Inspection on 24/07/07 for The Paddocks

This inspection was carried out on 24th July 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 Paddocks 30/07/08

The Paddocks 23/01/07

The Paddocks 20/01/06

The Paddocks 07/06/05

The Paddocks 02/12/04

The Paddocks 15/06/04

The Paddocks 16/06/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bramley Avenue (73)

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Paddocks Springfield Road Wellhead Nr Dunstable Bedfordshire LU6 2JT Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 24th July 2007 01:10 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 Paddocks DS0000014943.V342551.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 Paddocks DS0000014943.V342551.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Paddocks Address Springfield Road Wellhead Nr Dunstable Bedfordshire LU6 2JT 01582 601317 01582 673287 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) Mr Kenneth Janes Mrs Lilian Janes Mrs Lilian Janes Care Home 10 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (10), of places Physical disability over 65 years of age (10) The Paddocks DS0000014943.V342551.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2007 Brief Description of the Service: The Paddocks was registered to provide for ten older persons who may also have physical disabilities and/ or dementia. The registration for physical disabilities was not required because disabilities associated with old age could be met under the category for older people. Mr and Mrs Janes had operated the home since its original registration several years previously. Mrs Janes was the registered manager. The home was located in a small hamlet close enough to the town of Dunstable to take advantage of its amenities but at sufficient distance to retain the peaceful environment of this rural location and the pleasant countryside views from each window. The accommodation, which had been suitably adapted, was distributed over two floors that were accessed by a shaft lift and comprised ten single bedrooms with washbasin and call bell facilities. Adapted toilets and bathrooms were located for convenient access on both floors. Communal sitting areas, three interlinking rooms, lounge, dining room and an all weather conservatory were located on the ground floor as was the kitchen. An office was in the basement as were the proprietors private living quarters. An extension to the building housed the laundry, storage areas, another office and training room facilities. The rear of the property overlooked an attractive garden and extensive other grounds used to grow vegetables and fruits for the home. Information currently published and displayed in the homes ‘Service User Guide’ regarding the home’s range of fees and the manager’s figure provided in the pre-inspection questionnaire in July 2006, both stated that the weekly fee ranged from £425.86 to £450, exact fees were published in individual service users contracts. These fees did not include newspapers, hairdressers, personal telephone, toiletries, or private chiropodist; these services would incur an additional charge. The Paddocks DS0000014943.V342551.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out on 24/07/2007 over 6 hours by Pursotamraj Hirekar. The registered manager coordinated the inspection through out. The method of inspection included study of care plans, risk assessments, personnel records, staff deployment duty rota, relevant care delivery documents, discussions with manager, staff, conversation with service users’ and partial tour of the building. The information from the service users’ survey carried out by the commission and annual quality assurance assessment- self-assessment completed by the home is also considered for this report. What the service does well: What has improved since the last inspection? What they could do better: The home must complete the needs assessment and update as appropriate for all the service users. The service user plan must detail the action and objectives that need to be taken by care staff to ensure that all aspects of the health, social and personal care needs of all the service users are met. The home must enable service users make choice of activities to suit their expectations, preferences, and capacities. The home must ensure that all the service users’ health care needs are appropriately met and reasons for medication not given recorded. The Paddocks DS0000014943.V342551.R01.S.doc Version 5.2 Page 6 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 Paddocks DS0000014943.V342551.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 Paddocks DS0000014943.V342551.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 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provided sufficient information for prospective service users in a suitable format. The home had made arrangements for involving the service users and their family members in redoing the needs assessment of all service users. This enabled them to be assured that their needs will be met. However, all the service users’ needs assessment review and updating needed completion. EVIDENCE: The homes ‘Statement of Purpose’ and ‘Service User Guide’ were reviewed and updated on 01/03/07 and presented in a suitable language and format for the service users and their family members. There was evidence that the home had undertaken an assessment of the needs of service users on admission. They are provided with a summary assessment from the referring care management service, which they had used to form part of the information that contributed to their own needs The Paddocks DS0000014943.V342551.R01.S.doc Version 5.2 Page 9 assessment. The home had scheduled to complete redoing needs assessment of all the service users’ by the end of August 2007. As on this inspection, 1 service user’s comprehensive needs assessment were completed and signed of by the family member of the service user and the second service user needs assessment work was in progress. For example, the needs assessment carried out for a service user on 29/06/07 covered personal details, care of the dying relative, the residents profile, personal care and physical wellbeing, communication, personal safety and risk assessment, medical history, medication, mental health and cognition, diet and weight, food and meal times, dental and foot care, religious observance, daily living and social activities. The home did not admit service users for intermediate care. The commission had undertaken service users’ survey, to get feedback from the service users’ and their family members about the care and services they get from the home. Annual quality assurance assessment tool was also used for the responsible individual/manager to provide information to the commission with regard to various aspects of care provision and delivery they undertake. 5 service users’ have responded to the service users’ survey undertaken by the commission, of which all the 5 service users have said that they had prior information about the home, before they moved in and 4 had signed the contract of services. However, 1service user ignored this question. The Paddocks DS0000014943.V342551.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had initiated improvements with regard to the care planning process and need to ensure that the suitable medication procedures are practiced without placing service users at risk and of harm. EVIDENCE: The home had decided to revisit all the service users’ needs assessment and risk assessment and update their care plans with the involvement of the service users and their representatives. As, on this inspection, 1 service user’s care planning process was completed and the 2nd service user’s work was in progress. The manager informed the inspector that, all the service users’ care plan work was scheduled for completion by the end of August 2007. Summary details of Service user –1 completed care plan included information on; general risk assessment covering getting in and out of bed, call bell, fire, falling out of window, safe and door keys, using the lift, bath hoist, was carried out by the manager and was signed by both manager and the daughter of the service user on 04/07/07. The care plan covered detailed information in The Paddocks DS0000014943.V342551.R01.S.doc Version 5.2 Page 11 relation to personal and physical well being, communication, mobility and dexterity, personal safety and risk assessment, medical history, medication, mental health and cognition, diet and weight, food and meal times, dental and foot care, religious observance, daily living and social activities and the care plan agreement. The daughter of the service user signed the care plan on 21/07/07 and the home manager on 04/07/07. Monthly care plan reviews were carried out regularly. The son of the service user had signed monthly care plan reviews for the month of April and May 2007 and dying relative document as well. Waterlow skin condition assessment was carried out on the 08/05/07 and 29/06/07 and scored at very high risk and recorded in the care plan to check her skin every day to prevent pressure areas and to report if one is found. Daily care notes was seen and found that there was no record of regular check carried out for pressure sore prior to 24/07/08. The manger had said that this was discussed with the staff and they were told to record on checking pressure sore in the daily care record. The weight monitoring record of 16/04/07 indicated weight lost of 4 lb and 10lb on 08/05/07 and on 21/06/07 recorded gain of 6½ lb. These changes were reflected in the care plan with regard to her diet. It was found during the inspection that Alendronic acid 70mg tablets were not administered on 12/07/07 and 19/07/07, the manger agreed to investigate. In addition to the above, 2 more service users care plans were seen and their details are as follows: Service user –2 was admitted to the home on 20/03/07, the comprehensive needs assessment and service user’s profile work was in progress. Risk assessments regarding walking, going to bed, bath hoist, wheel chair, windows, stairs, keys, and going to toilet was carried out on 26/03/07 and was signed by the manager and the son of the service user as well. The service user had falls on 21/03/07, 23/03/07, 28/03/07, 30/03/07, 15/04/07, 17/04/07, 06/05/07, 14/05/07, 12/06/07 and 16/06/07. The preventative measures have been reflected in the care plan for staff to keep an eye on his mobility. The daily care record was seen and found out, the checks were carried out every one hour as planned, but the record maintained was confusing, the manager agreed to redesign the night time checks record to clearly show the time and date the checks carried out by the staff. The change of medication prescribed by the doctor dated 17/04/07, 02/05/07, 05/06/07, and 13/06/07 was not reflected in the care plan under the medication section. But the medication was administered on the basis of mar sheet. The son and the manager signed the care plan prepared on 19/04/07. The monthly care plan review was carried out regularly and signed by the manager and the son of the service user as well. However, the care plan review notes needed more detailing with regard to the care that needs to be provided by the staff. The manager was planning to prepare a summary of the care plan to facilitate the care staff for ready reference, prior to providing care and with a note to refer The Paddocks DS0000014943.V342551.R01.S.doc Version 5.2 Page 12 the main care plan for details when required. The manager informed on this inspection that the care plan was scheduled for an update to reflect changes basing on the care plan and risk assessments review, by the end of August 2007. The care of your dying relative was carried out in March 2007 but needed signatures of the relative. Medication refusal of lactulose on several occasions was recorded on mar sheet with out any reasons, the manager agreed to speak with the staff, to ensure the reasons for refusals are recorded as well. Service user- 3 care plan prepared was on the basis of the needs assessment carried out on the 23/07/07. However, the risk assessments carried out on 03/02/07 are scheduled for a review this week, then the care plan would be updated to reflect changes from the outcomes of the risk assessments, the manager informed. The monthly care plan review was carried out regularly. However, the care plan review notes needed more detailing with regard to the care that needs to be provided by the staff. The manager was planning to prepare a summary of the care plan to facilitate the care staff for ready reference, prior to providing care and with a note to refer the main care plan for details when required. Medication refusal of lactulose on several occasions was recorded on mar sheet with out any reasons, the manager agreed to speak with the staff, to ensure the reasons for refusals are recorded as well. In response to the service user’ survey undertaken by the commission, of the total 5 service users’ 4 service users have said that they always receive the care and support they need and 1 service users said they receive usually. When asked do they receive medical support they need, 3 service users’ said they received medical support always and 2 service users’ said usually. The Paddocks DS0000014943.V342551.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had made attempts to engage service users in a variety of activities and encourage them to maintain good relations with their family members and provide food of their choice. However, the home needs to make further improvements to meet the aspirations of all the service users’. EVIDENCE: On this inspection, minutes of the resident meeting of 16/02/07 and resident and family meeting of 24/03/07 was seen and found that the home had discussed about activities, menus, and redecoration of the conservatory. The home had prepared a detailed activity menu for each day and recorded evidence of its daily activities, which they supported service users with. The activity folder had information with regard to residents for 10/07/07, which said 3-service user were taken out for a walk around the garden to feed the fish, 3 service users played bowels. On 14/07/07, 1 service user went for a walk in the garden. On this inspection 2 service users’ were observed playing dominoes in the afternoon and the rest were watching television. Menus examined generally offered choice and a nutritious and wholesome diet to the service users, with a balanced and varied selection of foods. Service The Paddocks DS0000014943.V342551.R01.S.doc Version 5.2 Page 14 users spoken to said they enjoyed the meals at the home. The home had planned to introduce a nutritional assessment and body mass index tool as part of the care planning process, which would then be used to help prepare the diet plan of service users. Currently, the diet plan was based on the choices of the service users’. Evidence suggested that service users were able to maintain regular contact with their relatives and friends without restrictions and were supported to maintain contact if they wished, by the home. There was evidence that service users were encouraged to bring personal possessions with them into the home. Of the 5 service users’ who responded to the commission’s survey, of which 3 service users’ have said to the survey, that they usually like the meals at the home, 2 said always like the meal the home provides. What the service users’ and their family members have said in response to the service users’ survey carried out by the commission, in their own words is as follows: Service user – 1 said that ‘dad is always asked by the staff and encouraged by his family, but he doesn’t want to take part’ Service user – 2 said that ‘ evidence of a programme of activities but we have not seen any of these taking place’. The Paddocks DS0000014943.V342551.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had satisfactory complaints and adult protection procedures in place, which ensured that complaints were listened to and service users were safeguarded from abuse. EVIDENCE: The home had a satisfactory complaints policy and procedure in place, which enabled them to deal with complaints received. A record was kept of all complaints; the home had received 1 complaint since the last inspection. The complaint record seen on this inspection provided evidence that the home had taken appropriate action as per the action agreed at the strategy meeting of 11/01/07. The home had safeguarding vulnerable adults policy in place, which included whistle blowing and staff spoken to demonstrate they were aware of the procedure. Evidence examined, supported a process that had been followed to safeguard and protect service users. Of the 5 service users who responded to the commission’s survey, of which 3 service users’ have said that they always speak to if they were not happy with any of the service at the home, and 4 were aware, how to make a complaint. The Paddocks DS0000014943.V342551.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, 22, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was maintained clean and tidy without any offensive odours. EVIDENCE: As reported in the previous inspection report that, ‘call systems were provided in every room, however the system was not accessible to all service users, as there was only a limited supply of extension cords available for the system, for those service users who may require an extension cord to enable the system to be accessible for them. The manager said they had tried to obtain more but that they were no longer in production and therefore not available to purchase. This was recognised by the manager who was seeking alternative solutions to resolve this matter’. The home had now procured calling bells, which can be manually operated by the service users’ when in need. The home had reported in their annual quality assurance assessment, that the fire safety appliances are checked on a regular weekly / monthly basis. Safe The Paddocks DS0000014943.V342551.R01.S.doc Version 5.2 Page 17 systems were in place to ensure the homes heating and lighting was adequately maintained, which was evidenced by contractual arrangements. Water temperature checks were examined and evidenced that they had been recorded from all outlets and complied with the recommended safe temperatures. The home appeared clean and free from offensive odours. Training records identified some staff that had undertaken infection control training. Lift was operating ok; the home had replaced the ground floor and first floor shower and bathroom flooring. In response to the draft inspection report, the provider has sent in a copy of the emergency contingency plan dated 01/10/07 in relation to electrical power failure, water leakage, gas leakage, lift failure, loss of heating, accidents in the home, evacuation, temporary accommodation, home security, missing resident, action to be taken in the event discovery of a suspicious item, and nurse call system, which has detailed the actions the home intend to take, when such a situation arise. Of the 5 service users’ those who have responded to the service users’ survey 3 have said that the home is always fresh and clean, 2 service users said usually. The Paddocks DS0000014943.V342551.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staff recruitment were satisfactory and the home should continue to encourage staff acquire necessary knowledge and skills to provide the quality care to the service users’. EVIDENCE: The training provided to the staff was varied and relevant, which enabled them to be competent to do their jobs. Staff members spoken to report various training which they attended, including some recently. Some of the trainings staff received included; moving and handling, safeguarding adults, fire safety, first aid, health and safety, medication, challenging behaviour, dementia, infection control, death and bereavement, COSHH and 3 staff members are working for NVQ level 2. The home operated on a 3-shift model, the morning, and the evening shift had 2 staff members on duty and the night shift had 1 staff on duty. The manger stayed on the premises and was always available during day and night time as and when required. The home needed to review the staffing level especially, for the night shift, to determine the numbers are appropriate to meet the needs of 10 service users with dementia. The homes recruitment procedures were generally satisfactory. On this inspection 2 staffs records were seen; staff member – 1 had an application, The Paddocks DS0000014943.V342551.R01.S.doc Version 5.2 Page 19 interview questions, CRB, references and had received induction. Staff member- 2 application, interview questions, references, CRB had recorded common assault, the manager said that an explanation was received from the staff member and advised staff member to meet with citizen advice bureau to clear the situation. Of the 5 service users’ those who have responded to the commissions’ survey all the 5 have said that the staff listen and act to what the service users’ say and 3 service user said that the staff are usually available and 2 service users said that the staff are always available when they need them. What the service users’ and their family members have said in response to the service users’ survey carried out by the commission, in their own words is as follows: Service user –1 said that ‘I am happy here, the people are nice’ Service user – 2 when asked, do the staff listen and act when you need them, the service user said that ‘depending on the member of staff spoken to as to the action they take’. Service user –3 said that ‘care staffs are nice girls’. The Paddocks DS0000014943.V342551.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, and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager, staff and the service users had good working relations, which enabled the service users receive quality care. EVIDENCE: It was observed during the inspection that the manager, staff, and the service users have good working relations. The internal audit system and mechanism was seen on this inspection which, covered a wide range of business process, health and safety records and quality care delivery packages which ensured that the home was providing quality care in the best interest of the service users’. On this inspection, minutes of the resident meeting of 16/02/07 and resident and family meeting of 24/03/07 was seen and found that the home had discussed about activities, menus, and redecoration of the conservatory. The home had made attempts to introduce new activities and replaced the ground floor and first floor shower and bathroom flooring. The redecoration of The Paddocks DS0000014943.V342551.R01.S.doc Version 5.2 Page 21 the conservatory was being planned. Staff spoken to say they were receiving regular supervision. This was supported by recorded evidence on staff files. The home had prepared a manual that detailed the procedures on how to ensure privacy and dignity of the service users’. Health care records were appropriately stored and did not compromise with the respect, privacy, and confidentiality of the service users’. The health care needs of the service users were generally met by the home satisfactorily. No service users were selfmedicating at the time of this inspection. Samples of medication records, storage, and procedures were checked, of those service users whose lives were being tracked as part of this inspection. All staff administering medication had received training. There was no service user needing control drug, as on this inspection. Evidence available supported the fact that service users were enabled by the home to access a variety of health care services, to meet their assessed needs. In response to the draft inspection report, the provider has sent in a copy of the home’s fire policy, audit report of the fire safety arrangements dated 30/05/07 carried out by the Bedfordshire & Luton fire & rescue service that included specification of work required, and an action plan prepared by the provider; which the commission had received on the 01/10/07. It was noted from the action plan that some of the specification of work has been implemented and some work was outstanding. It is the expectation of the commission that the provider complete all the specification of work as required and to the satisfaction of the Bedfordshire & Luton fire & rescue officers. Service users spoken to on this inspection commented ‘we get looked after’ ‘we are not alone’ and ‘care staffs are nice girls’. What the service users’ and their family members have said in response to the service users’ survey carried out by the commission, in their own words is as follows: Service user –1 said that ‘I am happy here, the people are nice’ Service user – 2 said that ‘ improvements could be made in certain areas ie mums chair and table where she sits are nearly always stick and in need of a wash down’. Service user – 3 said that ‘ the home needs improvement on a small scale as for as decorating. The outside looks shabby and not very inviting’ The Paddocks DS0000014943.V342551.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 3 X 2 X X 3 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 2 The Paddocks DS0000014943.V342551.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 OP3 Regulation 14 Requirement The home must complete the needs assessment and update as appropriate for all the service users. The service user plan must detail the action and objectives that need to be taken by care staff to ensure that all aspects of the health, social and personal care needs of all the service users are met. (Previous time scale 30/04/07) When medication is not administered to people who use the service, reasons must be clearly recorded why a medication has not been given. (Previous time scale 31/01/07) The home must ensure that all the service users’ health care needs are appropriately met and reasons for medication not given recorded. Timescale for action 15/09/07 2. OP7 15 (1) 15/09/07 3. OP9 12(1)(a)1 3(2) 31/08/07 4. OP38 12 (1) 31/08/07 The Paddocks DS0000014943.V342551.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. 1. 2. 3. Refer to Standard OP22 OP27 OP38 Good Practice Recommendations The registered person should arrange for the premises to be assessed by a qualified occupational therapist. The home should review staffing levels, especially the night shift and have adequate staff to meet the changing needs of the service users with dementia. It is the expectation of the commission that the provider complete all the specification of work as required and to the satisfaction of the Bedfordshire & Luton fire & rescue officers. The home should further enable service users make choice of activities to suit their expectations, preferences, and capacities. 4. OP12 The Paddocks DS0000014943.V342551.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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 Paddocks DS0000014943.V342551.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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