Inspection on 12/01/06 for Steepleton Manor

This inspection was carried out on 12th January 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Steepleton Manor 19/02/07

Steepleton Manor 27/09/05

Steepleton Manor 16/03/05

Steepleton Manor 24/11/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Steepleton Manor Winterbourne Steepleton Dorchester Dorset DT2 9LG Lead Inspector Rosie Brown Unannounced Inspection 10:00 12 January 2006 th 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 DS0000026874.V276445.R01.S.doc Version 5.1 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. DS0000026874.V276445.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Steepleton Manor Address Winterbourne Steepleton Dorchester Dorset DT2 9LG 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) 01305 889316 01305 880165 elaine.pitney@steepletonmanor.co.uk Altogether Care LLP Mrs Elaine Pitney Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places DS0000026874.V276445.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximum of six double bedrooms to be used at any one time. The home can accommodate a maximum of two younger adults, in the category PD, in rooms for single occupancy only. One person (as known to the Commission for Social Care Inspection) who is under 65 years of age and who has a learning disability may be accommodated. 27th September 2005 Date of last inspection Brief Description of the Service: Steepleton Manor is a large Grade II listed late Victorian Manor House set in 6.5 acres of landscaped grounds, which include a Victorian walled garden. It is situated in the quiet rural location of Winterbourne Steepleton. The village church is nearby and Dorchester is approximately 4 miles away: a river runs alongside the property and provides the additional interest of abundant wildlife and birds. Steepleton Manor is registered to accommodate a maximum of 36 elderly people, in 24 single and 6 double bedrooms. With the exception of three single bedrooms (which have separate dedicated private bathrooms) all offer en-suite toilet facilities. A passenger lift enables access to the first and second floors of the home: at this level four bedrooms are accessed by a short additional flight of stairs. At first floor level a separate stair lift is fitted to a small staircase and provides assistance to negotiate the stairs. Other facilities include an outdoor heated swimming pool, which can be used during the summer months. The Registered Individual (RI) is Mr Peter Cotterill on behalf of Altogether Care LLP and he visits the home in a management capacity each month and the Registered Manager who takes responsibility for the day to day running of the home is Mrs Elaine Pitney. The home was previously owned by Mr and Mrs Westlake who continue to be involved with the business: Mrs Westlake visits the home each Wednesday, while Mr Westlake visits less often, always at a resident’s specific request and is usually present at residents’ meetings. DS0000026874.V276445.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 12 January 2006, it commenced at 10:00am and was concluded by 4:00pm. The purpose of the visit was to review the requirements and best practice recommendations set out in the previous inspection report date 27th September 2005. Twelve of the National Minimum Standards were assessed. The CSCI pharmacy inspector will assess standard 9, which concerns the medications arrangements in the home, in the form of an unannounced additional visit before March 31st 2006. It was the second of two statutory inspections planned for the year. Information was gathered through discussion with Elaine Pitney, the manager, five residents and six of the staff on duty at the time. The inspector used observation skills and noted positive interactions between staff and residents. The communal areas of the home were viewed along with a selection of residents’ bedrooms. Certain records, required by legislation were examined, as were a selection of residents’ files and some of the home’s policies and procedures. It is recommended that the report of the previous inspection be read in conjunction with this report so that a fuller ‘picture’ of the home is gained. What the service does well: As stated in the previous report the home is established in an elegant period building that has been developed and well cared for over a number of years. Residents who live in the home enjoy gracious surroundings balanced with a homely atmosphere established by the manager and staff team. The home offers a social care programme of a very high standard that involves the residents when decisions are made about arranging and holding social events and choices in their daily lives. The home supplies residents with a selection of healthy meals, which include alternative options, special diets and seasonal variations. The manager is properly qualified and experienced: she is well respected and liked by residents and staff. Arrangements are in place to ensure that the health, safety and welfare of residents and staff are promoted and protected. DS0000026874.V276445.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The homes statement of purpose should be updated to accurately reflect the management arrangements for the home, eg the correct name of the Registered Individual (RI). Although the RI undertakes the required monthly visits to the home, reports of these visits are not being supplied to the Commission. The inspector is aware that because of the age and stature of the building the house is continually being redecorated and refurbished. The home is generally well maintained but the chimney should be rebuilt as indicated by the local council surveyor. Consideration should be given to replacing the bath in the ground floor assisted bathroom because it is damaged and may pose a risk of cross infection to residents. The maintenance worker should also check that the hot water supplied to the two washbasins outside of this bathroom is safely controlled. A solution should be found to improving the ventilation in one of the Old Stable bed sitting rooms: currently there is no opening window and the resident may not always want to have the door open. In future management should consult with the Commission, Fire Safety Officer/Building Control Officer and Planning Department prior to alterations being made to ensure there are no requirements or recommendations when refurbishment/improvements are made to the environment: the home’s fire risk-assessment must also be updated to reflect the internal alterations. An action plan describing how a programme of guarding unprotected radiators will be gradually implemented using a risk assessment process must be supplied to the Commission. The registered persons must give consideration to the employment of a new DS0000026874.V276445.R01.S.doc Version 5.1 Page 7 Head of Care/deputy manager to provide management cover when the manager is off duty. The manager must be additional to the staff team when working. The staff training provided should be developed to include topics relevant to residents specific care needs, eg, Memory loss, diabetes, the identification of abuse and adult protection. All staff must be supplied with the local ‘POVA’ training and the manager must undertake the advanced training available: it is understood this has been arranged for February 2006. 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. DS0000026874.V276445.R01.S.doc Version 5.1 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 DS0000026874.V276445.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The home’s statement of purpose is presented in an attractive folder and clearly describes the services available. The information about management arrangements needs updating so that prospective residents’ representatives can make an informed choice about the home. Standard 3 was met at the previous inspection and standard 6 does not apply to this home. EVIDENCE: The home has a statement of purpose and residents’ guide, which is readily available in the home’s entrance hall with other information about local services and a copy of the home’s inspection report. A colourful wallet has been complied; this contains a letter acknowledging an enquiry, a pictorial guide of the home including it’s communal rooms and a single bedroom, local authority assessment arrangements, a sample menu, the home’s typical daily routine, other information about the facilities and services provided. The manager explained that this information is supplied to each prospective resident or their representative when they make an enquiry. DS0000026874.V276445.R01.S.doc Version 5.1 Page 10 The statement of purpose must be updated to reflect the change in management arrangements to reflect that Mr Cotterill is the Registered Individual (RI) on behalf of Altogether Care LLP. DS0000026874.V276445.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Each service user has a care plan that identifies the care being provided to meet identified needs. Standards 8 and 10 were met at the previous inspection. EVIDENCE: Care plans for three residents were examined and included details of personal hygiene, elimination, nutrition, mobility, sleeping, communications, safety, social care and activities, health, foot care, oral hygiene and the care and wishes of service users when they become critically ill and upon their death. The records demonstrated that the manager or senior staff organise health assessments for residents’ with other care professionals when necessary and seek advice guidance and support. Care related risk-assessments were documented, but some need to be developed to include more specific information, for example where medicines are safely stored in a bedroom and the arrangements regarding the use of an angina spray. DS0000026874.V276445.R01.S.doc Version 5.1 Page 12 Records evidenced that care reviews are undertaken regularly and involve the service users and/or their representative. Three service users confirmed they are include when decisions are made about their care and staff were observed consulting with residents about their care and preferences during the visit. DS0000026874.V276445.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 were met at the previous inspection. EVIDENCE: DS0000026874.V276445.R01.S.doc Version 5.1 Page 14 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 The company complaints procedure is supplied to residents and it was evident that their concerns are taken seriously and acted upon. The home has a policy concerned with adult protection to ensure that any allegation of abuse to a resident is properly responded to: staff training in this subject and local procedures has been arranged. EVIDENCE: The home has a complaints procedure and a complaints log is kept: no complaints have been received since the previous inspection. Residents confirmed they are aware of the complaints procedure and said they were confident that their concerns would be taken seriously and acted upon. One resident said, ‘Elaine is very approachable and although busy takes the time to listen to our grumbles’. It was also evident that Mr Westlake takes residents grumbles and concerns seriously and makes himself available at residents meetings for this purpose. A home has a procedure for responding to allegations of abuse and the identification of abuse and this is available for staff reference in the home’s policies and procedure file. In addition, there are other guidance documents held in the home and these include: a copy of the local ‘No Secrets’ and Protection of Vulnerable Adults (POVA) guidance and policies/procedures concerned with ‘Whistle Blowing’ and bullying in the workplace. The previous report notes that the home was subject to an adult protection investigation undertaken by the local Social Care & Health Dept: this DS0000026874.V276445.R01.S.doc Version 5.1 Page 15 investigation did not find evidence of abuse. The recommended outcomes were that: consideration and review be given to minimising long working hours for some staff, that the moving and handling policy be updated and that staff training be provided with regard to interpersonal skills. These recommendations have been addressed through supervision, training and the employment of additional staff. All staff must be supplied with local ‘No Secrets’ training: including the two-day advanced course for management. The manager explained this has been arranged for February 2006.Training in this subject is included in the staff induction programme. DS0000026874.V276445.R01.S.doc Version 5.1 Page 16 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 Residents live in a grand house set in it’s own grounds and mature gardens. The home is generally well maintained and has retained many original features, the communal facilities are comfortably furnished and pleasantly decorated and the majority of bedrooms are highly personalised. However, until the central heating radiators are guarded some vulnerable residents may be at risk. Standard 26 was met at the previous inspection. EVIDENCE: DS0000026874.V276445.R01.S.doc Version 5.1 Page 17 Steepleton Manor is a very well maintained spacious period building set in attractive landscaped gardens in a rural location. There is an ongoing programme of restoration and refurbishment and a very comfortable and elegant environment is provided. The house is set in approximately 6 acres of grounds and gardens, which are very well maintained. Garden seating is sited in sheltered positions around the property with some areas accessed directly from service users patios doors. The home has an outdoor heated swimming pool and this is currently being upgraded by the installation of hand grab rails in appropriate places. The manager explained that this matter had been raised during a residents’ meeting and during the winter improvements to this facility are being made. The spacious grounds include a grand gravelled driveway with a water fountain feature: a large car parking area is also available to the front of the house. Since the previous inspection the manager has drawn up a security riskassessment as recommended and some time was spent considering the possible scenarios and safe practice. The inspector viewed the communal rooms and a selection of bedrooms. Service users bedrooms are available over three floors, the first and second floors being accessed by a small passenger lift. The second floor corridor is currently being redecorated other work taking place on the day included: the installation of an internal call system with access to external telephone line in each bedroom/ suite, the redecoration of some vacant rooms and the refurbishment of one en-suite bathroom. The recommendation that consideration be given to how one of the Old Stable bed-sitting rooms can be better ventilated is repeated in this report. The previous report noted that the hot water supply to washbasins has been governed by the fitting of fail-safe valves. However, the hot water supply to the washbasins outside of the home’s ground floor bathroom felt very hot (almost 60 degrees) and it was not clear if these washbasins had been fitted with fail-safe controls. The inspector noted that the bath in the ground floor assisted bathroom would benefit from replacement because there are two filled areas in the base of the bath: this may be a cross infection issue. Central heating radiators are not protected. Risk-assessments concerned with individuals safety and vulnerability to scalding and burns have been drawn up, but remedial action has yet to be undertaken. The good practice recommendation for a programme of guarding unprotected radiators to be implemented using a risk assessment process and is repeated in this report. During the previous two inspections it was noted that the home’s chimneystack had cracked and that scaffolding was erected. The manager and one resident told the inspector that the chimneystack has to be rebuilt: the building stone has been obtained but the restoration work has yet to be commenced. DS0000026874.V276445.R01.S.doc Version 5.1 Page 18 The previous report also identifies a requirement for a retrospective building control certificate to be obtained in connection with alterations/improvements made to a bedroom/suite on the second floor, and another bedroom with a connecting door to this room, which is used as a fire exit. Following the inspection the inspector contacted the Fire Safety Dept to clarify that they are satisfied with the completed works. The result being that completed works are now satisfactory. It is recommended that in future management ensure the Commission, Fire Safety Officer/Building Control Officer and Planning Department are consulted prior to alterations being made to ensure there are no requirements or recommendations when refurbishment/improvements are made to the environment: the home’s fire risk-assessment must also be updated to reflect the internal alterations. All requirements set out in the Environmental Health Officer’s (EHO) letter dated February 2004 have been remedied and since the previous inspection new floor covering has been provided in the kitchen. DS0000026874.V276445.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The home is appropriately staffed 24hrs each day by management, care and domestic workers to ensure that service users needs are met at all times. The process of staff recruitment is robust thereby ensuring the protection of residents living in the home. A company training and supervision programme has been set up to ensure that staff are appropriately trained to meet service users needs. A staff-training programme that directly relates to specific residents medical conditions needs to be developed. EVIDENCE: The staff rota demonstrates that there are three staff on duty throughout the day and two wakeful staff on night duty between the hours of 8pm and 8am: usually there are three care staff on duty until 10pm. Agency care staff are currently being used to cover care assistant vacancies and at times when unexpected shortfalls arise. However, this situation does not provide consistency of care to service users. The staff team includes the manager, head of care, senior staff, key-worker carers, an activities organiser, two chefs, two kitchen assistants, three general domestics and a maintenance worker/driver. Two residents remain concerned because in their opinion one of the key posts: Head of Care, whose role provided management cover when the manager was DS0000026874.V276445.R01.S.doc Version 5.1 Page 20 off duty and working as part of the care team, remains vacant. The manager said that she is hoping to recruit to this post shortly. Since the previous inspection the full time activities co-ordinator has ceased employment for personal reasons. The manager has recruited a part-time activities coordinator and some residents are worried that the social care provision/standard will fall, although there was no evidence to support this view during the inspection. A concierge receptionist /administrator has been employed to alleviate some of the managers workload and the manager reported that she now feels she has more time to oversee care planning, carry out staff supervisions and to interact with residents. The general domestic vacancy has been filled. The recruitment records for two recently appointed members of staff were examined and these contained a copy of the application, two references including one from their previous employer, an interview record letters confirming the offer of employment, job descriptions and employment contracts plus identification information for CRB/POVA check. Staff on duty were friendly, polite, respectful and patient with service users. One resident said, ‘staff are really kind and helpful and I am gradually settling in’, while another said that two senior staff and the manager work very hard to ensure residents’ needs are met. There was evidence that the staff-training programme includes a supervised induction process that meets National Training Organisation (NTO) specifications. Staff training records indicated that all statutory training is up date. Ten care staff are employed to work in the home. Three care workers have NVQ level 2 qualifications and two hold a nursing qualification (obtained overseas). One senior staff has almost completed NVQ Assessor training while one care assistant is hoping to commence NVQ 2 training when they have completed the induction and foundation training. The recommendation to develop the staff training programme to include topics directly related to the needs of residents accommodated in the home, e.g. Diabetic Care, understanding sensory loss and Parkinsons disease is repeated in this report. DS0000026874.V276445.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 37 and 38 The manager is properly qualified and experienced: the home is effectively managed so that service users receive consistent care. The views of residents and other interested parties are obtained to help ensure the home is run in their best interests. The records required by the Regulations are in place to demonstrate how the home cares for service users. Arrangements are in place to ensure that the health, safety and welfare of residents and staff are promoted and protected. DS0000026874.V276445.R01.S.doc Version 5.1 Page 22 EVIDENCE: Elaine Pitney, the registered manager has achieved her NVQ level 4 qualification in Care and Management. Training records also revealed that she also undertakes regular training in moving and handling, first aid, food hygiene, and health and safety and fire safety. She has a job description and is only responsible for one establishment. The manager is highly thought of by residents and staff, described as being ‘very approachable and kind’. The home and company is reviewed by an external agency to the standard ISO 900:2000 each year. The findings of the most recent quality assurance survey noted staff are happy at work in the home and service users are satisfied with the services provided. However, it also noted both residents and staff would appreciate a more personal approach from management members who are involved with the home and better communication. During the inspection residents said that they feel their views are listened to but sometimes not acted upon as quickly as they would. For example their most current concern is how much the fees will be increased by in April 2006: this matter was referred to the manager so that the information could be shared with business members of the company. The home keeps records as required by the Regulations. During the year Mr Cotterill (RI) has commenced documenting and providing reports of his Regulation 26 visits to the home: these visits provide general support and supervision for the manager and enable management to view the home from a quality assurance perspective. Only two reports have been received by the Commission since July 2005: the manager confirmed that Mr Cotterill does visit the home on a monthly basis and on other necessary occasions although residents said they knew Mr Cotterill they did not confirm he visits the home each month. Records demonstrated that care staff and nurses are supplied with training in manual handling, food hygiene, and first aid, control of infection and fire safety. The home has a comprehensive policies and procedures manual for staff reference and practice guidance and Mr Westlake generally reviews the company procedures on an annual basis. The home’s fire records demonstrated that the regular in house tests and routine servicing of the fire safety system and equipment are up to date. The DS0000026874.V276445.R01.S.doc Version 5.1 Page 23 home has a fire risk-assessment in place but it was not clear if this is up to date and includes details of changes/improvements made to the environment. Specific risk-assessments are in place regarding the concern of unguarded radiators (see standard 19). Other maintenance records evidence that routine checks/servicing of the central heating system, passenger lift, hot water supply, electrical installations and moving and handling equipment with certificated documentation in place. The home has an insurance certificate in place to cover a level of £5 million and this is displayed in the home and up to date. DS0000026874.V276445.R01.S.doc Version 5.1 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 2 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X X STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X 2 3 DS0000026874.V276445.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? 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 All staff must be supplied with training in the local No Secrets guidance: the manager and senior staff must undertake the advanced training available regarding the protection of vulnerable adults, as planned. An action plan describing how a programme of guarding unprotected radiators will be gradually implemented using a risk assessment process must be supplied to the Commission. Consideration must be given to the employment of a new Head of Care/deputy manager to provide management cover when the manager is off duty, this person could also work as part of the staff care team. (It is acknowledged that the home is recruiting for new staff). The Registered Individual must provide monthly reports of his Regulation 26 visits to the home. Timescale for action 1. OP18 18 31/03/06 2. OP19 13(4)(c) 31/03/06 3. OP27 18 31/03/06 4. OP37 26 28/02/06 DS0000026874.V276445.R01.S.doc Version 5.1 Page 26 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 OP1 OP19 OP19 Good Practice Recommendations The homes statement of purpose should be updated to accurately reflect the management arrangements for the home, eg the correct name of the Registered Individual. The chimney should be rebuilt as indicated by the council surveyor. (Repeated from the previous report). The registered persons should consider how The Old Stable bed-sitting room: number 30, could be better ventilated. (Repeated from the previous report). Consideration should be given to replacing the damaged bath in the ground floor assisted bathroom. The maintenance worker should check that the hot water supplied to the two washbasins outside of this bathroom is safely controlled. In future management should consult with the Commission, Fire Safety Officer/Building Control Officer and Planning Department prior to alterations being made to ensure there are no requirements or recommendations when refurbishment/improvements are made to the environment: the home’s fire risk-assessment must also be updated to reflect the internal alterations. The homes staff training programme should be developed to include topics directly related to the needs of the service users accommodated in the home, e.g. Diabetic Care, understanding sensory loss and Parkinsons disease. (Repeated from the previous report). 4. OP19 5. OP19 6. OP27 DS0000026874.V276445.R01.S.doc Version 5.1 Page 27 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 © 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 DS0000026874.V276445.R01.S.doc Version 5.1 Page 28 - 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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