Inspection on 17/03/08 for The Noel

This inspection was carried out on 17th March 2008.

CSCI found this care home to be providing an Adequate service.

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 Noel 04/06/09

The Noel 28/04/09

The Noel 30/01/09

The Noel 24/01/07

The Noel 01/02/06

The Noel 27/07/05

The Noel 07/10/04

The Noel 07/04/04

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 Noel St Boniface Road Ventnor Isle Of Wight PO38 1PN Lead Inspector Annie Kentfield Unannounced Inspection 17th March 2008 12:30 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 The Noel DS0000012516.V359488.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 Noel DS0000012516.V359488.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Noel Address St Boniface Road Ventnor Isle Of Wight PO38 1PN 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) 01983 852292 Miss Sandra Vivienne Phillips Miss Sandra Vivienne Phillips Care Home 12 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (12), of places Physical disability over 65 years of age (4) The Noel DS0000012516.V359488.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The Noel is a residential care home providing care and accommodation for up to 12 older people, with some capacity for older people with a physical disability, or illness associated with dementia. The home is owned, and managed on a day-to-day basis by Miss Sandra Phillips. The home is a period three-storey (including basement) detached house in Ventnor, near to the town centre, with its shops and amenities. Accommodation for the residents is arranged over the ground and first floors and a stair lift assists with access to rooms on the first floor. Rooms at the front enjoy fine sea views and those at the rear face St Boniface Down. The home is registered to accommodate 12 older people, but the manager prefers to provide single room accommodation and therefore limits the occupancy to 8. Double rooms are used only if residents choose to share. There is off road parking to the front of the building. A stair lift is available to assist those with mobility difficulties to negotiate the steps up to the front door. The managers philosophy is to provide tailor made care that is relaxed and flexible to suit the individual needs of frail older residents. The home provides 24 hours staffing. Daily fees range from £52.75 to £64.63. The manager states that a copy of the statement of purpose and terms and conditions of residency are provided to all prospective residents, or their representatives where applicable. The Noel DS0000012516.V359488.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This report is a summary of information that we have received, or asked for, since the last inspection on 24 January 2007. We also include information from an unannounced visit to the service on March 17th 2008. This was with one inspector (Annie Kentfield) and over a period of 5 hours we spoke to four of the six residents, the manager and one member of the care staff. We also looked at some of the home’s records, including medication records and care plans, staff recruitment and training records and some health and safety records. We received the Annual Quality Assurance Assessment (AQAA) from the home, when we asked for it. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. We sent surveys to all of the residents and staff and also 3 Social Services care managers who have contact with the home. We received completed surveys from 5 residents and 8 members of staff. All of the feedback that we received was very positive about the service provided by the home. What the service does well: What has improved since the last inspection? At the last inspection we made some statutory requirements and the manager has taken action to comply with these in the given timescales: The Noel DS0000012516.V359488.R01.S.doc Version 5.2 Page 6 Medication procedures have been reviewed to reflect best practice and staff have received accredited training in the safe administration of medicines. The home environment has improved and some of the windows have been replaced, areas of the home decorated and carpets replaced. The manager confirmed that a number of health and safety requirements have been met. (Details are included in the body of the report) Recruitment procedures have improved, this demonstrates that staff are suitable to work in the home. The arrangements for making sure that staff are trained and qualified have improved, but more work is needed to demonstrate that the home has a planned programme for staff training and development. Since the last inspection the manager has updated some aspects of her own professional development and training. 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 Noel DS0000012516.V359488.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 Noel DS0000012516.V359488.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): 1, 3 and 6 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents who move into the home can be confident that all of their care and social needs will have been assessed and these will be met. Information about the home for prospective residents or their representatives is limited but covers basic details about the home. The home does not provide dedicated rehabilitative or intermediate care but can provide respite care if a room is available. EVIDENCE: The manager is very clear about the level of care that the home can offer, taking into account the layout of the building, staffing, and the needs of the existing residents. She is very clear that no person moves into the home unless the manager and staff are confident that care needs can be met. We saw some of the home’s records that confirm that the home gathers as much The Noel DS0000012516.V359488.R01.S.doc Version 5.2 Page 9 information as possible about each resident, often in liaison with other people involved in the care of the resident such as care managers, community nurses or the hospital. Comments from the residents in the home confirm that the manager encourages prospective residents and/or their representatives to visit the home before moving in to make sure that they are able to make an informed decision before they move in. Written information about the home is basic but covers what people who live in the home can expect to receive for the fee they pay. When we looked at the information about the home we found that the terms and conditions did not specify details of the period of notice and the manager said that this would be updated. The Noel DS0000012516.V359488.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 and 10 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home receive personal and health care support in the way they choose and with respect for privacy and dignity and as recorded in their individual care plan. The home has arrangements in place for the safe administration of residents’ medicines. However, action must be taken to ensure that the storage of controlled drugs meets amended regulatory requirements. EVIDENCE: We looked at the care records for two residents and although recording is brief, there is sufficient information in the care plans to guide care staff on the way that care needs to be provided. Individual care plans include a brief history, relevant information about next of kin and GP, dietary likes and dislikes, preferences for getting up and going to bed, plan of care for health care needs, manual handling risk assessments, daily recording of information and night log. The Noel DS0000012516.V359488.R01.S.doc Version 5.2 Page 11 The manager and staff confirmed in discussions that given the small size of the home (6 residents) and the effectiveness of verbal communication, they were very familiar with the needs and wishes of each resident and what was needed to meet those needs and wishes. The daily records confirm that residents have regular contact with GP’s, community nurses and other healthcare professionals and the manager has acquired all necessary equipment to assist with mobility and minimise the risk of pressure sores. Residents are supported to have access to a dentist, optician and chiropodist who visit the home. We received positive comments from the residents when we talked to them about their experience of living in the home. From our observation of practice in the home and discussion with residents and staff, it is evident that the day to day running of the home places great emphasis on ensuring that the choices and preferences of the residents are met with respect for privacy, dignity and promoting autonomy. We observed staff addressing residents by their preferred names and knocking on doors and seeking permission to enter rooms. Since the last inspection the manager has introduced new medication procedures using a measured dosage system. The manager and some of the care staff have updated their medication training with a certificated course in the safe administration of medicines via the local College. The new system for dispensing and administrating residents’ medicines means that the unsafe practice of ‘secondary dispensing’ from the original packaging is no longer used. However, the manager must review and clarify the use of ‘as required’ or PRN medicines as these do not easily fit into the new system. Although the manager monitors daily the medication and medication records it is safer practice for any PRN medicine to have a separate written protocol with details of when and why it should be given, with details of any discussion with the prescribing GP, recorded in writing. There is new guidance on the safe administration of medicines in care homes and we advised the manager that this guidance is freely available on the Commission website www.csci.org.uk At the last inspection we recommended that the manager replace the wooden drugs cabinet with an appropriate metal cupboard suitable to store controlled drugs. This is now a requirement because care homes must meet the amended regulations, and the home has three months to comply with this statutory requirement. The Noel DS0000012516.V359488.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 adequate. This judgement has been made using available evidence including a visit to this service. The Noel offers a service that supports and encourages residents’ choices and preferences for recreational and social activities. The home places emphasis on offering a varied and balanced diet of good quality food. EVIDENCE: It was evident from discussion with residents and staff that daily life in the home is organised around the choices and preferences of the residents with regard to times of getting up and going to bed, mealtimes, social activities and cultural and religious activities. When we talked to four of the residents, it was clear that most of the residents prefer to spend time in their own rooms, and also have meals in their rooms. The home has a living room with a dining table, and occasionally, some of the residents choose to take their meals there. We have been told on previous occasions, that visitors are welcome to visit at any time, and some of the residents enjoy trips out with family or friends. The manager told us that The Noel DS0000012516.V359488.R01.S.doc Version 5.2 Page 13 some of the residents take communion in the home and some of the residents enjoy watching ‘Songs of Praise’ on the television. The home does not arrange a programme of social activities but the manager makes a point of organising birthday celebrations with a special tea to which friends and relatives are invited. Likewise with Christmas festivities – we saw photographs of the most recent Christmas that residents had enjoyed, with a tree and presents for the residents, a special lunch, and a Christmas cake that the manager had made and decorated. We asked the residents if they would prefer to have organised social activities and the general consensus is that they are happy with the routines in the home. Residents enjoyed being able to read or watch TV in their rooms, or go into the living room to read newspapers provided by the home. The manager had assisted one resident to install satellite TV in their room for personal preference. Staff also support one of the residents to visit a day centre of their choice and will arrange transport if residents want to go out. Comments from the residents demonstrate that meals in the home are good, with lots of choice of home cooked and nutritious food. The manager told us in the AQAA that staff keep a record of meals eaten by the residents so that “we can keep an eye on residents’ diet” as part of overall monitoring of health care needs. The Noel DS0000012516.V359488.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents’ concerns, complaints and views are listened to, treated seriously and acted upon. The manager must ensure that residents’ are protected from harm or abuse through thorough and robust recruitment procedures. EVIDENCE: Residents felt confident about taking any concerns they may have to the manager. Concerns, complaints and feedback are usually dealt with informally as the manager has daily contact with residents, visitors and visiting professionals such as care managers or community nurses. However, the manager and staff are aware of the formal complaints procedure and would investigate and record any complaints, according to the complaints procedure, should they receive any. We spoke to one member of staff who said that they had seen information about how to be aware of safeguarding procedures; in the information given to care staff with the staff handbook. Formal training in safeguarding procedures has not been arranged but staff confirmed in the written surveys, that the manager provided training. The incidence of complaints or safeguarding referrals is very low for this service as a result of lack of incidents rather than a lack of understanding The Noel DS0000012516.V359488.R01.S.doc Version 5.2 Page 15 about when incidents should be reported and there have been no complaints or incidents recorded since we last visited the home in January 2007. The service does not have thorough and robust recruitment procedures and there have been shortfalls in the recording process. Staff have previously been appointed and started working without references and other checks being received. Although the manager has confirmed that satisfactory checks have now been received for three members of staff, the lack of proper procedures does not demonstrate that the home is consistently making sure that staff are suitable to work in the home. This has the potential to place people using the service at risk of harm or abuse from staff who may not be suitable to work in the home. The Noel DS0000012516.V359488.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, 21, 23 and 26 - 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 environment that meets the specific needs of the people who live there in a comfortable and homely way. The home is clean, pleasant and hygienic. EVIDENCE: We looked round the building so that we could see what improvements have been made to the home in the last 12 months. Since the last inspection, all windows on the top two floors have been replaced with new double glazed units. The laundry room in the basement has been fitted with a new double glazed door. The manager said that she is planning to replace the front door with a new double glazed door. All hallways and stairwells have been decorated and new carpet fitted to stairs and the bathroom on the upper floor has been decorated. The Noel DS0000012516.V359488.R01.S.doc Version 5.2 Page 17 A new fire alarm system has been installed with a new break glass system. This has been done in consultation with the local Fire Service. There is a new emergency light over the front door. When we visited, the home was clean and tidy and there were no unpleasant odours. Comments from residents confirmed that the home is always clean and fresh. The home has a bathroom and toilet on each floor and although bedrooms do not have en-suite facilities, each bedroom has a wash-hand basin, and residents are easily able to access the nearest toilet and bathroom. Both bathrooms have an assisted bath. The base of the toilet in the first floor bathroom is old and discoloured, however, this was felt to be cosmetic and did not compromise the home’s ability to maintain good hygiene and infection control Bedrooms are only shared in limited situations when residents actively choose to share. All rooms reflect the chosen style and personal belongings of individual residents and the manager and staff actively encourage residents to bring furniture and personal items when they move into the home. The home has infection control policy and procedures and the manager seeks advice from external specialists such as NHS infection control staff, when required, as part of the home’s action to reduce the risk of infection or cross infection. We saw evidence of good practice in that bathrooms and the staff facilities were supplied with liquid soap and paper towels, in line with good practice for promoting good hygiene. Overall, the building has some limitations for residents because it does not have a passenger lift and access to the building and to the upper floors is via a stair lift. This means that residents who need assistance with mobility cannot independently move around all parts of the home. Bedrooms do not have ensuite facilities and there is no dining room. There is a limited outside area for residents to use and residents who need assistance with mobility could not access the garden independently. However, the manager is aware of the limitations of the building and takes this into consideration when assessing the suitability of the home for new residents. The home meets the needs of the people using the service, and this was confirmed in the feedback we received from the residents and from visitor comments we have received at previous inspections. The manager has also taken action to meet the environmental requirements from the last inspection and considerable refurbishment work has taken place in the last 12 months. The Noel DS0000012516.V359488.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. The care and support needs of the residents are met by sufficient numbers of competent staff. However, the records for staff recruitment and staff training and development do not demonstrate a robust and organised approach to making sure that staff are suitable, skilled and qualified to work with people using the service. EVIDENCE: There are sufficient numbers of staff, including the manager and cook, to meet the care and support needs of the six residents. A member of the care staff told us that staff in the home work closely with the manager, work well as a team, and practice issues are discussed and agreed as a team. Supervision is informal and ongoing because the manager is always available during the day and is on call at night. Comments from residents and visitors, and observation of practice in the home, confirm that the standard of care provided by the home is very good. However, the quality of care and person centred care philosophy of the home is not supported by evidence of ongoing training and development that is accredited and reflects best practice in the care of older people. This is because the training programme is reactive rather than proactive and record keeping is disorganised. Since the last inspection, the manager and some of the care staff have updated their training in safe moving and lifting, safe The Noel DS0000012516.V359488.R01.S.doc Version 5.2 Page 19 administration of medication, and emergency life support. We saw accredited certificates for the manager, but not for the care staff because the certificates had been taken home. The manager is aware that record keeping is not her strong point and that the size of the home means that it is not practical to employ an administrator to organise record keeping. There are also limited resources to organise a planned programme of training and development. This means that although the service is able to recognise when additional training is needed, they are not always in a position to deliver the training needed. There is evidence that staff are clear about what is expected from them and residents report that staff working with them know what they are meant to do and that they meet their individual needs in a way that they are satisfied with. However, the home is not able to demonstrate that all of the care staff have received training in all areas of safe working practice or that training is regularly updated to reflect best practice. The procedures for the recruitment of staff are not thorough. At the last inspection we found that three new care staff had started working in the home before satisfactory criminal record checks had been received. We saw evidence that these have now been received and the manager has obtained references verbally, but not written references. The manager told us that written references would be requested. When we looked at the recruitment records we found that the information gathered on the job application form is very brief. This means that the manager is not gathering comprehensive information about new staff with regard to employment history, qualifications achieved or previous experience in care work. This information must be part of the recruitment process to demonstrate that staff are suitable to work in the home. The turnover of staff is low and the manager told us that she places emphasis on getting the right people for the work and the home does not use agency staff. However, there are some shortfalls in the recording and processes of staff recruitment. This means that the home’s recruitment procedures lack the safeguards to ensure that the residents are protected from the risk of harm or abuse. The home has not appointed any new staff since the last inspection and the manager confirmed that if and when new staff are appointed, the recruitment procedures will meet regulatory requirements. This will demonstrate that staff working in the home are suitable to work with people using the service and that residents’ safety is protected. The Noel DS0000012516.V359488.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. Residents live in a home that is run by an experienced registered manager. The views of the residents are listened to and taken seriously and the home is run in the best interests of the people using the service. The health, safety and welfare of the residents and staff are promoted but this is sometimes compromised by a lack of organisation and poor record keeping. EVIDENCE: The registered manager, Miss Sandra Phillips has owned and managed The Noel since 1984. Miss Phillips is very knowledgeable and familiar with the conditions associated with old age but she has no management or other formal qualifications and has no plans to achieve them. The Noel DS0000012516.V359488.R01.S.doc Version 5.2 Page 21 Comments that we have received from residents and staff and comments from visitors and visiting professionals at previous inspections, demonstrate that the manager is respected and trusted and the management approach of the home is caring and positive. There is no annual development plan or formal quality assurance systems but with the size of the home and type of service the home offers, the manager is in daily contact with the residents and visitors, providing them with what they want and need. This was strongly supported by the feedback that we had from residents and staff. However, more work is needed to develop systems for monitoring practice in the home, compliance with the Care Homes Regulations 2001 and compliance with other relevant legislation in the areas of health and safety and medication. This would demonstrate proactive and regular monitoring of the service and how well it is meeting outcomes and regulations rather than a consistently reactive process of only taking action when we make statutory requirements. The Annual Quality Assurance Assessment that was completed by the home gives us an incomplete picture of the service and there are areas where more supporting evidence would have been useful to illustrate what the service has done in the last year, what it does well or how it is planning to improve. The data section of the AQAA was completed although there are some inconsistencies. The manager is aware of the need to promote safeguarding and although there are some shortfalls in the recruitment procedures the manager said that these would be addressed. At the last inspection we made some requirements about health and safety and these have been addressed. We received confirmation that the home has been inspected by the Environmental Health Department (EHD) and that there are systems in place to provide adequate controls on any identified risks, however, the EHD also said that the manager does not record enough information to demonstrate that the service is fully compliant with the relevant legislation. The manager confirmed that health and safety risk assessments have been reviewed and recorded, but these records could not be found when we visited. The manager confirmed that the home has completed risk assessments on any hazardous materials in the home such as cleaning products. We saw evidence that the home has an accident recording book that meets the requirements of the Data Protection Act 1998. A qualified contractor has carried out an electrical wiring inspection of the home and the manager told us that she was awaiting a written report. The Noel DS0000012516.V359488.R01.S.doc Version 5.2 Page 22 The home is not directly involved with the management of residents’ finances and either family or formal advocates support residents. The Noel DS0000012516.V359488.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 3 X 3 X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X 2 2 The Noel DS0000012516.V359488.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 13 Requirement Controlled drugs must be stored in a designated cupboard that meets the requirements of the Misuse of Drugs (Safe Custody) (Amendment) Regulations 2007. Timescale for action 18/07/08 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 Noel DS0000012516.V359488.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 The Noel DS0000012516.V359488.R01.S.doc Version 5.2 Page 26 - 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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