Inspection on 27/09/05 for St Andrews House, Ashburton

This inspection was carried out on 27th September 2005.

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

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

Other inspections for this house

St Andrews House, Ashburton 10/01/07

St Andrews House, Ashburton 22/02/06

St Andrews House, Ashburton 01/02/05

St Andrews House, Ashburton 07/07/04

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 House West Street Ashburton Newton Abbot TQ13 7DU Lead Inspector Michelle Finniear Announced 27 September 2005 th 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 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 House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Andrews House Address West Street, Ashburton, Newton Abbot, Devon, TQ13 7DU Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01364 653053 www.standrewshouse.com Mrs Rosemary Christophers, Mr Jeremy Christophers, Mr Duncan Christophers Sally Jo Rhodes Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Old age, registration, with number not falling within any other category (24), of places Physical disability over 65 years of age (24) St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1/2/05 Brief Description of the Service: St Andrews House is a privately owned care home for elderly people, some of whom suffer from physical and mental health problems associated with old age, in the categories of OP, DE and PD. The home is a detached property set in its own walled grounds, consisting of the original rectory with an extension built about eight years ago. The home is well kept and managed by family owners and has a registered manager, who oversees the day-to-day running of the Home. There are two lounge areas and a garden room, which also serves as a dinning area located on the ground floor. There are also some Service User bedrooms on this level with the rest being on the first floor, which is accessed via a shaft lift or staircase.All rooms are currently used for single occupancy and most have ensuite facilities.The Home has attractive and well maintained grounds with level access for Service Users.The Home is situated within a short walk to local shops and amenities. St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over 5.75 hours on a Tuesday in September 2005. The inspection was announced, which means that the home received prior notice of the date and time. To complete the inspection a tour was made of the home; six service users were interviewed and time was spent with other service users with greater frailty; three members of staff and a visiting district nurse were spoken to; time was spent with the homes management and various records were inspected, such as care plans, the fire log book, and medication records. Discussion was also held on staff training and recruitment. Prior to the inspection seven relatives completed comment cards about the home, and the home owner completed a pre-inspection questionnaire. What the service does well: The home provides comfortable and attractive accommodation, with en-suite facilities, accessible level gardens and a choice of communal space for service user use in three lounges. Service users have a range of needs, however the home manages to integrate this variation within the space available. This means that communal areas are well used during the day, with a variety of activity going on. An excellent menu is prepared with evidence of several choices and healthy eating principles in use, ensuring service users enjoy a varied and nutritious diet. The home has thorough care plans, which reflected well the service users needs and the actual care given by staff. Plans include risk assessments and other user specific assessments, such as falls risk assessments, to ensure service users abilities and choices are maximised whilst their safety is maintained. Several staff, including the manager have been working at the home for many years, providing some consistency in care practice. Comments from service users, visiting professionals and relatives were very complimentary, and included “ I can’t find any fault with it”, “very good, very kind and helpful” and “I am happy with the way my Auntie is cared for”. St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: The glass in the low period windows at the front of the property should be protected by safety film or other means, to protect service users from risks from broken glass in case of the service user falling against them. The cracked window pane in one service user room needs replacement, to ensure service users live in a safe and attractive environment. Water temperature regulation must be restored to the required safe temperature in the ground floor bathroom, so that service users are not placed at risk of scalding. The registered person should ensure that prescription only dressings are maintained separately to those in the first aid box; this is to ensure that they are not accidentally used in an emergency. Some prescriptions should be rewritten and/ or reviewed to better reflect the current needs of service users, in particular in relation to where medication is prescribed as a variable dose i.e. ‘one or two tablets’. It is recommended that the home obtain a medication refrigerator, otherwise medication requiring refrigeration should be kept in a St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 Page 7 lockable facility within the fridge. This is to ensure medication is kept in the right conditions and cannot be misused. Where service users or their relatives have firm views on resuscitation procedures or non-intervention policies they should be encouraged to share them with the relevant GP. This is to ensure that service user views are respected and shared with all relevant parties. The registered provider must ensure that all radiators are covered or have low surface temperatures. This is to ensure all hot surfaces are protected, so that service users are protected from coming into prolonged contact, e.g. through falling against a hot radiator. 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 House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 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 standard(s) 1, 3, 6 Service users and potential service users receive good clear information about the home, in sufficient detail to enable them to judge whether the home is the right place for them. The home gathers sufficient information before admission to be able to make a decision about whether they can meet the service user needs. EVIDENCE: The home has a statement of purpose (which was not inspected on this occasion but has been previously), and a service user guide which has been issued to each service user and is kept in their room with a pen picture of each service users needs. Quality assurance forms completed by service users indicated that in the main they had read this information and had found it useful. The service user guide is written in plain language and has photographs illustrating the text. The service user guide is important as it gives clear information for service users about what they can expect to receive from the home and what services can be provided. An examination was made of five service user files, including a recent admission. The file for the most recent admission included a pre-admission St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 Page 10 assessment completed by the home, covering the majority of areas of care. Discussion was held with this service user concerning the admission process and reasons for admission, which verified the information contained within the assessment. The service user had signed some of the initial assessment carried out to verify the accuracy of the information contained. Other service users files examined also included this pre-admission assessment process, and evidence was also seen in some files of a Social Services Preassessment plan having been undertaken. Pre-admission assessments are important as they ensure that the home is the right place for the service user, and that the home can meet their needs. The home does not cater for intermediate care. This means that the home does not provide specialist programmes for rehabilitation as a primary function. St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10 St Andrews House has a clear and consistent system for the planning of care, ensuring staff have the information to satisfactorily deliver care to service users in the way in which they have indicated they wish it to be delivered. Minor attention was required to medication systems, which were otherwise safe. EVIDENCE: Each service user at the home has an individualised plan of care, linked to an assessment process and wherever possible signed by the service user or their relatives to indicate agreement. Specific areas of care planning such as those involving the use of beds sides or rails are covered by separate statements within service user files. One file also included a historic request for the use of a wrist alarm for one service user where there was grave concern this person could have left the home and been at risk in the local community from traffic. It is recommended where relatives have strong views on resuscitation practice this be discussed by them with the local general practitioners supporting their relatives care. This is to ensure that all people concerned are aware of service users wishes. St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 Page 12 Five service user plans were examined in detail, and in addition two service user pen pictures kept in rooms were also seen. Following this and the tour of the premises the care plans were verified through meeting the individual service users and discussions with staff. In the case of two service users an in-depth discussion was held with the head of care in relation to the actual care being delivered, and this correlated directly to the information in the care plan. This demonstrated that plans were an accurate reflection of the care being given. Care plans are reviewed monthly, or more frequently if required and this is recorded within the plans. Accurate and up-to-date care plans are important in ensuring that service users needs can be addressed consistently by all staff. Evidence could be seen also in files of service users health care needs being met. This included not only visits from general practitioners and district nursing staff, but also access to professionals such as opticians and podiatrists. A visiting district nurse was spoken to during the course of the inspection, and she confirmed that the home were responsive to changes in service user needs, had good supplies of equipment for preventing pressure areas and that they had no concerns about care practice issues within the home. She confirmed that if the home have any concerns about a service user, district nursing staff are contacted early for advice, thereby preventing minor problems developing into larger concerns. This demonstrates the home manager is aware of the limits of the care they can provide and has a good working relationship with healthcare professionals. The home has equipment for supporting the moving and handling needs of service users, including mobile hoists, pressure relieving equipment and an assisted bath. This ensures the home can meet the needs of the people who live there, without risking injury to staff or service users through having to lift them. Service users medication is maintained within the home in a locked cupboard, and risk assessments have been undertaken for those service users who wish to self-medicate. These could be seen in service user files. The home uses a monitored dosage system for the administration of medication, which means that the pharmacist dispenses the medication in a series of blister packs for the home to use when administering. This means that staff can easily see whether medication has been given, and reduces the risk of errors. The medication cupboard was inspected and found to be clear of excess stock, and the records seen were recorded appropriately to ensure a full audit trail could be carried out, however the home is advised to ensure that where prescriptions indicate a variable dose, i.e. “one or two tablets when required”, that the number actually given is recorded. Administration of controlled medication was satisfactory, but some medication requiring refrigeration is kept in an unlocked box in the refrigerator. St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 Page 13 Dressings and other first aid equipment is provided, however a first aid box examined also contained some prescription only dressings which will need to be removed to avoid accidental use. Service users spoken to confirmed they were treated with respect and dignity. Interactions witnessed during the course of the inspection confirmed this, for example staff were heard speaking to service users in a respectful manner using their preferred term of address, and staff could be seen knocking on doors before entering rooms. During the course of the inspection service users took part in “Armchair aerobics” aimed at improving flexibility, mobility and preventing falls. St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15 Dietary needs of service users are well catered for with a balanced and varied selection of food available. EVIDENCE: The home has an varied menu plan, changed four times a year, reflecting the compromise between healthy eating principles and service user choices of traditional British meals, as requested by them in the quality assurance questionnaires seen. Service users eat in two main areas of the home, but may also choose to eat in their rooms. Discussion was held with the homes cook, and lunch was eaten with the service users at the home. The meal served was a choice of Homity pie and a selection of salads or beef casserole. Dessert was a Tiramisu with cream. The menu was on display in the home and service users had been asked for their preferences in advance. Additional choices were also available, and the home is able to cater for some special diets. Currently a diabetic diet is provided and some service users require different textured foods to assist with problems in swallowing. The majority of the food in the home is home cooked, including home made cakes daily. St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 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 standard(s) 16, 17, 18 Procedures are in place to protect service users from abuse and abusive practice and to address any concerns or complaints that may be raised. EVIDENCE: The home has a complaints procedure which is detailed in the service user guide maintained in every service users roam and on a notice board in the lounge. The complaints procedure contains information on people outside of the home to whom complaints may be addressed. This is to ensure that if people were concerned about raising issues directly with the home they would have information provided as to who to go to. No complaints have been received by the home or by The Commission for Social Care Inspection in the last year, other than minor issues raised directly with the home in relation to fixtures and fittings which were dealt with immediately. Service users spoken to felt confident that they knew who they would raise concerns with at the home and confirmed they would feel able to do so. This was confirmed in the three service user comment cards returned prior to the inspection. Also in these a relative commented “Any concerns I have I can always discuss with staff or who’s in charge at the time”. Service users are registered voters. The home has a policy on protection of vulnerable adults, and staff have received training both in the policy and its implementation. Additional staff St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 Page 16 training is booked for the near future. The home has a copy of the local authority policy and guidance in relation to the protection of vulnerable adults available in the home for reference. This policy is based on local best practice and government guidance. St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 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 standard(s) 19, 20, 21, 22, 23, 24, 25, 26 St Andrews house provides a comfortable environment for service users. EVIDENCE: St Andrews house comprises of an old period property with a purpose-built wing attached to the rear. All bedrooms have en-suite facilities of either showers or baths, and there are three separate communal areas for service user use. There are extensive gardens to the rear, and some parking to the front. The Fire Officer last visited the home in May 2004, and the Environmental health officer visited in February 2005. Regular fire drills and practices are carried out at the home and evidence of this could be seen recorded in the fire log book. In addition the home has contracted for external fire training for staff, certificates for which were seen. The home has had a new fire panel installed since the last inspection. These measures mean that service users are protected as far as possible from the risks of fire. Discussion was held with the manager concerning one service users request to have the door open, and St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 Page 18 it was agreed that following consultation with the fire authority an approved device could be obtained for such a purpose. All areas of the home seen on this inspection were clean, warm, odour free and comfortable. The homes laundry is small but centrally located, and plans are in hand to replace the current provision in the near future. Infection control practices seen were satisfactory, including for the disposal of clinical waste, which is kept outside of the home and collected by contractors regularly. This means service users are protected from a risk of cross infection or odour. Rooms vary considerably in shape and size, and although there is a chairlift to the period rooms at the front of the property some are still have small flights of stairs either within the room or to access the room itself. In the rear of the property with the purpose-built extension there is a passenger lift to access the first-floor rooms. Some rooms on the first floor have balconies and discussion on these was held with the manager who stated she assessed any risks before letting these rooms. All bedrooms have locks fitted to the door to enable service users to lock the room if they so wish, however it is understood that currently only three service users have requested keys. Discussion was held with the manager on ensuring the safety of low windows, particularly in the period part of the property. It is recommended that safety film or glass be provided. This will ensure that if a service user were to fall against the window the risk of injury would be minimised. One service user has a cracked pane of glass in their room and the manager agreed to remedy this. A series of environmental risk assessments have been carried out, both for the environment of the home and also for the care tasks carried out within it. These risk assessments, regularly updated, review any risks inherent within the environment and detail any measures to be undertaken to remove or reduce the risks to staff and service users. Discussion was held on the provision of radiator covers all other hot surface protection. The home has commenced a programme of hot surface protection, however this is not has not been finally completed. The manager confirmed that water temperature regulation to a maximum of 43°C has been provided to all baths and showers, and it is understood that this will be increased in the near future to provide regulation to all wash hand basins. However the water temperature supply to a bath on the ground floor was tested at random and found to be in excess of 50°C. The manager agreed to have the regulator re-calibrated without delay. Service users rooms showed evidence of personalisation, with items of their own furniture, photographs and paintings. St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 Page 19 St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 The homes recruitment and employment practices protect service users and ensure that appropriate levels of trained staff are on duty to support service users. EVIDENCE: Service users confirmed that the home has a core of consistent staff but has had a turnover of staff in other positions. The pre-inspection questionnaire indicated that this has been due to maternity leave, house moves and a return to working in the NHS in the main. Several other staff have worked at the home since the mid 1990’s, including the manager. This means consistency of care can be provided for service users despite some staff turnover. No agency staff are used. Staffing levels appeared satisfactory to meet the number and dependency needs of the service users accommodated. The home has one waking and one sleeping staff member at night. Service users confirmed that all they had to do was ring the call bell and staff would attend at any time, day or night, even if they just wanted to have a cup of tea in the middle of the night. They also confirmed that staff were very kind and willing – one commented that “all the girls are lovely – I can’t fault them”. The home has a recruitment procedure that protects service users. Discussions with the manager outlined the homes procedure, which was then verified through the examination of three staff files selected at random. Files contained all the required information in relation to the appointment of staff St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 Page 21 such as references, medical checks, criminal records bureau checks, evidence of qualifications and evidence of induction and foundation training materials for new staff. This means that service users are protected from being cared for by people who are unsuitable to work with vulnerable adults as far as possible. Some dementia specific training has been undertaken since the last inspection. St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 St Andrews house provides a generally safe place for service users to live in and for staff to work in. Some attention remains to be paid in relation to the protection of hot surfaces and the temperature regulation of hot water. EVIDENCE: Evidence could be seen of comprehensive risk assessments having been undertaken at the home. This included those for the environment, for working practices and for service user activities. This is to ensure that all risks to service users and staff have been identified and minimised as far as possible. The home has maintenance contracts for all services, and could demonstrate evidence of a recent electrical inspection carried out following the last CSCI inspection. The home has regular fire tests, drills and instructions and servicing of the Fire system remains under contract which should mean that service users are protected by well maintained fire equipment and well trained staff. Evidence was seen of employers liability insurance being in place. St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 Page 23 All windows above the ground floor have restricted width openings, and discussion was held with the manager on the risks presented by the balconies. This is to prevent service users from any risks of falling from Windows or balconies. Some attention was required to protect the low period windows in the older part of the property from service users falling against them and breaking glass, and a bath tested at random had water temperatures in excess of the standard. This has the potential to scald service users and the manager agreed it would be rectified without delay. A programme of hot surface protection is being undertaken, and it is hoped that this will be completed within the next two months. This is to prevent service users from coming into prolonged contact with a hot surface i.e. by falling against a radiator. Safety data sheets could be seen for all cleaning chemicals in use, and discussion was held concerning the sterilisation of the Jacuzzi bath. This is to ensure service users are protected from any infection and that the home has safety information available in case of accidental misuse of cleaning chemicals. The home has six monthly legionella testing undertaken and staff receive training in health and safety practices. Staff training also includes first aid and food hygiene practices, as well as infection control practice. Equipment such as gloves and aprons is available, and the home also uses sterilising hand gels to prevent any risk of cross infection. Moving and handling equipment is serviced regularly, and staff receive training in moving and handling practices. This is to ensure that service users and staff are not injured during moving and handling procedures. St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 4 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x x x x x x 2 St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 Page 25 Yes Are there any outstanding requirements from the last inspection? 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 13 Requirement The registered provider must ensure that all radiators are covered or have low surface temperatures. Previous dates for compliance 30/8/04, 30/4/05. The glass in the low period windows at the front of the property should be protected by safety film or other means. The cracked window pane in one service user room needs replacement. Water temperature regulation must be restored to the required safe temperature in the ground floor bathroom Timescale for action By 30/11/05 2. OP38 13 By 30/11/05 3. OP38 13 By 30/9/05 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 OP9 Good Practice Recommendations The registered person should ensure that prescription only dressings are maintained separately to those in the first aid box. Some prescriptions should be re-written and/ or reviewed to better reflect the current needs of service users, in particular in relation to where medication could D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 Page 26 St Andrews House 2. OP7, OP11 be issued as one or two tablets. It is recommended that the home obtain a medication refrigerator, otherwise medication requiring refrigeration should be kept in a lockable facility within the fridge. Where service users or their relatives have firm views on resuscitation procedures or non-intervention policies they should be encouraged to share them with the relevant GP. St Andrews House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 House D54-D07 S3810 St Andrews House V239387 270905 Stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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