Inspection on 09/01/07 for St Anthony`s

This inspection was carried out on 9th January 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 Anthony`s 09/05/07

St Anthony`s 11/05/06

St Anthony`s 07/02/06

St Anthony`s 23/05/05

St Anthony`s 02/11/04

St Anthony`s 10/05/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE St Anthony`s 3 Mildred Avenue Watford Hertfordshire WD18 7DY Lead Inspector Mrs Sheila Knopp Unannounced Inspection 9th January 2007 09:40 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Anthony`s DS0000019534.V326497.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 Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Anthony`s Address 3 Mildred Avenue Watford Hertfordshire WD18 7DY 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) 01923 226 174 0208 8688375 rmd@ukgateway.net RMD Enterprises Limited Mrs Devereux Lisa Souter Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places St Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th May 2006 - Key Inspection 12th June 2006 – Follow up Inspection Brief Description of the Service: St Anthonys is a care home providing personal care and accommodation for 22 older people. It is owned by RMD Enterprises Limited, which is a private company. The home is situated in a popular residential area of Watford, within 15 minutes walking distance of the town centre, with easy access to local transport links. The home was opened in 1985 and consists of a two-storey house that has been extended and improved over recent years. There are 20 single rooms and 1 double room. None have en-suite facilities, but all have a washbasin. Six of the bedrooms are smaller than the 10 square metres required of newly registered services since 2002. There is a passenger lift. The home has a beautiful and well-designed garden to the rear of the property, which is both safe and accessible to all the service users. The current fees for accommodation and personal care range from £435.00 - £475.00 based on room sizes. Additional charges are made for items such as newspapers, chiropody and hairdressing where required. St Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on an unannounced visit to the home by one inspector who spent a total of 6 hours 20 minutes in the home. The inspector spent time talking to residents and reviewed relevant care, management, and health and safety records. Information received about the home since the last key inspection on 11th May 2006 has also been reviewed. A further unannounced inspection on 12th June 2006 confirmed that action had been taken to meet requirements with short timescales in relation to the safety of flooring and hot water. The Commission sent out 19 questionnaires to residents/relatives, 11 General Practitioners (GPs) and 6 Community Nursing and Social Work teams. The views of the 11 service users/ relatives, 9 GPs and 1 social worker who returned questionnaires to the Commission prior to this inspection have been included in this report. The standard of care in this home is very good but there are still health & safety issues, which need attention. What the service does well: St Anthony’s is a warm friendly home. The residents, their relatives and health & social care professionals expressed a high level of satisfaction with the service provided. A relative said ‘ The care is good, the staff are lovely, my relative is very content’. One GP said St Anthony’s was ‘the best home in Watford. Two others described it as ‘one of the better homes in the area’. Other GPs described St Anthony’s as providing a ‘satisfactory level of care’, ‘excellent care’ and as ‘sensible, kind, efficient and safe’. A social worker said ‘This home has warm friendly caring staff and a lovely happy environment’. Residents have a good relationship with the Manager and staff who they describe as being very good and kind. There is a low staff turn over so residents are being supported by staff who are familiar with their routines and preferences. Residents are provided with a good standard of personal care and laundry service enabling them to maintain their dignity and look smart. St Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 6 The health and well being of residents is regularly reviewed and additional support from outside health and social care agencies obtained where required. What has improved since the last inspection? What they could do better: St Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 7 Following recent changes in legislation more information is required in the Service User Guide regarding the fee arrangements to enable people to make a more informed choice about the options available to them. The lay out and size of the building places limitations on the environmental standards provided for residents in homes registered after 2002. Residents have to share toilets as none of the rooms have en-suite facilities. Some of the bedrooms are undersized. St Anthony’s is decorated and furnished in a style, which would be familiar to older people but there are several areas that now need updating as the décor needs refreshing and some of the furniture is showing signs of wear. The company have a maintenance and renewal plan in place to address these issues during 2007. Low surface temperature radiators to reduce the risk of accidents from heat related injuries are not currently provided. Following the inspection the company have provided the Commission with information confirming the action taken to maintain the safety of residents. This includes fitting radiator covers. 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 Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Anthony`s DS0000019534.V326497.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2 & 3 (Standard 6 does not apply to this service) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A Service User Guide and brochure are made available to individuals looking for accommodation at St Anthony’s. This now needs to be revised following changes in legislation, which require further clarification of the arrangements under which the fees are charged so that people can make an informed choice. Residents or their representatives are issued with a contract so that they are clear about the terms and conditions of their stay and the fees payable. The Manager meets with individuals in their own home or hospital prior to admission to assess whether the staff at St Anthony’s can meet their needs. St Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 10 EVIDENCE: Copies of the contract were available for the individuals whose records the inspector reviewed. Nine out of 11 residents/relatives who returned questionnaires said they had received a contract and had enough information about St Anthony’s prior to their stay to enable them to make an informed choice about the home. This includes visits to the home by individuals or those making choices on their behalf. The Service User Guide, which provides information about the services provided at St Anthony’s, has recently been updated. In light of recent legislative changes (1/9/06) further information is required to clarify arrangements for charging and paying for any additional services, and whether charges or arrangements are different for people who have all or part of their care funded by some body else such as a local authority. A revised copy of the Service User Guide should be provided to all residents and the Commission. The Manager carries out an assessment of the needs of each individual before they come to stay at St Anthony’s. Details of the assessments carried out and information from other relevant parties such doctors and social workers were available in the home to enable staff to plan the care required. A requirement regarding the availability of this information made following the last key inspection has now been met. St Anthony’s is not registered to admit residents with a diagnosis of dementia. Where this has developed following admission the Manager has responded by contacting appropriate services for assessment and support and provided staff with dementia care training to enable them to continue to meet their needs. St Anthony`s DS0000019534.V326497.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 & 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident has a plan of care, which sets out their needs and how they wish to be supported. This information is regularly reviewed and updated with the involvement of the resident and their relatives. Residents have good access to local GPs and the services of dentists, opticians, chiropodist and Community Nurses. Residents feel they are treated with respect and their privacy is maintained. EVIDENCE: The manager has recently introduced new care plans, which reflect a more person centred approach to meeting the needs of each resident. Nine out of eleven residents/relatives said they always got the care and medical support they needed. A relative said there is ‘excellent communication if a doctor is called I know within minutes and the doctor has called me on occasions’. St Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 12 The care plans reviewed reflected what residents and staff had told the inspector about the care and support being provided and had been signed by the resident concerned. Specific needs such as residents requiring additional support to maintain their nutritional needs or to prevent pressure sores developing are recorded. It was reported that none of the residents had pressure sores. Residents are weighed each month and at more regularly intervals if required. It was advised that this is also carried out at the time of admission and on re-admission from hospital to track changes more closely. Individual charts for each service user identifying the weight loss and gain each month with a record of the action taken would provide a clearer picture of changes over time rather than the central record currently in use. Following the inspection the Manager provided the Commission with details of the new weight monitoring process put in place to address these issues. The Manager has introduced a key worker system so that staff promote the interests of individual residents. The residents spoken with knew who their key worker was. The Manager is aware of promoting a culture in which staff encourage and support residents to be independent. One resident said that staff ‘give her the scope to do what she wants within her capabilities’. The medication systems have been changed since the last inspection to provide better facilities for storage. The dispensing pharmacist visits to review the systems and provide advice. The Manager caries out regular audits to ensure safe practice is being followed. As the competency of staff to give out medicines was carried out before the appointment of the current Manager it was advised that an annual review is recorded to demonstrate continued competency. Following the recent changes to the system the manager needs to update the medicines procedure and review the homely remedies policy with GPs concerned. The Manager should also ask the Community Pharmacist to confirm the fixings on the CD cupboard to ensure they fully comply with the Misuse of Drugs (Safe Custody) Regulations (1973). Guidance is available on the Commission’s web site. All the GPs who returned questionnaires confirmed staff had a clear understanding of the care needs of the residents and they were satisfied with the overall level of care provided. Information received by the Commission indicates services users and their families are supported at the end of their lives. One person said ‘ That the home not only made Mum’s last few days comfortable, she felt relaxed and well cared for, they also treated us with compassion and understanding.’ This view was also reflected in letters received by the Manager from other relatives. St Anthony`s DS0000019534.V326497.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): Standards 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the residents were satisfied with the approach taken to providing recreational activities within the home. Service users are provided with a varied seasonal menu and enjoy their meals. They have daily contact with cook to discuss their preferences. EVIDENCE: Residents are provided with a variety of things to do and records of the recreational activities and events residents have taken part in are kept. There was a busy Christmas programme, which included the opportunity to go shopping. In the summer residents enjoy the garden and last year grew tomatoes and are waiting for the spring bulbs they planted to come up. Bird tables on the patio provide a focus during the winter. The library books are replaced every two months by the library service and several residents were making use of the books. The spiritual needs of residents are supported and as well as visiting church representatives residents are supported to go out to church. St Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 14 Additional care staff time identified in the morning following a review of laundry and domestic tasks is being used to support resident activities. A new cook has started since the last inspection and residents confirmed they were pleased with the standard of meals served. The cook meets with residents each day and is able to respond to changes. The menu based on home cooking the residents would be familiar with looked varied and included fresh seasonal vegetables. Fruit and snacks are available. One person described the night staff making her Ovaltine during the night when she requested it. Dietary requirements can be met and aids to assist residents retain their independence at meal times are available. Residents had access to drinks throughout the day. Residents have recently been involved in a food survey so that they are involved in revising the menu. The Manager reported residents had also been involved in tasting various brands of bread before choosing the one to be ordered. The crockery although the same colour is made up from a variety of sets and designs. New crockery would improve the quality of the service provided to residents. St Anthony`s DS0000019534.V326497.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): Standards 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives can be confident from the approach of staff and the procedures in place that their concerns will be listened to and followed up. The interviews with residents and the questionnaires received indicate an open and supportive culture within the home, which does not raise anxieties for residents or their relatives. Staff receive training in protecting service users so they are aware of their responsibilities and there are procedures in place detailing the action to take if concerns are identified. EVIDENCE: The complaint procedure in place details how to make a complaint and what to do if the person making the complaint is not satisfied. Timescales for expected responses are included. The Manager satisfactorily investigated an anonymous complaint sent to the Commission related to the management of the kitchen. This was also reviewed by the Commission on 12/6/06 and the Environmental Health Department who were sent a copy. The complaint was not upheld. St Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 16 Staff interviewed were aware of their responsibilities under the code of conduct in place for social care workers. The Manager is aware of her role under the Hertfordshire Safe Guarding Adult procedure and a copy of the procedure is available in the home. Staff have received updated Safe Guarding Adult training since the last inspection. St Anthony`s DS0000019534.V326497.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): Standards 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. St Anthony’s provides residents with accommodation that has a homely domestic feel to it but there are areas that do not meet the standards for newly registered services as space is limited in some of the bedrooms and there are no en-suite facilities. Residents are encouraged to add personal possessions to their rooms. There is a well-tended private garden to walk and sit in during the summer. All areas of the home were found to be fresh and clean. Significant improvements have been made in the laundry arrangements. The Manager is in discussion with the Registered Provider regarding a programme of redecoration and refurbishment to address areas, which now need attention to maintain standards. Further action referred to under standard 38 was required to protect residents from unprotected radiator surfaces but has since been addressed. St Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 18 EVIDENCE: Two residents showed the inspector their rooms and the personal items they had brought with them to add homely touches. One resident had requested a door lock and this had been fitted but they are not fitted to each bedroom door. Residents do not currently have access to a lockable drawer for any valuables or personal items they may wish to keep securely. In response to a requirement made at the last inspection a new laundry system has been installed which meets current infection control standards. Liquid soap and disposable hand towel are also now available to staff in the required areas. Outstanding work to repair a section of flooring on the first floor has been completed and new carpet laid. The Manager is in discussion with the Registered Provider regarding a programme of redecoration and refurbishment to address areas, which now need attention to maintain standards. Further action referred to under standard 38 was required to protect residents from unprotected radiator surfaces but has since been addressed. St Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 19 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): Standards 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are supported by an experienced team of staff who are familiar with their daily routines and care needs. Staff are recruited according to the standards required to ensure that suitable people are employed and residents are protected. Staff receive training to enable them to support the physical, emotional and social needs of older people. Staff with qualifications at NVQ level 2 or above (41 ) has not quite achieved the 50 level. The Provider and Manager are taking steps to address this with the staff team. EVIDENCE: The residents were extremely positive about their relationships with the staff. One lady described them as ‘angels’. They also spoke of the great confidence they had in the night staff. The rota indicates staff are deployed to meet the needs of residents at peak times. In addition to the manager 5 care staff work in the morning and three cover the afternoon and evening. Two staff work at night. The Manager is on call and does some shifts at the weekend. Senior staff are also allocated supernumerary time during the week so that their management and record St Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 20 keeping time does not detract from the hours allocated for direct care. Changes to the domestic and laundry routines has also freed up additional time for staff to spend with residents. There is a low turnover of staff and agency staff are not used. Five out of 12 care staff have qualifications above NVQ level 2 (41 ). This includes 4 staff who are registered nurses outside the United Kingdom and therefore have transferable skills equivalent to the NVQ qualifications required for care staff. The company supports NVQ training and is looking at the needs of those who already have the required skills to support their continued development. Individual training records were available for staff demonstrating new staff receive an induction. The Manager has identified the refresher courses, which are now due. The last inspection recommended that the Manager put a training matrix in place to assist planning. The personnel records of three staff were reviewed. This confirmed that two suitable written references are obtained. Clearance is obtained from the Criminal Records Bureau before staff work in the home. St Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 21 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): Standards 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Mrs Souter is an experienced manager who has the qualifications and skills required for her role. The company consults with residents and their relatives as part of its quality monitoring processes to gain their views on the service being provided. A more structured approach to auditing all aspects of the service would enable the Registered Provider to demonstrate its commitment to a process of continuous monitoring and improvement. Copies of the reports required under Regulation 26 Should be made available to the Manager and if requested the Commission. To maintain the safety of increasingly frail residents a requirement was made following the last inspection regarding the risk assessments in relation to unprotected radiator surfaces. This was not fully complied with at the time of this inspection. However confirmation of the work carried out to reduce the risk St Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 22 of injury from contact with hot surfaces has now been received. Good practice guidance in relation to the use of electrically operated recliner chairs has been discussed with the Manager. EVIDENCE: The Commission has approved Mrs Souter as Registered Manager using the criteria set out in the Care Standards Act since the last inspection. She is an experienced manager and has the Registered Managers Award, which is the standard qualification set for care home managers. In her short time at St Anthony’s she has identified and prioritised areas for further action and development. This has included introducing a programme of formal supervision for staff and identifying policies and procedures, which need updating to ensure current practice is followed. The Proprietors are regularly in the home as part of their approach to monitoring the quality of the service. To fully comply with their obligations under Regulation 26 a written report needs to be available to the Manager and Commission. This was discussed with Mr Merali who agreed to review the arrangements and has since advised the Commission regarding the new quality control systems he intends to put in place. Annual questionnaires are sent out to residents and their families to obtain their views. The manager had also just completed a survey on meal preferences to involve residents in planning future menus. Copies of the outcomes of audits and reviews should be made available to service users and the Commission. Previous inspections have confirmed that the systems to enable residents to deposit small amounts of money for safekeeping are satisfactory. To ensure safe working practices staff receive moving and handling, fire safety and food hygiene training. Residents have detailed moving and handling assessments in place. Accident records are maintained and reported to the Commission as required. Service records were available for fire safety and moving and handling equipment. Water temperatures were found to be within the required health & safety range to protect residents. Windows above ground level are restricted to prevent accidents and it is the responsibility of staff to check them on a daily basis. Further work was required on the risk assessments in place where there are unguarded radiators to ensure they were specific to the service user in the identified room and updated as changes occur. The radiator in an identified room is close to the bed and staff had left the thermostat turned up indicating an increased level of risk. An immediate requirement notice was not served at this time as the proprietor agreed to have this radiator covered and provide the Commission with confirmation of the work carried out. Confirmation of the St Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 23 action taken has now been received by the Commission therefore no further requirements have been made. Increasingly care homes are seeing relatives providing domestic style electrically operated recliner chairs. The Manager needs to ensure clear systems and risk assessments are in place for their use and maintenance to ensure they are not used inappropriately and the resident is competent to use the equipment safely. Service agreements and user manuals need to be available. Guidance is available on the Commission’s web site – ‘The assessment process for the use of safety equipment and furniture’. Following the inspection the Manager has provided details of the risk assessments put in place to monitor their use. St Anthony`s DS0000019534.V326497.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 2 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 3 x 2 St Anthony`s DS0000019534.V326497.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 OP2 Regulation 5 5A 5B Requirement Update the service User Guide in line with the revised regulations (1/9/06). Provide a revised copy of the Service User Guide to residents and the Commission. To demonstrate full compliance with Regulation 26 provide a copy of the reports for February & March 2007. Timescale for action 31/03/07 2 OP33 26 06/04/07 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 OP28 Good Practice Recommendations 50 of care staff should achieve NVQ level 2. St Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hertfordshire Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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 Anthony`s DS0000019534.V326497.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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