Inspection on 08/06/06 for The Limes

This inspection was carried out on 8th June 2006.

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

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

Other inspections for this house

The Limes 07/04/09

The Limes 08/04/08

The Limes 10/02/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Limes Glebedale Road Fenton Stoke-on-trent Staffordshire ST4 3AP Lead Inspector Mrs Mandy Brassington Key Unannounced Inspection 8 June 2006 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 Limes DS0000064713.V297170.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 Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Limes Address Glebedale Road Fenton Stoke-on-trent Staffordshire ST4 3AP 01782 844855 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) Limes Fenton Ltd Miss Justine Gunn Care Home 41 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (15), Learning disability (1), Old age, not falling of places within any other category (41), Physical disability (10) The Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two Dementia - DE - Minimum age 55 years on admission. Date of last inspection 10th February 2006 Brief Description of the Service: The Limes residential home is located in Fenton, Stoke-on-Trent, close to local facilities and in walking distance of shops and the local library. The home has been operating for a number of years and was extended in 2003, bringing the number of beds available for residents up to 41. The home has recently come under a new Registered provider and continues to provide care for older people within a range of current registration categories including Dementia-over 65 years of age (5), Old age, not falling within any other category (33), Physical disability (4), Physical disability over 65 years of age (10). The accommodation is of a good standard throughout, and provides both single en-suite and double bedrooms. The communal areas included a large conservatory and a number of lounge/seating areas on both the ground and first floors. The home had a main dining room and other mixed sitting and dining areas. The car park is situated to the rear of the property and has adequate parking space for staff and visitors. There is a small area of garden to the rear of the property. The registered provider is Limes Fenton Ltd who has overall responsibility for the home. Mr R Patel informed the Commission for Social Care Inspection on 8 June 2006 that the fee level for The Limes is between £314 and £365 per week. The Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was an unannounced key inspection and therefore covered all of the core standards. The inspection took place over 8 hours by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. Prior to the inspection visit, a Pre-inspection Questionnaire had been completed and survey information has been obtained from two relatives and one General Practitioner. Feedback has been included within this report. A tour of the home was undertaken. The inspection included an examination of records, indirect observation, discussions with five service users, the deputy manager, and the staff on duty. Case tracking of four care plans was undertaken. Four staff records were examined and observation of daily activities took place. The inspector ate lunch with the service users and observed the staff administer medication. Twenty-one requirements and a further two recommendations were made as a result of this visit. This was considered to be a good inspection. What the service does well: The home has a well-established team of staff who provide a high standard of care. Staff observed had a knowledgeable and positive attitude towards service users. Staff offered choices and enabled the service users to make decisions with daily activities and to retain a level of independence. Staff were courteous and were observed providing care in a sensitive and dignified manner, using appropriate forms of communication. The service users spoke highly of the staff team and respectful attitudes were observed, whilst both enjoying a healthy banter. Service users’ comments relating to staff included: ‘Staff got me to walk again, they’re very good’ ‘Staff always ask you what you want’ ‘They’re very good at night and will always come to see how are you are’ The Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 6 ‘I can still have a large amount of control over my life’ ‘The staff will do anything for you, and come straight away if you need them’ ‘The staff listen to what you say’. The registered provider Mrs Shah visits the home and forwards the Regulation 26 report to the Commission For Social Care Inspection on a monthly basis. This evidences the home self audits and improves both the service delivery and environmental standards as required. The home is maintained to a high standard and is suitably decorated to create a homely atmosphere. There are a number of different communal areas to enable individuals to socialise, be involved in activities or spend time alone. Individual bedrooms have a good range of facilities; individuals are encouraged to bring in their own possessions and furniture as appropriate. The home provides a range of activities in the home including day and evening entertainment. Community excursions are arranged for service users on a regular basis and paid for through fund raising. What has improved since the last inspection? What they could do better: The home is registered to provide accommodation to people with dementia. Specific therapeutic activities are to take place to support individuals and their specific needs. The current medication storage systems need to be reviewed to ensure all medication is stored to comply with The Medicines Code. The home needs to provide a medication fridge to securely store identified medicines. The Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 7 The requirement to appropriately supervise staff six times per year is ongoing. It is essential that formal supervision begins and the manager is to be included in this process. A review of the training procedure developed under the previous management is needed to ensure the home provides the required training and the onus is removed from staff. Areas of need identified within this report were discussed with the provider. Gradual improvements have been made sensitively within the home over the previous six months since the change of ownership, and the provider recognised the areas where the home needs to meet the National Minimum Standards. It is pleasing to the Commission that the home is committed to improving standards and continuing to develop the service. 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 Limes DS0000064713.V297170.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 The Limes DS0000064713.V297170.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, The quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to this service. The manager undertakes assessments of potential service users and individuals receive formal contracts, which set out their terms and conditions of occupancy. EVIDENCE: The manager had carried out a pre-admission assessment of service users’ needs prior to individuals being admitted to the home, to establish whether the home had the capacity to meet their needs. The staff reported that the assessment could be carried out over several visits at different venues. The information gathered at assessment is transferred into the care plans. Staff confirmed they were involved with the assessment process during introductory visits and meals at the home, which provided opportunities to talk with the person and family members within a relaxed environment. Discussion with three service users revealed they had been able to visit the home prior to moving in and had been given a choice of the available rooms. The Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 10 The Statement of Purpose and Service User Guide are made available to all service users and their representatives; this needs to be amended in line with the current new management arrangements. New high quality colour brochures are available, giving an oversight of the facilities with photographs. Each service user is offered a written contract and statement of Terms and Conditions at the point of moving into the home. The Limes DS0000064713.V297170.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. The quality in this outcome area is ‘adequate’. This judgement has been made using available evidence including a visit to this service. The new care plan system documents the needs of the service users and the support required. The home must ensure that risk assessments are robust to include all identified areas of concern. The storage of medication is to be reviewed to adhere to The Medicines Code. EVIDENCE: The plans of care within the home have been developed to include a residents profile, a daily living needs assessment, personal care, personal safety and assessment of risk, medication, mental health, spiritual needs and daily living and social activities. The new plans contained a wide variety of information to enable individuals’ needs to be easily identified and the support required by staff. The initial assessment and service user plan did not demonstrate service user involvement. The manager needs ensure that evidence is available to confirm The Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 12 that service users and / or their representatives are offered the opportunity to participate in the care plan and subsequent reviews. One service user had been admitted to the home and a significant area of concern had been identified from the previous home and placing authority. The home had not completed an assessment of risk in line with this identified need and had not appropriately monitored or recorded this information. It is required that the plan of care and assessment of risk be reviewed to include this information. The home is also registered to provide a service for 17 individuals with dementia. There was no evidence to any specific services, facilities or stimulation to meet the needs of this group of residents. This had been recognised by the new providers and discussion revealed staff training had been planned and a range of therapeutic activities are to be implemented. All service users spoken with spoke highly of the service and the care provided. Service users stated they were treated with dignity and respect, and encouraged to be as independent as possible. Staff observed had a knowledgeable and positive attitude towards service users and feedback from service users was very encouraging about their relationship. Staff were observed knocking on doors, offering service users choice, and allowing them to complete tasks in their own time. Medication is stored within locked trolleys and the MDS system is used; a pharmacist reviews the system on an annual basis. The home appropriately stores and records all controlled drugs within the home. A stock of topical medications was stored in a cupboard that could not be locked. The home does not have a medication fridge and insulin was stored in the fridge door in the kitchen; it is required that all medication be stored appropriately and securely, and a lockable medication fridge is required. A small stock of homely remedies is maintained. A bottle of olive oil was out of date. Staff must ensure that all medicines including homely remedies are checked on a regular basis. The medication administered were observed and were of a good standard. All medication sheets included a photograph of the individual and a record of all trained staff was available. The Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to this service. The home enables service users to maintain links with family and friends and access community activities. A review of therapeutic activities for individuals with dementia is needed. EVIDENCE: An activities plan has been developed for events within the home during the day and an Entertainer is organised twice a month for individuals. The home conducts a range of fund-raising activities; monies raised, pay for trips in the community. A trip is planned to take all service users to Chester Zoo, previous trips have included a day trip to Blackpool and Theatre shows. Service users spoke positively regarding the events. The home has several lounge areas, a conservatory and some seating areas. Individuals reported they are able to choose where to go in the home according to the activity taking place and to socialise with other people; during the inspection there was a room that had music playing, individuals were watching television in one room and other areas were quiet. The Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 14 One individual spoke enthusiastically about his interests and how he was supported to be involved in community events with friends. All individuals stated that family and friends are able to visit flexibly and can be seen in private. The home has a number of small semi-private seating areas that can also be used. One service user stated that he received Holy Communion every two weeks in the home. This service is available to all individuals. At lunchtime, service users ate in the main dining room and one small dining area. The main meal is served at lunchtime and consists of three courses; a menu board displays the day’s menu in the hallway. On the day of the inspection, the meal prepared was soup, meat pie with potatoes and vegetables and rhubarb crumble with cream. The meal was unrushed and second helpings were offered, staff were seen supporting service users where necessary with their meals in a positive manner. Comments regarding the meal included: ‘The food here is excellent’, ‘The meals are very nice, you can’t grumble’, and ‘You can have what you want to eat’. The meals served were of a high standard, though inspection of the menu and discussion with staff and service users revealed only one main meal was prepared and individuals did not have a choice of meals. This issue was discussed with the provider who agreed that an alternative meal would be available. Staff reported that individuals are able to have a simple meal, snack or soft diet if required. A cold drink was served with the meal. Two service users spoken with stated they would prefer to have a hot drink. It is required that individuals be provided with a choice of a hot or a cold drink with the meal. The kitchen was inspected and found to be clean and tidy. A cleaning record was available for inspection. The kitchen window was open but there was no fly screen. It is required that a suitable screen be provided. The kitchen had a good range of food but there was no fresh fruit or vegetables. The staff reported that fresh produce was delivered once a week. A tour of the premises revealed there were two pieces of fruit in the home available for individuals. It is required that the home provides access to fresh food in line with service users needs and preferences. Service users stated they were able to come and go freely, and were able to receive their post unopened. Individuals are able to have a personal phone fitted in their room to maintain contact with family and friends. Service users are able to go out into the community, including church, with family and The Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 15 friends. These findings confirm that service users are offered a flexible routine that are varied to suit individuals expectations, preferences and capacities. The Limes DS0000064713.V297170.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 The quality in this outcome area is ‘adequate’. This judgement has been made using available evidence including a visit to this service. Further information is required to enable service users and their representatives a full understanding of the options available to them relating to making a complaint. EVIDENCE: The home has a complaints procedure within the service user guide and the complaints book was available at the front entrance. The procedure needs to confirm that service users may speak with the Commission for Social Care Inspection and make a complaint at any time, at present it suggests that the Commission would only be notified if the complainant was not satisfied with the outcome. Discussion with service users revealed individuals would speak with the manager or staff if they had any concerns and would be confident in doing so. Family members manage personal finances for the majority of service users; the home is appointee for two individuals and two service users manage their own finances. The manager had no concerns over individuals’ finances and there was a safe facility to hold any personal monies or valuables on the property. The Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 17 Staff demonstrated an awareness of the need to safeguard individuals from abuse and neglect and how to recognise the signs of abuse. The Deputy Manager had knowledge on the Vulnerable Adults procedure. The Limes DS0000064713.V297170.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26. The quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to this service. The home is very well maintained and provides a pleasant and comfortable homely environment for service users. EVIDENCE: The home has a good standard of accommodation and facilities throughout the home and provides both single en-suite and double bedrooms. There have been two extensions to the home to provide additional accommodation. The original house has retained many period features and provides the two main lounges and dining area. All bedrooms within the extensions are en-suite rooms, some of which are full en-suite with shower facilities. There are three double bedrooms, two of which are occupied by married couples. Other communal areas included a large conservatory and a number of lounge/seating areas on both the ground and first floors, and there is a The Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 19 hairdressing room. There is a garden and patio area to the rear of the building and a large private car park. There are exposed hot water pipes in the home; these are required to be appropriately covered. The home was cleaned to a high standard and tastefully decorated to provide a homely setting, and provided a safe and comfortable environment for service users. All bedrooms contained a good level of equipment and facilities and were of a good size. Individuals were able to accommodate larger rooms where additional mobility equipment was required. Individual rooms had been personalised with items of furniture and personal items. Three individuals stated they had been able to choose their room during an introductory visit. All bedrooms had a suitable locking device and service users were able to have a key to their room. Following assessment of risk where individuals do not want or are not able to have a key to their room, bedrooms were locked during the day, due to the mental health needs of some service users; individuals may enter others’ rooms without consent. It is required that consent to lock the doors is obtained, and this practice is to be included in the Statement of Purpose. Adequate toilet and bathing facilities were provided with appropriate aids and equipment available to assist manual handling and individual mobility requirements. The laundry area was situated on the ground floor and contained appropriate equipment, including sluice facilities, to meet the needs of the service users. Discussion with staff revealed laundry is transported in closed laundry bags and staff were aware of the need to maintain hygiene and infection control standards. The home had a supply of protective clothing and equipment. The Limes DS0000064713.V297170.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. The quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to this service. The home provides an appropriate level of staffing and there is a wellestablished team of staff who have the experience to provide a good standard of care to individuals in the home. EVIDENCE: On the day of inspection, there were 33 service users resident in the home and 2 individuals were receiving treatment in hospital. Inspection of the staff rosters and discussion with staff revealed there was one senior care and three carers working from 07.00 – 17.00, one senior care and two carers working from 17.00 – 22.00 and three waking night staff working from 22.00 – 07.30. Staff reported they come in prior to their shift for a handover. It is recommended that the shift system be reviewed to allow for a formal paid handover to comply with the Working Times Directive. There is one domestic staff 32.5 hours, and two laundry staff working a 52.5hour laundry services. There are two catering staff working within 49 hours per week. A hairdresser visits the home; it is required that the hairdresser completes a receives a satisfactory CRB clearance. There is a stable group of staff with many staff having worked at the home of a significant length of time. Agency staff are not used within the home and staff The Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 21 reported vacant shifts or covered by the existing team to ensure continuity of care. The home demonstrated there are good recruitment procedures, and a record of references, and CRB clearance is maintained; all files are to contain a copy of identity and a photograph. The providers are currently updating all the systems and information will be stored electronically. Due to the type of information stored electronically, the provider needs to register as a Data Controller. The provider must ensure that senior staff have access to the electronic data and all required information is available for inspection. The new management have reviewed staff training and updates have been organised for Fire training, moving and handling and Health and Safety. Training for dementia has been booked for August 2006. All staff are responsible for the evening meal and may prepare simple meals and snacks. It is required that all staff have a basic Food Safety Qualification. From discussion with staff it was revealed that under the previous management staff were expected to pay for training. It is the responsibility of the registered person to ensure that all staff are suitably trained. This was discussed with the new provider who agreed it is the home’s responsibility to train staff to a suitable level of competency in order to meet the requirements of the Care Standards Act. All of the staff on duty were spoken to during this inspection and observations were also made of staff attitudes and respect towards the service users. The staff members spoken to talked about service users in a sensitive and respectful way and understood the need to promote their dignity and maintain confidentiality. Service users comments regarding the staff included: ‘Staff got me to walk again, they’re very good’ ‘Staff always ask you what you want’ ‘They’re very good at night and will always come to see how are you are’ ‘I can still have a large amount of control over my life’ ‘The staff will do anything for you, and come straight away if you need them’ ‘The staff listen to what you say’. The Limes DS0000064713.V297170.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 The quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to this service. The health, safety and welfare of the service users and staff were promoted and protected as far as reasonably practicable. EVIDENCE: The home was purchased in December 2005 and is now owned by Limes Fenton Ltd. The providers demonstrated they are currently reviewing the systems, policies and procedures within the home and are committed to developing the home to ensure the standard of care delivered remains at a good level and requirements to meet the National Minimum Standards are met. The proprietor conducts monthly unannounced visits and a copy is forwarded to the Commission. The Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 23 Residents’ meetings take place and individuals are able to contribute to the management of the home. Evidence to demonstrate staff receive formal supervision was not available during the inspection. Staff are to receive formal supervision at least six times a year to cover aspects of care, philosophy of the home and career development needs. The manager is also to be part of the formal supervision process. The health and safety of service users and staff were promoted with safe regular fire checks and drills, servicing of gas appliances, and monitoring the water system. The home does not have an Emergency Contingency Plan as part of a Fire Risk assessment. The home is to develop a plan for ultimate evacuation to a place of safety and consider the needs of the service users and staffing levels. Due consideration is to be given to access alternative accommodation and emergency contact numbers. This plan is to be reviewed regularly and updated to reflect any changes. Service users’ financial interests were safeguarded; service users were encouraged to look after their own financial affairs with the support of their families or representative. A quality monitoring system has been implemented and feedback was available from service users. This is to be developed to include views from stakeholders in the community. A photocopy of the registration certificate is displayed. It is required that the original certificate is displayed in the home. The Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 3 2 3 3 3 3 2 2 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 3 X 3 X 3 2 X 2 The Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 6(a) Requirement The Statement of Purpose is to be reviewed to incorporate the recent management changes, as detailed in Schedule 1 One plan of care to incorporate an assessment of risk for inappropriate behaviour Plans of care to evidence of involvement from the service user and/or their representative A medication fridge is to be provided To discard/return out of date homely remedies Medication cupboard for storing topical medication to be locked Specific therapeutic activities to be provided for individuals with dementia To provide sufficient fresh fruit and vegetables to meet individuals needs A choice of hot and cold drinks are to be served at meal times The complaints procedure is to be amended to reflect service user and their representative may contact the CCSI at any time DS0000064713.V297170.R01.S.doc Timescale for action 30/08/06 2 3 4 5 6 7 8 9 10 OP7 OP7 OP9 OP9 OP9 OP12 OP15 OP15 OP16 15(1), 12(1)(b) 15(1)(2) 13(2) 13(2) 13(2) 12(1)(a) (b) 16(2)(i) 16(2)(i) 22(7) 20/06/06 08/08/06 30/06/06 20/06/06 20/06/06 08/08/06 20/06/06 20/06/06 30/06/06 The Limes Version 5.2 Page 26 11 12 13 14 15 16 17 18 19 20 OP19 OP24 OP25 OP29 OP29 OP30 OP30 OP36 OP38 OP38 16(2)(g), 23(2)(b) 15(1), (4)(1) 13(4)(a) 19(1)(b) (i) 19(1)(b) (i) 18(1)(a) (c) 18(1)(c) (i) 18(2) 17(1) 23(4)(c) (iii) Care Standards Act 2000, Part II, (28)(1) 21 OP38 A fly screen is to be fitted to the kitchen window Assessment of risk and consent required for locking of bedroom doors All hot water pipes are to suitably covered All staff files to contain a photograph and copy of identity as in Schedule 2 (1) The hairdresser is to have appropriate CRB Clearance as in Schedule 2 (7) The registered person is responsible for providing appropriate training for staff Staff to receive training for Basic Food Safety All staff including the manager to receive formal supervision a minimum of six times a year The registered person is to register as a Data Controller A comprehensive fire risk assessment is to be conducted an to include an emergency contingency plan The original registration certificate is to be displayed in the home 08/06/06 08/08/06 08/08/06 30/08/06 30/07/06 30/06/06 08/09/06 08/09/06 08/08/06 30/07/06 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP15 OP27 Good Practice Recommendations Review menus to provide a suitable alternative Staff shifts to be reviewed to allow for a formal handover The Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Limes DS0000064713.V297170.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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