Inspection on 19/02/07 for Steepleton Manor

This inspection was carried out on 19th February 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Steepleton Manor 12/01/06

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 Sally Wernick Unannounced Inspection 19th February 2007 09:30 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 Steepleton Manor DS0000026874.V328817.R02.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. Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 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 jackie@steepletonmanor.co.uk www.altogethercare.co.uk Altogether Care LLP Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 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. 12th January 2006 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 one single bedroom (which has a separate dedicated private bathroom) all offer ensuite 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 Responsible Individual (RI) is Mr Peter Cotterill on behalf of Altogether Care LLP and he visits the home in a management capacity each month. The appointed manager who takes responsibility for the day to day running of the home is Ms Jackie Watson. Fee range:- £567-£800.00 per week. See the following website for further guidance on fees and contracts. http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people_ choos.aspx Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and began at 09.30am on Monday 19 February 2007. This was a ‘key inspection’ where the homes performance against the key National Minimum Standards was assessed alongside progress in meeting requirements and recommendations made at the previous inspection. The registered manager assisted the inspector, as did other members of care staff. Methodology used included a tour of the premises, review of records and discussions with staff. During the inspection the inspector spoke with seven residents in their rooms and three others in the lounge area. The inspector also reviewed the contact sheet and service notes for the home. A Pre-inspection questionnaire was also sent to the manager in order that information could be provided prior to the inspectors site visit. That information where relevant is included in the main body of this report. Prior to the inspection, comment cards were sent out by the home on behalf of the commission. Of those returned four were received from residents, two were from health and social care professional three from care managers, two from G.P’s and two from friends or relatives. Surveys received from the residents indicated the following responses: “Do you receive the care and support you need” one said “always” three “usually”. To the question “Do the staff listen and act on what you say” “yes or no” all responded “yes” “Are the staff available when you need them”? All responded “usually” one comment included: “ sometimes lack of communication between members of staff means that there is sometimes a delay”. Do you receive the medical support you need three responded “always” one “usually” Other questions related to food, activities and complaints and again the response was generally positive. Only one care manager added an additional comment: Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 6 “First Class service for Magna Residents” What the service does well: What has improved since the last inspection? What they could do better: Quality of life within the home is generally good and residents told the inspector that they were content and happy. Residents had clear expectations of the level of service that should be provided although some of the information contained in the guest handbook needs to be clarified to reflect the exact nature of additional charges. To ensure residents are provided with the correct aids re-assessment would benefit one named individual to confirm the suitability of the equipment. Some staff have undertaken training in adult protection and this remains ongoing. Training is provided at the home so that staff can meet the assessed needs of residents it would be beneficial however if this were extended to include some specialist provision in areas such as diabetic care, sensory loss Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 7 and Parkinson’s disease to ensure a greater skill mix across the team as a whole. Regular fire training is also necessary to ensure the safety and well being of residents. Staff are well spoken of by residents however through induction, supervision and observation of practice staff should be reminded to respect the dignity of those living at the home at all times. Verbal and written complaints or concerns should be maintained in a record and audited to ensure good practice at regular intervals. The responsible individual should similarly undertake statutory visits of the home making written reports available to the commission at inspection on current standards achieved. The home will be developing its quality assurance systems and will be extending this to care professionals, families, staff and other stakeholders. It would be good if results could be published in a clear format to demonstrate how the home is meeting positive outcomes for service users. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admissions procedure enables prospective residents and their supporters to make informed decisions about the home and ensure that only service users whose needs can be met by the home are offered places there. Steepleton Manor does not provide Intermediate care standard 6 therefore was not inspected. EVIDENCE: Four files of residents who had come to live at the home since the previous inspection were examined. All showed that prior to arriving at Steepleton Manor, care needs had been assessed by the home’s manager. The outcome of the assessments are confirmed in writing, so prospective residents can be fully assured that their care needs will be met. Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 10 Pre-admission assessments contained information for managing personal and healthcare needs. All residents moving into the home received a copy of the terms and conditions, service user guide and a guest handbook. Information about the management arrangements in the service user guide has been updated following recommendation at the previous inspection some aspects of the guest handbook should also be clarified specifically around additional costs to residents. Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a good care planning system in place to ensure that staff have the information that they need to meet the needs of residents. The health needs of the residents are generally well met with support from a range of community health professionals. The medication at the home is well managed promoting the good health and well being of residents. Residents are treated with respect and their privacy and dignity are generally promoted. Residents are provided with the care and attention that they need at the end stage of their lives but in order to receive this service they may incur an additional fee. Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 12 EVIDENCE: Four care plans were examined all were of a good standard. They followed on from the assessments made by the home, were easy to read and were informative about the needs of the resident and of how the home was to meet them. Information in the care plans was up to date with plans being reviewed monthly. Information about social care needs is recorded, for example how the resident prefers to spend their day, likes and dislikes and preferred times of rising and going to bed. Daily notes support and evidence the delivery of care to residents and give a picture of the care provided as well as visits by community health professionals. All of the residents spoken to confirm that their health needs were generally well met with access to G.P s, district nurses, chiropodist and other community health professionals. For one resident the hoist in use did at times cause discomfort although the registered manager said that occupational health had said that was the hoist most suitable. There is a recommendation for this to be reviewed. One health professional commented in a written survey to the Commission for Social Care Inspection that there “were occasions when care could have been handed over sooner”. Another resident felt the care received “couldn’t be better”. A good system for the ordering, administering and recording of medication is in place at the home and only staff members that have completed a course in “medication” are able to carry out this task. Medicines were safely stored and countersigned where necessary. In line with the pharmacy inspection on 8 June 06 the medication policy has been updated to include all aspects of the handling and administration of medication. Staff were observed throughout the inspection to be treating residents with courtesy, patience and respect and most residents confirm that this is the case. Two residents felt that they had at times been spoken to sharply but on the whole staff were kindly and “ did their best”. Each resident has a telephone in his or her room and care is taken to address each individual in their preferred manner. The home’s guest handbook refers to “a bespoke care service that exceeds prescribed staffing levels” which can be arranged for residents at “extra cost”. This may include the support of care staff at the end stages of an individual’s life. It is the responsibility of the home however to ensure that residents receive appropriate attention and pain relief at all times and through liaison with G.P’s and other community health providers at the end of life. Any additional staffing costs should be clearly detailed and the home must demonstrate why the care of the resident at those times could not be met Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 13 within the standard fee rates. Additional funding should be sought through the PCT in accordance with the eligibility criteria. Steepleton Manor DS0000026874.V328817.R02.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 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There is a continuing high commitment to promoting dignity, with a focus on valuing the diverse needs of people who live at Steepleton Manor. People who live at Steepleton Manor are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. The home has sought the views of the residents and considered their varied interests when planning the routines of daily living and arranging activities both in the home and the community. Routines are very flexible and people can make choices in major areas of their life. Outcomes for people who live at Steepleton Manor are positive, and there is evidence that they are enjoying the life opportunities that they experience, including the recently introduced A La Carte evenings where family and friends may dine at the home – an additional fee is charged for this service. EVIDENCE: Activities are arranged on a daily basis at Steepleton Manor and there is a dedicated activities organiser. The Bridge club is a popular option, which friends and family also attend as well as those in the local community. There Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 15 are art classes, exercise groups, excursions the hairdresser attends three times a week and for all residents there is a complimentary daily newspaper. There is a well stocked library, satellite television and church services available, During the summer there are cream teas in the garden, themed events such as fete’s mystery bus tours in the home’s own transport as well as trips to the theatre and the occasional entertainer. There is a range of games available such as dominoes and a key worker system encourages individual interaction between staff and resident. Visitors are actively welcomed at the home family and friends may stay for meals and A la Carte evenings have been introduced for a nominal fee (£5.00 for residents £10.00 for guests), which includes a fivecourse dinner. Many of those living at the home are independent and pursue their own activities externally. Of all the residents spoken to all were happy with daily life at the home and felt their expectations were well met. Rooms are highly personalised, comfortable and the living accommodation is of a very high standard. Steepleton Manor is a home of the residents and is run in a manner that supports them to live their lives making the choices they can. Those living at the home manage their own financial affairs supported by friends, family or advocates. Steepleton Manor employs a chef who provides a varied menu with wide ranging choices throughout the week. Many residents choose to dine together there is always a cooked breakfast available and lunch with a choice of meals and supper which may include, pastries, sandwiches cakes and other dessert. Residents were happy with the food, which is served in an attractive dining room. Special and therapeutic diets can be provided for those who may require them. Complimentary sherry, wine, lager is served daily. Alcoholic drinks above the complimentary level are available at an additional cost. Steepleton Manor DS0000026874.V328817.R02.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 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a formal complaints procedure allowing residents and visitors to express their concerns. Adult protection procedures are in place to deal with allegations of abuse for the protection of the residents. Training for staff remains ongoing. EVIDENCE: The home has a complaints procedure which is provided to all residents as well as a complaints log. Whilst no written complaints have been received by the home there have been occasions where residents or their families have expressed verbal dissatisfaction and these have been explored and acted upon by the Registered Manager. A written record should be kept of all complaints in the log whether received in written or verbal form and should detail the action taken. The 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 including “No Secrets” and Protection of Vulnerable Adults (POVA) guidance, “whistle blowing” and bullying in the workplace. Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 17 A requirement made at the previous inspection identified the need for all staff to undertake ‘No Secrets’ training including the advanced course for management. The Registered Manager confirmed that training has been undertaken for some staff however these are in the minority and this remains ongoing. The requirement is therefore repeated. Steepleton Manor DS0000026874.V328817.R02.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 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who live at Steepleton Manor to live in an elegant, safe, well-maintained and comfortable environment, which encourages independence. The owners and staff of Steepleton Manor go that ‘extra mile’ to provide an environment that fully meets the needs of all people using the service and plans for the diverse needs of people that might use the service in the future, this includes use of a heated outdoor swimming pool, which is in use during the summer months and an accessible, landscaped garden with sheltered seating areas and features such as a water fountain. People living at Steepleton Manor have a choice of places to sit quietly, meet with family and friends or be actively engaged with other people who live at the home. Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 19 EVIDENCE: A number of improvements have been set in place since the previous inspection and all of the requirements and recommendations relating to maintenance have been met. The Registered manager confirmed also that fire risk assessments have been updated throughout the premises. 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, elegant environment is provided. The house is set in approximately 6.5 acres of grounds and gardens, which are also very well maintained. Garden seating is sited in sheltered positions around the property with some areas accessed directly from resident’s patio doors. The home has an outdoor swimming pool, which is in use in summer. The grounds include a grand gravelled driveway with a water fountain feature and a large parking area to the front of the house. The home was clean and pleasant throughout and no unpleasant odours were detected. The laundry was clean and well sited. Steepleton Manor DS0000026874.V328817.R02.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff are sufficient to ensure that the assessed needs of residents are met. Robust recruitment procedures are in place to ensure the protection of residents living at the home. There is a programme of formal training designed to improve and develop staff knowledge and skills for the benefit of people living at the home although this needs to be expanded further to include specific medical conditions. EVIDENCE: Throughout the inspection it was clear that there were sufficient numbers of staff on duty and staff rotas confirm this. Residents confirmed that staff were generally available if assistance was needed although there were inevitable delays on occasions. At the current time staffing is stable and almost 50 of the staff team have achieved National Vocational Qualifications. Three of the care team have obtained their certificates two further staff have almost completed. In addition to the Registered manager there is a deputy head of care and a front of house concierge who deals with general enquiries and provides assistance with Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 21 administration. There is also a team of dedicated cleaning staff, a chef /kitchen staff and maintenance person. Robust recruitment procedures are in place and good staff files evidenced that. Altogether Care LLP has their own training provider and there is a rolling induction programme for new staff each month to cover all of the mandatory training identified in skills for care. The previous inspection reports identified the need for some specialised training to include topics directly related to the needs of residents accommodated at the home for example diabetic care, understanding sensory loss and Parkinson’s disease. This recommendation is seen as an area of good practice and is therefore repeated. The registered manager informed the inspector that medication training and dementia care are planned for the future. The following website is a useful guide and can also offer advice and information about induction and training programmes. www.skillsforcare.org.uk Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager has the experience and qualifications to run the care home in the best interests of the residents. The quality assurance system in place does not yet fully reflect the views of residents, staff and stakeholders. Residents are assured of sound management of their financial interests. The health, safety and welfare of service users will be improved by the introduction of up-to-date training and procedures. Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 23 EVIDENCE: The current appointed manager Ms Watson joined the home in April 2006 having managed another home for the same company. She is a Registered Mental Health Nurse and is currently studying for her NVQ 4 Registered Managers Award. Ms Watson was able to demonstrate that she has kept up to date with her mandatory training and has also received up to date training in adult protection. The home does distribute questionnaires to residents within the home on an annual basis these are due to be sent out within the coming month. This is not yet extended to staff, family friends or community health professionals nor are the results fed back to those whose views have been sought in an easily understood format. Residents meetings were held regularly until last year, which provided a forum for an exchange of views and for residents to comment on standards within the home. However these have not taken place for some period following the death of a number of residents. The home and company is reviewed by an external agency to the standard ISO 900:2000 each year this review however does not include the views of family, friends and stakeholders. Resident’s at Steepleton Manor do where possible manage their own finances. Those who are unable to do so have a relative or other representative to assist them. Where necessary the home pays for services such as chiropody and a record is maintained. The amount is then invoiced to residents or their representatives for payment at appropriate intervals. The previous report identified a requirement for the Registered Individual to provide to the Commission for Social Care Inspection reports on his Regulation 26 visits to the home. These visits are to provide general support and supervision for the manager and enable management to view the home from a quality assurance perspective. The manager confirmed that Mr Cotterill does visit the home on a monthly basis and there was a signed sheet to confirm this. There was no evidence that a report had been compiled. Whilst the Commission no longer routinely require Reg 26 visit reports to be sent in monthly, the visits should still occur and records should be kept and available for inspection. Maintenance records evidence that routine checks/servicing of the central heating system, passenger lift, hot water supply, electrical installations and moving and handling equipment are in place. All staff has received their mandatory health and safety training. Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 24 Staff records indicate that formal fire training and evacuation is undertaken yearly with the home’s owner although fire training within the home was found to be not up to date. Regular in house tests and routine servicing of the fire safety system and equipment are safely maintained. See www.firesafetyguides.communities.gov.uk for further information on fire safety requirements, including training. Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 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 Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP18 Regulation 18 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. The timescale for action was 31/03/06. (This requirement is repeated). The Responsible Individual must conduct monthly Regulation 26 visits to the home and make a record of these, which must be available for inspection if required. Timescale for action 20/06/07 2. OP37 26 20/03/07 Steepleton Manor DS0000026874.V328817.R02.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 OP8 Good Practice Recommendations Specialist advice and a reassessment of the suitability of the hoist currently in use for a named service user should be undertaken to ensure that the correct equipment is in use. Residents must be treated with courtesy, dignity and respect at all times. Staff should be reminded of this through induction, regular supervision and observation of their practice. The home’s terms and conditions and the guest handbook should be more explicit about the circumstances under which an additional fee will be incurred e.g. at the end stage of a service users life where additional care is needed. All verbal and written complaints and concerns should be contained in one record these should include details of investigation and any action taken and should be audited at required intervals. 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). In order to safeguard residents the registered persons must ensure that all staff receive training in fire prevention and that fire drills and practices are undertaken at regular intervals. Clear and detailed records must be kept in order to fully demonstrate compliance. 2. OP10 3. OP2 OP11 4. OP16 5. OP27 7. OP38 Steepleton Manor DS0000026874.V328817.R02.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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Steepleton Manor DS0000026874.V328817.R02.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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