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Inspection on 29/06/06 for Smalley Hall Residential Home

Also see our care home review for Smalley Hall Residential Home for more information

This inspection was carried out on 29th June 2006.

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

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

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

What the care home does well

Comments made from the residents was very positive regarding the care provided to them at the home and this was demonstrated within the relaxed atmosphere that was noted as many residents were freely moving around the home, chatting with each other as they wished. In the files seen evidence was in place that demonstrated that one resident was supported to maintain their independence and autonomy by having their own washing machine and refrigerator at the home, this enabled them to undertake their own domestic tasks such as laundry and shopping, and through staff support the maintenance and health and safety of this equipment was maintained satisfactorily.

What has improved since the last inspection?

Medication practices at the home have improved following requirements left at the last inspection. The medication administration record (MAR) sheets had been signed at each administration or appropriately coded when resident`s medication had not been administered to demonstrate why medication was not administered. All as required medication with optional doses was appropriately recorded to show the actual dose that had been administered, and all handwritten medication instructions had been checked and signed by two staff, this indicates that safe working practices regarding staffs administration of medicines were in place at the home. Quality Assurance questionnaires had been sent out to residents and there relatives and it was stated by the area manager that questionnaires were sent out on a monthly basis to residents and relatives and twice to visiting professionals to year to ascertain the views of the home.

What the care home could do better:

The homes adult protection policy advocated internal investigation of complaints. There was no reference made to locally agreed statutory procedures as must be accepted by the Provider when accepting service users funded by Local Authorities. It is also a statutory right of service users living within Derbyshire to have access to Social Services Protection of vulnerable adults procedures as implemented in response the Department of Health `No Secrets` document. The majority of the homes pre-admission assessments care plans and risk assessments seen required more detail to ensure they were person centred and contained sufficient detailed information for staff to support and meet resident`s needs. A new format to review care plans and risk assessments should be considered, to avoid confusion in staff understanding in what the original care plan was and the reviewed/ revised plan of care, as the present system could lead to inadequate or incorrect care or support being given.

CARE HOMES FOR OLDER PEOPLE Smalley Hall Residential Home Main Road Smalley Derbyshire DE7 6DS Lead Inspector Angela Kennedy Key Unannounced Inspection 29th June 2006 09:40 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 Smalley Hall Residential Home DS0000020215.V300402.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. Smalley Hall Residential Home DS0000020215.V300402.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Smalley Hall Residential Home Address Main Road Smalley Derbyshire DE7 6DS 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) (01332) 882848 (01332) 882351 Ashmere Care Group Mr Gerald Poxton, Mrs Sandra R Poxton, Mrs Ann Theresa Poxton, Dr Michael G Poxton, Mr David A Poxton Mrs Rosamund Morley Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Smalley Hall Residential Home DS0000020215.V300402.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2005 Brief Description of the Service: Smalley Hall is a large building that was extended and re-furbished in 1988/89. The home is in attractive surroundings on the outskirts of the village of Smalley. The home is registered to provide personal care and accommodation for older people. 27 places are provided with 23 single bedrooms and 2 double bedrooms. The home is on 2 floors with a passenger lift provided. There is a large lounge area and a connecting dining area with a smaller sitting room. A spacious conservatory overlooks the patio. Car parking space is provided. For information regarding the fees and accommodation the manager at Smalley Hall can be contacted by telephone or by email. The company also has a web address that provides information regarding Smalley Hall and other homes provided by the company. Smalley Hall Residential Home DS0000020215.V300402.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. There were 16 people living at the home on the day of inspection. The inspection was unannounced and took place over a 5 ½ hour period. The registered manager was unavailable on the day of inspection; therefore the inspector was assisted by the area manager and a senior member of the care team in providing the required documents and information. The care plans, risk assessments and other relevant information within three residents files were examined. Other documents relating to the health and safety, adult protection, staff recruitment and training, and medication practices of the home were also examined. Several residents were spoken to and two members of the staff team. What the service does well: What has improved since the last inspection? Medication practices at the home have improved following requirements left at the last inspection. The medication administration record (MAR) sheets had been signed at each administration or appropriately coded when resident’s medication had not been administered to demonstrate why medication was not administered. Smalley Hall Residential Home DS0000020215.V300402.R01.S.doc Version 5.2 Page 6 All as required medication with optional doses was appropriately recorded to show the actual dose that had been administered, and all handwritten medication instructions had been checked and signed by two staff, this indicates that safe working practices regarding staffs administration of medicines were in place at the home. Quality Assurance questionnaires had been sent out to residents and there relatives and it was stated by the area manager that questionnaires were sent out on a monthly basis to residents and relatives and twice to visiting professionals to year to ascertain the views of the home. 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. Smalley Hall Residential Home DS0000020215.V300402.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 Smalley Hall Residential Home DS0000020215.V300402.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Residents with a care manager have a full assessment of their needs undertaken prior to admission, however further development is required of the homes pre-admission assessment to ensure privately funded residents needs are fully assessed prior to admission to ensure their needs can be met by the home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Three residents files were seen and all residents had been referred through care management arrangements and copies of the pre-admission needs assessments were in place within their files, these assessments contained satisfactory information relating to the residents needs and the support required. A resident admitted without a care manager (privately funded) would be assessed using the homes pre-admission assessment only. Smalley Hall Residential Home DS0000020215.V300402.R01.S.doc Version 5.2 Page 9 Copies of the home pre-admission assessments were also in place within the residents files seen, however the information within this assessment did not contain the level of detail required to ensure a thorough assessment of each residents needs can be undertaken. This was discussed with the area manager. Smalley Hall Residential Home DS0000020215.V300402.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Information contained within care plans and risk assessments requires development to ensure residents strengths and support needs are adequately detailed. Evidence must be in place to demonstrate that residents who self-administer their medication have been assessed as being competent to do so. The arrangements for health and personal care indicated that resident’s privacy and dignity was maintained. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The required information regarding the residents needs was available on the pre-admission assessment undertaken by the care manager, however evidence was in place to demonstrate that this information had not been transferred in sufficient detail onto care plans and risk assessments. Although there were several care plans and risk assessments seen within the three residents files examined the majority of these were lacking in detail, for example one care plan stated that a particular resident should be checked throughout the night Smalley Hall Residential Home DS0000020215.V300402.R01.S.doc Version 5.2 Page 11 as they were frightened of being alone. The care plan did not state how often this resident should be checked on throughout the night or what intervention should be given to reassure this resident, or if the reasons as to why this resident being frightened were known. Another care plan stated that this resident was at risk of getting very depressed and anxious. It did not state if the causes of this depression and anxiety were known. The action given to take was ‘make sure…goes out and does not spend a lot of time on her own. This information is vague, it doesn’t inform the staff what activities this resident likes to do or the approach that should or could be used to; 1) involve this resident in daily tasks and activities within the home, 2) if the resident is found in an anxious condition. A risk assessment stated that a resident was ‘at risk of a water infection’. It gives no indication as to why they were at risk. The action required was ‘monitor…. toilet habits. This does not inform staff as to how this should be achieved or how often the resident should be monitored or if they are able to verbally inform staff if they have any problems. Some care plans that were read did not appear to give instruction or guidance for staff but rather a statement to the reader of what the home would do, i.e. ‘… Feet are checked regularly and any discoloration or pain we will get the doctor’. The purpose of the care plan is to instruct care staff as to 1) the residents condition/health issue.2) how often the residents feet should be checked.3) the signs to look for regarding the condition. 4) the action to take and 4) who any concerns should be reported to and were these concerns should be documented. One care plan seen stated that a resident had a high level of independence but required some assistance in bathing, instruction was given regarding 1 area of support where assistance was required although it did not state how much assistance, neither did the care plan inform the staff of this residents strengths and abilities within this area. When care plans provide information regarding residents strengths and abilities and identify the level of support that staff need to give, it ensures that a working partnership is developed between the resident and member of staff, and allows the skills and abilities of the resident to be maintained. Many of the original care plans and risk assessments did no have a staff signature or date. All care plans had been reviewed, however the review sheet was placed at the back of the residents’ files and any alterations to the original care plan were documented on this sheet and not on the original care plan. Therefore there were care plans in residents’ files that were no longer valid. These invalid care plans didn’t indicate that they had been reviewed each month or demonstrate the changes made. There is great potential for staff that aren’t familiar with the residents to follow an out of date care plan, which could put residents at risk or allow their needs to go unmet. Further development is required to ensure that care plans are used as a working document that clearly Smalley Hall Residential Home DS0000020215.V300402.R01.S.doc Version 5.2 Page 12 demonstrate the changing needs of each resident and the level of support required. Although there was evidence in place to demonstrate that residents or their representative had given their consent to allow care staff and the relevant professionals to view their care plans, there was no evidence to show that residents had been consulted and involved in the formulation of their care plans. The homes medication practices were examined and considerable improvements had been made since the last inspection when four requirements relating to medication practices were left. Three of these requirements have now been met. The requirement still unmet was in relation to a policy for administering and recording homely remedies- these are medications that can be purchased over the counter and do not require a prescription. On discussions with the area manager it was confirmed that discussions are still ongoing at present and therefore this requirement will remain unmet. The medication administration practices undertaken by staff were found to be satisfactory. Staff administering medication had undertaken a safe handling of medicines course. On resident who self-administered medication did not have an adequate risk assessment in place to demonstrate that she had the capacity to administer her medication. No evidence of a signed disclaimer regarding the resident’s agreement to retain or administer their medication could be found within their personal file. Discussions took place with several of the residents who felt that staff were respectful when assisting and supporting them with any care needs. One of the residents said that the “staff were lovely and always having a laugh and a joke with us”. Some residents chose to have their own private telephone line within their private accommodation, however most of the residents spoken with said they preferred to use the telephone within the main reception area and confirmed that if they wished to make a private call they were able to use the duty office. It was noted within the residents files seen that their preferred name had been documented within their personal information. Smalley Hall Residential Home DS0000020215.V300402.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Routines within the home allow residents the opportunity to exercise choice and participate in the activities provided. Residents are encouraged to maintain contact with family and friends and the meals provided received positive remarks from residents regarding their quality, however further consultation with residents would demonstrate that a greater variety of meals available appealed to a wider resident group. Quality in this outcome area is good. This judgement has been made using the available evidence, including a visit to the service. EVIDENCE: Residents spoken with confirmed that the home had a flexible approach with regard to day-to-day living, and this allowed the residents to exercise their choice in their daily routines. The activities log was seen and showed the activities that were undertaken each day, the activities included: • Making hanging baskets • Craft work • Reminiscence and quizzes • Ball games Smalley Hall Residential Home DS0000020215.V300402.R01.S.doc Version 5.2 Page 14 • • • • • Movement to music Trips to garden centre Boat trips Trips to Chatsworth House Summer Fayre A hairdresser visited the home once a week, and the home employed a physiotherapist who visited the home for an hour each Wednesday and provided physiotherapy exercises for individuals and group sessions as required. A chiropodist also visited the home to provide foot care. to residents as required. Residents spoken to felt that the activities provided were good but stated that the frequency of the activities was dependent on the availability of the staff. The home did not employ an activities co-ordinator; one member of staff on each shift was allocated to co-ordinate the activities. Residents spoken with felt that if someone was employed to co-ordinate the activities of the home this could provide a better-scheduled activities programme. Residents were able to receive their visitors within any of the communal areas provided or within their private accommodation as they wished. Visiting within the home was not restricted and an open visiting policy was in place. An information box was available within the entrance area of the home that provided details of the local advocacy services for any residents requiring this information. Meals were provided within the dining area, although many residents spoken with said that they chose to take their breakfast within their private accommodation, this indicates that the home strives to ensure that the home maintains a flexible approach to mealtimes in order to meet residents preferences. The menus were seen and demonstrated that meals were rotated over a fourweek period. The menus showed that an alternative meal was available at teatime; only one main meal was indicated on the menus for lunchtime however the catering staff stated that alternatives were available if required. This was confirmed with the residents spoken with who had chosen alternative meals that day. Four of the residents spoken with stated that the quality of meals provided was good but said they would like more variety to be available at the teatime meal, when asked what preferences they had they said an alternative to sandwiches or something on toast, such as kippers, ham salad, fresh salmon and pork pie. These requests should be further discussed with the residents at the home to ensure all tastes and preferences can be established and thereby catered for. Smalley Hall Residential Home DS0000020215.V300402.R01.S.doc Version 5.2 Page 15 A diary was kept within the kitchen and meals taken by each resident were recorded. The fridge temperatures were also recorded within this diary and were within the required temperatures. Smalley Hall Residential Home DS0000020215.V300402.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 An effective complaints procedure is in place at the home. There is the potential for any allegations of abuse to be mishandled due to the lack of appropriate procedures being available to staff. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service EVIDENCE: The complaints procedure and complaints log was seen and demonstrated that complaints were dealt with promptly and effectively. A copy of the complaints procedure was on display within the entrance area of the home. The home has received 2 complaints since the last inspection both had been dealt with satisfactorily. Residents spoken with had knowledge of the complaints procedure and stated that the manager of the home dealt with any concerns they had effectively. The Protection of vulnerable adults procedure advocated internal investigation of complaints. There was no reference made to locally agreed statutory procedures as must be accepted by the Provider when accepting service users funded by Local Authorities. It is also a statutory right of service users living within Derbyshire to have access to Social Services Protection of vulnerable Smalley Hall Residential Home DS0000020215.V300402.R01.S.doc Version 5.2 Page 17 adults procedures as implemented in response the Department of Health ‘No Secrets’ document. Staff spoken with confirmed that they had attended internal training in abuse of vulnerable adults and where able to demonstrate knowledge regarding the whistle blowing policy. Smalley Hall Residential Home DS0000020215.V300402.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The home is generally maintained to a satisfactory standard and provides a clean, spacious home. The completion of maintenance work will further improve the environment. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A redecoration and development plan is in place within the home and includes plans to develop 8 en suites for resident’s private accommodation. Work continues and the area manager confirmed that the requirements left at the last and previous inspections have not yet been met due to ongoing structural changes, i.e the lowering of ceilings. A tour of the building was undertaken and it was noted that all areas seen were clean and pleasant in odour. Several of the resident’s rooms were seen and demonstrated each resident’s individual tastes and preferences. Smalley Hall Residential Home DS0000020215.V300402.R01.S.doc Version 5.2 Page 19 Residents spoken with were complimentary regarding the maintenance and cleanliness of the home Smalley Hall Residential Home DS0000020215.V300402.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The numbers and skill mix of staff are adequate to meet residents care needs, staff have training opportunities which provide the knowledge and skills required to ensure residents needs can be met. The homes recruitment practices support and protect the residents from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A copy of the rotas for the week of inspection and the previous week were obtained and demonstrated that the required numbers of staff were available on shift each day and night; the minimum numbers of staff per shift were: Early shift – 1 manager or senior care 1 carer =2 staff Late shift- 1 manager or senior care 1 carer = 2 staff Night shift- 1 manager or senior 1 carer or 2 care staff = 2 staff On 11 of the 14 days seen it was noted that on early shifts 2 care staff were rostered on shift with 1 manager or senior carer. = 3 staff. As the staffing levels, although meeting requirements are kept to two or three staff per shift, it is recommended that consideration be given to the deployment of an activities co-ordinator to ensure residents needs can be met with regard to mental stimulation and leisure pursuits. (See standards 12- 15). Smalley Hall Residential Home DS0000020215.V300402.R01.S.doc Version 5.2 Page 21 10 of the staff have achieved a national vocational qualification (NVQ) 2 in care and 4 staff have an NVQ 3 in care, the home therefore has met the governments requirement of 50 of the staff team achieving NVQ level 2. A training matrix is now in place, which demonstrates the training, undertaken by staff and the dates any training is due. This was a requirement from the previous inspection that has now been met. The recruitment practices of the home were examined within two staff files and all the relevant and required safety checks were in place, this included satisfactory criminal records bureau checks, 2 satisfactory references, proof of identification including photo identification and full employment histories. This demonstrates that the home endeavours to protect the residents’ safety in ensuring the staff working at the home have undergone the required safety checks prior to employment. Smalley Hall Residential Home DS0000020215.V300402.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The registered manager of the home has the qualifications and experience to ensure that the home is well managed and run in the best interests of the residents. Residents financial interests are safeguarded and their health and safety is promoted and protected by the Safe Working Practices of the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The registered manager of the home was not on duty on the day of inspection. However the area manager confirmed that the registered manager had been in post at the home for the last two years and had achieved the registered managers award. Smalley Hall Residential Home DS0000020215.V300402.R01.S.doc Version 5.2 Page 23 The quality assurance systems of the home included: • A Quality control report that was undertaken in May 06 • Regulation 26 visits undertaken each month by the area manager • Residents meetings twice a month • Satisfaction questionnaires undertaken each month by residents, relatives and staff • Satisfaction questionnaires undertaken twice a year by visiting professionals. Several of these documents were examined and indicated that the opinions and views of people living at the home and visitors were sought. No evidence was seen of the feedback given regarding the opinions received in the surveys or any action that was taken from these surveys, however the area manager stated that this information was fed back to the residents by means of a newsletter. Some of the residents had chosen for the home to keep their money for them until required. The practices of the home with regard to this were therefore inspected. All monies were stored securely. Each resident had their own transaction record, which showed all transactions, and 2 signatures were provided upon each transaction. One resident’s money was chosen at random and counted to ensure the figures on the transaction record were correct, which they were. All receipts were retained with resident’s monies. Some of the Safe Working Practices of the home were examined and all were found to be satisfactory, these included: • Gas safety maintenance service last done in April 06 • Lift service done in April 06 • Waste Certificate dated February 06 • Ambu-lift service May 06 • Hoists service May 06 • Boiler Service April 06 • Scales service November 05 • Legionella report September 05 (water inspection) • Electrical installation certificate March 05 (required every 5 years) • Water temperatures (baths and hand basins) • Fire extinguishers Nov 05 • First Aid certificates (for 8 staff) • Accident Book • Weekly fire alarm checks Smalley Hall Residential Home DS0000020215.V300402.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 3 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 2 X X X X X X 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 Smalley Hall Residential Home DS0000020215.V300402.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Information contained within care plans and risk assessments requires development to ensure residents strengths and support needs are adequately detailed. The Registered Persons must develop and implement a policy on administering and recording of homely remedies. (Requirement repeated from previous inspection report, previous timescale 01/01/06) Evidence must be in place to demonstrate that residents who self-administer their medication have been assessed as being competent to do so. The homes procedure for the handling of allegations of abuse must respect resident’s statutory rights and refer to the Derbyshire Protection of Vulnerable Adults procedures which are there to protect the service users residing in DS0000020215.V300402.R01.S.doc Timescale for action 01/10/06 2. OP9 13 (2) 30/09/06 3. OP9 13 (2) 30/08/06 4. OP18 13 01/08/06 Smalley Hall Residential Home Version 5.2 Page 26 Derbyshire 5. OP19 23 (2) The Registered Persons must complete the programme to replace the bathroom floor and corridor carpets. (Requirement carried forward) The Registered Persons must ensure that all areas that require redecoration must be completed. (Requirement carried forward) 31/10/06 6. OP19 23 (2) (d) 31/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP12 OP15 Good Practice Recommendations Evidence should be in place to demonstrate that residents have been consulted and involved in the formulation of their care plans. Consideration should be given to the deployment of an activities co-ordinator at the home. Discussions should take place with residents regarding their preferences of food at meal times, to ensure all tastes can be catered for. Smalley Hall Residential Home DS0000020215.V300402.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Smalley Hall Residential Home DS0000020215.V300402.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!