CARE HOMES FOR OLDER PEOPLE
South Cary House South Street Castle Cary Somerset BA7 7ES Lead Inspector
Ms Sue Hale Unannounced Inspection 19th April 2007 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 South Cary House DS0000016092.V335215.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. South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service South Cary House Address South Street Castle Cary Somerset BA7 7ES 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) 01963 350272 rory.garden@btinternet.com MRS CHRISTINE ANNE GARDEN MR RODERICK FINLAY GARDEN MRS CHRISTINE ANNE GARDEN Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 16th November 2005 Brief Description of the Service: South Cary House is a large Georgian property located on the outskirts of Castle Cary. Residents accommodation is arranged on the ground, first and mezzanine floors. All residents’ rooms have en suite facilities. A passenger lift and call system are provided. The home has been decorated and furnished to a high standard. There are attractive gardens that are accessible to residents. The home is registered with the Commission for Social Care Inspection to provide accommodation for up to eighteen residents over the age of 65 years who require assistance with personal care. The Registered Providers are Mr and Mrs Garden. Mrs Garden is also the Registered Manager. The homes current fees range from £390 to £440 per week. South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the first key inspection of South Cary Residential Home using the Inspecting for Better Lives methodology introduced by the Commission for Social Care Inspection in April 2006.The inspection methodology used by the Commission for Social Care Inspection enables the inspector to make a judgement on the quality of the service delivery based on the outcomes for residents. The inspection took place over the course of one day in April 2007. The inspector looked at selected staff and residents’ files, policies and procedures and other documentation related to the running of the home. The inspector looked around the home and also viewed several residents’ private rooms and the garden. As part of the inspection surveys were sent to some residents, medical and health care professional and relatives/representatives of residents. The responses and comments are incorporated into this report. The inspector spoke to some staff, Mr and Mrs Garden, a visiting health care professional, a visitor to the home and several residents. As a result of this inspection three requirements were made and seven recommendations relating to good practice. What the service does well:
All residents are seen as individuals with life experiences and these are valued and respected. The statement of purpose and brochure makes it clear that prospective residents from all sections of the community will be made welcome and their needs accommodated. Residents are able to continue to pursue their spiritual needs and this is supported by the homes staff. The homes equal opportunities policy is relevant to residents and staff and makes the value system of the home clear, that is to provide a safe environment for all who live and work there. One resident surveyed said that ‘I am extremely happy here and have no regrets about giving up my home’ and another resident said’ I don’t think there is anywhere better to stay’. A visitor to the home commented that the home ‘makes each resident feel special’. The home produces a statement of purpose that is readily available in the entrance hall. All residents surveyed said that they had been given enough information to make a decision when they were looking at moving into the home. A copy of the latest CSCI inspection report is also freely available for all to see. All residents are given a terms and conditions of residency.
South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 6 Admission doesn’t take place unless the prospective resident has been assessed by Mrs Garden and it has been confirmed in writing that the home is able to meet their needs. Prospective residents have the opportunity to visit and spend time in the home before they make a decision about residency. All residents have a care plan that details their health, social and care needs and how staff will meet these in an individual way that respects people’s dignity and privacy. Risk assessments are in place but individuals’ rights to take risks and retain their independence is recognised. Residents are fully involved with care planning and reviews and are aware of their rights to see any of the documents kept about them by the home. Medication is administered and handled by trained staff to safeguard residents’ health and well being. The routines of the home are flexible to suit the needs, preferences and choices of residents. The residents are satisfied with the quality and range of the food served and mealtimes in the dining room are social occasions. The food was described as ‘lovely’, ‘excellent’ and’ very good’. Visitors are made encouraged in the home and are made welcome, enabling residents to maintain their relationships with family and friends. One visitor to the home said ‘It is like one big family, everyone is so friendly, nothing is too much trouble’. Another visitor commented that the home’ far exceeded expectations’ in the care their relative received and that the home was ‘truly remarkable’. The whistle blowing and complaints policy are clearly written and contain all the information recommended. All residents spoken to and surveyed were aware of how to raise any concerns and were confident that they would be listened to and taken seriously. The home provides a high standard of furnishings and fittings. Residents are encouraged and supported to bring in small items of their own furniture and are able to personalise their private rooms in line with their preferences and choices. All areas of the home were very clean, tidy and there were no unpleasant odours. Residents told the inspector that their rooms had been freshly decorated before they moved in and one resident had been consulted and chosen the colour scheme and furnishings. There is sufficient staff to meet residents needs. Residents are very satisfied with the care they receive from staff. The majority of care staff is qualified to NVQ level 2 or above to make sure they have the skills and experience to provide a high standard of care. Residents spoken to were very positive about the staff and Mr and Mrs Garden who were described as ‘very good and helpful’ and ‘very kind’. The staff team is stable with many staff having worked at the home for some years this gives the residents continuity of care and confidence that they will be well looked after.
South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 7 Management prioritise training and facilitate staff to undertake external qualifications beyond basic requirements. Mr and Mrs Garden have the required skills and experience and are competent to run the home. Staff described the atmosphere within the home as ‘very supportive’. One resident surveyed said that ‘I only have praise for the way I am treated by management and staff’. The home works to a clear health and safety policy and procedure that safeguards residents and staff. 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
South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 8 be made available in other formats on request. South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 9 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 South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 10 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): 1,2,3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The statement of purpose is out of date and the home does not produce a service user guide. Individuals are provided with a statement of terms and conditions/contract, which gives basic information about what people who live in the home can expect to receive for their fee. Admissions are not made into the home until a needs assessment is undertaken that involves the prospective residents and their families and/or representatives. EVIDENCE: South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 11 The home has a statement of purpose dated 2002.It contains basic details about the home but needs amendment to include all the information required in the Care Home Regulations 2001 and updating to reflect the current situation at the home. A copy of the latest CSCI inscption report is freely available for all to see in the entrance hall. The home does not produce a service user guide but has a colour brochure available. This has a photograph of the home and contains basic information about the services offered. It is given out to interested parties with a copy of the statement of purpose. However, there is some information recommended in the national mimum standards as needing to be available to prospective residents and their families that are not detailed in either document. The number of places available differs in the statement of purpose and brochure. All residents are given a contract/terms and conditions of residency. This needs minor amendment to include all the information detailed in the national minimum standards. The registered manager Mrs Garden visits prospective residents in their home, hospital or wherever they are staying, to undertake pre admission assessments. A letter confirming that the home can meet prospective residents needs is sent to them. Residents spoken to confirmed that they were supported and encouraged to visit the home and spend time there before they made a decision about moving into the home. All admissions are on a four week trial basis and are reviewed with all parties before the placement is made permanent. On one case file checked a pre admission assessment had not taken place as the person was admitted on an emergency basis. However, the resident concerned was well known to the home. Mrs Garden was advised to complete an assessment as soon as practicable after an emergency admission. A copy of the funding authorities care plan and assessment is obtained for those residents funded via care management arrangements. South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 12 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 good. This judgement has been made using available evidence including a visit to this service. All residents have a detailed care plan that records their health, social and care needs and how these will be met. People who live at the home have access to healthcare and remedial services as necessary. Medication practice at the home is of a good standard and safeguards residents’ health and well being. . EVIDENCE: The care files of four residents were checked. All had a care plan that detailed their individual need and give instructions to staff on how to meet these. Personal support is responsive to the varied and individual needs and preferences of residents, including support and encouragement to remain as
South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 13 independent as possible and to retain daily living skills. Residents have access to health and medical care as necessary and visits from the G.P’s, district nurses, optician, dentist and chiropodists are recorded in individual files. A healthcare professional visiting the home on the day of the inspection spoke of the positive relationship the healthcare practice had with Mrs Garden and the staff. Referrals received were appropriate and made in a timely way. Staff were said to always seek advice and follow this and any instructions given by district nurse about the care of residents. Staff have training in health matters and recently had access to training about strokes. Records are kept of residents’ weights and appropriate action taken if any problems occur. Nutritional risk assessments are not undertaken and Mrs Garden was advised to obtain such a tool although she did not feel there were any residents currently at risk. Risk assessments were in place in relation to pressure sores, these were reviewed and updated regularly and appropriate referrals made to the district nursing service and equipment provided as necessary. Residents are involved in care planning and review and if they are able to, they sign their agreement to the care plan. One resident said that ‘Sally (deputy manager) talks to me about what care I need’. All residents have a moving and handling assessment that is reviewed and updated regularly. This included details of any risk of falls. Mrs Garden was advised to consider developing an individual falls risk assessment for those at risk or who have had a fall. This should include control measures to reduce the risk of further falls. The home has developed an efficient medication policy, procedure and practice guidance. All staff has undertaken training in the safe handling of medicines. Medicines are stored securely. Medication records seen were correctly completed. The culture of the home is relaxed and friendly but offers a professional standard of care. The inspector observed staff treating residents with respect and their right to privacy was respected by staff knocking on doors and waiting to be asked to enter. The homes policy on autonomy underlines these principles to staff and residents are very much seen as individuals with life experience that is valued and respected. South Cary House DS0000016092.V335215.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. Activities are available and residents consulted about the programme. Routines are flexible and residents are supported to make choices in all areas of their lives, this includes developing and maintaining family and personal relationships. Residents are satisfied with the quality of meals served at the home and staff are familiar with their individual choices. EVIDENCE: Activities are arranged by care staff. Some of the things available currently are scrabble, whist, sherry evenings, films, gardening and beauty treatments such as manicures. Some residents go out for walks locally unaccompanied. Trips out of the home have been arranged to places such as West Bay, Mrs Garden stated that they were currently looking at using the local community transport to make such outings more accessible for residents with impaired mobility.
South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 15 Some residents spoken to said that they would welcome more opportunities to go out on trips, although others said that the level of activities available was ‘just enough’. Residents are able to continue practising their religion with either the visiting clergy or by attending local churches. The service promotes the rights of individuals to make informed choices and takes into account peoples life history and respects their individuality. Visitors confirmed in surveys that they are made welcome to the home at times to suit them and are able to see their relatives/friends in their private rooms, communal areas or on the day of the inspection in the garden. A visitor spoken to on the day of the inspection said that they were always made welcome and offered refreshments and had been invited to stay and have meals with their relative. Residents spoken to confirmed that the daily routines of the home are flexible to suit their preferences and choices. Residents have breakfast on a tray in their rooms and their choices are recorded and regularly checked by staff to make sure that alternatives are offered if required. All food is prepared in the home and staff are familiar with individuals likes and dislikes with these taken into account before meals are served. Special diets are catered for. Residents have a cake on their birthday. The dining room tables were very nicely laid with a cloth, cloth napkins and condiments. The inspector observed lunch was served in a relaxed atmosphere and treated as a social occasion. Assistance was available from staff if required. All the residents surveyed and spoken to were very satisfied with the quality and range of food served at the home. South Cary House DS0000016092.V335215.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. Residents and others understand how to make a complaint and are confident that they will be listened to and taken seriously. An adult protection policy to safeguard residents from the risk of abuse is in place but needs revising to reflect good practice advice. Detailed information is available to staff about whistle blowing. Poor recruitment practice could put residents at risk. EVIDENCE: The home has a clear complaints policy that includes the timescales within which a complaint would be investigated and makes clear that complainants are able to contact the CSCI at any stage of a complaint. Advice was given about how to record complaints in a way that meets the requirements of the Data Protection Act 1998 and this was acted upon during the inspection. South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 17 The home has a whistle blowing policy for staff that is detailed and includes the telephone number of Public Concern at Work and the CSCI. The home has an adult abuse policy and a copy of the Safeguarding Vulnerable Adults Adult Protection in Somerset Multi Agency Policy and Practice Guidance. However, the policy needs amendment to make clear that advice should be sought should an allegation be received before any investigation takes place by the home. Mr and Mrs Garden were advised to ensure that the policy should be line with the local guidance and the Department of Health’s document, ‘No Secrets’ good practice advice. Mr and Mrs Garden were unaware of the correct procedures to follow when employing new staff in relation to requesting a POVA First check and that staff must not be employed until a satisfactory check of the register has been made. This has led to at least one member of staff starting work at the home before a satisfactory POVA First or CRB disclosure was recived. The inspector supplied information about this. South Cary House DS0000016092.V335215.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): 19,20,21,24,26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use services are encouraged to see the home as their own. It is a very well maintained, attractive home and has good access to local community facilities. EVIDENCE: Residents’ accommodation is arranged over the ground, mezzanine, and first floor. All residents’ rooms have en suite toilet facilities. There is an assisted bathroom, passenger lift, internal telephone system and call system available to residents. Communal space comprises of a large lounge and dining room. Adaptations have been provided as required. A stair lift has been installed to improve access to one resident’s room. Residents’ rooms have been
South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 19 personalised to reflect individual tastes and preferences. The home has been decorated and furnished to a high standard and is well maintained. The home has a large garden at the rear, which was being used by several residents on the day of the inspection. Garden furniture is available. However, for residents with restricted mobility or who use a wheelchair, access is not possible through the home but has to be by going through the front door and entering the garden by a side gate with staff support. Mr and Mrs Garden are hoping to be able to offer direct access to the garden for all residents if a planning application in relation to this is approved. Radiators have been guarded, or risk assessments completed as necessary. Some but not all window openings have been restricted. Hot water outlets were tested and found to be within appropriate limits. There is emergency lighting available throughout the home. This is tested on a monthly basis. The laundry facilities are adequate for the size of the home. All residents spoken to said that they were satisfied with the laundry service and that they always received their own clothes back promptly. The home follows good practice in relation to infection control, with protective clothing being readily available to staff. South Cary House DS0000016092.V335215.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 good. This judgement has been made using available evidence including a visit to this service. There is sufficient staff to meet residents needs. Residents are very satisfied with the care they receive from staff. The majority of care staff is qualified to NVQ level 2 or above to make sure they have the skills and experience to provide a high standard of care. Management prioritise training and facilitate staff to undertake external qualifications beyond basic requirements. Recruitment checks need to be more robust to protect residents. EVIDENCE: Duty rotas are maintained. Feedback from residents and staff indicated that there was sufficient staff to meet residents’ needs. All the residents surveyed said that they always or usually received the care they needed and the majority said that there was always staff available when needed. All residents spoken to knew the names of all the staff and were confident they were very well looked after.
South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 21 Information supplied by the home stated that there is currently 14 care staff employed and 5 ancillary staff, with 77 of care staff qualified to NVQ level 2 or above. The inspector looked at three staff files. All contained personal details about the applicant, two references and terms and conditions of employment. All staff had been given a job description. They did not contain a photograph of the employee or a record of what proof of identity had been seen. The home does not have an application form but notes down applicants’ details at interview. Advice was given to Mr Garden on checking that this record complies with current employment legislation. The home must ask applicants to make a declaration with regard to any convictions and must make it clear the posts at the home are exempt from the Rehabilitation of Offenders Act. The home should also make it clear that applicants should put their last employer as a source of reference. One member of staff had started work at the home without a satisfactory POVA First or CRB check. A copy of the amended Care Homes Regulations in relation to employment of staff and POVA and CRB checks was given to Mr Garden. Advice was given to Mrs Garden about how to obtain copies of the General Social Care Council code of conduct. Staff are provided with regular opportunities to undertake training and since the last inspection training had included dementia care, medicines administration, first aid appointed person, infection control and manual handling up dates. The service focuses training to improve outcomes for residents. Staff are paid to attend training and the home pays course fees. All new staff now undertakes the common induction standards. South Cary House DS0000016092.V335215.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 good. This judgement has been made using available evidence including a visit to this service. The manager has the required skills and experience and is competent to run the home. The home works to a clear health and safety policy and procedure that safeguards residents and staff. EVIDENCE: There was a relaxed and open atmosphere within the home. Residents spoke highly of the Mr & Mrs Garden and their role within the home. One resident described Mr and Mrs Garden as ‘excellent, very good’. Mrs Garden is a
South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 23 qualified nurse Residents’ views are regularly sought informally on an individual basis and in residents meetings. The last residents meetings had taken place in November 2005,this had focused on activities and residents had been asked to suggest what they would to like to see happen in the home. The home has obtained Quality Rating from Somerset Social Services. Appropriate Employers Liability Insurance is displayed. There is evidence of ongoing investment in the maintenance of the interior, exterior and furnishings and fittings of the home. Internal quality assurance systems are in place so that Mr and Mrs Garden can find out what residents think about the service offered at the home and evaluate and act upon their responses. Policies and procedures are in place, these should be reviewed and updated as necessary to reflect changes in legislation and current good practice advice. Records were stored securely. Advice was given to Mr and Mrs Garden in relation to how to maintain records in line with the Data Protection Act 1998. The home does not keep any money on behalf of residents. The home has a finance policy; advice was given on making it clear that staff can’t accept gifts from residents. The fire system had been regularly serviced and tested on a weekly basis. All staff has undertaken training in fire safety. Emergency lighting is checked weekly. All but one member of staff has qualifications in moving and handling. Staff meetings take place and staff spoken to confirmed that they are to contribute and their views are listened to. The last residents meetings had taken place in November 2005,this has focused on activities and residents had been asked to suggest what they would to like to see happen in the home Hazardous substances had been stored securely and were not accessible to residents. Accidents had been recorded and reported as required. South Cary House DS0000016092.V335215.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 1 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 3 4 X X 4 X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 South Cary House DS0000016092.V335215.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 OP1 Regulation 4(1) Schedule 1 Requirement The registered person must ensure that the statement of purpose includes all the information detailed in Schedule 1. (This refers to the qualifications and experience of the registered providers, the current organisational structure of the home, the current number and qualifications of staff employed at the home, whether or not nursing is provided, more specific details of the emergency and fire precautions at the home, the arrangement for respecting the privacy and dignity of residents, details of any therapeutic techniques used in the home). The registered person shall produce a service user guide. The registered person shall not employ a person at the home unless he has obtained the relevant documentation. (This refers to a satisfactory POVA First check and/or an enhanced CRB disclosure). Timescale for action 30/06/07 2 3 OP1 OP29 5(1) Schedule 2(7) 19(1)(b) 30/06/07 03/05/07 South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP1 OP2 Good Practice Recommendations The statement of purpose and service user guide (brochure) should be reviewed yearly and updated as necessary to make sure it contains up to date information. The contract should be amended to include clear details of who (the resident, local or health authority, relative of another) is responsible for paying the fees and who is liable if there is a breach of contract. A nutritional risk assement tool should be obtained and undertaken on admission and as necessary thereafter. A copy of the Department of Health’s documents No Secrets should be obtained and used to inform the revision and updating of the adult abuse policy. The information about complaints in the statement of purpose and contract should make clear that complainants are able to contact the CSCI at any stage of a complaint. Prospective employees should be asked to put their last employer as a source of reference. All applicants should be informed that that Rehabilitation of Offenders Act does not apply to the home and should be asked to sign a suitable declaration. The record of staff information /application form should comply with employment legislation. All upstairs windows should have restrictors fitted unless a risk assessment determines otherwise. 3 4 5 6 OP8 OP18 OP16 OP29 7 OP38 South Cary House DS0000016092.V335215.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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
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