Inspection on 08/08/07 for The Ellenborough Nursing and Residential Home

This inspection was carried out on 8th August 2007.

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

The inspector 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

The Ellenborough Nursing and... 27/07/06

The Ellenborough Nursing and... 06/12/05

The Ellenborough Nursing and... 27/07/05

The Ellenborough Nursing and... 16/02/05

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Fairfields Country Rest Home

Poldhu

Queensmount

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 The Ellenborough Nursing and Residential Home 9-11 Neva Road Weston Super Mare North Somerset BS23 1YD Lead Inspector Grace Agu Key Unannounced Inspection 8th August 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 DS0000062713.V343897.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. DS0000062713.V343897.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Ellenborough Nursing and Residential Home Address 9-11 Neva Road Weston Super Mare North Somerset BS23 1YD 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) 01934 621006 01934 418569 ellenborough@cedarscaregroup.co.uk Ellenborough Care Limited Ms Susan Jane Welsh Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places DS0000062713.V343897.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 31 people aged 65 and over requiring nursing care May accommodate one named persons under the age of 65 years. Date of last inspection 27th July 2006 Brief Description of the Service: The Ellenborough Nursing and Residential Care home is owned by Mr and Mrs Yilmaz (Cedars Care Group) since November 2004, operating under the name of Ellenborough Care Limited. The home accommodates residents of 65 years or older who require nursing or personal care. The home is an attractive Victorian building conversion of two detached properties. The accommodation is arranged over two floors with a passenger lift or chair lift for access. The majority of the rooms offer en-suite facilities with 15 en-suite single rooms and 5 en-suite doubles. There are two separate lounge areas and two separate dining areas. The home accommodates residents who smoke with a designated smoking area overlooking the rear garden. It is close to local amenities and public transport, bus and rail are within easy reach. DS0000062713.V343897.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit which was undertaken as a part of key inspection over seven hours to review the requirements made at the last inspection and also to review the care practice to ensure that it is in line with the legislation and that best practice is followed at the home. At the last inspection ten requirements and five recommendations were made in relation to various areas of service provision including issues that affect the healthy of individuals living and working at the home. It was pleasing to note that all these requirements had been met. At this inspection several requirements were made to include reviewing care plans to make the experience more person centred reviewing the risk assessment of an individual with recent fall at the home and ensuring that the fire doors are not wedged open. I met with Ms Susan Welsh, the home manager and a trained nurse. Whilst touring the building. I spoke with a number of residents, and staff. A number of records were viewed. What the service does well: The home has a statement of purpose, which has information about the service provided, staff training as well as service user accommodation. There is a service user guide, which has information about the home, it’s aims, and fees and services to enable a prospective service user to make an informed decision about the home. The home has satisfactory care planning in place, which is holistic and specifies how identified needs are to be met. The care plans are reviewed regularly. The home provides meaningful activities for residents and ensures that individual interaction is provided as necessary. Good meals are provided for residents and staff ensure meals are not hurried and that residents who are unable to feed themselves are assisted in a respectful and dignified manner. A complaint procedure is in place to enable service users, families, friends and advocates to complain if unsatisfied with the services provided. There is an ongoing training programme to enable staff to meet individual residents needs and ensure that residents are protected from harm and abuse. The home has thorough recruitment practices to ensure that appropriate staff are employed at the home. DS0000062713.V343897.R01.S.doc Version 5.2 Page 6 Aids and equipment are provided in sufficient quantity to assist care staff in meeting the needs of service users. The environment is well maintained, tidy and safe giving the residents a sense of homeliness and security. What has improved since the last inspection? What they could do better: To ensure that residents, staff and visitors are adequately protected fire doors must not be wedged open. Staff members would be enabled to perform their duties effectively if regular formal documented supervision is provided. To ensure that residents are protected, residents who self -medicate must sign to give their consent following a risk assessment. Residents would be better protected and their needs met if their care plans are clearly and comprehensively written after assessment and consultation with them and or their representatives. In particular residents with specific needs for example ‘wandering’. The home must undertake a risk assessment of the present nursing station and any other area that residents have access to in order to minimise hazards to the independent and mobile residents, staff and visitors. The home must ensure that the electrical installations at the home are inspected regularly to ensure that any identified hazards are eliminated in order to protect the residents. To ensure that the residents’ staff and visitors are adequately protected issues identified at the recent health and safety check must be fully implemented including the recent lift service check findings. It was disappointing to note that the recommendation made at the last inspection in relation to renewal of the vanity unit in poor condition in one DS0000062713.V343897.R01.S.doc Version 5.2 Page 7 bedroom had not been implemented. This recommendation is repeated and will be reviewed at the next inspection. 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. DS0000062713.V343897.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000062713.V343897.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The process of admission of prospective residents is comprehensive, detailed and well planed to enable the resident to make a positive choice of moving to the home with the assurance that their needs will be met. EVIDENCE: The home has a Service Users’ Guide that is given to prospective residents and their relatives or representatives when they visit the home to enable them to make an informed choice about moving to the home. The care file of a recently admitted resident showed that the resident was assessed before being admitted to the home. Some of the information noted in the care file included, Activities of Daily Living, and other relevant information to enable staff to meet the residents’ needs. DS0000062713.V343897.R01.S.doc Version 5.2 Page 10 There is evidence of a one-month trial to enable the resident to decide to stay. Individual contracts are provided to self-funded and local authority funded residents. DS0000062713.V343897.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home offers care and support to residents throughout their life and towards the end however, it fails to provide personalised care plans for residents. The process of medicine, administration recording and disposal is satisfactory. EVIDENCE: On the day of site visit three care files were reviewed. There was evidence of pre-admission assessment before admission of one new resident to the home. This assessment was to determine whether the home is suitable and able to meet residents’ needs. The resident was reassessed on admission before care plans are provided detailing how the assessed needs are to be met. This is followed up by monthly reviews and intervention as needs change. DS0000062713.V343897.R01.S.doc Version 5.2 Page 12 However it was noted that one resident admitted on 22/12/06 and had entries on 03/07/07, 16/07/07 and 28/07/07 for ‘wandering’ had no care plans in place oh how this need was being managed. At a discussion, Manager stated that the registered nurses are aware that care plans need to be developed for this need to reflect the changing needs of the resident. She would ensure that this is implemented. A requirement has been issued to ensure that care plan is in place to meet the resident’s identified need. Furthermore, it was noted the care plans are generalised for all residents. Care plans need to be personalised and tailored to meet individual needs. It was agreed that this would be reviewed at the next inspection. Other information seen in the care files reviewed were detailed and up to date. Residents interviewed confirmed that staff treated them with respect and knocked at the doors and waited for an answer before entering to attend to their personal hygiene needs. One resident interviewed stated “I like it here, staff are kind, I wake when I want to and go to bed when I want”. There was evidence of General Practitioner (GP), Dentist, Chiropodist and Optician visits. Care staff were noted knocking at doors and waiting for an answer before entering residents’ rooms to assist them with personal care. There was evidence in the care files viewed of details of residents’ wishes in the event of death. Staff interviewed are aware of policies and procedures for dealing with a dying resident at the time of death. Three staff members spoken with are aware of the importance of keeping information about residents confidential. A local pharmacy provides medication using a monthly monitored dosage system. A check of the blister packs indicated that medication had been administered as recorded. All medication seen was stored securely. Medicines trolleys are used to transport medication around the home. There is a medicine fridge and temperatures are recorded daily. Two areas in the home where oxygen cylinder were stored had statutory warning notice on the doors. Controlled drugs were stored correctly and recorded in a register. A policy is available to enable staff to provide safe service to residents. All medication is ordered and received by staff. The pharmacy supply printed medicines administration record sheets each month. Records of administration of medicines were clear. Two records were seen indicating that two residents were self administering some of their DS0000062713.V343897.R01.S.doc Version 5.2 Page 13 medication had no risk assessment and no consent had been obtained from the individuals. It is required that this is implemented. Records are kept of medicines received into the home. DS0000062713.V343897.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home enables residents to maintain contact with family, friends and community. It also provides meaningful activities and choice in respect of meals and meal times. EVIDENCE: Residents spoken with confirmed that the home supports them to remain in contact with their family and friends. One resident stated, “My daughter comes to see me”. Staff spoken with confirmed that the visitors are not restricted from coming into the home. The home’s visitor’s book evidenced that there are a number of regular visitors to the home. The home activities programme was reviewed and was satisfactory. The key worker completes the resident’s preferred activity or their relatives on admission to enable the home plan a suitable activity based on details given and assessed on individual capabilities. DS0000062713.V343897.R01.S.doc Version 5.2 Page 15 Activities recorded in each resident file include music entertainment painting, jig saw puzzle, crafts and bingo. There were also records of interaction on an individual basis with residents who prefer to be in their rooms or declined or were unable to attend to the general planned activities. There is an external input organised for two residents with learning difficulty. A couple living at the home told the inspector that they regularly went out for lunch. A local church provides Church service and Holy Communion monthly for residents that would like to keep their religious obligation. In relation to choice in their daily routine, residents spoken with stated that they have a choice of when to get up and retire. One resident stated, “The place is very good. Staff are very kind to me”. The menu on the day contained a good variety of nutritional meals and a choice of pudding. Staff were assisting the residents during lunch in particular residents who were unable to feed themselves. All residents spoken with after lunch stated that they enjoyed their food. The kitchen was found to be clean and tidy. The chef had attended basic food hygiene training and the certificate that was unavailable on the day was forwarded to the Commission for verification. The manager stated that she is working with the kitchen assistant whose first language is not English to undertake the basic food hygiene training to ensure that the resident staff and visitors are adequately protected. There is a risk assessment of kitchen to protect the staff residents and visitors however it should be updated. DS0000062713.V343897.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to complain and are confident that their complaint will be listened to. Practices at the Home ensure protection of resident from harm and abuse EVIDENCE: The Home has appropriate and robust procedures in place for management of complaints. The complaints procedure was noted displayed in the hallway at the entrance. This document contains information about the Commission for Social Care Inspection to enable individuals to contact the Commission if they were not satisfied with the outcome of their complaint to the organisation. This inspection was also undertaken to follow up strategy meeting held about a complaint received from a concerned relative about his/her mother’s care. The complaint was investigated by the Council and the Commission for Social Care Inspection and the outcome of the investigation is still ongoing. The action plan agreed at the strategy meeting is yet to be reviewed. The resident looked well cared for on the day of inspection. The manager stated that the family is planning to transfer the resident to another home. The allocated Social Worker is assisting the resident and the DS0000062713.V343897.R01.S.doc Version 5.2 Page 17 family to make the right choice ensuring that the outcome for the resident takes precedent. The Commission will continue to monitor the complaint to ensure that it is satisfactorily resolved. Other recorded complaints were satisfactorily investigated and the outcomes were fully recorded. Residents spoken with and responses noted on the comment cards evidenced that residents are aware who to complain to. One resident stated, “I know where to go if I have any reason to complain”. The manager stated that new residents/ families are informed about the complaints procedure on admission and that this is also included in the Service Users Guide. Staff are aware of the Whistle Blowing policy and would report any bad practices to the Manager without fear of reprisal. There is evidence of staff training in relation to Protection of Vulnerable Adults from Abuse. The manager is aware of the Council’s policy on The Protection of Vulnerable Adults from Abuse to ensure that the protocol is followed if incidences of abuse occur. Evidence from the records showed that Registered Nurses working at the home had their own Personal Identification Numbers verified by the Nursing and Midwifery Council (NMC) before commencement of employment and periodically to ensure that residents are adequately protected. DS0000062713.V343897.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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 generally well-maintained environment, it has also provided clean and comfortable environment for residents. However it has not made the carpet in the nursing station safe. EVIDENCE: The Ellenborough Nursing and Residential Care home is an attractive Victorian building conversion of two detached properties. The accommodation is arranged over two floors with a passenger lift or chair lift for access. The majority of the rooms offer en-suite facilities with 15 en-suite single rooms and 5 en-suite doubles. There are two separate lounge areas and two separate dining areas. It is close to local amenities and public transport, bus and rail are within easy reach. DS0000062713.V343897.R01.S.doc Version 5.2 Page 19 Generally, the home was found tidy, clean well lit, warm, comfortable and suitable for its stated purpose. It was well maintained with on going refurbishment. Residents were noted sitting in the lounge relaxed and enjoying each other’s company. Staff were well presented in uniform and were wearing disposable aprons when serving and assisting residents with meals. This demonstrated that infection control and principles of hygiene are being followed at the home. Residents interviewed stated that they felt comfortable at the home. The home has an ongoing refurbishment programme, it was noted whilst touring the building that most bedrooms and the landings on the residential side of the building have been redecorated. On the nursing side of the building, the lounge and most bedrooms have been redecorated. Work is in progress to convert an existing bathroom to a shower room in other to give the residents more choices regarding how their personal care is to be met. The manager stated that the nursing station is to be relocated. It was agreed that a risk assessment of the carpet in the present station should be under taken whilst waiting for the relocation to take place in order to protect staff visitors and mobile independent residents. The laundry was noted to be clean and tidy. The home recently purchased two new industrial machines and a tumble dryer have been purchased to provide better Laundry services for the residents at the home. There are risk assessments of both laundry and kitchen, however they should be updated. The maintenance book was up to date clearly stating jobs/ tasks to be carried out, date completed and any relevant comment in relation outstanding jobs. DS0000062713.V343897.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with sufficient numbers of staff to meet their needs, adequate training is also provided to its staff to protect the residents. EVIDENCE: Evidence from staff rota and discussion with the manager showed that the home has a sufficient staffing level to meet the needs of the residents. Residents spoken with stated that staff attended them promptly when they rang the bell. The home operates a key working system to enhance the resident/staff relationship. In relation to domestic staff the manager stated the home is currently advertising for cleaner/laundry staff to increase the number of domestic staff to ensure that better service is provided for the residents. The manager has developed a training matrix to enable the home to identify what courses each staff member has attended and to ensure that relevant courses are provided. Staff have attended training to include manual handling update fire safety, Protection of Vulnerable Adult form Abuse and Care skills. DS0000062713.V343897.R01.S.doc Version 5.2 Page 21 This enables the home to keep up to date and apply current practice in the care of the residents. It was also noted from staff records that some staff members have achieved National Vocational Qualification (NVQ) at level 2 and 3. Review of records of recently employed staff members showed that statutory required documentation were in place before commencement of employment. DS0000062713.V343897.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed however; it fails to protect the residents through lack of appropriate health and safety practices and regular staff supervision. EVIDENCE: The atmosphere at the Home on the day of inspection was positive and welcoming. Staff were noted interacting with residents in an informal and friendly manner. Staff spoken with stated that staff work as a team and that the Manager is ‘the best manager you will ever have’. She is very approachable. These have enabled staff to provide quality care and to support the residents. DS0000062713.V343897.R01.S.doc Version 5.2 Page 23 Residents spoken with made positive comment about the Manager. One resident stated,” the manager is very good, she is always here when you want her.” One health professional stated in the comment card ‘Sue Welsh and the management at Ellenborough have always responded to any requests/issues in a positive and professional way’. Another comment card states ‘it is a well run home’. Staff supervision records were reviewed. Evidence from the records viewed showed that staff has received supervision. However not regularly Staff spoken with confirmed that they have received only one yearly appraisal last year. The staff member stated that they benefited from the exercise. It afforded them the opportunity to express their opinion about the services provided at the home and to discuss areas of concern in relation to residents’ care. The manager stated that the home would ensure that regular supervision is put in place. A requirement has been made to ensure that this happens. Health and Safety records showed that the home had undertaken generic risk assessments of vulnerable areas of the home. In relation to other health and safety records the manager stated that gas boilers are to be replaced in both houses the quote has been approved and awaiting the commencement of the work. The manager would discuss the electrical installation inspection for the home with the provider and would ensure that it is carried out to in order to protect the residents. Furthermore lift service carried out on 25/07/07 identified unsatisfactory performance and hazardous concerns that must be addressed. The inspector saw the quote for the work to be done the manager stated that the quote had been sent to the provider for approval. A requirement has been issued to protect the residents’ staff and visitors that this work must be undertaken. Accidents were noted to be properly recorded however it was noted that three minor accidents to residents were not reviewed and it was agreed these are reviewed and the evidence sent to the Commission For Social Care Inspection. This evidence was received the following day. The manager stated that they would ensure that all accidents to residents are reviewed in future including the minor ones. The fire logbook was noted up to date and evidence from records and confirmation from some staff showed that staff have attended fire drills. How ever it was disappointing to note that the recommendation made regarding the issues identified in November 2005 following a fire risk assessment has not been implemented. DS0000062713.V343897.R01.S.doc Version 5.2 Page 24 The Health and Safety representative of the home made reference to these issues in the report following a recent fire safety check in June 2007.The home is required to put an action plan in place on how the issues identified are to be implemented. Whilst touring the building several fire doors were noted wedged open. The home manager must ensure that the local Fire Brigade is consulted for advice in relation to the above to ensure that residents are protected in fire emergencies. A requirement notice has been issued that the fire doors must not be wedged open. Quality assurance for the home was reviewed. The Manager stated that the home audits it quality of service using different tools. These include three monthly employee satisfaction surveys residents/ family surveys. These are analysed and published for staff to see how the home is performing. All areas that need to be addressed are dealt with in a professional and constructive manner. Other methods used to review the quality of is service include monthly care plan reviews, Social Services periodic reviews, resident/ meetings, staff meetings manager regular one to one visit to residents and monthly providers visits in line with the regulation. Residents’ money kept at the home had records of how the money was spent and the balance seen tallied with the amount recorded. Policies and procedure noted at the home include Protection of Vulnerable Adults from Abuse, Concerns and Complaints, Confidentiality, Moving and Handling, Infection Control and Health and Safety. DS0000062713.V343897.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 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 X 3 3 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 3 3 X 3 2 3 2 DS0000062713.V343897.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP36 Regulation 18 Requirement Ensure that staff are supervised regularly to undertake their duties effectively. Ensure that a residents care plans accurately reflect their needs at all times. Implement the findings identified in the recent health and safety and lift safety service checks. Undertake a risk assessment of the carpet in the nurses’ station and remedy any hazards identified. Undertake a thorough periodic inspection of all electrical installations at the home and implement all hazards identified. Ensure that fire doors are not wedged to protect residents’ staff and visitors in event of fire emergency. Ensure risk assessment and consent is place for residents that chose to self medicate. DS0000062713.V343897.R01.S.doc Timescale for action 07/11/07 2. OP7 15 07/09/07 3. 4. OP38 OP38 13(4)(a) and (c) 13(4)(c) 07/09/07 07/09/07 5 OP38 13(4)(c) 07/10/07 6. OP38 13(4)(c) 07/09/07 7. OP9 13(2) 07/09/07 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. . Refer to Standard OP19 Good Practice Recommendations The redecoration and maintenance schedule should address and include renewal of bedroom furniture such as the vanity unit in poor condition identified at this inspection. This is REPEATED. DS0000062713.V343897.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Region 33 Colston Avenue Bristol BS1 4UA 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 DS0000062713.V343897.R01.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. 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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