Inspection on 27/06/06 for St Ann`s

This inspection was carried out on 27th June 2006.

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

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

Other inspections for this house

St Ann`s 11/06/07

St Ann`s 01/09/05

St Ann`s 02/05/05

St Ann`s 13/12/04

St Ann`s 13/04/04

St Ann`s 13/01/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE St Ann`s The Crescent Kettering Northants NN15 7HW Lead Inspector Mrs Kathy Jones Unannounced Inspection 27th June 2006 08:30 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 DS0000012921.V301692.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. DS0000012921.V301692.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Ann`s Address The Crescent Kettering Northants NN15 7HW 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) 01536 415637 01536 519304 Collycare Limited T/A B&M Care Mrs Teresa Ann Hayward Care Home 39 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (39), of places Physical disability over 65 years of age (4) DS0000012921.V301692.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Up to 7 service users with Dementia may be accommodated on the First Floor A maximum of 14 service users with dementia may be accommodated on the ground floor A maximum of 4 service users with a Physical Disability can be accommodated on the first floor. 1st September 2005 Date of last inspection Brief Description of the Service: St Anns is a care home providing personal care and accommodation for 39 older people over the age of 65 years. Collycare Ltd trading as B & M Care owns the home. The home is located in Kettering Town and within walking distance of the train station and town centre shops and amenities. The home is purpose built and separated into two self-contained units on two floors. A passenger lift provides access to the first floor. On the ground floor, the home can care for 14 Older People who have dementia. On the first floor the home can care for Older People including up to 7, who have a mild form of dementia and up to 4 with a physical disability. 27 of the bedrooms are single occupancy and 20 have en suite toilet facilities. The home has an enclosed garden, which is well maintained, and has a small raised fishpond accessed directly from the ground floor lounge. The following fees were provided by the registered manager as being current at the time of submission of the pre-inspection questionnaire on 2 May 2006: • Fees per week are between £385:00 and £420:00. The fees include personal care, accommodation, meals and laundry. Chiropody and hairdressing services can be arranged and are charged separately. DS0000012921.V301692.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. All standards identified as ‘key’ standards and highlighted through the report were inspected. The key standards are those considered by the Commission to have a particular impact on outcomes for residents. Inspection of the standards was achieved through review of existing evidence, pre-inspection planning, an unannounced inspection visit to the home and drawing together all of the evidence gathered. The pre-inspection planning was carried out over the period of half a day and involved reviewing the report of statutory inspections carried out in May 2005 and September 2005 and the service history, which details all contact with the home including notifications of events reported by the home and telephone calls. A pre-inspection questionnaire submitted by the registered manager was received following the inspection and prior to the production of the report. Completed questionnaires were received from six relatives/visitors, three residents’ and seven health care professionals. Some of this information has been included in the report and all information gathered assisted with planning the particular areas to be inspected during the visit. The unannounced inspection visit covered the morning and afternoon of a weekday. The inspection was carried out by ‘case tracking’ which involves selecting residents’ and tracking their care and experiences through review of their records, discussion with them, the care staff and observation of care practices. The inspector also met with other residents’ who were not part of the case tracking process and visiting relatives to listen to their views on the care provided. Observations were made of residents’ general well being, daily routines and interactions between staff and residents throughout the inspection. The management of residents’ medication and money held on their behalf was reviewed. Recruitment procedures were checked through discussion with a recently recruited member of staff and review of two staff files. Communal areas and a sample of residents’ bedrooms were viewed with the registered manager. New care planning processes, which were being implemented, were discussed with staff, the registered manager and the director of care who has been training and support staff. Feedback was given to the registered manager throughout the inspection. DS0000012921.V301692.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The findings of this inspection reviewed alongside those of the previous two inspections identify that improvements have been made. For example previous requirements have been made regarding the planning and monitoring of residents’ care. A requirement relating to the need for up to date care plans has been repeated following this inspection however work is now being carried out to train and support staff with care planning. A new system is being introduced which staff confirmed they were finding easier to use. A comment received from a health professional stated that the home had improved over the last year. Discussions during the inspection indicated that more support in achieving good outcomes for residents’ is being received from staff at head office. DS0000012921.V301692.R01.S.doc Version 5.2 Page 7 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. DS0000012921.V301692.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 DS0000012921.V301692.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): 2, 3, std 6 is not applicable as intermediate care is not provided. Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. The admission process establishes the home’s ability to meet the needs of people admitted to the home prior to admission. EVIDENCE: Comments received from two residents and a relative confirm that they received sufficient information about the home prior to moving in to decide it was the right place for them. A sample check of a resident’s file confirmed that terms and conditions are agreed with the resident and or their representative. Review of a recently admitted resident’s care file confirmed that an assessment of need had been carried out prior to the resident being admitted to the home and an assessment from the local authority had been obtained to aid the decision as to whether the resident’s needs could be met in the home. A recommendation received from the hospital appeared to suggest that nursing DS0000012921.V301692.R01.S.doc Version 5.2 Page 10 care rather than residential care was required. However discussion with the registered manager indicated that this was not the case and since admission the home had no difficulty in meeting the needs of the resident. Advice was given to ensure that clarification is always sought on any information that may indicate a prospective resident’s needs are outside the range that the home is registered for and able to meet, and that a record is kept of how a decision to admit was arrived at. The assessment tool currently used to identify the needs of a prospective resident is in the process of being revised to ensure all relevant information regarding needs and preferences have been gathered. The current assessment tool is in a tick list format and although there is space for the assessor to add additional comments the form is difficult to use and staff are not expanding on the information. Discussion with the registered manager and the care director confirmed that more care is being taken to ensure that the needs of people admitted to the home can be met. DS0000012921.V301692.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using all the available evidence including a visit to the service. The overall care provided appears to be good however the lack of up to date care plans in some cases and the discrepancies in medication has the potential to put residents at risk of their needs not being fully met. EVIDENCE: Questionnaires returned from seven relatives confirmed that they are satisfied with the overall care provided. Of the two questionnaires received from residents one said they always receive the care and support they need and the other said they do sometimes. Residents spoken to during the inspection were happy with the care they received, staff were aware of residents’ needs, and observations indicated that residents’ needs were being met. New care plan formats and record keeping systems to monitor and plan residents’ care were being put in place at the time of the inspection. Review of a sample of care plans and discussion with staff identified that they were finding the new formats easier to work with. Advice was given to include the DS0000012921.V301692.R01.S.doc Version 5.2 Page 12 date the care plans was drawn up as in some cases it was difficult to ascertain when the plan had been implemented. Observations and discussion with staff about residents’ needs highlighted that care plans had not been updated to reflect residents’ changing needs. For example there was no reference in a resident’s care plan to them having a pressure sore even though this was highlighted in the staff communication book. Another resident’s dietary needs had changed which was not reflected in the care plan. Discussion with staff identified that a lot of the information about residents’ care needs is passed over informally which runs the risk of staff not receiving full or accurate information and residents needs not being met. One resident had a syringe driver in place to provide pain relief and although the district nurses were visiting twice a day there was no care plan to inform staff as to what to check to ensure that it was still working effectively or what to do if the district nurse didn’t arrive. An entry in one resident’s care plan stressed the importance of touch to them and holding their hand showing consideration is given to resident’s emotional needs as well as their physical care needs. Records show that relevant health professionals are accessed on behalf of residents’. Prompt action was taken to contact a resident’s General Practitioner during the inspection due to a change in condition. Seven questionnaires were received from health professionals, mainly General Practitioners’, the comments were very positive confirming that the home communicates clearly with them and works in partnership with them. They also confirmed that staff demonstrate a clear understanding of residents’ needs. One response confirmed that improvements had been made in the last year. A sample check of the medication system identified that there is a clear system in place for recording medication received into the home, medication administered and medication returned to the pharmacy. The majority of medication is supplied in a blister pack format, which aids stock control and auditing. A check of medication for a resident whose medication had not been supplied in the blister pack format identified discrepancies, with two tablets short for one type of medication and one tablet over for another. As all medication had been signed as given in accordance with the prescription the reasons for the discrepancies could not be established during the inspection. It was also identified that alterations had been made to the pharmacy label on a medication. The reasons for this were explained during the inspection however advice was given that any errors must be taken up directly with the pharmacy on receipt of the medication and that alterations must not be made. Staff have received training in the management of medication and the home have a system in place to audit medication which takes account of individual DS0000012921.V301692.R01.S.doc Version 5.2 Page 13 staff competence. However following the inspection the registered manager has informed the inspector that the auditing process is to be revised in the light of the findings during inspection. Residents’ confirmed that their privacy and dignity is respected. Staff were observed to assist resident’s with dementia to maintain their dignity. DS0000012921.V301692.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 at least once during a 12 month period. 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 all the available evidence including a visit to the service. Visitors are encouraged and welcomed into the home and residents’ are happy with the food provided. Routines are flexible however residents’, particularly those with dementia, would benefit from more occupation and stimulation. EVIDENCE: Observations during the inspection identified that routines are relatively flexible with residents being assisted to wash and dress as and when they were ready. Two residents’ told the inspector that they preferred to spend most of their time in their rooms but liked to join others for coffee and meals. A resident confirmed that he was supported in maintaining his religion and that the local priest visited regularly and gave communion to residents’ who wished. Visiting arrangements are flexible and relatives and visitors confirm in questionnaires that they are made welcome in the home and that they are able to visit in private if they wish. DS0000012921.V301692.R01.S.doc Version 5.2 Page 15 The home has an activity organiser however nothing was planned for the day of the inspection. Of the two questionnaires received from residents one said that the home always provide suitable activities while the other said that they never do. On the morning of the inspection, a group of residents’ in the upstairs lounge were discussing and laughing about a morning television programme. Residents’ upstairs confirmed that they are able to use the garden if they wish and do sometimes in the warm weather. Downstairs some residents’ spent some time wandering out into the garden and when staff were not involved in assisting with personal care, meals or administration of medication they were observed to spend some individual time with residents particularly those who were becoming restless. For example they were looking at some pictures of film stars, which had been laminated. Discussion with the registered manager and the care director confirmed that they have identified the need to improve the level of activities and stimulation particularly for those residents with dementia. The registered manager is currently attending some dementia care training and intends to implement some ideas from the training. Residents’ said that they are happy with the meals provided. There is a rotating menu, which the cook advised is altered periodically according to residents’ feedback. Residents are able to have a cooked breakfast if they wish; there is a choice of main meal at lunch time and choices at tea. Residents are asked what they would like for the meals the day before but often forget what they have ordered or change their minds, however staff confirmed that there is usually sufficient for them to have their preferred option. At the time of the inspection the only special diet was a liquidised meal, it was confirmed that the ingredients are liquidised separately to maintain taste and appearance. Observations of the service of the lunch time meal on the ground floor identified that some residents’ with dementia were reluctant to sit at the table and finish their meal. Staff were observed to encourage and assist where needed and to offer the meal in a different place, either the lounge or another dining area. The registered manager advised that she is considering making some alterations to the provision of meals for residents with dementia and perhaps providing smaller meals/nutritious snacks more regularly. DS0000012921.V301692.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. The home has procedures for dealing with concerns and complaints and staff are aware of their responsibilities for protecting the people in their care. EVIDENCE: The Commission for Social Care Inspection have received no complaints about the service since the last inspection. The Registered Manager has confirmed in the pre-inspection questionnaire that no complaints have been received by the home. Responses to residents and relatives’ questionnaires identify that the majority of people are aware of who to talk to if they have any concerns or wish to make a complaint. Residents’ and staff spoken to during the inspection had no concerns about how residents’ were being treated and staff were aware of their responsibilities to act to protect residents’. DS0000012921.V301692.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. The home was clean, comfortable and re-decoration was underway providing a pleasant environment for residents, however a problem with controlling the temperature was making life uncomfortable for some residents’. EVIDENCE: Communal areas of the home and a sample of residents’ bedrooms were seen during the inspection. Communal areas and bedrooms are located on both floors of the home. The layout and organisation of the home allows residents’ to seek company or to spend time on their own. There is an enclosed garden, which leads directly off the lounge on the ground floor, it was well maintained and contains flower borders and a raised fishpond and water feature. DS0000012921.V301692.R01.S.doc Version 5.2 Page 18 Residents’ on the ground floor are able to wander in and out freely and those upstairs said they are able to use the garden. There is a programme of re-decoration and refurbishment in place and the upstairs corridor was in the process of being re-decorated at the time of the inspection. The registered manager has implemented a monthly check of the premises to identify any areas for improvement. Details of the findings are forwarded to head office to arrange any necessary work; the manager then monitors the action taken. At the time of the inspection it had been identified that there was a possible leak affecting the lounge near to the entrance to the garden and possibly the corridor on the ground floor. The registered manager confirmed that a verbal report had been made to head office the previous week and confirmed she would chase this up as although no risk had been identified to residents’ at the present time there is the potential for risk if the leak worsens. A sample check of residents’ rooms identified that they are able to bring their personal possessions into the home. Some bedrooms have had furniture replaced and the registered manager advised that some items in other rooms were due to be replaced. Discussion with residents’ on the first floor identified that they were generally happy with the environment however some residents’ said they were very uncomfortable due to the heat in the communal areas and some bedrooms. There appeared to be quite a variance in temperature between rooms but unfortunately thermometers could not be found in the home to check the temperature. Portable fans are in place in some residents’ rooms. It was noted that although it was a hot summer day the heating was on in one bedroom that was particularly hot. Staff advised that they have been instructed not to adjust the radiator in residents’ bedrooms as it upsets the boiler. The registered manager confirmed she would raise this problem again with head office and ask them to review the situation. The problem with temperatures appeared to relate on this occasion mainly to the first floor however issues have been raised in the past during summer and winter about the inability to adjust the temperature to meet residents’ needs. Advice was given to again start to check and record temperatures and consider how the problem can be resolved. A resident told the inspector that they were happy with the standard of cleanliness and that their room was kept clean. All areas of the home seen were generally clean and tidy and care is taken to try to keep the home free from offensive odours. A sample check of residents’ rooms identified that where commodes were in use these were not thoroughly cleaned in all cases and the lids to the pots could not be found. DS0000012921.V301692.R01.S.doc Version 5.2 Page 19 The pre-inspection questionnaire identifies that staff have received training in infection control. Staff were observed to use protective gloves and aprons and instructions for correct hand washing to reduce the risk of transferring infection were posted next to staff hand washing facilities. The registered manager was informed of recently published guidance for care homes on infection control. DS0000012921.V301692.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. Staff training, recruitment procedures and staffing levels provide good care and protection for Service Users. EVIDENCE: Five out of six relatives/visitors who responded to a question about the sufficiency of staff confirmed that in their opinion there are sufficient staff on duty. Observations during this unannounced inspection indicated that there were enough staff to meet resident’s needs. Resident’s spoken to said they are happy with the staff team. Staff were observed to respond appropriately to resident’s needs and to have a calm, caring and professional approach. The pre-inspection questionnaire identifies that 55 of staff have achieved a National Vocational Qualification (NVQ) at level 2, which provides staff with a basic understanding of the care needs of Older People. Future training planned includes NVQ2, NVQ3 and the two assistant managers are working towards a registered managers award, which is the equivalent of NVQ4. The preinspection questionnaire and discussion with the registered manager during the inspection confirm that plans for training take account of the need to ensure DS0000012921.V301692.R01.S.doc Version 5.2 Page 21 staff have the skills to meet the specific needs of residents. For example additional dementia care training is planned. The director of care has been providing some training on care planning for staff alongside the implementation of the new care plans. Discussion with staff indicated that the ongoing support and training they are receiving is key to the successful implementation of the care plans to support resident’s care. A staff member confirmed that there is an appropriate induction process enabling new staff to understand their responsibilities and the needs of the individual resident’s. The registered manager confirmed that the programme meets the sector skills guidelines. The recruitment process was discussed with a recently recruited member of staff and files for two recently recruited staff were reviewed to check the adequacy of the recruitment process in protecting residents’. It was confirmed that interviews are held and that references including criminal record bureau clearances are obtained prior to staff working in the home. DS0000012921.V301692.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using all the available evidence including a visit to the service. The management and organisation of the home is good promoting the health, safety and welfare of the people living in the home. EVIDENCE: The registered manager has achieved the National Vocational Qualification Level 4 in Management and the Registered Managers Award since the last inspection. The registered manager is currently undertaking dementia care training and confirmed a commitment to continuing to update her knowledge. Discussion during the inspection indicated that the registered manager is receiving good support from the head office team in achieving good outcomes for residents’. DS0000012921.V301692.R01.S.doc Version 5.2 Page 23 Elements of a quality assurance programme are in place and the inspector was informed that quality assurance systems continue to be developed. Residents’ and relatives have been asked for their views on the care provided. Results of this survey, which were mainly very positive, were displayed in the home with details of the actions that were going to be taken to address issues raised. Questionnaires are due to be sent to staff to gain their views on the service provided and any required improvements. Regular audits of the premises and medication are carried out. The inspection highlighted some shortfalls in both these areas, which the registered manager is looking into. Small amounts of money are held on behalf of some residents’ to pay for additional services such as hairdressing and chiropody. Records are kept detailing all transactions and a sample check confirmed that there are receipts to verify payments. Health and safety issues are reviewed as part of the regular premises checks. The pre-inspection questionnaire confirms that regular servicing and maintenance checks on the premises and equipment are carried out. For example servicing of the central heating system, lift and fire equipment. Discussion with staff confirms that they receive appropriate training in safe working practices. DS0000012921.V301692.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000012921.V301692.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 12(1)(a & b) Requirement Up to date care plans must be in place, which cover all areas of care needs including pressure area care and other health care needs, which detail the required actions of the carer. (This requirement is outstanding from the previous inspection) Timescale for action 30/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP25 OP26 Good Practice Recommendations Improved auditing and monitoring of staff competence in the management of residents’ medication should be implemented to reduce the risk of error. Ventilation and heating systems should be reviewed to ensure they can be adjusted to take account of residents’ needs and changing outside temperatures. Practices in relation to the cleaning of commodes should be monitored to ensure there is no infection control risk for residents’. DS0000012921.V301692.R01.S.doc Version 5.2 Page 26 DS0000012921.V301692.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 DS0000012921.V301692.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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