Inspection on 20/12/06 for Silverways

This inspection was carried out on 20th December 2006.

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

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

Other inspections for this house

Silverways 20/09/07

Silverways 19/12/05

Silverways 03/06/05

Silverways 06/09/04

Silverways 26/04/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Silverways Silver Way Highcliffe Christchurch Dorset BH23 4LJ Lead Inspector Carole Payne Key Unannounced Inspection 11:10 20 and 21st December 2006 th 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 DS0000020493.V324700.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. DS0000020493.V324700.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Silverways Address Silver Way Highcliffe Christchurch Dorset BH23 4LJ 01425 272919 01425 277981 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) Christchurch Housing Society Mrs Marie Madders Care Home 69 Category(ies) of Old age, not falling within any other category registration, with number (69) of places DS0000020493.V324700.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th December 2005 Brief Description of the Service: Silverways Nursing Home was purpose built in 1985 and is situated in a quiet residential area of Highcliffe. It is set in one and a half acres of gardens and provides facilities for sixty-nine service users. The home is owned and managed by Christchurch Housing Society, a voluntary organisation registered with charitable status. The society was founded in 1946 to provide accommodation and care services for older people. Silverways has accommodation on the ground and first floors. The premises comprise of single and shared rooms, assisted bathrooms, showers and toilets, and a hairdressing salon. Each wing of the home has a communal lounge /dining area. The home also has an activities and exercise room. Christchurch Housing Society is considering up grading and refurbishment of the home to create better use of available space. The home is managed by Mrs M Madders. DS0000020493.V324700.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out on the 20th and 21st December 2006 and took a total of 16 hours, including time spent in planning the visit. The inspector was made to feel welcome in the home during the visit. This was a statutory inspection and was carried out to ensure that the fifty-six residents who are living at Silverways are safe and properly cared for. Requirements and recommendations made as a result of the last inspection visit and key standards met at the last inspection on 19th December 2005 were also reviewed. The premises were inspected, records examined and the daily routine observed. Time was spent in discussion with ten residents living in the home and five staff members on duty. Thirty-two resident survey forms were received by the Commission for Social Care Inspection prior to the visits; three comment cards from health and social care professionals who visit the home; five relative / visitors’ comment cards and four comment cards from General Practitioners. The home also returned a detailed pre-inspection questionnaire prior to the inspection. Throughout the inspection the management and staff team demonstrated a positive and proactive commitment to addressing any issues raised and improving the quality of live for people living at Silverways. What the service does well: Comments received from residents in survey forms and relatives / visitors to the home were generally very positive regarding the quality of service provided at Silverways. Comments included: ‘This home is excellent in every way, especially the staff.’ ‘I am completely happy here.’ ‘On the whole Silverways is a brilliant nursing home and I am so grateful she is there.’ ‘We are very satisfied with the care and standards and could not wish for anything better.’ Detailed assessments ensure that no resident moves into the home without having their needs assessed. DS0000020493.V324700.R01.S.doc Version 5.2 Page 6 Three General Practitioners (GPs) returning questionnaires said that they are satisfied with the overall care provided in the home. Generally detailed care plans ensure that residents personal, health and social care needs are satisfactorily met. Good practice, record keeping and links with local healthcare professionals support the meeting of residents’ healthcare needs. Generally efficient procedures for the safe administration will be supported by the introduction of a formal auditing system for medicines, protecting residents by safe practice. Residents are treated with care and respect and the privacy and dignity of people living in the home is upheld. A varied and flexible programme of activities and events supports residents to experience a qualitative lifestyle. Friends and families are made welcome at Silverways enabling residents to continue to enjoy relationships that are meaningful to them. Residents are given choices about the way they live and they can exercise both autonomy and control over their lives. People living at the home are offered a varied and nutritious diet and residents enjoy eating in the surroundings of their choice. People who live at Silverways and their families and friends can feel confident that they can raise any issues that they have, that they will be listened and responded to. The home has an awareness of adult protection and how to respond to and protect people from abuse. Residents live in a safe and adequately maintained environment. People living at Silverways are protected by clean, pleasant and hygienic surroundings. The numbers of staff members working in the home satisfactorily meets residents’ needs. Staff members receive regular training to equip them to meet residents’ needs. The home is well run and efficiently managed, by a person who is fit to be in charge and works in the best interests of residents. DS0000020493.V324700.R01.S.doc Version 5.2 Page 7 The home ensures that training and good practice enables residents’ well being, health and safety to be promoted. What has improved since the last inspection? What they could do better: 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. DS0000020493.V324700.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 DS0000020493.V324700.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, Standard 6 is not applicable to this home Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed assessments ensure that no resident moves into the home without having their needs assessed. EVIDENCE: Twenty-four residents returning survey forms said that they had received enough information about the home prior to moving in; three said that they had not. One resident commented that they were able to come in and experience a respite stay prior to making a decision regarding making Silverways their home. Pre-admission assessment forms were viewed for two residents who had recently moved into the home. Detailed assessments had been completed and residents and, or their family members, had been offered the opportunity to come and visit the service. Assessment details included all aspects of daily living, medical history and specific requirements in terms of DS0000020493.V324700.R01.S.doc Version 5.2 Page 10 support, enabling the home to make an informed decision as to whether they were able to meet the prospective residents’ needs. The manager had sought information from health and social care professionals involved with the care and support of people wishing to move in. Assessments also included details of the people who had provided the information. DS0000020493.V324700.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 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally detailed care plans ensure that residents personal, health and social care needs are satisfactorily met. Good practice, record keeping and links with local healthcare professionals support the meeting of residents’ healthcare needs. Generally efficient procedures for the safe administration will be supported by the introduction of a formal auditing system for medicines, protecting residents by safe practice. Residents are treated with care and respect and the privacy and dignity of people living in the home is upheld. DS0000020493.V324700.R01.S.doc Version 5.2 Page 12 EVIDENCE: Detailed care plans were seen for four residents. On admission a 72-hour care plan is completed, which enables staff members to meet identified needs in the initial period following moving into the home. This plan informs staff members about specific care required, special equipment needed and other important information, which staff need to know, such as whether a person is able to utilise the call bell to request assistance. Information provided by external health and social care professionals is also incorporated into the plan. Thorough assessments are completed and include risk assessments for manual handling, nutritional status and a pressure sore risk assessment. Plans are then produced as to how a resident’s needs are to be met and any identified risks minimised. Personal, health and social plans include references to people’s wishes about the care that they receive. Care plans had been reviewed monthly or sooner according to changing needs. Audits were seen in the plans viewed. The deputy manager reviews care plans and recommends amendments and improvements in order to ensure that people’s needs are satisfactorily being met. Registered nurses are then expected to amend care plans accordingly. One care plan seen had not been updated. The importance of staff members taking responsibility for the care plans delegated to them was discussed and ensuring that where important issues are highlighted, that these are updated promptly. One care plan seen required updating as the person’s needs had changed and the resident was now being cared for in bed. This care plan had been reviewed and amended on the second day of the inspection. Daily records are completed and handovers take place-informing staff coming on duty of care given and needs highlighted. Although most records had been completed, the importance of Registered nurses describing care given, rather than stating ‘all care given’ was discussed. Care plans included reference to the healthcare needs of residents. Where necessary, it was observed that monitoring charts had been completed, ensuring, for example, that the fluid intake of residents living in the home is recorded and ongoing needs identified and met. A continence care pathway assessment is completed as necessary. Records seen included reference to the involvement of healthcare professionals as needed and to exercise and rehabilitation, where appropriate. The home links with seven local General Practitioner surgeries, and residents are registered with the surgery of their choice. Three General Practitioners (GPs) returning questionnaires said that they are satisfied with the overall care provided in the home. All said that if they give specialist advice it is DS0000020493.V324700.R01.S.doc Version 5.2 Page 13 incorporated into the care plan. Twenty-two residents returning survey forms said that always receive the medical support that they need; eight said that they usually receive the support that they need; one resident said that this was usually the case. Two Registered nurses demonstrated a good working knowledge of the home’s medication procedures. Details are kept of medicines received into the home and records of disposal include the signature of the person checking the medicines, and a staff member verifying the medication to be removed from the home. Documentation also includes the signature of the person collecting the medicines for disposal. Records include a clear photograph of the resident, for identification purposes and details of any allergies, or none known. A controlled drugs book is kept on each floor of the home and records of one controlled drug sampled corresponded with the amounts held. Temazepam is appropriately stored as a controlled drug. A requirement was made in the last report that staff members have written instructions regarding the use of topical applications. Written instructions were noted in care records seen. Although the home has started to introduce systems to ensure that there is an audit trail for medications in the home; for example some medicines had labels with start dates attached. This must now be formalised so that there is a clear auditing process, ensuring that medicines held at any one time can be tracked and checked against medicines held. Medicines requiring refrigeration are appropriately stored and the temperature of the drugs fridges is monitored daily. Throughout the visit staff members were observed responding to residents’ needs with care and respect. Two residents responding in survey forms said that staff members are ‘very kind and always ready to help’. ‘Everybody is kind, caring and helpful.’ Staff members were careful to knock on residents’ doors before entering. General Practitioners returning comment cards said that they are able to see residents in private. Reference to the basic values of good practice in care giving is included in the home’s induction programme. Records of one induction were seen and included asking the staff member about their understanding as to how people’s privacy and dignity is protected. DS0000020493.V324700.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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A varied and flexible programme of activities and events supports residents to experience a qualitative lifestyle. Friends and families are made welcome at Silverways enabling residents to continue to enjoy relationships that are meaningful to them. Residents are given choices about the way they live and they can exercise both autonomy and control over their lives. People living at the home are offered a varied and nutritious diet and residents enjoy eating in the surroundings of their choice. EVIDENCE: The home has an activities area, where residents’ craftwork was displayed. The home benefits from staff members who are allocated to organise and take part in events and activities in the home. Time is spent both in organising shared DS0000020493.V324700.R01.S.doc Version 5.2 Page 15 social events and with residents who choose to spend time in their rooms, or are in bed. Staff members enjoy companionable time with residents. A resident said that they very much enjoy the activities organised by the home, especially the ‘scrabble on the big board.’ One resident responding in a survey form said that they particularly enjoy the outings. The home has a mini bus with a tail hoist. On the first day of the inspection residents were enjoying an entertainer, who was singing in one of the home’s lounges. An activity profile is completed as well as a life biography so that staff members are aware of people’s interests and can share residents’ memories. Four relatives / visitors to the home returning comment cards said that they are welcome in the home at any time. Care plans; personal information and daily records included references to the involvement of relatives and friends in the life of the home. Two visitors said that they always enjoy coming to see their friend at the home and are always made very welcome. A relative said that they visit the home every day and very much feel part of the life of the home. It is ‘fantastic’. They said that they were looking forward to spending Christmas day with their family member at the home. A resident said that they are given choices about what they would like to do and when. Residents are offered choices regarding meals, when they get up and go to bed and where they prefer to be. One resident likes to have their own place in the lounge surrounded by special items. All rooms seen were personalised with residents’ belongings and special possessions. During the inspection residents enjoyed meals in the dining areas and in their own rooms, according to their personal preferences. One resident responding in a survey form said ‘I like the food.’ Eight residents completing survey forms said that they always like the meals; seventeen said that this was usually the case; four people said that they sometimes like the meals. One resident said that ‘the meals could be hotter.’ During the visits meals were served from hot trolleys and two residents asked said that they were satisfied that meals were normally served at a satisfactory temperature. A record of food provided is maintained. DS0000020493.V324700.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live at Silverways and their families and friends can feel confident that they can raise any issues that they have, that they will be listened and responded to. The home has an awareness of adult protection and how to respond to and protect people from abuse when issues arise. EVIDENCE: The home has a very clear and user-friendly complaints procedure, which is displayed in the reception area of the home and is provided to prospective residents in the service user’s guide. Four relatives / visitors to the home said that they are aware of the complaint’s procedure. Twenty residents responding in a survey form said that they know who to speak to if they have a complaint. One resident said ‘Matron and deputy matron are always accessible.’ One resident expressed concern re noise from a television. The manager confirmed that this issue had been raised at a residents’ meeting and the issue had been resolved. The home has conducted its own survey of residents’ views and issues raised are responded to. DS0000020493.V324700.R01.S.doc Version 5.2 Page 17 There have been two investigations of adult protection in the past year. The home has responded proactively to these issues, managing and acting responsively to protect people living in the home and work with outside health and social care agencies in a shared commitment to keep people safe. The manager and deputy have received adult protection training from Dorset County Council, and, according to summary records seen, an external training provider updates all staff members in adult protection training. DS0000020493.V324700.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a safe and adequately maintained environment. People living at Silverways are protected by clean, pleasant and hygienic surroundings. EVIDENCE: On both days of the inspection the home was clean. There were no unpleasant odours. At the time of the visits it was the festive season and the home was thoughtfully decorated. One resident returning a survey form said that the home is ‘always clean and tidy.’ DS0000020493.V324700.R01.S.doc Version 5.2 Page 19 Four of the home’s eight bathrooms are currently out of use and there are plans in place to reorganise the rooms to make them fit for purpose to take hoists. The home has four further assisted bathrooms. The reorganisation will involve loosing some of the home’s toilets. However additional en suites are planned and the manager confirmed that there would remain sufficient toilets for the needs of residents. One resident returning a survey form said that they have to queue for the toilet. The manager said that this could occur if several people ask to use the same toilet at the same time. The home currently has twelve toilets and four toilets as part of bath / shower rooms. One resident said in the home’s survey that they would like more chairs for visitors, the manager confirmed that this feedback had been noted and action taken to ensure that sufficient seating is available. In the survey residents made less positive comments about the décor and the laundry. The manager was utilising the comments to improve the service in the future. One resident returning a survey form said that ‘the walls in the room are decidedly grubby although they have been washed recently.’ The home has begun a programme of redecoration in the home. The pre-inspection questionnaire states that all public communal areas have recently been redecorated. Some walls are looking in need of painting in personal rooms. The laundry is well organised. It was noted that a sluice on the ground and first floors do not have extractor fans fitted. The rooms do not have any forms of ventilation. DS0000020493.V324700.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers of staff members working in the home satisfactorily meets residents’ needs. Staff members receive regular training to equip them to meet residents’ needs. The home is working to ensure that staff members are protected by the service’s recruitment procedures in the future. EVIDENCE: From rosters seen and staff members on duty on both days of the inspection the home has satisfactory staffing levels to meet the needs of residents. On the first day of the inspection the manager and deputy were on duty, two Registered nurses and eight care staff members. A care manager responding in a comment card said that the staff members at the home are ‘very good.’ Forty-nine care staff members work in the home, excluding Registered nurses. Nineteen staff members have National Vocational Qualifications in Care, eighteen at level 2 and one at level 3. DS0000020493.V324700.R01.S.doc Version 5.2 Page 21 Three staff files were viewed. Two written references were on the files, one from the last employer. A record of interview is made. Proof of identity, including a photograph was on each file. A copy of the employee’s contract is also kept on file. Two of the three staff members had started work prior to the receipt of a check of the Protection of the Vulnerable Adult’s register and Criminal Records Bureau check. The most recent starter commenced work following the receipt of all necessary checks. The manager organises the service’s induction programme. A member of staff said that they had found their induction to the service helpful. A partly completed programme was viewed; it was very detailed and well organised. A summary record of training is maintained and staff members undertake regular training in mandatory areas of practise. Specialist training is also provided to enable staff members to meet the needs of residents. Copies of certificates were also seen on staff files sampled. DS0000020493.V324700.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well run and efficiently managed, by a person who is fit to be in charge and works in the best interests of residents. By ensuring that residents’ monies are held in separate accounts this will support the home’s commitment to ensure that residents’ financial interests are safeguarded. The home ensures that training and good practice enables residents’ well being, health and safety, to be promoted. DS0000020493.V324700.R01.S.doc Version 5.2 Page 23 EVIDENCE: The home benefits from a manager who is well organised, well respected and has strong managerial skills, which are reflected in the overall running of the home. The deputy manager has worked at the home for a number of years and takes lead responsibility for some areas of working practice in the home. The management team ensured that the Commission for Social Care Inspection’s survey forms were sent out to people involved with the life of the service and a good response was received. The home has also started to conduct its own internal audit and compile results, from which an action plan will be produced. The home also audits care plans in the home. Regular meetings are held of staff members and residents. The home maintains an account for residents’ monies. The Housing Association maintains a float of money in the account, which can be used by residents who may need funds and are reimbursed at a later date. Some residents, or their representatives, pay money into this account. This account needs to have a separate section for each resident. Receipts are kept of money spent at the home’s shop. The manager confirmed that in future copies of the receipts would be kept on the home’s file, so that the audit trail is available for inspection. All staff members now receive regular fire safety training. Regular checks are carried out of fire equipment in the home. Regular training also takes place in other aspects of health and safety. A health and safety meeting is held once every three months in the home. Efficient records are maintained of accidents occurring in the home. DS0000020493.V324700.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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 DS0000020493.V324700.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13 Timescale for action The registered person shall make 31/01/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The home must introduce a formal system for auditing medicines held in the service, protecting residents living in the home. 2. OP29 19 The registered person shall not employ a person to work at the care home until recruitment checks are complete including: A check of the Protection of Vulnerable Adult’s register. An applicant may then start work under supervision in accordance with the Department of Health’s Protection of Vulnerable Adult’s guidance until a Criminal Records Bureau check is received. 3. OP26 13 & 16 The registered person shall make 31/01/07 suitable arrangements to prevent DS0000020493.V324700.R01.S.doc Version 5.2 Page 26 Requirement 20/01/07 infection, toxic conditions and the spread of infection, standards of hygiene at the care home: Sluices must be fitted with extractor fans ensuring that residents live in a hygienic environment. The registered person shall not pay money belonging to any resident into a bank account unless: Accounts must be in the name of the resident, or any of the residents to which the money belongs thus safeguarding the financial interests of residents. 4. OP35 20 31/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Daily records completed should describe details of care given, support and details of residents’ current condition and needs. Care plans should be updated, where audits completed identify key changes required to make sure that plans inform care giving, meeting the needs of residents living in the home. 2. OP9 It is recommended that a record of the balance of medications held is carried forward to the current months administration record. This recommendation was issued in the report of the visit to the home on 19/12/05. DS0000020493.V324700.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 DS0000020493.V324700.R01.S.doc Version 5.2 Page 28 - 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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