CARE HOMES FOR OLDER PEOPLE
St Aubyns 35 Priestlands Park Rd Sidcup Kent DA15 7HJ Lead Inspector
Maria Kinson Unannounced Inspection 11th July 2007 09:35 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 Aubyns DS0000006771.V340222.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 Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Aubyns Address 35 Priestlands Park Rd Sidcup Kent DA15 7HJ 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) 020 8300 4285 020 8309 5435 terri.??@premierchoicebroadband.com Mr Dilipkumar Tanna Mr Kirtikumar Tanna Mrs T Earle Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. An additional five (5) day care places for people falling into the above Service User Categories One (1) place for a service user under the age of 65, requiring general nursing care, can be accommodated. 30th May 2006 Date of last inspection Brief Description of the Service: St Aubyn’s Nursing Home is situated in a residential area of Sidcup, near to a mainline rail station, bus routes and Sidcup town centre. The home was first registered in 1988. The building was extended in 1995 and is registered with the Commission for Social Care Inspection to provide nursing care for thirtynine older people. There are nineteen single bedrooms and ten shared bedrooms in the home. Twenty-two of the bedrooms have en-suite facilities. Service users have shared use of the dining room and two lounges. There is a garden at the back of the property and limited parking at the front of the home. The fees charged by the home range from £562.83 - £645.00 per week. This does not include additional charges such as chiropody, hairdressing, newspapers and toiletries. This information was supplied to the commission on 11.07.07. St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place on 11th July 2007 between 09:35 am and 19:30pm and was unannounced. The inspector was joined by an ‘expert by experience’ for part of the inspection. ‘Experts by Experience’ are people who visit a service with an inspector to help them get a picture of what it is like to live in or use the service. The inspector and ‘expert by experience’ spoke with residents, staff and visitors. All of the communal areas and a selection of bedrooms were viewed. Care, health and safety and staff records were examined. A random sample of residents, relatives and health care professionals were asked to provide written feedback about the service. The commission received nine comment cards back from relatives, five from health care professionals and five from residents. The information provided by residents, relatives, staff, other professionals and the ‘expert by experience’ forms part of this report. The commission visited this home on one occasion since the last key inspection to undertake a random inspection. The report from this visit is available on request from the office listed at the back of this report. What the service does well:
The arrangements for admitting new residents into the home were satisfactory. Staff obtained information about peoples needs before they agreed to admit someone new. People were able to visit the home to view the facilities and meet staff. The home received regular support from a local GP and other health care professionals. Staff maintained good working relationships with other professionals and frequently contacted health care professionals for advice. Residents said that staff treated them with respect and maintained their privacy. This home was clean and tidy. The domestic staff worked hard to keep the home comfortable and fresh for residents and their visitors. There was a good supply of soap and hand towels in the toilets and bathrooms. Relatives were satisfied with the visiting arrangements and staff supported one resident to take telephone calls from a relative that lived abroad. Relatives
St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 6 said they were kept informed about important issues and there was always a staff member on duty who could provide information about their relatives care. Feedback about the service was positive. Residents and relatives said that staff were “friendly”, “caring and cheerful and most approachable”. Residents said they were able to make personal choices and staff respected their decisions. The choice and quality of food provided in the home was good. Meals were nicely presented and tasty. Good records were maintained about resident’s money. There were good systems in place to monitor and identify health and safety concerns and to check that fire safety equipment was working properly. What has improved since the last inspection?
A number of improvements had been made since the last key inspection. Care plans provided information for staff about the action they should take to meet each person’s need. Wound care records were up to date and easy to follow. The home had introduced a number of changes to make the handling of medicines safer. A new medication trolley had been obtained. This made it easier and quicker for staff to store and locate medicines. A number of checks and audits had been introduced to ensure that staff were maintaining proper records. This meant that staff were able to account for all of the medicines that were used in the home. The home had appointed a dedicated activities coordinator. This person was not responsible for meeting residents care needs so was able to devote all of her time to activities. The range of activities provided in the home had increased and a number of entertainment sessions and social events had taken place. The activity person had compiled a list of people that wanted to go out and the manager was looking at the practical arrangements that needed to be put in place for this. A new television and DVD had been purchased. The lounge had been rearranged. This made it easier for residents to view the television and talk to other residents. To resolve the recurrent problem of the garden becoming waterlogged the area had been paved over. The inspector was told that some new garden furniture had been purchased. The carpets had been professionally cleaned and all parts of the home were clean, tidy and odour free. St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 7 The number of care staff on night duty had increased. Staff had access to ongoing training and felt supported by the manager and senior staff. The number of care staff with a recognised qualification in care had increased and a programme of training had been introduced for new care staff. Staff were reviewing accidents and injuries and were taking action where possible to avoid incidents from happening again. The manager was now registered with the commission. The manager and staff had worked hard to address the previous requirements and recommendations. There were systems in place to monitor the quality of care and facilities provided in the home and to obtain feedback from residents and relatives. 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
St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 9 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 Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 10 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 and 4. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Written information about the service was provided and prospective residents were able to view the facilities before making a decision to move into the home. Staff carried out a care needs assessment before confirming if the home could meet a person’s needs. EVIDENCE: A copy of the ‘Service User Guide’, an information booklet for residents was seen in some of the rooms visited. The manager or a senior member of staff assessed people that were referred to the service. The assessment usually took place in hospital but was also carried out in people’s homes or other care homes if necessary. St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 11 The pre- admission assessment for two residents that had moved into the home during the past nine months were examined. The assessment form included information about the person’s mobility, personal care needs, interests and hobbies, religion, skin integrity and personal views. The home also received a copy of the local authority assessment, which provided detailed information for staff about the persons care needs. Residents were encouraged to view the home prior to making a decision to move in but were often too frail or unwell to do this. One resident said her family “visited the home and were satisfied that it was alright”. Most residents said they received adequate information about the home, before they moved in. St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 12 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. This judgement has been made using available evidence including a visit to this service. Staff worked in partnership with other professionals to ensure that resident’s health care needs were met and their privacy and dignity was maintained. EVIDENCE: Two sets of care records were assessed. All of the care plans seen provided good information for staff about the action they should take to meet people’s needs and maintain their safety. Care plans and wound evaluation records for people with wounds or pressure sores were satisfactory. The records seen provided information for staff about the grade, location and appearance of the sore and stated the type and frequency of dressing changes. Staff also completed a pain assessment record and stated what action was required to maintain the person comfort. Access to community health care services was satisfactory. A GP and physiotherapist visited the home regularly to assess residents that were unwell
St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 13 or had mobility problems. Residents were satisfied with the medical support they received but two residents expressed concerns about access to chiropody treatment. One resident said, “My feet are in a shocking state”. The deputy manager said there had been cuts in the provision of NHS chiropody services locally but a number of staff had attended nail care training sessions in the past. See requirement 1. Written feedback about the service was obtained from five health care professionals that were in regular contact with the home. The respondents said that the service was almost always able to meet people’s health needs and staff contacted the relevant professional for advice if they were unsure about health care issues. One care manager said that her client’s health had been very unstable, but since moving in to St Aubyns Nursing Home her “physical health and wellbeing had improved, as well as her mobility”. Another person said staff provided “good” care but could improve by having “full and frank discussions” with residents and relatives about ‘end of life care’. Relatives said that staff were usually able to meet their family members needs and kept them informed about significant issues. The home had recently changed to a new pharmacy supplier. Medicines were stored appropriately and an additional medicine trolley had been obtained to make it easier and quicker for staff to locate medicines. Records of medicines received in the home, carried forward from the previous months supply and given to residents were good. Handwritten entries on the medication administration charts were easy to read and checked and countersigned by a second person to avoid errors. The register of drugs that required special storage were well maintained and up to date. Several staff members were observed assisting residents to eat, moving residents from wheelchairs to the dining room, serving the lunch and giving out medication. Staff were courteous and according to one person often had time for a “good laugh”. Residents said staff were kind and maintained their privacy and dignity. There was a significant amount of toiletries stored on a shelf in the bathroom. It was not clear who these items belonged to. Staff should ensure that toiletries are stored in resident’s rooms. St Aubyns DS0000006771.V340222.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided a regular and varied programme of activities and work was in progress to provide opportunities for residents to go out. Residents said they were able to make personal choices and were satisfied with the quality of food provided in the home. EVIDENCE: Since the last inspection the home had appointed a new activity coordinator who worked between 2-4pm each weekday. The activity coordinator had experience of supporting people with health care problems in the past and was very resourceful and motivated. Several people said they enjoyed the activities provided by the “lady who works afternoons”. The activity coordinator had developed a programme of activities based on resident’s needs and interests. The range of activities provided was varied and interesting. In recent months some residents had attended reminiscence, sessions, completed sewing and stick weaving activities, used salt dough, made cards and scratch pictures and played bingo and card games. One
St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 15 resident said he was learning to play chess and others said they had played cards board games and were supported to knit. There were framed puzzles on the walls that had been put together by a resident. They were labelled in honour of his hard work and achievements. A radio played quietly during the meal, and later a television was turned on. The activities person had also arranged various entertainment sessions such a french horn and flute recital, belly dancing and a strawberry tea to celebrate Wimbledon. A theatre company was due to visit and enquiries were being made about the availability of other artists. There were no outings or trips but the activity coordinator had compiled a list of residents that wanted to go out and plans were being made to provide this service. One person said he would like to go out, “to the pub”. Residents that chose to remain in their rooms or were confined to bed said they spent most of their time watching television and reading books and newspapers. One person that spent all of their time in their room said they had received a manicure from a staff member and had seen the hairdresser. See recommendation 1. Records of activities were good but did not show that residents were often encouraged to take part in activities but had declined. Relatives were satisfied with the visiting arrangements. A number of relatives said that staff were helpful and attentive and there was always a member of staff that they could speak to. People said they were able to make personal choices about what they wore and how they spent their time in the home. One person refused to have a wash and although they were encouraged more than once by staff, they chose not to, and this decision was respected. The menu included a wide variety and choice of dishes but did not always meet the current recommendation regarding the daily intake of fruit and vegetables. See recommendation 2. There were two meal choices at lunch- time and a lighter dish and soup at suppertime. Residents were asked to choose their preferred dish from the menu and an alternative dish was provided if residents did not like any of the food listed. At lunchtime the meal for one resident was changed three times, after they tasted the food and decided they did not want what was provided. Staff made sure that each person was satisfied with their meal and provided a second helping for one resident. The meal was tasty, hot and well presented. Residents said the food was “first class, and plenty of it”, another said “it’s tasty, as you would cook for yourself at home”. One person said the stews were too much like soup but acknowledged that it might be prepared this way to help people with eating problems. There were several drink choices provided. Staff offered assistance if required but did not force their help on those who wished to be independent. St Aubyns DS0000006771.V340222.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had procedures in place for investigating concerns, complaints and allegations. EVIDENCE: The complaints file was examined. The home had received three complaints about unexplained injuries, an increase in fees and general care issues during the past year. Information about one of these complaints could not be located in the file but was seen by the inspector prior to the inspection. All of the complaints were investigated and a written response was sent to the complainant. The Registered Provider had also offered to meet one of the complainants to discuss their concerns. The file also included several old complaints. Some of which dated back to 2002. Old complaints should be archived or stored in a separate file. Most people said they were familiar with the complaints procedure and one relative said they had seen the procedure on the notice board by the front door. The home notified the commission about significant events. The inspector was told that the home followed the local authority ‘Safeguarding Adults Multi Agency Procedures’. A copy of this procedure was kept in the office and was accessible to staff. Staff that the inspector spoke with had a
St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 17 good understanding of abuse and knew what they should do if they witnessed or were told about an allegation of abuse. There was no evidence on the training matrix that staff had received abuse training. See standard 30. St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 18 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): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home provides a clean, comfortable and safe environment for residents. EVIDENCE: All of the communal areas and a selection of bedrooms were inspected. The building was maintained to a satisfactory standard and was clean, tidy and odour free. A few maintenance issues were identified such as a broken lock in the toilet opposite the dining area and poor water pressure in the first floor bathroom. See requirement 1. All of the carpets were professionally cleaned in April 2007 but some stains were still apparent. The Registered Provider said that a regular carpet cleaning programme would be implemented. St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 19 Since the last inspection the garden area had been paved over and some planters and garden seating provided. The inspector was told that additional garden furniture had been purchased. The seating in the lounge had been rearranged and a new television had been purchased. The Registered Providers said that funding had been obtained from the Department of Health to replace some of the bedroom and dining room furniture and purchase some variable height beds. Some work had been undertaken in the laundry room to make it easier to clean behind, and to repair the machinery, and to ventilate the room. Hand washing facilities were provided where clinical waste or infected material was handled. Protective equipment was provided for staff and cleaning materials were stored securely. St Aubyns DS0000006771.V340222.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 good. This judgement has been made using available evidence including a visit to this service. Staff were supported to attend relevant training sessions and to obtain recognised qualifications. Recruitment practices had improved but further checks must be carried out to comply with legislation. EVIDENCE: The staff team was comprised of a full time manager, deputy manager, registered nurses, care assistants, an activity coordinator, and domestic and maintenance staff. The duty roster showed that there were two nurses and six care staff on duty during the morning shift, two nurses and four carers on duty during the evening shift and two trained nurses and three care staff on duty overnight. The night-time staffing levels had recently increased from two to three carers. Fifty percent of the care staff had attained a vocational qualification at level 2 or had another relevant qualification at this level. The number of care staff with a vocational qualification had increased since the last key inspection. The personnel files for two recently recruited staff members were examined. Records indicated that the homes recruitment practices had improved but some further work was required to ensure that gaps in employment histories
St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 21 were explored and recorded and that one reference was obtained from the current or most recent employer, if the person had worked with vulnerable adults. See requirement 2. There were no interview notes in the staff files but new staff confirmed that they had attended an interview. To provide evidence that the homes recruitment and selection process is fair, the manager should keep a copy of the interview notes on the staff members file. Discussions with individual staff members and examination of training records indicated that most of the staff had attended a moving and handling training update. During 2006 some staff had attended first aid, food hygiene, diabetes, tube feeding, wound care and end of life care training. The manager should ensure that staff have access to safeguarding adults training. See recommendation 3. The manager had developed a new induction-training programme for care staff. The programme covered all of the common induction standards. Staff should make sure that the competence part of the paperwork is also completed to show that care staff have understood the training provided and issues discussed. St Aubyns DS0000006771.V340222.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, 32, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed and led. Systems had been introduced to monitor and improve the standard of care provided in the home. Health and safety issues were monitored closely to provide a safe environment for residents and staff. EVIDENCE: The manager was assessed by the commission in April 2007 and was found to be a suitable person to manage a care home for older people. The manager has experience of working with older people in hospital and residential settings and is a registered nurse. The manager said she had submitted an application
St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 23 to undertake a vocational qualification in management at level 4 and the Registered Managers Award. Staff said the manager and deputy manager were approachable and supportive. The home had implemented a number of new initiatives to monitor and assess the quality of care provided in the home. This included audits to assess compliance with medication procedures and to check that staff were maintaining adequate records. The manager and owners of the home completed a comprehensive quality assurance audit in April 2007. Following the audit an action plan was prepared to address the issues identified. A residents and relatives meeting was held in the home in November 2006 and a satisfaction survey to was sent to relatives and health care professionals to obtain feedback about the service. The manager was developing a questionnaire for staff and planned to update the other questionnaires to obtain more detailed information. Most residents required some help to manage their personal finances. Resident’s relatives or friends usually undertook this task. One resident that did not have any family had arranged for money to be sent to the owners for her use. The financial records for this resident were satisfactory. Most of the nursing and care staff were now receiving supervision. Records were maintained about the supervisor’s observations and the issues that were discussed with the staff member. The manager should ensure that supervision records are checked and signed by the supervisor and the staff member. A maintenance person carried out routine health and safety checks and repairs. This includes testing fire safety equipment and checking wheelchairs, window restrictors and hot water temperatures. Equipment was serviced regularly. Service reports for portable electrical and gas appliances, the call bell system, water chlorination and passenger lift were examined and were found to be up to date. Fire safety arrangements were good. Regular checks were undertaken to ensure that the fire alarm system, emergency lighting and fire doors were in working order. Fire safety equipment was serviced regularly and staff received fire safety training updates. Accidents records were examined. The forms provided a factual account of the event if witnessed, or stated how the resident was found if the incident was not witnessed. There was evidence that staff had taken action to reduce the risk of further accidents and maintain residents safety. This included changing a resident’s chair, removing bedrails and carrying out a routine test to see if the resident had an infection. St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 24 Some of the residents were using bedrails. Although there were references to the use of this equipment in residents care plans, it was not clear why the person required bedrails and if staff had considered alternative ways of maintaining the persons safety. See requirement 3. St Aubyns DS0000006771.V340222.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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 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 3 3 3 X 3 3 X 2 St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 Requirement Timescale for action 04/09/07 2. OP29 19 3. OP38 13 The Registered Person must ensure that the lock in the ground floor toilet is repaired and that adequate water pressure is maintained in the first floor bathroom. The Registered Person must 04/09/07 ensure that all of the information and documents listed in Schedule 2 are obtained before staff commence work in the home. The Registered Person must 18/09/07 ensure that: • Staff assess risks to residents before applying bedrails • Establish regular checks to ensure bedrails are fitted correctly and in good working order St Aubyns DS0000006771.V340222.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. 2. 3. Refer to Standard OP12 OP15 OP30 Good Practice Recommendations The Registered Person should ensure residents that choose to remain in their rooms or are confined to bed have access to activities. The Registered Person should review the menu to see whether it is possible to increase the fruit and vegetable content of the diet. The Registered Person should ensure that staff receive training about prevention of abuse and procedures to safeguard vulnerable adults. St Aubyns DS0000006771.V340222.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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
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