers last week, whilst fire checks are carried out and recorded regularly. Risk assessments have been completed for the home’s environment and the deputy manager, who has considerable experience in teaching health and safety, is delegated to oversee all aspects of health and safety and has facilitated a course that all staff are completing in relation to health and safety that covers all aspects of health and safety within a residential environment. Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home deploys suitable numbers of staff during the day and most of the night though night time cover should continue to be monitored. Improvements have been made to staff training and this is enabling staff to increase their knowledge of working as professional carers and assisting them to pursue formal qualifications. Staff are experienced, committed and caring, whilst the homes recruitment procedures protect residents from the risk of harm. EVIDENCE: The home employ a small team of carers with several members of the proprietor/manager’s family engaged as carers. At the time of the unannounced inspection, there were two care staff on duty, along with the proprietor/manager, the deputy manager and the cook. One carer noted that the home has employed one new carer since the last inspection and that this appointment is enabling an extra member of staff to assist at busier times of the day. There are staff available on call during the night who live in a flat at the top of the home. No waking night staff are currently employed, though there is a carer awake until 2am. The proprietor/manager stated that a requirement made at the last inspection to review this situation took place and he noted that the current arrangements are satisfactory to meet the night-time needs of residents. Both the proprietor/manager and deputy manager stated that the provision of waking night time cover will continually be monitored, though noted that the residents current needs do not indicate a need for a full Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 19 time waking night carer as the on-call system allows residents to access help and support from the on site carers. Residents stated that they knew how to call staff during the night via the ‘call-bell’ system. Since the last inspection the deputy manager has completed a training matrix for each member of staff that outlines their qualifications and any care related training needs they may have. As previously mentioned since the last inspection staff have undertaken training in adult protection and health and safety and also food hygiene. Several care staff hold the required National Vocational Qualification (NVQ) Level 2 in care and are enrolled to continue to work toward their Level 3 awards. One new member of care staff had been employed since the last inspection. This member of staff’s records confirmed that they did not start work at the home prior to the required Criminal Records Bureau (CRB) checks being confirmed, whilst their employment history showed that they had considerable experience in caring for older people in residential care and indeed they held an NVQ Level 2 in care. Since the last inspection staff meetings have been implemented to take place regularly. Minutes of these meetings evidenced that key areas of care provision are addressed with a clear emphasis on improving and maintaining good care practice standards. The deputy manager stated that it had been necessary to hold a separate meeting to include evening staff but that it is envisaged that future meetings will involve all staff. All staff spoken to stated they were ‘very well supported’ by the proprietor/manager and deputy manager and spoke positively about the changes that have occurred since May. Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 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. Improvements have been made to the overall management of the home and a more structured senior management team has contributed to residents benefiting from a higher standard of care provision. EVIDENCE: As noted in the summary to this report the proprietor/manager attended a meeting with the CSCI following the last inspection in May this year to answer the poor outcomes of that and previous inspections. This meeting culminated in an agreed timescale for improvements to occur in many key areas of care provision, notably the recording of care needs assessments, care planning and review, access for residents living upstairs and the homes overall management structures and responsibilities. Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 21 It is therefore pleasing to note that all of the requirements made at the previous inspection have now been addressed and whilst there remains room for continued improvement to be made and sustained to some aspects of care provision considerable steps have already been taken to raise the level of care standards in the home. The proprietor/manager has owned and managed Shalom for a considerable number of years and states the home is family run with several members of his family working and living there. The proprietor/manager has not obtained the required NVQ Level 4 in care and management, however he stated that he holds a care management qualification that the City and Guilds foundation have recently stated is an equivalent award. A friend of one resident said that the proprietor/manager is ‘very good’ at helping whenever she has made enquiries about any aspects of the residents care and noted that she is always kept informed of the residents changing needs. Recent improvements to the running of the home have included the full time appointment of Mr McMeekin’s daughter as deputy manager; the deputy manager was previously engaged in some aspects of the running of the home but only on reduced hours due to other working commitments. This appointment has lead to a more defined, structured and pro-active management approach toward meeting the needs of residents and staff alike. The proprietor/manager and deputy manager acknowledged that there was scope to improve the quality assurance system and noted that they will up date the current resident questionnaire and would consider placing comment cards and questionnaires next to the visitors signing in book. The deputy manager stated that she will add a space for residents views on the level of care they receive to the new care planning review document. The home does not handle any of the resident’s personal finances, with a majority of residents having their financial affairs directed by their designated ‘power of attorney’. Care staff noted that they feel ‘supported’ by the proprietor/manager and his deputy and noted that having the deputy manager in place has improved the homes efficiency. The deputy manager explained that her role is to bridge the gap between the proprietor/manager and care staff and to provide a consistent and structured approach to supporting staff to carryout their tasks. The deputy manager provided evidence of a new formal supervision format and stated that the process of supervising all care staff 6 times a year will begin shortly, though she reiterated that such a small staff team allows for informal to occur throughout the day. The home keeps a fire log and this was seen to have dates of regular fire safety checks such as fire alarm testing taking place. There is a fire safety certificate displayed in the home confirming that the home had it’s yearly fire Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 22 safety audit completed last week. The home’s accident book was viewed and was seen to be suitably recorded and kept up to date. Shalom DS0000021210.V314166.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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 3 X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP25 Regulation 23(4)(c) (v) Requirement The home must ensure that residents do not prop open their bedroom doors. Timescale for action 03/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP25 OP27 OP33 Good Practice Recommendations That the home should consider fitting automatic door closures to the bedrooms that residents continually prop open. That the home continues to assess staffing cover for the night time and where necessary introduce a system of a waking night carer/s. That the home develops it’s current quality assurance process to enable them to gain more regular feedback from residents and others regarding the home and the services it offers. Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shalom DS0000021210.V314166.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!