Inspection on 17/05/07 for St Anne`s Residential Home

This inspection was carried out on 17th May 2007.

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 Anne`s Residential Home 16/05/08

St Anne`s Residential Home 20/11/06

St Anne`s Residential Home 15/11/05

St Anne`s Residential Home 22/06/05

St Anne`s Residential Home 18/01/05

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

CARE HOMES FOR OLDER PEOPLE St Anne`s Residential Home St Anne`s Residential Home Clifton Deddington Banbury Oxfordshire OX15 0PA Lead Inspector Ruth Lough Unannounced Inspection 17th May 2007 10:50 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 Anne`s Residential Home DS0000062413.V336070.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 Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Anne`s Residential Home Address St Anne`s Residential Home Clifton Deddington Banbury Oxfordshire OX15 0PA 0796 8490068 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) ruralcareltd@aol.com Mr Prashant Brahmbhatt Care Home 22 Category(ies) of Dementia - over 65 years of age (22) registration, with number of places St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th November 2006 Brief Description of the Service: St Annes care home is situated in the village of Clifton, near Deddington on the edge of the Cotswolds. The property is a period stone built cottage, which has been extended. St Annes was first registered as a care home in 1987 and is today home to 21 older people who suffer from forms of memory loss, Alzheimers and other types of dementia. Accommodation is provided in single and double rooms on two floors. The fees range from £490.00 to £700.00. Basic hairdressing needs are also included. St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection process that was generated by the concerns raised from a previous process carried out on 20th November 2007 where a number of requirements were made. This inspection process included information provided by the home prior to the one-day visit to the service. Relatives of the people living in the home and some of the healthcare professionals who attend at the home were consulted through questionnaires. Five relatives and four healthcare professionals returned questionnaires prior to the inspection visit. The inspection process identified that the home has rectified the majority of the concerns found previously. This also showed that they have implemented strategies to improve their work practices that have an impact on the lives of the people living there. However, there are two outstanding requirements that have not been met within the given timescales in the inspection visit in November 2007. What the service does well: What has improved since the last inspection? The staff team have implemented new care planning records that support a person – centre approach to providing support to the individual. They have taken time, with the support of families, to record the personal life history of the service users that has been helpful for them to understand and care for them. Medication administration practices have improved with the change in method of how they are supplied to the home and the training provided to staff. St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 7 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 Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. Service users needs are assessed thoroughly before they are admitted to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home carries out an assessment process of service users needs prior to admission to the home. They use information provided by either the local social services or the service users current care provider, relatives and the prospective service user if they are able. They have a standard assessment form that guide the assessor through the key topics such as health and physical needs, support that they may require and the communication problems that they may have. The assessment process is usually the responsibility of the manager or deputy manager. St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 9 They have also instigated a new process to seek greater information about the individual’s wishes through a questionnaire that could be completed with the support from relatives and friends that will assist with the development of the care plan. Two assessment processes that have been carried out in the last six months were reviewed. The home does not offer an intermediate care service. St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. The care planning for service users ensures that their health and personal care needs are met and that their choices and wishes are taken into account. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Comments from relatives indicated that they were happy with the support provided to their family member who is living in the home. These included, “Excellent care provided” and “Well looked after”. One relative did express a concern in the delay in staff observing care required but this has already been dealt with and suitable action implemented through the complaints process. The health professionals also expressed confidence in the care service the home provides with comments such as, “ I feel they know their clients as people and treat them with respect” and “I honestly believe that individual needs are met very successfully.” St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 11 The care plan records for two service users were reviewed. Additional service users records were looked at as to sample the different documents used to record information. The home has implemented new care planning documents that ensure that the information is provided to staff with a person centred approach. Each care plan gives good details of the individual’s choices and wishes, identifies communication needs and informs staff of how to understand behaviour. They have now implemented monitoring systems for service users nutrition (MUST), weight and risk of pressure sores (Waterlow). They routinely carry out risk assessments for the mobility, bathing and personal safety of the service users and implement actions plans to eliminate or reduce risk. The staff have access to information and the planned care in two different record documents, which are ‘ What matters to me’ and the Care Plan Diary. These documents cover providing good information regarding the healthcare input from visiting healthcare professionals and healthcare appointments, their involvement with activities and where able, an in depth personal history so staff have a better understanding of the person they are providing support to. These are helpful to ensure that they continue as much as possible to support them to continue with their previous religious observances and social interests and preferences they had before moving to the home. These new document tools have been gradually introduced over the last six months and the Acting Manager stated that they appear to be used effectively by staff. The staff record the outcomes of the service users day appropriately and give a good picture of the individuals personality whilst doing so. These records are now stored in an appropriate place that is accessible to staff throughout the day, but still keep the information confidential. In regard to the health care professionals opinion of how the home responds to concerns about service users care they gave positive comments including, “Any concerns about individuals have always been acted upon.” The home has improved its management of storage and administration of medication and has implemented a new Monitored Dosage System that ensures that safe practices are in place. They have been working with this new process approximately one week and have ensured that all the involved staff have had the required training to carry this out. The Acting Manager has put additional safety measures in to record the movement of medications in an out of the home and has included audit checks as part of the homes quality assurance programme. Staff are using the records well and have added photographs of the individual to ensure that medication is given to the correct person. The current medication policy and procedure does not reflect this new process but is part of the general review of all the policies and procedures that is being carried out by the proprietor. Staff were seen to be interacting with service users well, managing to comfort and support them when they became anxious and encouraging them to continue with looking after themselves as much as possible. St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 12 Where there is shared bedroom accommodation they have provided screening to maintain service users privacy when personal care is being carried out. On relative wrote, “ My mother has advanced Alzheimer disease. She is no longer able to make conscious choices, but her personality and dignity are respected.” St Anne`s Residential Home DS0000062413.V336070.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. The service users are provided with support to continue with their lives as they wish and are able. The home ensures that there is varied nutritional diet for service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff support service users to make decisions and choices about their lives for as long as they are able. The new care plans record personal choices and wishes of the individual where they are able to obtain them and assist staff to carry out their wishes accordingly. There is a programme of activities carried out in the home that is provided by staff and the activities organiser. Information about planned activities and events are on display in the home and these include communal activities such as musical entertainment and preparing for significant events such as Christmas or Easter. St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 14 Similarly there is time set aside for one – to – one periods for hand and feet massages for the less able and shopping trips with those wanting to go out. Staff do record the enjoyment and participation of the service users in the activities in their daily records and this could be enhanced to show that staff are using this to plan and develop what the individual is offered and is able to take part in. An observation made on the day of the visit was that some of the service users did not have anything left to occupy them with, when not interacting with staff or others. The home has reviewed the meals and menu planning that it currently has on offer. They are in the process of improving the content and variety of the meals that are provided on a four weekly rotational plan. There is hot and cold fare on offer each mealtime and although this is not indicated fully on the menu, there are always alternatives available should it be required. Personal preferences and dietary needs identified are recorded in the care plans and information is passed to the catering staff. The home has a designated small dining area that can offer seating for at about half of the people living there and as communal space is limited, others either take their meals in their rooms or in the two small lounge areas. Staff confirmed that there were seven service users who required full assistance with their meals and the majority of the others requiring medium to low supervision. Staff were observed assisting with the main meal of the day and appeared to give the necessary time and support whilst communicating well with the individual. St Anne`s Residential Home DS0000062413.V336070.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. The home listens and acts upon service users or their relative’s concerns and implements changes to improve the service. The home should ensure that they have the necessary information and training for staff to manage any concerns of possible abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy and procedure is supplied to service users, relatives and staff in the Statement of Purpose, Service User Guide, staff handbook and on display in the front lobby of the home. The omissions found previously in the complaints procedure have been rectified and as yet the home is still looking for support to translate this in an appropriate format to meet some of the service users needs in order for them to understand the process. The home has instigated using formal complaints recording tools that support a structured process for investigating concerns and implementing an action plan to rectify them. The home reported that they have had 4 formal complaints since the last inspection process and on examination they appear to be managed well and suitable interventions put in place. On discussion with the acting manager it was evident that they do not have a method of recording minor concerns or for analyzing trends that could be helpful for quality assurance processes. St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 16 The Commission has not been in receipt of any concerns or complaints since the last inspection process. The home does have some policies, procedures and information for staff about safeguarding adults from possible harm. The current policy and procedure does not reflect the local interagency protocols and does not direct staff comprehensively to manage an event if concerns are raised. On discussion with the Acting Manager it was evident that the home did not have an appropriate trained member of staff to lead or manage should a concern arise and therefore a recommendation was made for this to be put in place. The staff are provided with training in the induction process and have had regular updates in the training programme. St Anne`s Residential Home DS0000062413.V336070.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. The home is suitable and safe for service users to live in but it needs some improvement in décor and facilities to maintain hygiene and control of infection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is not purpose built but has been altered and had additions made to accommodate twenty-two residents in the 18 bedrooms. The original building at the front of the property is in keeping with the other buildings in the village and has many original features associated with the period that it was built. To the rear of the property is a two-storey extension that provides bedrooms with en – suite facilities and the larger of the two communal spaces. The home has two assisted bathrooms, one on the ground floor and one the first floor. St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 18 The first floor is accessible via three separate flights of stairs and for the less able, a chair lift. The external parts of the home and its grounds are kept secure by a locked gated entrance and an enclosed garden area. The current practice of housing the refuse and contaminated waste bins at the front of the property parallel with unwanted equipment does not provide a pleasant view for those entering and leaving the building through the main entrance. One relative did express concern about the external appearance of the premises, “ The internal cleanliness of the care is generally good, however, the appearance outside, at the front, with waste bins, yellow bags and discarded furniture and electrical items gives an appearance of general lack of interest and care for relatives passers by and prospective clients.” The home employs a member of staff for four days a week to carry out routine maintenance and repairs and basic redecoration. On a review of the facilities it was evident that a programme of some renewal and redecoration had commenced that included new carpets and some repainting. However, there are areas in the home that could be improved by redecoration such as the ground floor bathroom and some of the bedrooms. The furniture and fittings in the home are equally variable in quality, with some furniture and commodes in a worn state and possibly compromising infection control. The Acting Manager confirmed that this had already been identified as a concern and that action had been commenced to replace some of the soft furnishings and some of the commodes in the home. The bathing aid hoist in the ground floor bathroom did show that some of the protective covering around the framework had been damaged and that the metal work was rusting in places. This was of concern to the Acting manager as all hoists had been serviced a week previously by an approved contractor and this had not been identified in that process. This was left with the home to review and implement action to rectify this. Generally the home is kept clean and tidy with two staff specifically employed for this purpose during the week and care staff carrying out interim cleaning at the weekends. The laundry area was of concern during the last inspection in regard to control of infection and the storage of clean linen. There has been no structural change to the laundry facilities as yet, and these remain external to the home in a converted brick built shed that have difficult flooring and wall coverings to keep clean. What they have done is to protect the drying laundry from dust and removed the stored linen from the building. They also use the laundry areas as storage on open shelves for disposable goods such as gloves and incontinence pads and it was recommended that they found an alternative solution in order to reduce possible contamination from the soiled laundry. The home only launders service users personal clothing and all bedding and household linens are sent to an external contractor. The storage of some of the clean linen and towels is now in the ground floor bathroom on open shelves. St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 19 The Acting Manager may need to look at finding alternative storage facilities for these as to ensure that possible cross infection is reduced. Staff are provided with liquid hand soap, paper towels and anti- septic hand rub around the home to ensure there is good hand hygiene. There is a system of alginate red bags for soiled clothing and linen and they have suitable washing machines for the services they provide. St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. There are sufficient numbers of staff employed to meet the needs of the service users in the home. The current recruitment practices do not reflect that the service users are protected by a robust process to employ staff to work in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Relatives and health care professionals gave mixed comments about the staff in the home. Some of the positive comments were, “Always have a good skill mix on duty when I visit the home,” and “St Annes is a very special care home with very caring and loving staff.” One relative wrote “There is a real lack of qualified staff especially at weekends.” The staff employment, training and induction records were reviewed for two employees who had been employed since the last inspection process. The duty rota was also reviewed to assess the number of staff deployed around the home and how they manage to meet the needs of people with varying mental health needs. St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 21 The duty rota identified that it was usual for five care staff were on duty at all times during the daytime, evening and including weekends. At night there are always two staff on duty. There is a regular team of cooks and kitchen staff for the main meal times of the day including weekends and bank holidays. The Acting Manager confirmed that they are recruiting to improving the ratio of skilled and experience staff to include a ‘head of care’ role and senior carer to compliment the team. The Acting Manager was advised to record the full name of the staff members and the times of the night shift on the rota as to keep accurate records of staff present in the home. There is a programme of staff training in place including NVQ and the mandatory topics to support the roles of staff and the health and safety needs of the service users. Currently, according to information supplied by the home, there are seven staff with an NVQ 2 or above and three undertaking training to achieve this. They have implemented training for medication administration as this was identified as a deficit previously and continued with providing training for the specific needs of service users such as distance learning for dementia awareness. The recruitment records for the two staff reviewed evidenced that there were deficits in the management of the recruitment practices. Both applicants had completed an application form and given proof of identity. What was evident that the applicants full work history was not provided and that any gaps in employment had been explained. This is partially due to the application forms not requesting this information and the poorly completed forms by both applicants. This information could have been reviewed in the interview process but this did not occur and only one new staff recruitment records supported that the interview outcomes were recorded. One of the two required references had not been obtained for one staff member. A Criminal Records Bureau and POVA list check had been carried out for one staff. For the other, they were waiting for the Criminal Records Bureau check to be returned. However, they had implemented a POVA check and the staff member in question was still undergoing their induction training. What they had not done was to ensure that both applicants had supplied copies of the training and qualification certificates they had obtained. What was evident is that staff are given comprehensive job descriptions and contracts that outline the probationary employment period. The Acting Manager was advised to review the recruitment policy and procedure and implement methods of ensuring that the required information is obtained to evidence a robust recruitment process is carried out. St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate. The proprietor needs to consolidate the management structure in place to ensure that the service continues to improve the quality of support it provides to service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: General comments from both relatives and the health care professionals were positive about the home including, “ St Annes provides an exceptionally high standard of care to a group of clients” and “Provides a good standard of care.” When asked what could be improved about the home comments were, “Communication with relatives could be better” and “ Discussions regarding the care plans would be reassuring.” St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 23 The home has been without a registered manager since December 2006. In the interim time the Deputy Manager has taken the responsibility for running the home with the support of the proprietor. During this period she has reviewed and put in changes required from the last inspection process and has implemented new systems and processes to improve the service. She has been in the role of Deputy Manager for over two years and has previously worked as a care worker and senior care worker in the home for period before this, so she has a good understanding of the home, the staff team and the people living there. She has undertaken NVQ 4 training appropriate for the role and has continued to update the necessary mandatory health and safety training. Previously there has been an infrequent process for consulting with service users, relatives and others about the services the home provides. This has been developed and a recent survey was undertaken, but as yet the findings have not been passed back to the participants and other interested parties. It was evident that the programme of quality assurance had been recommenced with checks and audits carried out for medication administration, care planning and housekeeping. Again the process of formalizing the information from these has not been developed and the Acting Manager was advised to look at how this information could be collated and provided to service users and their families. The Acting Manager and proprietor were not able to provide evidence that Regulation 26 visits have been carried out. The Acting Manager has implemented changes in regard to the homes management and administration of service users personal money. Although previously stated during the last inspection process that the home does not handle service users money. This was incorrect as the Acting Manager has since then been made aware of small amounts of service users money that had been kept in the home. All the records for these and the money and valuables in safekeeping have now been checked. Families have been informed and a suitable record keeping process has been put in place. Staff are provided with key information about protecting service users money and valuables in the staff handbook, induction and policies and procedures. However, the policies and procedures now need to reflect the changes and the homes handling of small amounts of service users money. The supervision programme for staff has improved since the last inspection process with a concentrated effort by the Acting Manager to implement a continuing timetable for these to be carried out. What was evident, was the improved records for this that supported that care practices, skills and training needs of the individual are identified during this process. The home has systems in place for safe working practices. These include training for staff, routine safety checks and risk assessments for the environment or tasks that staff may be required to carry out. The local Fire St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 24 Officer has visited the home during the last six months and there is programme of fire drills and safety checks carried out by staff. The concerns about the health and safety of staff in the laundry area that were identified previously have been rectified and risk assessments have been put in place. St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 25 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 x 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X 2 X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 26 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 OP29 Regulation 19 Requirement The registered provider must make sure that all the information and documents specified in regulation 19 and Schedule 2 regarding persons working at the home is available. Previous requirement not met by 31/12/06. That the registered provider must visit the home in accordance with Regulation 26 and ensure that evidence of these visits are available in the home and available for inspection. Previous requirement not met by 31/12/06. Timescale for action 30/06/07 2. OP33 26 30/06/07 St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 27 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 OP12 Good Practice Recommendations The home could develop the recording and analyzing process in regard to service users involvement and interests in the activities provided. This could improve the planning and development activities that are focussed on the individual’s needs and wishes. That a senior member of staff or management undertakes the necessary training in order to take appropriate action should a concern of possible abuse arise. That the home looks at improving the storage of linen and the condition of equipment to ensure that it reduces the risk of cross infection. 2 23 OP18 OP23 St Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Anne`s Residential Home DS0000062413.V336070.R01.S.doc Version 5.2 Page 29 - 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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