Inspection on 27/07/06 for St Andrew`s, Cullompton

This inspection was carried out on 27th July 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Andrew`s, Cullompton 24/07/07

St Andrew`s, Cullompton 29/11/05

St Andrew`s, Cullompton 15/06/05

St Andrew`s, Cullompton 28/02/05

St Andrew`s, Cullompton 06/08/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Andrews, Cullompton 1-5 Pye Corner Church Street Cullompton Devon EX15 1JX Lead Inspector Michelle Oliver Key Unannounced Inspection 27th July 2006 09:00 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 St Andrews, Cullompton DS0000022036.V293215.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. St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Andrews, Cullompton Address 1-5 Pye Corner Church Street Cullompton Devon EX15 1JX 01884 32369 01884 32369 standrewscarehome@yahoo.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) Mrs Brenda Wise Mr Barry James Wise Mrs Angela Beryl Cunningham Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (23), Old age, not falling within any other category (23), Physical disability over 65 years of age (23) St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Manager must gain an NVQ level 4 in care by April 2006 Date of last inspection 29th November 2005 Brief Description of the Service: St. Andrews Care Home comprises of a main building, which can accommodate up to 19 residents, and a smaller house situated in the grounds, which can accommodate up to 4 residents. The home provides personal care together with accommodation and board up to 23 older people who may also have a physical disability and /or mental disorder such as Alzheimers Disease or a related disorder. The home is situated within a short level walk from the main street in Cullompton, which offers a wide range of shops, cafes and the local health centre. The home is approached by way of a level paved area and there are ample facilities for car parking. The home’s statement of purpose and service user guide is available at the home, which includes details about the philosophy of the home and details about living at the home. This is made available to all potential residents before they make a decision about living at the home. A copy of the most recent inspection report is available on request. Information received from the home indicates that the current fees are £295£400 weekly. Services not included in this fee include hairdressing, chiropody, newspapers and magazines and personal items. St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on Thursday 27th July 2006 over a period of 7 hours. The provider was present throughout the inspection. Some positive informative discussion and exchange of information took place. During the inspection the inspector case tracked 3 residents, which helps us to understand the experiences of people using the service. A number of other residents were met and spoke with during the course of the day. The inspector also spent a considerable time observing the care and attention given to residents by staff. Several staff were spoken with during the day. Prior to the inspection 13 questionnaires were sent to residents to obtain their views of the service provided; 8 were returned. Comments were in the main satisfactory with the majority of the respondents confirming that they receive the care and support they need. Eight staff were sent questionnaires in order to hear their confidential views; 7 were returned. The responses indicate that staff feel supported in their role. Comments included “ I feel that St Andrews is a warm cheerful friendly clean and very comfortable retirement home throughout”, “Staff do their jobs very well” and “ the care is very good”. Four health and social care professionals were also contacted prior to the inspection including a local doctor and 3 district nurses. Commented included “Excellent standards maintained. Never received complaints” and a district nurse commented, “Staff at St Andrews are extremely professional and good. Pathways of communication are in place ensuring the best for their residents”. Twenty questionnaires were sent to relatives, thirteen of which were returned. Commented included “This is a very clean and friendly home, all staff are helpful and kind to residents and visitors,” “well fed with fresh and local produce,” “very good overall care,” “very satisfied that my relative is so well cared for and so happy,” “could not receive better care and affection from all the staff- I am very grateful,” “satisfied with overall care at the home-brilliant” and “this is an excellent, clean, caring home with kind and dedicated staff. Absolutely no complaints”. The inspector toured the premises and a sample number of records were inspected which included care plans, medication records, staff recruitment files and fire safety records. The manager had completed a pre-inspection questionnaire and the inspector appreciated the preparation undertaken by the manager to assist with this St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 6 inspection. Finally the outcome of the inspection was discussed with the owner and manager. What the service does well: What has improved since the last inspection? What they could do better: Care plans should be further expanded to include details of how residents prefer their individual care to be carried out, plans of how individual goals for residents have been decided, with their involvement, and how these will be met. Residents or their representatives should be involved in the planning and reviews of their individual care needs. To ensure that all medication is stored at the manufacturers recommendation temperature a fridge other than the homes domestic fridge should be available. Although all staff were able to identify, and would not hesitate to report any suspicion of, poor practice, the procedure for reporting an allegation to the relevant authorities needs to be fully understood. St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 7 The results of quality assurance surveys should be published and made available to current and perspective users, their representatives, any other interested bodies and the CSCI. A door leading to the kitchen is a fire door and should be kept closed at all times. At the time of this visit this door was wedged open. This was discussed with the owner and the cook who both confirmed that they thought the risk of accidents from having to open the door when carrying food or drinks outweighed the risk of fire. The owner has confirmed that the kitchen door will be fitted with an electric magnetic release, connected to the fire alarm system, within the next 21 days. Written assessments will be undertaken to minimise the risk of the kitchen door being kept closed until the closure has been fitted. 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. St Andrews, Cullompton DS0000022036.V293215.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 St Andrews, Cullompton DS0000022036.V293215.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): OP 3 & 6. Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. Residents benefit from good admission and assessment practice, which ensures that the home is able to meet their needs. People needing rehabilitation are not admitted to the home. EVIDENCE: Most residents were unable to remember their move to the home but were sure that their family had checked that it was “alright”. The manager and owner said that family members and potential residents were welcome to visit the home, ask any questions, meet the other residents, have a meal if they wished or stay for a few days. None of the current residents spoken to could recall being shown the home’s statement of purpose or service user guide, which includes comprehensive information about the home, but said they were very happy living at St Andrews. Thirteen questionnaires were sent to residents before this visit and eight were returned. Only one stated that they had not been given enough information St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 10 about home the as decision was made urgently by other health care professionals. Three residents’ plans of care were looked at; all included an assessment of the health, welfare and social care needs carried out by the manager, provider or other health care professional before a person decides to move to the home. The assessment ensures that people’s individual needs are known and that potential residents can be assured that they can be fully met at the home before deciding to live there. St Andrews, Cullompton DS0000022036.V293215.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): OP 7, 8, 9 & 10. Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the service. Individual care plans have been developed and all aspects of health; personal and social care needs are identified or planned for. Attention is needed to recording individual preferences, involving residents in the review of their care and reviewing the plans of care regularly. Medication is generally managed well. Residents are treated with respect and their dignity and privacy is maintained. EVIDENCE: Three residents’ care plans were looked at. There was no evidence of any achievable goals being set with the input of residents to maintain their independence. Care plans are reviewed by the manager but not monthly as recommended. It is not clear to what extent residents, or their representatives, are involved in, consulted or informed of any changes when the plans are reviewed. The manager described talking to relatives and St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 12 residents when any changes occur and accepted the need for these reviews to be recorded. A relative commented, “I am never worried about the care and feel this is a partnership between us, her family and the staff at St. Andrews”. The manager plans to continues to develop the information to include details of individualised care so that staff know just how residents want everyday needs carried out, for example, bathing and dressing. This will further ensure that individual, person centred care is a priority at the home. Staff were aware of the details of residents individual preferences and residents said that they were satisfied with the care. The manager and staff work closely with health care professionals. At the time of this visit a district nurse had visited a resident to carry out treatment. Good, comprehensive discussion took place relating to changes of treatment and pain control ensuring that the resident received good continuity of care. All but one questionnaire returned from residents stated that they always receive the care and support they need. A local doctor wrote, “ Excellent standards maintained. Never received any complaints”. Four district nurses confirmed that they have received complaints about the home and that “Staff at St Andrews are extremely professional and good. Pathways of communication are in place ensuring the best for their residents”. None of the residents currently look after their own medication. Staff described, and the inspector saw, a satisfactory method of giving medicines to residents. The home does not have a separate refrigerator for storing medication. Medication requiring to be refrigerated to be effective is currently stored in a box in the homes’ domestic refrigerator, which is frequently opened. The advised temperature at which medication is advised to be kept will therefore be inconsistent. This was discussed with the manager and owner who immediately agreed to buy fridge to be used only for the storage of medication. All residents spoken to confirmed that they are treated with dignity and that their privacy is respected by staff at all times. Staff were seen knocking on residents’ doors and waiting to be invited in before doing so. A telephone is provided on the first floor at the home and a hands free telephone is available to enable residents to make, or receive, calls in comfort and privacy. St Andrews, Cullompton DS0000022036.V293215.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): OP 12, 13, 14 & 15. Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. Social needs and meals are generally well managed. A varied balanced diet is provided served in a pleasant atmosphere. Residents are encouraged to maintain contact with their families or friends as they wish and to take control of their lives whilst living at St Andrews. EVIDENCE: The daily routine, including getting up and going to bed and mealtimes, appeared to be flexible. They said that all staff were very kind and helpful. None of the residents spoken to were involved in local social or community activities. The home has a comprehensive programme of planned activities. During this visit some residents were accompanied and went out for a walk, another went up to the town “to collect the bread” others played a word game outside on the shaded patio and others chose to play “net ball “ in the lounge. Staff spent time with residents, chatting and assisting them generally and encouraged and supported some to undertake their individual interests. Some St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 14 residents choose to stay in their room as they enjoyed watching TV or listening to music of their choice. Residents are supported to maintain their religious beliefs by staff at the home and a record of individual wishes is recorded in their plans of care. Visitors are welcome to come to the home whenever they wish. The home has a comfortable homely atmosphere, which the residents enjoy. All residents spoken to said they enjoyed meals and mealtimes at St Andrews. Residents are given the choice of where they have their meal but most choose to go to the home’s comfortable dining room. On the day of the visit residents had the choice of three main dishes and four sweets. Meals were served individually to residents and were well presented. Staff helped residents, who needed assistance with eating, discreetly. Currently, the home is employing an agency cook to cover periods of leave. The cook was aware of specialist diets such as vegetarian and diabetic requirements. Residents are asked daily what they would like for lunch and evening meal. The manager and provider are committed to providing choice and a high standard of meals to residents. Their understanding of the importance of a balanced nutritional diet in relation to maintaining a good healthy lifestyle for residents was discussed. A questionnaire returned from a relative stated, “Home cooked, plenty of food, served hot. Assisted to eat by staff” and another “She is well fed with fresh and local produce”. St Andrews, Cullompton DS0000022036.V293215.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): OP 16 & 18. Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the service. The home has a satisfactory complaints process. Staff have a good knowledge and understanding of the forms of abuse thereby ensuring that residents are protected at the home. EVIDENCE: Residents confirmed that they feel comfortable discussing any concerns with staff at the home although some were unable to confirm that they had seen the home’s written policy. A copy of the home’s complaint procedure is available in each resident’s room and on a table in the entrance hall. No complaints have been made to either the home or the Commission since the last inspection. All six residents’ questionnaires stated that they “always know how to make a complaint” and “always know who to speak to”. There was nothing to suggest that residents are anything other than well cared for at the home. Residents said that staff were very helpful, respectful and that nothing was ever too much trouble for them. Staff have undertaken Adult Protection training since the last inspection and were able to discuss different forms of abuse. They all said that they would not hesitate to report any suspicion of poor practice. One member of staff was unsure of the appropriate action to be taken if an incidence of alleged abuse were reported to her. She agreed that she would update her existing knowledge. St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 16 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): OP 19 & 26. Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. The home is well maintained and kept clean. EVIDENCE: During this visit all shared areas of the home and some private rooms were seen; all were clean and well-maintained. Comfortable accommodation is provided for residents including a lounge and dining room. Residents’ rooms were homely and many had been personalised with their own belongings and some small items of furniture; all were well decorated and fresh. Decoration, furniture and fixtures throughout the home are of a consistently high standard. A comment card received from a relative said “This is a very clean and friendly home, all staff are helpful and kind” another “If I visit early morning or late evening the standards of house keeping is constantly high”. Eight questionnaires received from residents stated that the home is always clean and fresh. St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 17 All windows have been fitted with window restrictors, all radiators have been covered and all basin hot water taps have been fitted with thermostatic valves, to promote the safety of all residents St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 18 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): OP 27, 28, 29 & 30. Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. The number of staff on duty throughout the day and night meets residents’ personal and health needs. Residents are protected by the homes robust recruitment procedure. EVIDENCE: The number of staff on duty on the day of the inspection was sufficient to meet residents’ needs. The manager is generally on duty between 8am- 5pm. She aims to have 3 carers on duty between 8am-7pm. At 10pm 2 carers are on duty until 8am, one has a sleeping duty and is only woken to assist if necessary. The home employs a cook to work until 1pm daily therefore care staff are sometimes responsible for preparing residents’ evening meals. When feasible the evening meal is prepared by the cook during the morning so that care staff have to serve the meal. Eight residents returned questionnaires stating that staff are always or usually available when needed. Currently, 20 of care staff have an NVQ qualification and the home is working towards meeting the standard of at least 50 of care staff having a qualification at NVQ level 2 or above. At the time of this visit an NVQ trainer came to the home to enrol 3 carers onto an NVQ training programme and expects three others to enrol shortly. St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 19 All newly employed staff undergo a period of training when they start working at the home which includes the role of the worker, maintaining safety at work, communication, recognising and responding to abuse and professional development. A comprehensive record was looked at during this inspection. The time taken to complete this training will depend on past experience and individual abilities. Staff training at the home is ongoing. Training undertaken in the last 12 months includes protection of vulnerable adults, Understanding and care of incontinence, food hygiene and safety, diabetes education, basic emergency aid and management of medicines. Training planned to take place during the coming year next 12 months will include dealing with dementia, fire safety awareness, risk assessment, diet and nutrition, manual handling, infection control, coping with aggression and NVQ training. This will protect residents by ensuring that they are cared for by competent staff. A survey returned by a relative stated “Staff always have time to stop and chat and tell me about my relative, tell me what they have done since my last visit and what they have eaten”. Three staff recruitment files were looked at during this visit. The documentation was consistent with evidence of a safe and robust recruitment process being carried out before a person is employed at the home. This protects residents, as only people who have undergone this robust procedure will be employed to work at their home. St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 20 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): OP 31, 33, 35 & 38. Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the service. There is clear leadership and guidance to staff to ensure residents receive consistent care in a reasonably safe environment. EVIDENCE: The manager has almost completed a Registered Managers Award. She gives clear direction and leadership to the staff at St Andrews. Residents, staff and relatives all said how approachable she is if they have any problems. The home has a system to monitor the quality of care and enable residents and their families to contribute to the running of the home. This ensures that standards of health, social care and welfare needs will be maintained and a programme of continuing improvement developed at the home. Residents will benefit by being assured that the home is working towards delivering high standards of care. The home’s system for assuring quality includes a St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 21 suggestion box prominently placed in the hall, regular residents’ meetings, when residents are encouraged to feedback any suggestions to the manager, and monthly unannounced visits to the home by the home’s administrator, a report of which is sent to the manager, owners and the Commission. Residents and relatives have recently been sent a questionnaire asking them to comment on various aspects in the home, for example, meals, staff, decoration and cleanliness. The results of quality assurance audits should be published in the home’s statement of purpose to ensure that the information collected will be available to all current and potential residents. The manager said that residents are also consulted daily about the running of the home. The home does not look after any residents’ monies. Those who might choose to look after their finances are encouraged and supported to do so. A record is kept of any bills paid on behalf of a resident and a monthly account is sent to whoever deals with their finances. This may be a relative, solicitor or financial advisor. Residents’ records are securely stored and would be made available to them, or their representative with their consent. Records show that staff undertake training in the prevention of fire and fire alarms and emergency lighting tests have been carried out regularly. Fire safety equipment, for example fire extinguishers, had been regularly serviced and the fire log showed regular checks and maintenance on emergency lighting and fire alarms. A door leading to the kitchen is a fire door and should be kept closed at all times. At the time of this visit this door was wedged open. This was discussed with the owner and the cook who both confirmed that they thought the risk of accidents from having to open the door when carrying food or drinks outweighed the risk of fire. The owner has confirmed that the kitchen door will be fitted with an electric magnetic release, connected to the fire alarm system, within the next 21 days. Written assessments will be undertaken to minimise the risk of the kitchen door being kept closed until the closure has been fitted. Assessments of identified hazards and associated risk relating to the environment, have been undertaken which contribute towards ensuring that St. Andrews provides a safe, comfortable and pleasant home for residents to live. St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 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 2 St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 23 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 OP38 Regulation 23[4][c] Requirement The registered person shall after consultation with the fire authority make adequate arrangements for containing fires. [This relates to the kitchen door, which is a fire door being wedged open. Since the inspection the owner has confirmed that a magnetic release will be fitted to the door within 21 days. Written assessments will be undertaken to minimise the risks of the door being kept closed until the device has been fitted] Timescale for action 24/08/06 St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 24 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 Residents or their representatives should be involved in the planning and reviews of their individual care needs. Individual goals for residents should be recorded in care plans. Care plans should include details of how individual residents choose to have their care given. 2 OP9 A separate fridge should be available to ensure the correct temperature is maintained for the storage of some medication. [The owner has agreed to obtain a separate fridge] Procedures for reporting allegations of suspected abuse or neglect should be understood by all staff. The results of quality assurance surveys should be published and made available to current and perspective users, their representatives, any other interested bodies and the CSCI. 3 4 OP18 OP33 St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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 St Andrews, Cullompton DS0000022036.V293215.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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