CARE HOMES FOR OLDER PEOPLE
Snapethorpe Hall Snapethorpe Gate Broadway Lupset West Yorks WF2 8YA Lead Inspector
Tony Railton Unannounced Inspection 23rd May 2006 08.10 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 Snapethorpe Hall DS0000006209.V296494.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. Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Snapethorpe Hall Address Snapethorpe Gate Broadway Lupset West Yorks WF2 8YA 01924 332488 01924 332499 snapethorpehall@schealthcare.co.uk 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) Southern Cross Healthcare Services Limited Mr James Alvin Cranmer Care Home 62 Category(ies) of Dementia - over 65 years of age (62), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (62), Physical disability over 65 years of age (62) Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. A maximum of 31 beds for the combined categories of MD and DE Date of last inspection 16th January 2006 Brief Description of the Service: Snapethorpe Hall is a purpose built residential care and nursing home which provides places for up to 62 older people who may also need nursing care or have a physical disability or who are suffering from dementia. The home is divided into two separate units over two floors, one providing care for elderly mentally ill people and one providing general nursing and personal care. All bedrooms are single en-suite and each floor has its own lounge and dining room. From the hallway and downstairs lounge, a very pleasant patio and garden area can be accessed. The home provides a passenger lift for those who require it and allows easy access to both floors. The provider informed the Commission for Social Care Inspection on 23rd May 2006 that the fees range from £359 to £560 per week. Additional charges include hairdressing, private chiropody, newspapers and some selected activities. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Service users can access these and inspection reports from the home. The home is situated on the outskirts of Wakefield, is easily accessible from the M1 motorway and there is a regular bus service to the city centre. Car parking is available to the front of the home. An activities programme, including organised outings, is available and is co-ordinated by the homes activities organiser. The home employs the services of a visiting hairdresser who is available several times each week. Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was a positive unannounced inspection visit. The visit commenced at 08.10 and ended at 16.40. The early start gave the opportunity to sit and observe breakfast and the morning routines of residents. There was the opportunity to speak to almost all residents, a few relatives, nearly all care and nursing staff, the activities coordinator, the housekeeper, domestic staff, cook and kitchen staff. There was also the opportunity to look at some residents’ files, including their care needs assessments, care plans, reviews, medical and daily records. Some staff personal files were looked at and included employment details, induction, training and supervision records. One of the meals was sampled and the residents’ choice of menu checklist and proposed menus seen. An inspection of the home was undertaken and included looking at residents’ bedrooms, the dining rooms, lounges, toilets and bathrooms. On the day of the visit, it was noted that the home met almost all statutory requirements and nearly all the minimum standards. Other information received by the Commission over the inspection year about the home was also considered when forming judgments about the quality of the services provided. The inspector would like to take this opportunity to thank the residents, their relatives and the manager and his staff team for their patience and hospitality throughout the inspection visit. What the service does well:
There is a relaxed and homely environment created and all residents seen and spoken to, without exception, appeared to be comfortable and happy. On the day of the visit there appeared to be enough staff on duty to meet residents’ personal care needs in a relaxed and unhurried manner. Although there are a number of residents diagnosed as having dementia none of these appeared to be upset or agitated. Positive relationships were observed between residents and their carers and residents were treated with dignity and their choices respected at all times. Staff, when questioned, had a positive attitude towards residents and residents spoken to said that they are well cared for. One resident said that the staff are “wonderful” and others that they are very “caring”. One relative said that the care staff are “very patient” and “wonderful” with her mum. There was evidence that residents have a choice of menu and that they are satisfied with the meals provided. One resident said that “the food’s good” another said “Its
Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 6 not like at home, but its alright”, another said that he gets “plenty to eat”. One relative said that her mum “did not eat” before she was admitted but now she is “eating well and putting weight on”. Another relative said that what she liked about the home is “that its local people looked after by local people”. Staff training has a high profile and there was evidence of an increase in training since the previous inspection in January 2006. All areas of the home were clean and free from any unpleasant odours. The housekeeper and her domestic team are to be commended for their efforts in maintaining such a good standard of cleanliness throughout the home. What has improved since the last inspection? What they could do better:
Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 7 All areas of the home are clean and free from any unpleasant odours, however, on the corridors and in some of the bedrooms some minor remedial work was observed. The smoke-room carpet still needs to be replaced following a statutory requirement at the last inspection. The manager said that a laminate floor covering is due to be laid in the smoke-room later in the week. There is some minor remedial repair and decoration in the corridors, bedrooms, lounges and dining rooms. Although no errors were noted on this occasion, as a matter of good practice, an independent pharmacist should look at the home’s medicine administration and storage systems on an annual basis. Staff supervision notes found that some staff have not had regular planned line management supervision for a number of months (3 and 4 months). The manager said that staff supervision has fallen behind and needs to be addressed. Service users may benefit from more care staff having National Vocational Qualification training. The manager also needs to ensure that all staff receive Adult Abuse and Protection training. On the day of the visit, residents were observed making decisions about their day to day lives and choosing what they did and what they had to eat. To capture and reflect all the good work carried out by carers, the daily records would benefit from the use of descriptive words to reflect and show residents’ choices, preferences, likes, dislikes and any decisions made by them on a daily basis. Adult Abuse and Protection training, although planned, has not yet been provided. Service users may benefit from having a more consistent management approach. A review of the management systems may be prudent by the service providers and in particular given the amount and seriousness of previous adult protection referrals. 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. Snapethorpe Hall DS0000006209.V296494.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 Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 Quality in this outcome area is good. This judgement has been made using the available evidence including this visit to the home. New residents’ personal and healthcare needs are assessed before they are admitted to the home and prospective residents and their families have the information they require to make a informed choice about the home. The home does not provide an intermediate rehabilitation facility. EVIDENCE: Discussion with the registered manager found that he or a qualified Registered Nurse goes out to assess prospective service users’ personal and healthcare needs before they are admitted. The Registered Nurse said that, if the manager is not available, she goes and assesses residents’ care needs. The residents’ files show that new service users’ care needs are assessed before they are admitted. Two files also contained an Integrated Care Management Programme assessment completed by Wakefield Social Services. It was noted that the Service User Guide has been updated with a report reflecting the outcomes following a quality assurance survey of 120 service
Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 10 users and relatives. The information gathered from the quality assurance questionnaires has been collated and published in the Service User Guide. Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using the available evidence including this visit to the home. Service users’ personal and social care needs are set out in their individual plan of care, however, some social histories should contain more information. Service users’ healthcare needs appear to be met and they are protected by the procedures for the administration of medicines. Service users and their relatives feel that they are treated with dignity and their wishes are respected. EVIDENCE: Examination of four service users’ case files found that their personal and healthcare needs are assessed and care plans implemented to meet those needs. It was found that some care plans have been agreed and signed by service users or their relatives, however, some care plans had not been signed by the service user or their representative. Service users’ medical records, including doctor and district nurse visits, show that their healthcare needs are met. Although service users have a social history in their case notes, the information in some is less than in others.
Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 12 The service users who were ‘tracked’ as part of the inspection visit had appropriate care plans in place which were also reflected in the reviews and daily records. The medicine administration systems are appropriately maintained which is an improvement on the last inspection report in January 2006 when a number of errors were noted. The manager said that it has been a number of years since the medicine administration systems in the home has been checked by an independent pharmacist Throughout the inspection visit, positive relationships were observed between service users and care staff. Service users were observed to be treated with dignity, offered alternatives by care staff and their choices respected. The home’s quality assurance report based on the information returned from service users’ and their relatives’ survey questionnaires indicates that service users and their relatives are happy with the care provided by the home. Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using the available evidence including this visit to the home. Service users find the lifestyle experienced in the home matches their experience. Service users are encouraged to maintain positive links with family, friends and the community. Service users are helped to exercise choice and control over their own lives and receive a wholesome and appealing balanced diet in pleasing surroundings. EVIDENCE: Discussion with service users and their relatives found that they are generally happy with their experience of the home. One relative said that her mum “did not eat” before she was admitted and now “she is happy and is eating and putting on weight”. Another service user said that the “meals are good “ and that he got “plenty to eat”. Another said that the meals are “alright, but it’s not like home”. Service users were observed being offered a choice of menu by care staff. One service user, after receiving his meal, changed his mind and wanted something not on the menu. After a few minutes the carer returned with the chosen food. Service users were observed having breakfast and lunch in a quiet and relaxed atmosphere and carers were observed carrying out their duties in a relaxed and unhurried manner. The inspector liked with the way the care staff
Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 14 conducted themselves and, in particular, their patience and the empathy shown towards service users. In sampling one of the meals provided, it was found to be well presented and tasty. Discussion with the cook and kitchen assistant found that the cook orders all the food and sets the menu, however, residents are asked which menu they would prefer the day before and their request is recorded. It was found that service users are also asked on the day as they may need reminding about the menu. Two relatives spoken to said that they are pleased with the standard of food provided. The quality assurance report produced as a result of the home’s returned relatives and service users survey questionnaires finds service users and relatives happy with the meals provided. Discussion with the manager and examination of the minutes of the residents’ meetings show that service users voted recently to change the main meal from lunch to early evening. Discussion with the activities co-ordinator, and examination of the record of activities, show that activities are arranged on an almost daily basis and that a record is kept of those residents participating. There is also a record maintained of 1:1 work carried out by care staff, and of the trips and outings enjoyed by service users. A photographic record is also maintained of trips and outings. A group activity was observed in the afternoon and service users were happy, laughing and enjoying the session. Throughout the day, carers were observed treating residents with dignity and respecting their wishes. Choices were continually offered to residents. One carer said that “some residents can choose their own clothing”, others “what they have to eat” another carer said that residents can choose “where they sit” or “who they sit with”. Residents can also “choose to stay in their room if they wish”. Although all of these choices were observed throughout the day, none of this good work was recorded. The manager and care staff agreed that the daily records would benefit from an increase in the use of descriptive words to reflect residents’ choices, preferences, likes and dislikes on a day to day basis. Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using the available evidence including this visit to the home. Service users know that their complaints will be listened to and acted upon. Adult abuse training is planned for staff, however, this has not yet been provided. EVIDENCE: The case tracking of two specific service users’ records show that the home takes complaints seriously and takes action to ensure that residents are safe. The CSCI service history shows that the home has improved in reporting regulation 37 ‘Reportable Incidents’ occurring within the home as there has been failure to do this in the past. A letter from the Operations Manager, discussion with the registered manager and record of complaints, show that the provider has investigated specific complaints and responded appropriately. The induction training provided by the home includes some Adult Abuse and Protection training and there are policies and procedures in place for dealing with allegations of abuse. Discussion with the manager found that Adult Abuse and Protection training is planned for all staff in the coming year but this has not yet been provided. It was noted that there have been eight adult protection referrals since January 2006 and adult abuse and protection training for staff remains an issue.
Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 16 Discussion with care, nursing, domestic and kitchen staff found that they are aware of what constitutes adult abuse and how to report it. Two relatives said that they have never had any reason to complain but that they know who to speak to if they did. One resident said that he has “never had anything to complain about”. The quality assurance report, as a result of the home’s returned service users’ and relatives’ quality assurance surveys, 88 in total, finds that residents and relatives are happy with the services provided and know how to complain if they need to. The pre- inspection questionnaire completed by the manager shows that, over the past twelve months, there have been 10 complaints but only one recorded since the last inspection in January. This shows a general improvement. Complaint records show that 90 of the complaints received have received a response within the required 28 days. Snapethorpe Hall DS0000006209.V296494.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,23,24,25 and 26 Quality in this outcome area is good. This judgement has been made using the available evidence including this visit to the home. Service users live in a safe, well maintained environment with comfortable indoor and outdoor facilities. Service users’ rooms are comfortable, clean and they are surrounded by their own possessions. Residents also have suitable and sufficient washing facilities and lavatories. Residents live in a home which is clean and hygienic. EVIDENCE: All areas of the home were clean and free from unpleasant odours. The housekeeper and her domestic team are to be commended for their efforts in maintaining such a good standard of cleanliness throughout the home. Discussion with the housekeeper and two domestic staff found that they get what they need with regard to materials and cleaning products but the housekeeper and domestic staff said “ it’s hard work keeping on top of things”, “there are some bedrooms that need cleaning everyday”. The housekeeper said that it’s “teamwork” that keeps the home clean.
Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 18 One resident said that her bedroom is “lovely” and that she has “everything she needs”. Another said that she liked her room as it was “nice”, her relative said that she is new to the home and she has “not quite got her bedroom as she wants it yet”. Inspection of almost all the bedrooms found them to be homely and comfortable. However, some minor repair and decoration was noted in some bedrooms, corridors, lounges and dining rooms and on the passenger lift key pad. For the most part, these minor repairs are cosmetic, nevertheless they have been identified as needing attention by the manager and the handyman will address these as soon as is practicable. Replacing the smoke-room carpet was a requirement following the last inspection. The manager said the laying of a new laminate floor covering in the smoke room is imminent. It was noted that a new cooker has been provided for the kitchen, however, there have been delays in its fitting. The manager said that the person coming to fit the cooker is unable to do so and alternative arrangements may have to be made. Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made on the available evidence including this visit to the home. Staffing arrangements are sufficient to meet the personal care needs and recreational needs of residents. The skill mix of staff is good and service users benefit from having some qualified nursing staff, however, they may benefit from more staff having National Vocational Training. Service users would also benefit from staff having Adult Abuse and Protection training. EVIDENCE: Staff were observed to be available in sufficient numbers to carry out their duties in a relaxed and unhurried manner. The inspector was impressed by the positive attitude and professionalism of the staff on duty. The tone of the home was set by service users who were themselves relaxed, happy and comfortable. The care staff are to be commended for the positive relationships they fostered with service users and the good positive atmosphere created in the home. This was particularly noticeable on one unit where people with dementia live and where everyone, without exception, appeared to be relaxed and not agitated in any way. There was a real sense of team work and cooperation between carers, nurses, domestic, laundry and kitchen staff. Staff rotas and discussion with nursing and care staff suggest that usually there are enough staff on duty, however, problems arise when staff are sick. Staff personnel files show that suitable checks including CRB (Criminal Records Bureau) and POVA ( Protection of Vulnerable Adults List) and references are
Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 20 taken up before they are employed. Records show that all new staff receive induction training which includes some Adult Abuse training. It was noted that Adult Abuse and Protection training provided by the local authority is planned , however, this has yet to be provided. Training records show that only eight out of 34 care staff (23 ) have a National Vocational Qualification Level 2. Residents may benefit by having more staff trained to NVQ Level 2 or above. Staff training records show that staff have received training and update training in Dealing with Challenging Behaviour, First Aid, Fire Prevention, Moving and Handling, Food Hygiene, COSHH and Infection Control. One service user said that the staff are “wonderful”, another said that they are “very caring”. One relative said that they are “very patient and understanding”. Residents spoken to said that all of the staff are generally very good, however, one said that they can “get a bit busy sometimes”. Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using the available evidence including this visit to the home. Service users may benefit from a more consistent management approach. Service users’ financial interests are safeguarded and protected as are their rights by the home’s record keeping policies, procedures and practices. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: Observation throughout the day found that residents live in a home that is run in their best interests. However, records show that, previously, the manager has failed to report an adult protection issue to the CSCI. Discussion with service users, their relatives, nursing and care staff show that people are happy living and working in the home. The atmosphere is open and relaxed
Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 22 and the home’s quality assurance report shows that people are happy with the services and facilities provided. The home holds a small amount of residents’ personal allowance monies. The procedures and documentation in relation to this were checked and found to be appropriate. The balances of three residents were checked and found to be correct. Residents may benefit from having appropriately supervised staff although, on the day of the visit, all staff were very professional giving a very good example of working practice with older people, demonstrating empathy and understanding of older people’s care needs. Records show that there have been extended absences by the registered manager and there is a heavy reliance on nursing staff to ‘act up’. A review by the service providers of the management of the home by may be beneficial. The CSCI service history record indicates that only one Regulation 26 ‘Service Provider Visit Record’ has been received. Given the amount of adult abuse referrals about the care provided by the home since January 2006, it may be beneficial as part of the home’s quality assurance monitoring process for a copy of the monthly Regulation 26 visit reports to be sent to the CSCI. The pre-inspection questionnaire shows that staff receive Health and Safety, Moving and Handling, First Aid, COSHH, Food Hygiene and Infection Control training. Records also show that the hoists and passenger lift receive regular servicing and maintenance. The manager said that, out of 120 of the home’s service users’ and relatives’ quality assurance survey questionnaires, 88 of these were returned. The information was then collated and a report provided reflecting the views of service users on the quality of care provided by the home. This report has now updated the Service User Guide and is given to prospective service users and their relatives. This good practice is to be commended. Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 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 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 2 1 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 3 3 Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 14 Timescale for action Service users’ social care needs, 01/11/06 by way of a history, should be identified and care planned accordingly. The smoking room carpet on the 01/09/06 Northgate Unit needs to be replaced. (The manager said that a laminate floor covering is due to be laid within the coming few days of the inspection.) 3 OP31 9 (1) (2) The service provider needs to 01/10/06 undertake a review of the management of the home to ensure consistency in approach to service provision and ensure the welfare and wellbeing of service users. Note: Extended absences of manager, eight adult protection referrals since January 06,and 1 incident of failure to report Regulation 37, failure to ensure staff receive appropriate supervision. Requirement 2 OP20 23 (2)(c) (d) Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 25 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 Every effort should be made to ensure that residents’ social histories contain as much information as possible to enable staff to plan service users’ care more effectively. The daily records would benefit from the use of descriptive words to indicate and reflect residents’ choices, preferences, likes , dislikes and any decision they make to influence how they live their day to day lives. For the safety and the protection of service users, the manager should ensure that all staff receive the planned adult abuse and protection training. For the benefit and comfort of residents, the minor repairs and decoration should be carried out to the corridors, bedrooms, dining rooms and lounges as soon as is practicable. To meet minimum standards 50 of care staff should be trained to NVQ Level 2 or above in care. A copy of the Regulation 26 visits to the home by the provider should be sent to the CSCI. All care staff should receive a minimum of six recorded line management supervision sessions per year. 2 OP14 3 OP18 4 OP19 5 6 7 OP28 OP33 OP36 Snapethorpe Hall DS0000006209.V296494.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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