Inspection on 05/06/07 for Shelburne Lodge

This inspection was carried out on 5th June 2007.

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

The inspector 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

Shelburne Lodge 27/05/08

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Shelburne Lodge Rutland Street High Wycombe Bucks HP11 2LJ Lead Inspector Barbara Mulligan Unannounced Inspection 5th June 2007 10:30 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 DS0000069275.V340665.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. DS0000069275.V340665.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shelburne Lodge Address Rutland Street High Wycombe Bucks HP11 2LJ 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) 01494 440404 01494 449562 shelbourne@barchester.net Barchester Healthcare Homes Ltd Mrs Pam Camichel Care Home 54 Category(ies) of Old age, not falling within any other category registration, with number (54) of places DS0000069275.V340665.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That as of the 21st of October 2005 the home is registered to admit Service Users over the age of 55 respite care only. Date of last inspection New service Brief Description of the Service: Shelburne Lodge is a care home providing nursing and personal care up to 54 elderly people. The home is located in a residential area in High Wycombe, a short distance from the local shops, amenities and public transport networks. The home is purpose built and consists of a two-storey building set in small grounds. All the bedrooms, except for two, are single rooms and have en suite facilities. The communal space is pleasant and the gardens are well maintained. There is qualified nursing staff on duty at all times, supported by a team of carers. There is an experienced management team in place overseeing the running of the home. The home has its own mini bus ensuring easy access to local amenities. Fees for the service range from £850 to £900 per week according to information supplied by the manager. Chiropody, hairdressing and personal items such as toiletries and sundries would be at additional cost to the service user. DS0000069275.V340665.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was undertaken on Tuesday 5th June 2007 at 10:30am. The visit consisted of discussions with the registered manager and the deputy manager, care staff and service users, a tour of the premises and an examination of the homes records, policies and procedures. The inspection officer was Barbara Mulligan. The registered manager is Mrs Pam Camichel. Twenty-five of the National Minimum Standards for Older People were assessed during this visit to the home. All of these have been fully met. Two recommendations for good practice have been made. The inspector would like to thank the registered manager, the deputy manager, the staff team and all service users for their cooperation and assistance during this visit. Due to sick leave the registered has been unable to send out a service satisfaction survey on behalf of the Commission for Social Care Inspection, however, this was to be sent out shortly. The evidence seen and comments received from discussions with service users during the inspection indicate that this service meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals within the limits of its Statement of Purpose. What the service does well: Potential service users receive a thorough needs assessment to ensure the home can meet the care needs of the service users. Healthcare support for service users is good. Service users feel that they are treated with respect and dignity. Care plans have been produced for all service users that are detailed and informative. The home provides a pleasant and comfortable environment in which service users can live. Individuals are encouraged to personalise their own rooms with their own furniture and personal belongings. One service user told the inspector “this is the best home around here, that’s why I chose it”. DS0000069275.V340665.R01.S.doc Version 5.2 Page 6 Communication between service users and visitors was observed to be positive and open. The home has developed an activities programme that offers varied and appropriate recreational activities for the service users living in the home. Meals are of a good standard and presented in an appealing way. Comments made from people who use the service include, “ the food is always good” and “ you won’t find better food any where”. Medication is well managed in the home with relevant procedures in place for the administration of medicines. Training for care staff is good and service users benefit from a staff team who are appropriately trained to do the job. The care staff are undertaking relevant training and working towards their National Vocational Qualifications. There is a motivated and established staff team who respond to service users in a respectful and appropriate manner. Service users spoken to said that the staff were “very helpful and kind” and “ the girls will do anything you ask them. They always have a smile on their face”. There is a good range of policies and procedures, providing care staff with relevant information about all aspects of care and the home/organisation. What has improved since the last inspection? What they could do better: A recommendation has been made for all senior staff to receive complaints training, to make sure that all complaints can be dealt with correctly in the absence of the registered manager. A recommendation has been made for the registered manager and the deputy manager to receive up to date POVA training. DS0000069275.V340665.R01.S.doc Version 5.2 Page 7 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. DS0000069275.V340665.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 DS0000069275.V340665.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. Effective assessment is undertaken of prospective service users to ensure that needs are identified and that the home is able to meet these needs. Intermediate services help service users maximise their independence and return home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It is the responsibility of the registered manager or a senior staff member to carry out the initial assessment of need. Staff will visit a potential service user either in the hospital or in their own home to undertake the initial assessment of needs. DS0000069275.V340665.R01.S.doc Version 5.2 Page 10 The inspector observed the assessment documentation for four service users, including those most recently admitted to the home. The admission tool outlines areas such as physical and emotional care needs and medication regimes. Upon admission, care plans and accompanying risk assessments and nursing assessment tools have been completed, providing thorough records for each service user. The admission documentation seen is fully completed, detailed and demonstrates that prospective service users, family members or representatives are included in the assessment process if this is appropriate. Intermediate services can be provided by the home. However there is no dedicated space or rooms for this. The registered manager said that there would be good multi disciplinary team working for any service users admitted to the home for intermediate care. DS0000069275.V340665.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. The care planning system adequately provides staff with the information they need to meet the service users needs. Healthcare support for service users is good, which means that their health and well-being is promoted and protected. Medication procedures within the home are clear and there is consistent implementation resulting in safe working practices. The manner in which personal care is delivered ensures service users are treated with respect and dignity and that their right to privacy is upheld. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care of four residents was case tracked and their care plans were examined. Following the initial assessment a plan of care is developed. Care plans include details such as a photograph of the service user, observations on admission, basic information such as doctor, next of kin and religious and cultural needs, a care needs assessment, assessments for continence and moving and handling, nutritional tools, and risk assessments on moving and DS0000069275.V340665.R01.S.doc Version 5.2 Page 12 handling and prevention of falls. Information on the person’s interests and hobbies is also recorded. Files are well presented, and user friendly. Where appropriate, information is in place regarding treatment of pressure areas with evidence of tissue viability nurse input. Care plans are dated, signed, show evidence of service user involvement and evidence of review as needs change. Record sheets in service users’ files contain information about visits from external health care professionals such as doctors, speech and language therapists and opticians and details of any treatment or change to nursing regime was noted clearly. Weights were being checked and recorded monthly. Service users at the home are registered with nine different GP surgeries. The registered manager stated that service users can register with their own GP if this is practical and agreeable to both parties. All have access to local NHS Services. At the time of the inspection there was one service user who needed pressure area care and there is evidence that this is being monitored and treated by the nurses at the home. A domiciliary optical service visits the home twice a year and on a needs only basis. Referrals for a hearing test go through the service users G.P. The local hospital holds a drop in centre for assistance with troublesome hearing aids and the home access this regularly. The home is able to gain advice from the dietician and nutritional risk assessments are in the care plans of service users. Weight monitoring is undertaken monthly and recorded in care plans. Chiropody services visits the home fortnightly and service users are seen six weekly. Dental services are accessed at a local dental surgery and the home staff take service users to these appointments using the homes mini bus. Records of all medication received and returned are completed and recorded by the registered or senior staff. Medication storage and medication records were checked. Arrangements for the storage of medicines are satisfactory with medication being kept in one lockable mobile trolley and two metal lockable cabinets. DS0000069275.V340665.R01.S.doc Version 5.2 Page 13 The home uses controlled drugs, and the controlled drugs register was looked at. This is fully completed with two signatures for each entry. All controlled drugs are stored in a metal cupboard, which complies with the Misuse of Drugs Regulations 1973. Photographs of service users, on medication charts, are used for identification. Medication records were examined and found to be fully completed. Overall, the systems for the administration of medicines are robust and to be commended. Service users receive care from staff and health care professionals in complete privacy. Staff were observed during the inspection to knock on service users bedroom doors before entering. The homes induction programme includes training regarding privacy and dignity. The Statement of Purpose and Service Users Guide include information about maintaining the privacy of service user’s. Service users can have a key to their rooms if they wish to use this facility. DS0000069275.V340665.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is excellent. Systems in the home ensure that where appropriate service users are supported to exercise choice and control over their lives. Individuals are able to receive visitors at the home and there are no restrictions imposed on visiting unless requested by the service user. Service users are encouraged to bring personal possessions in with them allowing personal space to reflect the character and interests of its occupant. The presentation and standard of food is good and meets the nutritional needs of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans show routines of daily living and include bathing, rising and retiring times. As part of the admission process, the home ask service users and/or their families to complete a life history to give staff information about previous leisure pursuits, hobbies and other interests. DS0000069275.V340665.R01.S.doc Version 5.2 Page 15 On the day of the visit the activities time-table indicated that there was a coffee morning scheduled and the inspector observed this taking pace. This appeared to be enjoyed by most service users and there were discussions about the recent derby, gardening, rationing and food during the war. All service users were encouraged to take part and staff interaction was carried out in a manner that was respectful and appropriate to the service users. Service users spoken to said they do this regularly and that they enjoy various other activities in the home. Examples given to the inspector include, a quiz, bingo, regular trips out, gardening and a mobile shop. Examples of involvement in the home by local community groups and individuals are visits by mobile hairdressers; various visiting entertainers and the local school attend to provide singing concerts to the people living in the home. Appropriate provision is made for service users to practice their religion, by involving the churches various denominations within the home. The home hold church services every two weeks, and the Roman Catholic and Church of England priests bring Holy Communion to individual residents as required or requested. Service users are able to receive visitors in the privacy of their own rooms and are able to choose whom they see and do not see. There are no restrictions on visiting, and this is documented in the Service Users Guide. Family and friends are invited to participate in some of the social event organised. There is a motivated and established staff team that consists of care/support staff who respond to service users in a respectful and appropriate manner. Service users spoken to said that the staff were “very helpful and kind” and “the staff are very good and always smiling”. Service users and/or their families are encouraged to look after their own financial affairs whenever possible. If this is not practicable a chosen solicitor will be responsible for an individuals financial dealings. An invitation to bring in personal items of furniture and other belongings is included in the service users guide and this was evident during a tour of the premises. When questioned about service users having access to their personal records, the inspector was informed that this could be facilitated if it was requested. Service users are offered three meals a day. The menus cover a four weekly rotating system. A choice of main meal is available. The inspector had the opportunity to join service users for lunch. DS0000069275.V340665.R01.S.doc Version 5.2 Page 16 This was relaxed, unrushed and well organised. The meal was attractively presented and plentiful. In discussions with service users it was confirmed that meals are always of a high standard and there are sufficient snacks and drinks available throughout the day. Comments made from people who use the service include, “ the food is lovely” and “there is always enough food and snacks in between meals”. The inspector was told that service users can take their meals in their rooms if they wish and this was the choice of several individuals on the day of inspection. The nutritional needs of service users are assessed and there is evidence of regular monitoring in all care plans seen. DS0000069275.V340665.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 and 18. Quality in this outcome area is good. The agency has a satisfactory complaints procedure that is routinely given to service users enabling individuals to voice concerns about their care. However, this has not recently been consistently followed in line with the organisations procedure and within the stated timescales. There are adult protection and whistle blowing procedures in place to ensure that the risk of harm to service users is reduced. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure is in place that is accessible to service users and their representatives. A record of all complaints is maintained, and this was viewed. One complaint was received by the home in April, from a relative of a service user living in the home. The complaint is regarding concerns about the relatives care. When the complaint was received by the home the registered manager had just gone on sick leave. A letter was sent to the complainant in April to say that the complaint could not be dealt with until the registered managers return mid May. This is not in line with the organisations complaints procedure and needs to be addressed. Complaints’ training for senior staff was discussed with the registered manager. It was felt that this would be beneficial and would ensure that all DS0000069275.V340665.R01.S.doc Version 5.2 Page 18 complaints are dealt with appropriately in the absence of the registered manager. This is strongly recommended. Complaints seen within the complaints log do not detail the action taken or the outcomes. The deputy manager has just developed a complaints recording sheet that will be completed when a complaint has been received. This will detail the nature of the complaint, the action taken and the outcome of the complaint. There have been no complaints received by the Commission. The registered manager is aware of the POVA register and would submit staff for inclusion if it became necessary. The home uses the Bucks Multi Agency POVA policy and an organisational policy in conjunction with this. This includes guidelines for staff about the responsibilities of the staff, types and signs of abuse and what to do if you suspect abuse. All care staff receive training about Adult Abuse and this is carried out in house, by the registered manager. During discussions with the registered manager and the deputy manager it was apparent that they would both benefit from refresher POVA training and this is strongly recommended. The registered manager does not act as appointee for any service users. There are systems in place to look after small amounts of personal allowance or for the safekeeping of service users valuables. DS0000069275.V340665.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, 20, 21, 25 and 26 Quality in this outcome area is excellent. The standard of the environment within the home is excellent, providing service users with an attractive and homely place to live. The overall quality of the furnishings and fittings is good ensuring the safety and comfort of service users. Standards of cleanliness at the home are good meaning that service users live in an environment that is clean and hygienic, protecting their health, safety and welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Shelburne Lodge is close to the centre of High Wycombe, set back from a through road and next to a sheltered housing complex. The premises are DS0000069275.V340665.R01.S.doc Version 5.2 Page 20 spread over two floors with single bedroom accommodation throughout and widened doorways and corridors for easy access by wheelchair. The front entrance of the home includes a reception area and this is welcoming and contains a comfortable and pleasant seated area. Communal space consists of a spacious dining area, and several lounges that are both set in a homely and attractive fashion. The internal decoration of the home is of a high standard and there are personal touches around the home such as flowers, plants, books and pictures. There is a small hairdressing room that is nicely decorated and suitable for its purpose. Bathrooms and shower rooms are close to bedrooms and each room has its own en-suite toilet and wash-basin, with one room additionally having a shower. Lighting in communal areas is domestic in character and sufficient to facilitate reading and other activities. The furnishings observed in communal areas are of good quality and suitable for the range of interests and activities preferred by service users. The home is fitted with aids and adaptations to assist people with disabilities. There is a small garden area that is well maintained and parking for several vehicles. Laundry facilities are very spacious and sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten and do not intrude on service users. There were no offensive odours around the home and one service user spoken to said “ my family chose this home because it was the only one they looked at that has no unpleasant odours”. The home has an infection control policy and the inspector observed this. Instructions are in place for the washing of soiled linen. DS0000069275.V340665.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 and 30. Quality in this outcome area is good. Staffing numbers are good, and ensure that the assessed needs of the service users are met. Service users benefit from a staff team who are up to date with their training, to ensure that staff are competent to do their jobs. There are effective recruitment procedures in place to ensure service users are protected from harm. Service users benefit from clarity of staff roles and responsibilities that results in a good quality care service being delivered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s staff rota demonstrates that there are adequate numbers of staff on duty at all times to ensure the needs of the service users are always met. This includes sufficient numbers of ancillary staff. The registered manager is extra to these numbers. There are no staff working in the home who are aged under 18 years of age and there are no members of staff under the age of 21yrs left in charge of the home. DS0000069275.V340665.R01.S.doc Version 5.2 Page 22 The home continues to support staff on NVQ training and at the time of this inspection there are two care workers with NVQ level 2 training and one care worker with NVQ level 3 training. A random selection of staff files were made available for inspection purposes, including those most newly recruited. All files looked at contain the necessary documentation as detailed in schedule 2. There is evidence that all staff CRB checks have been obtained. The home does not employ any volunteers. There is an induction programme in place to ensure that new staff members are familiarised with the organisation and their roles and responsibilities and provides the staff member with a personal development portfolio. This includes fire safety, moving and handling techniques and core skills training. There is specialist training available for staff, an example of this is Dementia Care, Parkinson’s, Peg Feeding, tissue viability and Multiple Sclerosis. Staff confirmed that there are regular staff meetings. DS0000069275.V340665.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 and 38. Quality in this outcome area is good. The manager is supported well by the staff team in providing clear leadership and demonstrating an awareness of their roles and responsibilities to the benefit of the service users. The home operates a consistent approach to quality assurance resulting in the home being proactive in identifying issues that may affect the well being of services users. The home does not manage service users’ finances. There are systems within the home that are used to ensure that service users health, safety and welfare are protected and promoted. This judgement has been made using available evidence including a visit to this service. DS0000069275.V340665.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager is a qualified nurse, experienced in management and care of the elderly. She is registered with the Commission and has attained the Registered Manager’s Award/National Vocational Qualification level 4. She has an experienced and competent deputy and staff understand lines of accountability and their own responsibilities and maintain good quality records at the home. Examples of further training undertaken by the manager include fire marshal training and various workshops undertaken when completing the Registered Managers Award. The manager is not responsible for any other registered establishment. There is an equal opportunities policy in place and this was looked at during the inspection. Regular monitoring visits are undertaken on behalf of the provider to check standards of care, with reports produced of the findings. A quality assurance questionnaire exercise had been carried out since the last inspection and in-house evaluation of key elements of care, such as medication, were being self-audited as part of a rolling programme. Accident and pressure sores and complaints are monitored on a regular basis. There is a folder containing compliments and thank you letters, mainly from the relatives of service users. It is corporate policy not to have involvement in service users’ financial affairs and families would deal with this area. There did not appear to be any problems with this arrangement; service users can still make purchases or go on outings with the home invoicing relatives afterwards. The manager does not undertake the role of appointee for any service users. Health and safety was being managed well with thorough procedures and checks in place in the kitchen. Training records were in the process of being updated and it was difficult to assess if all staff were up to date with mandatory health and safety training. When this has been completed the inspector requests that evidence is sent to the Commission of all mandatory training undertaken by the care homes staff. The homes maintenance person is responsible for health and safety checks around the premises and has put in place systems to ensure that checks are carried out at the required frequencies and that external contractors visit when required. These are up to date, accurate and to be commended. DS0000069275.V340665.R01.S.doc Version 5.2 Page 25 Disposal of clinical and sanitary waste was being managed safely. Records were seen for fire safety. These cover the homes fire procedures, practice fire drills, fire prevention, fire alarm testing and emergency lighting testing. Testing of the homes fire alarm system is undertaken on a weekly basis and evidence was seen of this. There is a fire based risk assessment that is reviewed annually. Records of fire training show that this was carried out with staff on 06/02/07, 10/04/07, 26/04/07 and 15/05/07. Evidence of mandatory health and safety training demonstrates that staff are up to date with this training. Service reports are in place for the maintenance of hoists and the lift. There are service certificates for the gas boiler dated 02/04/07, the kitchen appliances dated 02/03/07 and the tumble driers date 30/10/06. PAT testing is due to be carried out in June 2007 and the inspector requests confirmation that this has been carried out. A legionella assessment was undertaken on 10/04/07. There are systems in place for water testing and kitchen hygiene. COSHH sheets are up to date and accurate. The inspector looked at Infection Control guidelines that are available for all staff. Accidents are well recorded, regular visual hazard checks were being undertaken of the premises and the lift had been serviced. Numerous health and safety policies were in place to provide guidance to staff. DS0000069275.V340665.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 3 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 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 X X 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 X 3 X 3 X X 3 DS0000069275.V340665.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/a 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP16 OP18 Good Practice Recommendations It is strongly recommended that all senior staff undertake complaints training to ensure complaints can be dealt with correctly in the absence of the registered manager. It is strongly recommended that the registered manager and the deputy manager attend refresher POVA training. DS0000069275.V340665.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. Extracts may not be used or reproduced without the express permission of CSCI DS0000069275.V340665.R01.S.doc Version 5.2 Page 29 - 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. 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