Inspection on 08/05/07 for The Gatehouse

This inspection was carried out on 8th May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Gatehouse 13/01/10

The Gatehouse 26/09/07

The Gatehouse 08/02/07

The Gatehouse 21/08/06

The Gatehouse 19/01/06

The Gatehouse 22/07/05

The Gatehouse 18/01/05

The Gatehouse 24/08/04

The Gatehouse 18/09/03

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE The Gatehouse 64 Becton Lane Barton-on-sea New Milton Hampshire BH25 7AG Lead Inspector Mrs Pat Trim Chris Johnson Unannounced Inspection 8th May 2007 10:00 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 The Gatehouse DS0000012359.V336203.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. The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Gatehouse Address 64 Becton Lane Barton-on-sea New Milton Hampshire BH25 7AG 01425 613465 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) Sallyprice@thegatehouse.biz Mr E Breckon Mrs J Breckon Mrs Sally Price Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (21) of places The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 2007 Brief Description of the Service: The Gatehouse is set in a semi-rural location on the outskirts of the town of New Milton at Barton-on-Sea. It provides residential care for up to 21 elderly residents, some of whom have dementia. The home is on ground and first floors and there is a stair lift between these. There are a variety of aids and adaptations to allow residents to move about more independently. Nineteen of the bedrooms are single, and one is a double. All of the bedrooms bar one single have an en-suite facility. There is a communal bathroom with toilet on the ground floor, and two bathrooms with toilets on the first floor. There are large gardens around the building, and car parking space to the front. Current fees are between £450 and £550 a week. Items not covered by the fees include hairdressing, chiropody, newspapers, personal toiletries and reflexology/massage. The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection carried out by two inspectors in 5 hours. The key standards were assessed by case tracking 2 residents and talking with 7 people currently living in the home. Time was also spent observing staff practice and talking with the provider, registered manager and cook. Some time was spent reviewing a random selection of documents and a partial tour of the premises was carried out. In preparation for this visit, the inspector examined information obtained about the service, including incident reports and the most recent inspection reports on the home. Comment cards were received from 1 resident, 2 relatives and a health care professional. Their comments have been reflected in this report. Information was also obtained from the Annual Quality Assessment Audit (AQAA) completed by the registered manager. The people living in the home had previously expressed their wish to be called residents. This term is therefore used throughout this report. What the service does well: The home continues to provide a warm homely environment, where residents are able to join in activities or pursue their individual hobbies. Residents felt they were supported to maintain their independence by doing as much as they could for themselves, but were confident support was offered when they needed it. Comments included • • • • ‘It’s very comfortable, everyone is very friendly’ ‘I enjoy living here’ ‘They don’t interfere, you can live the way you like’ ‘I can’t fault it. They look after us very well’ The home listens to what residents have to say and take action to improve the service based on the comments they receive. For example, in response to residents asking for more outings and activities the home has employed a second cleaner to give care staff more time to spend with residents, booked a caravan for a week in the summer to provide an opportunity for residents to spend time away from the home and is looking at ways of providing more trips out. What has improved since the last inspection? The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 6 The registered manager has spent time looking at different systems for assessment and care plans. She has found one that will enable her to make sure the mental health needs of residents are assessed and reviewed. The system includes a care plan that provides a suitable format to show staff how these identified needs can be met. The medication policy and procedure has been reviewed and amended. Staff now have clear guidance on how to deal with medication. Similarly, the adult protection policy and procedure has also been reviewed and amended, so that staff are clear on what action they must take if there is an allegation of abuse. They also have information on what would happen and who would be involved. Arrangements have been made for all staff to have fire safety training. The majority of staff have received this and the rest are going to a local college for theirs in the next few weeks. The communal areas have been redecorated to provide a bright, fresh environment and a new industrial washing machine is being fitted that will provide a more efficient laundry service. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 7 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 The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 8 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. Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A comprehensive assessment tool enables residents to have their needs assessed before they move into the home. Residents may be confident they will only be offered a place at the home if their needs can be met. EVIDENCE: Residents were given information about the admission procedure in the statement of purpose. This informed them that a full assessment of need would be completed prior to admission and that a member of the management team would visit them to complete it. They were also told they were welcome to spend a day at the home before deciding to move in on a month’s trial basis. Feedback from comment cards confirmed that residents and relatives felt they had sufficient information given to them about the service prior to admission. The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 9 The AQAA identified an improved assessment process as an objective for the service. The registered manager said there had been no new admissions since the last inspection, so no new assessments could be seen. However, the registered manager said she had been looking at new assessment tools that would enable her to assess residents’ mental health needs and was going to use one on a trial basis to see if it was suitable. The system provided a comprehensive assessment of need, including mental health needs. There was evidence that assessments were regularly reviewed using monitoring tools such as nutritional assessments, activities of daily living assessments and risk assessments for falls and mobility. The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 10 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. EVIDENCE: The AQAA identified improved care planning as an objective for the service, specifically in relation to identifying and meeting mental health needs. Two care plans were seen. Both contained detailed information about how individual residents liked to receive personal care, what they could do for themselves and what help was needed. For example, one resident was able to dress herself, including doing up buttons, but needed help to choose what to wear. The bathing procedure, for another resident, told staff to help her get into the bath and then leave her to wash independently. They then had to offer to wash her back and help her get out of the bath. There was evidence that mental health needs were being considered. For example, care plans identified where residents needed prompting with personal care tasks due to their short-term memory loss. The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 11 Social and emotional needs were assessed and care plans completed to meet them. For example, one care plan recorded how staff were to respect a resident’s preference for solitude, but had to make sure they were aware they were welcome to join in any activities. Residents said staff gave support when it was required, but that they were encouraged to do what they could for themselves. ‘When you do need help, everyone is there to give it’. Risk assessments are completed and regularly reviewed. These identify whether any specific action needs to be taken. For example, nutritional risk assessments identify whether someone needs a special diet or encouragement to eat. Health care needs are well met. Care plans showed referrals were made to health care professionals when required. Residents said they saw their doctors when they wanted to and were regularly visited by the district nurse when they needed to be. A health care professional felt that residents care needs were met with dignity and respect. The medication policy and procedure had been reviewed and now gave staff clear information about ordering, receiving, storing, administering and returning medication. Medication was stored in a locked cupboard and the shift leader held the key. A record is kept of who holds the key on each shift and spare keys are kept with the registered manager and provider. Only staff who have completed training and been assessed as competent are allowed to give out medication. Staff were observed giving out medication at lunchtime. This was given to each resident, with a drink and the individual record signed as the medication was given. Residents are supported to manage their own medication if they wish, provided a risk assessment has been completed. A completed risk assessment was seen in respect of a resident who had requested his medication be left with him each morning so he could take it when he was ready. Residents said staff treated them with respect at all times. Comments included ‘they don’t interfere with you’ ‘Let you do things at your own pace’. Staff were observed giving assistance discreetly and unhurriedly. They knocked on doors and waited for permission to enter. Residents’ choice of name was recorded on their file and staff were heard using this form of address. The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to make choices about all aspects of their daily living. The activities they are offered provide mental stimulation doing things they enjoy. The food provided offers a balanced diet with choices that residents like. EVIDENCE: Feedback from comment cards and from residents spoken with during the inspection evidenced the fact they felt able to make choices about all aspects of their daily living. Residents said there were no rules and they chose when to get up and go to bed. Care plans recorded individual daily routines, such as what time someone liked to get up and have breakfast. Residents were seen throughout the day moving freely around the home, spending time in the communal areas and their rooms. The home provides some organised activities, such as an exercise class, board games and visits by entertainers. The registered manager said a recent survey had indicated some residents would like more activities. Changes had been made in the daily running of the home to enable staff to have more free time to spend with residents, doing activities of their choice. The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 13 Feedback from comment cards and from the residents spoken with during the inspection evidenced they were mainly satisfied with what was offered. Comments included ‘I like the visiting library, you can tell them what sort of books you like and they will bring them’, ‘the home makes sure I get my daily newspaper. We also have the parish magazine every month’. Care plans record whether residents like to go to church or see the minister who calls regularly. Residents said how much they enjoyed walking in the gardens. The registered manager said she regularly takes residents down to the beach for a cup of tea and tries to organise trips out during the summer. The registered manager said that in response to requests from residents, the home has booked a caravan for a week in the summer so that residents may spend time in a different environment. The plan is to take some residents each day. Comments from relatives evidenced that they feel very welcome in the home. Residents said their relatives were made welcome and offered drinks when they visited. A notice in the hallway states that visitors are welcome at any time, but asked to avoid lunch if possible. Residents said they liked the food provided. The daily menu is displayed on the meal tables. Only one main meal is offered, but residents confirmed they would have something else if they wished. On the day of the inspection the main meal was roast lamb, roast potatoes, leeks in white sauce with raspberry pavlova to follow. A vegetarian option was available. The cook said the vegetarian option often looked no different from the main meal, as she used vegetarian meat substitutes. Several residents have diet-controlled diabetes. The cook said they are offered sugar free alternatives to puddings and cakes. Meal times were relaxed. Residents sit at a number of small tables and drinks are served before lunch. Residents spent time over their lunch, sitting and chatting after whilst tea and coffee were served. The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have the information they need to enable them to make complaints and be confident they will be informed of the outcome of any investigation. The in house policy and procedure and staff training enable staff to have the information they need to identify and report allegations of abuse. EVIDENCE: Feedback from residents, both verbally and in comment cards, showed that they had information about the complaints procedure. There was information about it in the statement of purpose and service user’s guide. Residents spoken with said they knew how to make a complaint, but had not had to do so on a formal basis. They felt informal complaints were dealt with swiftly and efficiently, and believed the registered manager would treat formal complaints in the same way. The commission had received no complaints about the service since the last inspection and the registered manager said the home had received none. The home had a policy and procedure for the protection of vulnerable adults. This had recently been amended and now complied with the guidance given in Hampshire’s protection of vulnerable adults procedure. Some staff had attended adult protection training as part of their national vocational qualification (NVQ) and were aware of their responsibility to report any abuse. The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 15 The registered manager said she was currently trying to find more adult protection courses so that staff could have further training. The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to live in a clean comfortable and safe environment that meets their needs and that they like. EVIDENCE: Residents said how much they liked the layout of the home and felt it was well maintained. The communal areas had been repainted since the last inspection and the lounge was being redecorated at the time of the inspection. A lighter paint had been chosen to try and make the room brighter than it had previously been. The house provides a homely environment and gives residents a choice of where they spend their time. Some like to sit in the lounge, whilst others prefer the conservatory or their own rooms. The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 17 Residents said the home was cleaned to a high standard. The registered manager said a second cleaner had been employed so that care staff no longer had to do any cleaning and could spend more time with residents. The home was clean and there were no unpleasant smells. There are well-maintained, enclosed gardens that provide a pleasant area where residents may walk or sit. The registered manager said there were plans to provide a quiet area by clearing one section of the garden and putting more seating there. The registered manager said the laundry was being improved and a new boiler system was being fitted. A new industrial washing machine was also being fitted that would enable staff to manage the washing more effectively. There was a policy and procedure for infection control. Staff were provided with gloves and aprons and were observed using them when required. The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported by well trained staff in sufficient numbers to meet their needs. There is an employment procedure, but the failure to follow it consistently means residents are not protected. EVIDENCE: Residents said there were usually staff on hand to provide help when needed. They said calls for help were answered promptly and this was observed during the inspection. Staff felt each shift had sufficient care staff on duty to enable them to meet the needs of residents. The registered manager said staffing levels were monitored to ensure they were sufficient to meet changing needs. There was evidence of this, as the appointment of a second cleaner had been made in response to a request for care staff to have more time to spend with residents. The registered manager said she had recently employed two new staff. One worked as a cleaner and the other as a night care staff. Both had been required to complete an application form, attend an interview, provide referees and have a criminal records bureau (CRB) and protection of vulnerable adults (POVA) check before beginning their induction. The person employed as a cleaner had one reference on file. The registered manager said she had telephoned for a second reference, but had not recorded this call. The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 19 The night care staff had no written references, but there was a record of a telephone call made to the previous employer to chase up the reference request. Some information had been obtained from the previous employer during this call, but there was only brief details had been recorded. The registered manager said she was aware she needed to obtain two references for employees and that she usually did so. She said she thought she had done so this time but had not written down the information she got from telephone calls. She agreed to review current practice to make sure there was a system for recording verbal references consistently and to get the missing references. The care staff was currently completing her induction by shadowing other staff. She was on the rota to work her first unsupervised night on 10/5/07. On Tuesday 15/05/07 the registered manager stated in a telephone call that following the concern raised during the inspection about the lack of references the care staff had not been permitted to work unsupervised. She confirmed this arrangement would continue until written references had been received. Further telephone calls had been made to the referees. On the previous inspection an induction checklist had been seen that was completed by new care staff to assess competency in each area. The new member of staff had no record of any induction, but had been allocated two night shifts shadowing a more experienced member of staff. There was no record of fire safety induction for either of the new staff. The registered manager said she had done this briefly on their first days but had not recorded it. She said she would do it again on their next working day, but both staff had already been working in the home. The AQAA identified that the registered manager felt the induction programme required further development. She had information about the Skills for Care induction programme, but had not yet introduced this for staff. The AQAA stated that 9 staff have achieved a national vocational qualification (NVQ) and 2 more were completing it. The new member of staff was already completing the course as she had started it in her previous employment. The evidence demonstrates the home has a commitment to supporting staff to develop their skills. The registered manager said she regularly arranged training for staff such as moving and handling. Staff had also recently completed first aid training. She and the deputy manager were attending a ‘Train the trainer’ course so they could deliver some training in house. An arrangement had been made with a company who could source appropriate training courses that the registered manager had identified as needed by staff. The registered manager had identified in the AQAA that adult protection training was needed and was trying to find an appropriate course. The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 20 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 and 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 generally well managed, but attention must be given to the issues identified in this report if the home is to be run in the residents’ best interests. There are systems in place that enable residents to give feedback about the service they receive. The majority of health and safety issues are addressed to protect residents, but fire safety and storage of hazardous chemicals must be reviewed if risks to residents are to be minimised. EVIDENCE: The registered manager has managed the service for some years and has achieved a National Vocational Qualification (NVQ) 4 in care and the Registered Manager’s award. She has continued to develop her practice through additional training and study. The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 21 Feedback from residents and relatives indicated that she has an open management style, is approachable and committed to developing the service to meet the needs of residents. They are able to give their views about the service at residents’ meetings and through questionnaires sent out annually. The registered manager responded to feedback, as evidenced by the increased staff time to spend with residents and the arrangements for trips out and activities. The home is well managed in many areas and there was evidence that improvements had been made since the last inspection. However, there was also evidence that some systems were not being effectively monitored and records were not being maintained. The recruitment procedure had not been followed properly in respect of references and records of verbal references had either not been recorded or had insufficient detail. There was no record of 2 new staff receiving induction, including fire safety induction. A requirement for staff to receive fire safety training had been met. The majority of staff had attended a training session and those who had been unable to had another session arranged. However, the requirement to carry out a fire drill had not been met. On 15/5/07 the registered manager said she had contacted Hampshire Fire and Rescue service for advice in respect of fire drills immediately following the inspection and had carried out a fire drill in accordance with their guidance. She was now clear about how often she needed to do this. The AQAA recorded that the home kept records of any money held on behalf of residents. The registered manager confirmed the home was still using the system seen at the last inspection of 8/2/07. During the inspection it was noted that a cupboard storing cleaning products and with a ‘Keep Locked’ sign on it was locked but had the key in it. Another cupboard, unlocked, also had cleaning products in it. The registered manager removed the key immediately and said she would remove the products from the other cupboard. The registered manager said staff were required to complete mandatory training such as food hygiene, first aid and moving and handling. Recent training included first aid, moving and handling and fire safety. During the inspection a random selection of service contracts and certificates were seen. These evidenced the health and safety of residents and staff was maintained. The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 23 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 OP29 Regulation 19 (1)© Requirement The registered manager must consistently follow the home’s recruitment procedure and obtain two written references for staff before they are employed to minimise the risk of harm to residents The registered manager must carry out regular fire drills so that residents and staff know what action to take in the event of a fire and to enhance the safety of residents and staff. Repeat requirement – previous timescale of 01/04/07 not met. The registered manager must make sure hazardous substances are locked away when not in use in accordance with health and safety guidance to minimise the risk of harm to residents who have dementia. Timescale for action 01/06/07 2. OP38 23(4) 01/06/07 3. OP38 13(4)© 01/06/07 The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 24 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 Good Practice Recommendations The Gatehouse DS0000012359.V336203.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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