Inspection on 29/05/09 for Shire House

This inspection was carried out on 29th May 2009.

CQC found this care home to be providing an Poor service.

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

Shire House 13/05/10

Shire House 22/03/10

Shire House 18/01/10

Shire House 18/01/10

Shire House 15/12/09

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Shire House Sidmouth Road Lyme Regis Dorset DT7 3ES Lead Inspector Mr John Hurley Unannounced Inspection 29th May 2009 08:00 DS0000072630.V375921.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. Shire House DS0000072630.V375921.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 Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shire House Address Sidmouth Road Lyme Regis Dorset DT7 3ES 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) 01297 442483 01297 442483 Sentry Care Limited Tracey Smart Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 22 29/06/09 Date of last inspection Brief Description of the Service: Shire House is established in a large detached house set in its own grounds on the western outskirts of Lyme Regis. The home is accessed by a driveway and is surrounded by mature grounds and gardens: there is level access to most parts of the gardens. There are large parking areas at the side of the house for visitors convenience. The original Edwardian house has been extended to provide additional bedrooms. There are two communal lounges and a separate dining room on the ground floor. People who live at the home are accommodated on the ground, first and second floors of the home and a passenger lift is available to the first floor for less ambulant residents. There are eighteen single and two double bedroom/suites, all of which are decorated to a good standard. Of the twenty bedrooms, seventeen have ensuite facilities. There are sufficient communal bathrooms and WCs to meet the needs of residents, including an assisted bath. Shire House provides 24-hour personal care, all meals, laundry and domestic services. Shire House DS0000072630.V375921.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 the people who use this service experience poor quality outcomes. This was the first inspection of Shire House since the new owners took over the home. The inspection was undertaken over the course of one day in May 2009 by one inspector. The focus of the inspection was to look at relevant key standards under the Commission for Social Care Inspection (now the Care Quality Commission) Inspecting for Better Lives 2 Framework. This focuses on outcomes for residents and measures the quality of the service under four headings; these are excellent, good adequate and poor. The judgment descriptors for the seven sections are given in the individual outcome groups and these are collated to give an overall rating for the quality of the service provided. The home completed an Annual Quality Assurance Assessment( AQAA) and information provided in that is also referred to in this report. We looked at three selected care files in detail, the staff files, undertook a tour of the building and looked at all the documentation relevant to the running of a care home. What the service does well: The people who live at the home inform us that staff are kind to them and treat them well. They said that their individual rooms meet there needs and that the food is home cooked and of good quality. People important to those who live at the home say they can visit at any time within reason and consider that the staff at the home keep them informed of significant events as appropriate. What has improved since the last inspection? As this is the homes first inspection since the new owners have taken over improvements in the service cannot be measured at this point although it is noted that the home has benefited from some inward investment with the refitting of the communal bathrooms and some of the communal areas within the home. It is also noted that a selection of new specialist chairs have been purchased. Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 6 What they could do better: If you want to know what action the person responsible for this care home is 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. Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3,6. 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. The assessment documentation needs to provide sufficient and robust information to staff to ensure that a persons needs are met in the way that has been agreed with the recipient of the care. EVIDENCE: We looked at the documentation of a person who had recently moved into the home. The recording evidenced that an assessment of need had been made prior to the person entering the home. This covered assessment in areas such as self medication, falls risk assessment and outlined a reviewing process. There was an initial care plan that had been generated from the assessment which set goals and stated tasks that the staff would assist with. Whilst the documentation described the tasks it did not guide and inform staff as to how the person wanted the tasks to be performed. Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 9 There was a section relating to the persons mental health. This was by way of expressing a numerical score against a set of questions. The deputy manager could not inform us what the score meant or its relevance to the persons wellbeing which may mean they have unmet needs. These documents had not been signed by either the assessor or the person they related to. The assessment documentation did not explore any issues relating to the persons ethnicity or sexuality. At the time of the inspection we were informed that there was no one receiving an intermediate care service. Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans and subsequent reviews do not give an accurate picture of the person at the centre of the care, which may mean they have unmet needs The administration of medication may put people at risk. People are treated with dignity and respect. EVIDENCE: We were informed that the home has is now using a new care planning system. The deputy manager informed us that they were nearing the end of the process of transferring records from one system to another. These records will help the home to make in depth comprehensive assessments giving staff more detail with which to meet the needs of those who live at the home. Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 11 The home operates a key worker system where a nominated member of staff is responsible for monitoring the well being of the individual. The record that we viewed evidenced that key workers write in the records and provide their view of the person on a monthly basis. In one case the recording by the keyworker informs the reader that the individual sometimes falls at night and bruises are always treated. We looked at the accident recording that did not reference any of these comments. The monthly review of the persons care carried out by management did not reference any falls or subsequent risk assessments. The specific falls risk assessment did not consider the keyworkers comments relating to falls and bruising. We discussed the issue with the deputy manager who was unaware of the recording of this issue made by the keyworker and so consequently actions were not taken to investigate and take action to minimise these falls. In this persons notes the doctor had asked that a certain medication be stopped for two weeks to see if this alleviated some symptoms expressed by the person. The care plans and associated documentation did not contain evidence of any evaluation or ongoing monitoring of the condition that was cause for concern and so it is unsure how this persons health needs continue to be met. It was further stated in the plans that staff must “push fluids” but assuming this meant that the person should have plenty to drink no fluid charts had been started or considered with which to monitor the amount the person was drinking. There was no guidance for staff about how much or what type of fluid the person would need to judge the adequacy of their intake. In another persons care plans it was recorded that the person was “very confused all of the time” but there was no recording as to what staff need to do to assist the person or actions taken to explore the confusion, the possible causes, triggers or indicators that the person may be confused. Through discussion with the deputy manager it was established that at least two people have ongoing mental health problems associated with old age. The Annual Quality Assurance assessment submitted by the home on the 4/3/09 informed us that no one had any mental health issues. This may indicate a lack of understanding of the psychiatry of old age and so staff may not be proactive in ensuring health care needs are met. Many of the care plans viewed described what the issue or task was but did not go on to give staff guidance as to how to assist the person to meet their individual needs. We looked at the reviewing process of the care plans and discussed the process with the deputy manager. It was established that they reviewed the dependency profile of the person rather than taking a holistic view of their Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 12 needs and care package. We found that people in the home are not formally involved in their review process, which was discussed with the deputy manager. When we first entered the home we had a walk around the first floor corridors prior to a member of the management team coming on duty. We saw a staff member dispensing medication. It was noted that medication was on a tray on top of the medication trolley, pre-dispensed, in labelled pots. It was further noted that the pots were dirty. This is poor practice and puts people at risk from harm as it increases the risk of a medication error. It was further noted that the pots were dirty. We asked the staff member who had dispensed the medication into the posts being informed it was them. We asked what would happen if a person knocked the tray on the floor turning over all the pots? The staff member then said “oh I should not do it like this should I”. When the deputy manager came on duty we spent some time in the office explaining the reason for our visit and discussing how the inspection would take place. We noticed that on top of a filing cabinet was a packet of controlled drugs with a return slip dated January 09. We asked the deputy manager why they were there, they did not know. Later when carrying out a check of the controlled drug register we could find no reference to this medication being received into the home. Similarly we could find no reference to this in the returns book. Controlled drugs must be stored securely and a clear record of receipt and return must be maintained. We looked at the Medication Administration Records (MAR) sheets and found that in the case of the person who had recently came into the home there was no record of the amounts of medication received into the home. As the person self medicates and the risk assessment states the person may overdose this lack of an audit trial puts the person at risk. The home must also ensure that they have a clear record of receipt of all medication to ensure that it can be accounted for. The MAR’s contained many references to people being administered medication on a Per Required Needs (PRN) basis but it was found that in a significant number of cases it was always given as if prescribed to be given daily. Some people did have a rationale for giving it but in the main it said for pain, but did not state where the pain may be. Staff need to have clear instructions for giving any medication on a PRN basis to ensure that it is given appropriately. The reviews that had been carried out did not consider having a medication review with regards to the issue of always given medication that was given daily that should be administered on a PRN basis. We discussed with the people who live at the home how they considered they were treated by staff. They informed us that staff treat them well and are always available to help. They said that staff did not always knock before Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 13 entering their personal rooms but they did not mind. They said that they get their mail unopened and staff will help them to read it should they wish. One visiting relative informed us that they considered the service given to be fantastic and the staff were very caring and considerate. They informed us that the staff will respond to any little thing that may be wrong and try and put it right. Shire House DS0000072630.V375921.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. 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. More needs to be done to ensure all those who live at the home have opportunities to have their social and recreational needs met. Visitors are welcomed and individuals are assisted with maintaining contact with relatives and friends EVIDENCE: People who use the service were observed in a number of different locations. They choose when to get up and when to retire. They have free access to their bedroom and communal facilities. Those who use the service are able to meet privately with visitors either in their rooms or in a designated lounge. Those who were spoken with indicated that they were happy with their life in the home and confirmed that the staff support them in following their preferred lifestyle Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 15 At the time of the inspection the home was seeking to employ someone to lead activities for the resident group. The people who live at the home informed us that there are things to do and the pace of life suits them, but at the time of the inspection no activities were available. Visitors were observed entering or leaving the home. All visitors were warmly welcomed. The inspector spoke with one relative who spoke highly of the home. People’s records and the visitor’s book in the entrance hall demonstrate contact with family and friends as well as visits by professionals. We joined the people for lunch. We were informed by them that the food was always good and that choices were available. We spoke with the cook who informed us that there had previously been a budget to work to but that had not been removed and that spending was in line with peoples needs. They reported that they knew peoples likes and dislikes and as such were able to cater for their needs. During lunch it was noted that two people required assistance. This was achieved by one member of staff assisting one person and then another by sitting in-between them. This does not offer either of the people receiving a service the dignity and respect that they should have. Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 16 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service felt confident that any complaints or concerns would be listened to and taken seriously All staff should receive training with regards to the Protection of Vulnerable adults EVIDENCE: The people who we spoke with informed them that they felt able to complain and said they would have no concerns complaining to any staff member should they have need to. They felt that the manager and staff are very approachable and will deal with any issues, no matter how minor, there and then if they could. The home keeps a record of any complaints made. There have been no issues recorded at the home. We looked at the staff training records and found that not all staff had received training with regards to Safegaurding vulnerable adults, the deputy manager agreed with our observations. Shire House DS0000072630.V375921.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, 20,21,25,26 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. More needs to be done to ensure the safety of those who live at the home. People who use the service can personalise their private space and contribute to the décor. Infection control procedures need to be improved upon in order to protect those who live at the home. The communal bathrooms have been updated for the benefit of those who use the service. There have been improvements in the seating arrangements in some areas. Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 18 EVIDENCE: During our tour of the building we noted that in the staff room the bin was over flowing at 8.35 am, this was still the case at 14.00. It was noted that the laundry was clean, tidy and well organised. However there was no lid for the “Sangenix” bin used for disposing of personal continence aids was missing. This will undermine infection control procedures. The hot water temperature at the sink exceeded 50 degrees centigrade. The risk assessment relating to the hot water could not be found at the time of the inspection. We noted that a fire door with a “keep locked” was open. When we looked inside and found that this small room was being used to air clothes, it was very full and we had to move clothes to find the light switch. It was then evident that the clothes were hanging from the ceiling and in contact with a bare light bulb. This may be a fire hazard. The room had no natural light or ventilation and was malodorous. During our brief look around the premises it was noted that several fire doors did not close properly and required maintenance. Some areas of the home have recently been updated with items of new furniture and soft fittings. The ground floor bathroom had recently been refitted and was bright clean and airy. There was no pedal bin in this area and the hot water posed a risk of scolding, there was no warning of this displayed. We also looked at the new wet room. The deputy manager told us that people enjoy this new facility. Again the hot water was very hot with no warning signs. The original lock to the door had been replaced but the hole left by the locks removal needed to be filled in to ensure peoples privacy. People informed us that they are able to bring personal possessions with them into the home. We looked at a sample of the bedrooms used by people who use the service and found that they had been personalised with pictures, furniture and photographs to reflect the individuals taste. We noted that the dining room carpet was very dirty and required to be either replaced or cleaned. The dining area was pleasantly laid out. We asked those who live at the home there comments on the seating as the cushions provided were not secured. All informed us they were uncomfortable and slipped around. The management informed us that the home has purchased 16 new specialist chairs for the comfort of those who live at the home. Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 19 It was noted that all risks associated with the environment were out of date and required to be reassessed. Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 20 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not all staff have the necessary training with to provide a safe service to those who live at the home. The recruitment of new staff does not fully establish the fitness of those who wish to work at the home and may put people at risk of harm. Staff must have a comprehensive induction into the work that they do in order to promote the safety of those who live at the home. EVIDENCE: We sampled the files of the last members of staff to take up employment. Prospective staff had completed an application form, and attended an interview. In order to assess their fitness to work with vulnerable adults Criminal Records Bureau checks had been carried out but not all had references from previous employers or people that could vouch for the fitness. The application forms that are used do not make any reference to ethnicity, religion or disability and so ignores equal opportunity issues. Not all application forms were signed or dated. Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 21 In one case there was found to be gaps in their employment history that were unexplained although there was a record of the interview. It was further noted that no evidence of those newly appointed staff having undergone any form of formal or informal induction to the home. Two staff who had been employed on the night shift had no fire safety training. An immediate requirement was made requiring the home to ensure that all staff have fire training. We looked at a sample of the staffs training records and found that the statutory training had not been kept up to date. This needs to be addressed to ensure staff have the necessary skills to work at the home. As mentioned earlier at dinner time there was one member of staff assisting two people with their food. We discussed this issue with the deputy manager as it appeared to indicate there was not enough staff on duty at this key time of the day. The staff we spoke with were knowledgeable with regards to the people they care for and impressed as professional and compassionate. Through discussion with the staff group and by observing the people who use the service it is reasonably clear that the staff team have an empathy for the people who live at the home. There were many good examples observed of staff interacting positively with the people who use the service. Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 22 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): 31,32,33,35,37,38 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. The management need to do more to ensure the National Minimum Standards are adhered too. The health and safety procedures at the home needs to be risk assessed in order to protect those who live and work at the home. EVIDENCE: We found that a number of key issues that can seriously effect the well being of people who live in care homes have not been maintained to a satisfactory standard as outlined in this report, for example medication practices, recruitment practices and risk assessments. This means that significant Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 23 improvements in the management of the home are required in order to reestablish the National Minimum Standards. The feedback from the people who use the service confirmed that they continue to feel a sense of belonging living at the home and gave examples of how staff do that little bit extra to help out. They informed us that they can raise issues with the management, can identify who the manager is and are confident that issues are dealt with promptly and effectively. The staffs files did not evidence that staff are receiving formal supervision and so management have no formal way of ensuring standards are being consistently applied, peoples needs are being met in a consistent manner and issues such as “falls” are being robustly addressed. The management hold some cash on behalf of those who live at the home. We looked at the system for managing this and examined the recording regarding cash flow. We found this is to be in good order and amounts sampled by way of a brief audit tallied. All substances that could be potentially hazardous to health are handled and stored safely. The records relating to what is on the premises could not be found at the time of the inspection. We looked records relating to fire safety and found that the last fire safety check had been carried out on the 21/05/09 with the fire protection equipment being checked on the 8/01/09. As already discussed the fire safety training for staff was not up to date and so may put people at risk. As already discussed risk assessments were out of date and so the health and safety of those who live and work at the home may be compromised. Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 24 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 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 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 2 2 2 x x x 2 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 1 1 1 Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NA 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 The registered manager must ensure that all care plans and reviews accurately reflect the needs of the person and give enough detail to guide and inform staff as to how to met the agreed needs The registered manager must ensure that the receiving, administration, recording of and returning of medication is carried out in accordance with the National Pharmaceutical requirements so as not to put people at risk of harm. The registered manager must ensure that all accidents are recorded and evaluated to maintain the safety of those who live at the home. The registered manager must ensure that all staff have the necessary statutory training to ensure that peoples needs can be met in a safe manner. The registered manager must ensure that any prospective staff member has their fitness to work with vulnerable people DS0000072630.V375921.R01.S.doc Timescale for action 17/07/09 2 OP9 13 07/07/09 3 OP37 13 07/07/09 4 OP30 18 01/08/09 5 OP29 19 07/07/09 Shire House Version 5.2 Page 26 6 OP30 18 7 OP26 13 8 OP38 38 9 OP38 13 established in order to protect those who live at the home. The registered manager must ensure that all staff under a formal recorded induction into the work they are going to perform to ensure people are not put at risk The registered manager must ensure that infection control policies are adhered too so as to promote the well being of those at the home. The registered manager must ensure that the hot water temperature does not poise a significant risk of injury. The registered manager must ensure that all risk assessments demonstrate how the safety of the people who use the service or work at the home is being maintained. 17/07/09 07/07/09 18/06/09 17/07/09 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 2 Refer to Standard OP32 OP3 Good Practice Recommendations It is recommended that the homes policies and documents demonstrate a commitment to equal opportunities It is recommended that when carrying out initial assessments the assessor has had the necessary training to interrupt the results of the assessment tools used. Shire House DS0000072630.V375921.R01.S.doc Version 5.2 Page 27 Care Quality Commission North Eastern 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. 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