CARE HOMES FOR OLDER PEOPLE
St Bridget`s Residential Home 42 Stirling Road Talbot Woods Bournemouth Dorset BH3 7JH Lead Inspector
Debra Jones Unannounced Inspection 09:40 30th May 2006 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 DS0000003985.V297366.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. DS0000003985.V297366.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Bridget`s Residential Home Address 42 Stirling Road Talbot Woods Bournemouth Dorset BH3 7JH 01202 515969 01202 291347 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) Mr Anthony Howell Mrs Denise Simpson Care Home 10 Category(ies) of Old age, not falling within any other category registration, with number (10) of places DS0000003985.V297366.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 14th October 2005 Brief Description of the Service: St Bridgets Residential Home has the capacity to care for ten older people all enjoying single rooms. The home is set in a large 1930s converted house, in a quiet residential area of Bournemouth - Talbot Park - close to shops and other local amenities. The home is over two floors - ground and first - and there is a passenger lift. There are a variety of aids around the building to allow residents to move about more independently. One bedroom has an ensuite. There are four communal toilets and two baths - the more popular one has a mechanical bath seat. The average current charge is £445 a week. DS0000003985.V297366.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection visit took place over two and a half hours and was the anticipated inspection of the year. The 4 recommendations and 5 requirements made at the last inspection were followed up with the manager to see if the home had made any progress towards meeting them. They had. The Inspector looked around some of the building and a number of records were inspected. All residents spoken with expressed satisfaction with the home. ‘It’s like a hotel here.’ ‘I’ve no complaints.’ ‘It’s lovely.’ Prior to the inspection visit the home gave out comment cards on behalf of the Commission to people living in, and interested in the service so that they could give feedback about their experience of the home. Four cards were returned from relatives, 6 from residents and 1 from a GP surgery. All 6 residents said that they liked living at the home, were well cared for, treated well by the staff, had their privacy respected and felt safe there. Five out six said they liked the food and all felt that the home provided suitable activities. Comments included :‘I find no problems with the care I receive at St Bridget’s.’ (a resident) ‘I’m 93 years old and not always easy to please, but we get along very well’. (a resident) ‘The manager and staff go out of their way to make visitors welcome at any time (with tea or coffee!)…… and develop a personal caring relationship with residents.’(a relative) ‘The staff are always caring and helpful and the rooms are always kept tidy and clean.’ The GP said that he was satisfied with the overall care provided to residents within the home and commented ‘No problems here, warm caring and efficient staff.’ DS0000003985.V297366.R01.S.doc Version 5.2 Page 6 What the service does well:
The manager and staff at St Bridget’s have created a very homely and comfortable environment for the residents to live in. The home is clean and smells fragrant throughout. Before anyone is offered a place at the home a thorough pre admission assessment is carried out by the home, usually the manager. After this is done the home then writes to the person who has been assessed with the outcome of the assessment letting them know if the home can meet their needs. Prospective residents and their supporters / families are welcome to visit the home before making the decision to move there. Care plans are written for all residents that are clear about what the residents can do for themselves and what they need help with. Daily notes are kept about what care is given to the individual residents along with other things that happen at the home. Having good care plans in place ensures that staff have all the information they need to fully meet residents’ care needs. Residents health needs are well met by the home working with community health professionals. Medication is well handled at the home promoting the health and well being of residents. Residents confirm that they are well cared for and treated with respect and dignity. Residents are free to, and encouraged to spend their days as they choose. Current residents who have expressed a view have said that they are happy with what is on offer at the home. Residents are able to see visitors when they wish and make decisions about how they spend their days within the constraints of a residential care home setting and their own abilities. Meals are wholesome and varied and planned around the likes and dislikes of residents. The complaints procedure reassures residents that their views are important to the home and that any complaints they, or their supporters raise will be properly investigated. The adult protection policy demonstrates the home’s commitment to providing a safe environment for residents that is free from abuse. The home has a good, experienced, committed manager and sufficient care staff are employed to meet the current needs of residents.
DS0000003985.V297366.R01.S.doc Version 5.2 Page 7 Staff have access to the basic training that they need to do their jobs well. Criminal Record Bureau disclosures and POVA checks are completed for all staff employed at the home, and proof of the person’s identification is obtained. This goes toward protecting residents from unsuitable staff working there. The manager and some of her staff have worked at the home for a long time. This stability is good for the staff as they are used to working together and for residents who benefit from having the same people looking after them. The home respects residents’ rights to look after their own finances. The manager has made sure that every member of staff has had their fire training when it was due. The home is also regularly checking and getting their fire equipment checked. Accident records are kept and regularly analysed to see if there are any steps that can be taken to reduce the risk of accidents happening again. What has improved since the last inspection? What they could do better:
It is recommended that the room that the resident is to occupy is put on the terms and conditions they are issued with when they move into the home. The home should carry out assessments, and regularly review these assessments, for any items of equipment in use at the home that might restrain the movement of residents e.g. bed rails. Residents would benefit from their care plan including a section on medication. It would be good if there was a written programme of maintenance and renewal of the premises, with time scales for action, that included the outstanding areas of concern noted by the Commission and the fire service. It would also be good if the building / premises was / were assessed to ensure that the facilities were right for the people living there. The radiators and pipe work that need covering to protect residents from burns need to be covered. It would be good if all staff had statements of terms and conditions. It would also be good if more care staff had an NVQ level 2 qualification in care. This would make care staff more knowledgeable about the job they do and potentially improve the quality of care delivered to residents at the home.
DS0000003985.V297366.R01.S.doc Version 5.2 Page 8 The home must get recent photographs of residents as required by law to protect them e.g. from anyone mistaking their identity or for use should they go missing. Recommendations made by other authorities such as the fire and rescue service, in respect of upgrading the building for fire safety, and environmental health, in respect of the kitchen, need to be addressed. In addition some good practice suggestions have been made in this report. 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. DS0000003985.V297366.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 DS0000003985.V297366.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 is not applicable to this home.) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A thorough pre admission procedure is in place and assessments are undertaken to ensure that only residents whose needs can be met by the home are offered places there. EVIDENCE: Files for three residents who had recently moved into the home were reviewed. All files contained pre admission assessments. After the assessments were completed and the manager was sure that the home could meet the needs of the residents they were all issued with letters confirming this. Files also contained contracts / terms and conditions of residents. These did not have the room that person was to occupy on them. A new resident talked of how she had moved to the home from another residential home and of how well it was working out for her. ‘It’s like a hotel!’
DS0000003985.V297366.R01.S.doc Version 5.2 Page 11 Prospective residents and / or their representatives are always welcome to visit the home to decide if the home suits them. Information about the home aimed at residents is all in rooms and a copy of the most recent inspection report is available in the main hallway. DS0000003985.V297366.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 at least once during a 12 month period. 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. There is a clear care planning system in place to provide staff with the information they need to meet residents’ needs. The health needs of residents are also well met with evidence of good support from community professionals. Medication at the home is well managed in order to promote the good health and well being of residents. Residents confirmed that they felt treated with respect and that their right to privacy is upheld. EVIDENCE: Six residents returned comment cards to the Commission prior to the inspection. All said that they liked living at the home, felt well cared for, were treated well by staff and that their privacy was respected.
DS0000003985.V297366.R01.S.doc Version 5.2 Page 13 Care plans are well written and reviewed / updated every month. They clearly set out individual care needs and how they are to be met. Plans are clear about what residents can do for themselves and what staff need to assist them with. All care files include risk assessments, manual handling assessments, and those that were seen had been reviewed recently. Some residents have equipment in their rooms e.g. aids to help them get in and out of bed and bed rails. Assessments and reviews for the use of this equipment were not in place. Nor were specific written plans as to the medication needs of residents. Daily notes support and evidence the delivery of care to residents. All residents spoken to at the visit said that they were well looked after. One resident said If I want anything I ring the bell, staff come quickly and ask me what I want.’ Community health professionals support staff at the home in caring for residents. Documentation shows that residents regularly access GP services, district nursing services, chiropodists, dentists, opticians and physiotherapists. One resident had a hospital appointment on the day of the inspection visit and the manager was going with her for support. A number of residents need aids to help them get around or live more comfortably. These were in evidence at the home e.g. pressure relieving mattresses, an electrically operated chair, zimmer frames and raised toilet seats. Wheelchairs are also available for use. One resident is waiting for a pair of slippers to be made for her by the NHS. The GP surgery that returned a comment card to the Commission said that the home communicated clearly, worked in partnership with them and that staff demonstrated a clear understanding of the care needs of residents. They also said that the home took appropriate decisions when they could no longer manage the care needs of residents. Of the four relatives who responded to comment cards all said that they were happy with the level of information they received about important matters and the consultation they had with the home in respect of their relatives/ friends. No residents are administering their own medication. Medication at the home is only administered by staff who are trained and confident in carrying out this task. Medicines and dressings were tidily stored in appropriate places. No controlled drugs are currently in use and no medicines are being kept in the fridge. A system is in place for the disposal of medicines that are not used at the home and records are kept. DS0000003985.V297366.R01.S.doc Version 5.2 Page 14 Details of any residents’ medicine sensitivity or ‘none known’ are noted on the medication administration records. Where there is a choice of dose of medication it is noted how much is actually given. Where hand written changes had been made to the medication administration records by staff at the home examples were seen of two people signing to confirm the changes. Medication Administration charts are now being completed at the time that the medicines are administered to residents. The home are not auditing themselves in respect of their medication administration and it is suggested that they do. The GP surgery that returned a comment card to the Commission prior to the inspection said that in their opinion residents’ medication was appropriately managed in the home. Residents confirmed at the inspection that their privacy and dignity were respected through staff knocking on their doors, and being polite and helpful. One resident talked of how she appreciated the staff always calling her by the name she likes to be known by. The GP surgery that returned a comment card to the Commission confirmed that they are always able to see their patients in private. DS0000003985.V297366.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ lives are enriched by the social opportunities afforded by their visitors and they are encouraged to exercise choice and control over their lives by staff at the home. Social activities suit current residents. Food is wholesome, varied and plentiful. EVIDENCE: Residents are able to do what they like and spend their days as they choose. Some residents like to spend their days in the lounge, others in their rooms – reading or watching TV. Some residents are able to go out on their own while others are more dependent on visitors taking them on trips or outings arranged by the home. Daily papers can be arranged. The library service visits. The home are looking to have an activities person coming to the home for 3-4 hours a week in the near future to provide more stimulation for residents. Some games are available. The six residents who returned comment cards to the Commission said that they felt the home provided suitable activities for them. DS0000003985.V297366.R01.S.doc Version 5.2 Page 16 Residents are able to have visitors when it suits them and some talked about their families visiting them at the home. A newer resident talked of how one of her visitors had been made welcome, offered a cup of tea and had commented ‘what a wonderful place.’ The visitors’ book confirmed the number and range of visitors to the home. All four visitors who returned comment cards said that they felt welcome in the home and would be able to visit their relatives in private if they wished. During the inspection visit a vicar called in to see a couple of residents. Residents at this home are well able to make their choices and opinions known to staff and are very much in control on how they live their lives at the home. Most have the support of families or supporters / solicitors to help them with their affairs. The lunch on the day of the visit was baked haddock with chips and tomatoes, (potatoes if preferred). With fruit and cream for afters. Food records show that there is a variety of food on offer and residents are able to make choices and have their preferences accommodated. Appetites are also noted to help the home monitor the health and well being of the residents. One residents talked of how her food was pureed for her and that she found the meals ‘wonderful.’ In addition to the meals, fruit and fruit juices are on offer throughout the day. The dining area is at the end of the lounge. The dining table overlooks the garden. When residents moved into this area music was played creating a relaxing atmosphere to eat in. About half the residents usually come to the dining area to eat their lunch; others have stated a preference to eat in their rooms. Prior to the inspection 6 comment cards were received from residents. Five of the six said that they liked the food and the other that they liked the food sometimes. One relative described the food as ‘adequate if a little unimaginative.’ The home is currently working through the Food Standards Agency pack ‘Safer Food, Better Lives.’ All staff involved in the preparation of food have up to date food hygiene certification. It is suggested that staff access to training in nutrition to widen their knowledge. DS0000003985.V297366.R01.S.doc Version 5.2 Page 17 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A system is in place to deal with any complaints made will be taken seriously and where possible resolved. The home’s adult protection policy demonstrates an understanding of abuse and of how residents are protected from it. EVIDENCE: The home has a satisfactory complaints policy and system for dealing with complaints. No complaints have been received by the home or by the Commission in the last 12 months. The six comment cards received prior to the inspection from residents all confirmed that residents knew who to speak to if they were unhappy with their care. Residents confirmed at the inspection visit that they had no complaints. Three of the four relatives who returned comment cards said that they were aware of complaints procedure. All four said that they had never had to make a complaint. The home has a satisfactory adult protection policy. No concerns have been raised with the home in respect of adult protection issues in the last 12 months.
DS0000003985.V297366.R01.S.doc Version 5.2 Page 18 No staff have had to be referred to the Protection of Vulnerable Adults list by the home. The six comment cards received prior to the inspection from residents confirmed that they all felt safe at the home. DS0000003985.V297366.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is generally good providing residents with an attractive and homely place to live. Slow progress is being made to ensure the safety of residents at all times and the manager has a good understanding of what needs to be done e.g. cover radiators. EVIDENCE: The home is registered for 10 people and has 10 bedrooms. One bedroom has an ensuite. Communal bathrooms and toilets are readily accessible in the home, along with commodes. Residents are able to bring personal possessions and furniture into the home. All rooms have emergency call bells in them for residents to summon help if they need it. Residents are able to reach the bells from wherever they usually lie or sit.
DS0000003985.V297366.R01.S.doc Version 5.2 Page 20 The home was clean and smelt fragrant throughout. Some radiators in the home are guarded. Others identified as posing a potential risk to residents are yet to be covered. In the meantime furniture is being placed in front of them or other methods employed to minimise the risk of burns. No major works are planned at the home but the manager said she is hopeful that this year will see the refurbishment of one of the communal bathrooms and of the kitchen. When the kitchen is updated it is expected that the recommendations made by the Environmental Health Officer will be addressed i.e. putting diffusers on the fluorescent strip lighting and creating a rack to store the chopping boards. An assessment of the whole premises has not yet been undertaken by suitably qualified persons as recommended in previous reports. DS0000003985.V297366.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient, adequately trained staff are on duty at all times to meet the needs of the residents. The procedures for the recruitment of staff are robust and therefore provide the necessary safeguards to offer protection to people at the home from unsuitable workers. EVIDENCE: Staff rosters showed the number of staff on duty and what jobs they do. It was clearer from the rosters at this inspection who is in charge of the home at any time i.e. when the manager is on duty and when she is not. (Two members of staff appearing on the roster at this inspection visit mainly work at St Bridget’s nursing home – sister home of this residential home.) All four relatives who returned comment cards to the Commission said that in their opinion there were always sufficient numbers of staff on duty. The GP surgery that returned a comment card to the Commission said that there was always a senior member of staff to confer with at the home. One member of staff out of the 6 care staff employed at the home has a NVQ at level 2.
DS0000003985.V297366.R01.S.doc Version 5.2 Page 22 No new members of staff have started working at the home since the last inspection visit. Previous inspection reports have noted that the home keeps well ordered staff files containing evidence of the necessary recruitment checks undertaken to ensure the protection of residents. Staff are not issued with statements of terms and conditions. Staff files reviewed showed that staff are getting the basic training and updates they need to do their jobs. In the last six months there has been fire training, infection control training, moving and handling, health and safety, food hygiene and emergency aid. As there are no new members of staff no one is currently going through an induction programme. The manager is aware of the new induction programme that has been developed by Skills for Care that should be used in future. DS0000003985.V297366.R01.S.doc Version 5.2 Page 23 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home is generally good and the manager is open to reflecting on the way things are done in the home to improve on practice to make the home even better for the people who live there. Whilst there is nothing to demonstrate that the home is not run in the best interest of residents a robust, documented quality assurance system is not in operation. The home is not involved in the finances of residents. Records demonstrate that the health and safety of residents is protected by checks of equipment and facilities and through regular staff training. However, the progress of meeting the recommendations made by the fire service in respect of the overall safety of the building is slow.
DS0000003985.V297366.R01.S.doc Version 5.2 Page 24 EVIDENCE: A suggestions box is available. Residents continue to express satisfaction with the home both to home staff and in Commission surveys. Policies and procedures are regularly updated and the manager does what is in her power to comply with any requirements and recommendations made by the Commission. Comment cards are made available generally at the home but few are completed. The manager is yet to establish a quality assurance system that is effective and meets the size and character of the home. Residents or their relatives look after money for day-to-day expenditure. The Responsible person for the home receives some money for one resident that is passed on to the resident when it arrives and appropriate records are kept by the home. All records asked for at the inspection were made available with the exception of photographs of residents. An up to date certificate of insurance was on display as was the registration certificate for the home. The home documents all accidents and analyses these records regularly, looking for any trends that can help them prevent future accidents. Fire training records confirmed that the home has a robust system for ensuring that staff are trained at appropriate intervals. Fire evacuations and drills take place. Records are made of these events. It is suggested that it is noted on these reports what time of day the exercise is carried out and how it takes. The Proprietor is working with the local fire and rescue service to progress the recommendations that they have made about improving fire safety at the home. The recommendations made by the Environmental Health Officer about the kitchen prior to the last inspection are yet to be addressed i.e. putting diffusers on the fluorescent strip lighting and creating a rack to store the chopping boards. DS0000003985.V297366.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 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 2 x x 2 x x 2 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 X 2 2 DS0000003985.V297366.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. Standard Regulation Requirement The programme of covering / guarding or replacing with low temperature surfaces all radiators and pipe work, assessed as posing a risk to residents, is to be completed. (Previous timescale of 1 August 2005 not met) The registered person shall establish and maintain a system for reviewing at appropriate intervals and improving the quality of care provided in the home. There must be a recent photograph of each resident in the home. Adequate arrangements must be in place to comply with the recommendations of the Fire and Rescue Service. (Timescale of 31/12/04 not met and renegotiated). Timescale for action 1. OP25 13 01/08/06 2. OP33 24 01/12/06 3. OP37 17 01/07/06 4. OP38 23 01/12/06 DS0000003985.V297366.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 OP3 Good Practice Recommendations Terms and conditions given to residents should include the number of the room they are to occupy. • Care files should contain bed rail assessments where appropriate and these assessments should be regularly reviewed. • All care plans should include a section on medication, which should be regularly reviewed. A programme of routine maintenance and renewal of the fabric and decoration of the building should be produced and implemented with records kept. Where a timescale has been set for compliance with any standard relating to the physical environment of the home, a plan and programme for achieving compliance should be produced and followed with records kept. It is recommended that an assessment of the premises is undertaken by an occupational therapist or another suitably qualified person. It is recommended that all staff employed at the home have statements of terms and conditions of employment. It is recommended that the home ensures that 50 of care staff attain NVQ level 2 by the end of 2005. It is recommended that the recommendations made by the Environmental Health Authority are carried out. 2. OP7 3. OP19 4. 5. 6. 7. OP22 OP27 OP28 OP38 DS0000003985.V297366.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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