Inspection on 02/04/08 for The Worthies

This inspection was carried out on 2nd April 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 Worthies 01/04/09

The Worthies 03/05/07

The Worthies 27/06/06

The Worthies 25/11/05

The Worthies 04/05/05

The Worthies 11/01/05

The Worthies 28/06/04

The Worthies 11/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Worthies 79 Park Road Stapleton Bristol BS16 1DT Lead Inspector Sandra Jones Unannounced Inspection 09:30 2 & 4th April 2008 nd 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 Worthies DS0000026524.V360822.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 Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Worthies Address 79 Park Road Stapleton Bristol BS16 1DT 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) 0117 9390088 0117 9655881 shenbutt@hotmail.com The Worthies Residential Care Home Ltd Ms Sehnaz Bi Butt Care Home 24 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (19) of places The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 24 persons aged 65 years or over Date of last inspection 3rd May 2007 Brief Description of the Service: The Worthies is a care home registered with the Commission for Social Care inspection to accommodate 19 people in the older persons category and 5 older people with dementia. The home is located in Stapleton village situated on a bus route, within quarter of a mile to shops, libraries and health centres. The accommodation is arranged over three floors, with shared space on the ground floor and bedrooms on all floors, accessible to all floors by a passenger lift. There is a courtyard at the rear of the house. However, this area is not enclosed With two exceptions, bedrooms are single. The double bedrooms are en-suite offering privacy with personal care. The fees range from £348.00 - £415.00 per week and extra charges are made for chiropody, hairdressing, etc. Currently this information is initially only provided verbally prior on admission. The Worthies DS0000026524.V360822.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 one star. This means the people who use this service experience adequate quality outcomes. This key inspection was conducted unannounced over two days in April 2008. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedure. During the site visit, the records were examined and feedback sought from individuals, their relatives and staff. Prior to the visit some time was spent examining documentation accumulated since the previous inspection, including the Annual Quality Assurance Assessment (AQAA). This information was used to plan the inspection visit. Six people were case tracked. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the deputy manager, staff and people using the service were gathered through face- to- face discussions. What the service does well: People that use the service said that the staff were able to meet their needs, the food was good and who to approach with complaints. Relatives said that there is open visiting, the staff make them welcome when they visit. Also the level of care observed is the same whenever visits take place and they feel confident to approach the service provider with complaints. Members of staff giving feedback said that there is good communication and information is passed on between shifts. This ensures that there is enough information to care for the people at the home. The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There are eleven requirements and one recommendation arising from this inspection. Four of these requirements are repeated from the previous key inspection. The service provider has failed to meet previous requirements and must ensure that requirements are met, as enforcement action may be taken for unmet requirements. Unmet requirements from previous inspection are based on updating information including care pans, improving systems and recruitment of staff. In terms of information the Statement of Purpose must be reviewed and must be clear about the age range and the need of the people accommodated at the home. The home is accommodating people with dementia and people wishing to live at the home must be able to make decisions about living at the home. People at the home must be consulted about the activities to be provided at the home this will ensure that people at the home can lead active and interesting lives. As access to the cash and valuables was not available, the requirement to maintain clear accurate records and receipts of possessions handed over for safekeeping could not be checked and therefore repeated. Individuals at the home must have access to their cash and valuables at all times. Regarding staffing, the service provider must obtain a Criminal Records Bureau (CRB) check for all staff at the home. This will ensure that the recruitment process is robust and staff employed are suitable to work with vulnerable adults. Members of staff must be qualified and competent to meet the needs of the people accommodated, this includes people with mental health care needs and dementia. The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 7 Requirements arising from this inspection are based on care planning, risk assessments and policies and procedures. The care planning must be further developed to fully achieve a person centred approach to meeting needs. In order to provide a consistent and individulised service, care action plans must integrate the persons likes, dislikes and preferred routines. In terms of meeting individuals changing needs, care plans must be kept under review. Medication profiles must be developed for each person to ensure safehandling of medicines at the home. Profiles must contain the purpose of the prescribed medications, side effects and compatibility with homely remedies. Where “when required” medications is prescribed medication profiles must include protocols for administering the medication. Policies and procedures that safeguard individuals from abuse must be reviewed to ensure that staff are aware of the steps to be followed for reporting poor practice. Fire risk assessments must be reviewed to ensure that appropriate steps are taken to prevent an outbreak of fire. 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 Worthies DS0000026524.V360822.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 Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (3) & (6) Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. The Statement of Purpose must inform people wishing to live at the home about the accommodation that is provided to people with dementia. The home ensures that the needs of the people wishing to live at the home are assessed. The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 10 EVIDENCE: The Annual Quality Assurrance Assessments completed by the service provider states that the the Statement of Purpose and the Service User Guide was reviewed to enable service users to settle in more quickly and feel more homely. The Statement of Purpose in place is dated March 2006 and must be reviewed to meet legislation to review the document annually. The Statement of Purpose must be reviewed to add information about the age range, the admission criteria must be appended and information about the needs of the people that accommodation can be offered must be clearer. The home is accommodating people with dementia and the Statement of Purpose must be clear about the number of people with dementia that can be accommodated. The Service User Guide in place was recently reviewed, the format includes photos to ensure the people for whom its intended can understand it and copies are in each bedroom. Three people were admitted to the home since the last inspection and their case files were examined to establish that the home is able to meet the needs of these individuals. Care records show that care plans are developed and during the trial period individuals likes , dislikes and preferred routines are sought. Providing evidence that a person centred approach to meeting needs is used. However, care plans are not fully person centred. The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (7), (8), (9) & (10) Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. Care plans must be more persons centred for people at the home to benefit from individualised and consistent care. Medications systems must provide more guidance to staff for safer handling of medicines. The rights of the people at the home are respected. The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 12 EVIDENCE: The Annual Quality Assurance Assesment completed by the manager about improvements pection stated that since the last inspection new care plans have been introduced to provide a more person centered approach. All care plans have been put together with service users views as to what is important to them. The deputy manager described the process followed, it was explained that from the information received from the social worker, a decision is made about the home’s capacity to meet the person’s needs. Once it has been established that the assessed needs can be met at the home, initial assessments are conducted and where appropriate family are invited to visit the home. Care plans are then formulated by the keyworker with the person and relatives that are involved in the care of the person. Care plans are monitored monthly following from the trial period. The case files of six people accommodated at the home were case tracked during the inspection and needs assessments, care plans and risk assessments form the care planning process at the home. However, gaps were found in the care planning process. While individuals likes, dislikes and preferred routines are sought through the assessment, the information is not integrated into the care action plans. Individuals preferred routines, likes and dislikes must be used to provide a person centred approach to meeting needs. Daily reports examined show that care plans are not updated as individuals needs change. Through discussion with the deputy manager and comments received at the Commission it was established that eleven people with dementia are accommodated. Communication, safety and decision making are not currently part of the care plan. Care plans for people that have communication needs must include the way they communicate and how they make decisions. Information recorded within the daily reports indicates that staff hold cigaretts. While its acknowledged that the actions taken are appropriate, risk assessments are not in place. Risk assessments must be completed to ensure that the actions taken reflect the level of risk. Also one individual may at times exhibit aggressive and violent behaviours. Risk assessments that set a strategy for staff to follow to consistently manage aggressive and violent behaviours are not in place. Risk assessments that guide staff to divert and diffuse violent and aggressive situations must be devised. The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 13 Assessments on the individuals dependency levels are conducted in respect of mobility, continence, personal care and sleep patterns. This ensures that where necessary action is taken to reduce the levels of risks to the individuals health and independence. Moving and Handling risk assessments are in place for one person with mobility needs. Hoists and handling belts are provided to assist individuals with maintaining their independence with moving around the home. The accident book supports that individuals with a history of falls are not accommodated. A record of multidisciplinary visits from health and social care professionals is maintained. Members of staff giving feedback about consistency of care said that medical advise is folloewed because it is passed on during handovers and recorded in daily reports. Medications are administered by the staff from a monitored dosage system for individuals that have regular prescribed medicines. The records of administration were checked against the medications held to establish the home’s ability to manage medications safely. The records of adminstration supported the medications held in the system and there were no gaps in the recording. This shows that staff are competent to adminster medications. However, information about the individuals medications is not specific and records of homely remedies are not maintained. Individuals medication profiles that detail the purpose of the medication, compatability with homely remedies and protocols for administering when required medication must be introduced. A record of homely remedies administered with a running balance of the medications held must be maintained. The Privacy and Dignity policy is detailed in the Statement of Purpose and specifies the approach to be followed at the home. People consulted at the home said that the staff respected their rights. Knocking on doors and providing discreet personal care were examples used to describe the way dignity and privacy was observed at the home. The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (12), (13),(14) & (15) Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. Individuals must have more choice about routines and activities so they can lead more active and interesting lives. People are able to keep in touch with family, friends and representatives. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) completed by the manager about the improvements made in the last twelve months state that there is a regular driver to do regular trips. An enclosed sitting area in the back garden where residents can sit out safely was created. In terms of future improvements the AQAA states that there are plans to recruit an activity coordinator to organize more activities tailored to residents needs. The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 15 The deputy manager explained that since the last inspection more board games, arts and crafts and outside entertaiment has taken place. Senior staff said that they know which indiviudals like to participate in in-house activities. During the admission process, members of staff complete a personal profile that seeks the persons likes, dislikes, hobbies and interes. However, the activities organised are not consistent with the hobbies and interests specified. The records show that generally activities provided are more suitable for people with dementia. Residents meeting are organised monthly and at the recent meeting NHS facilities were discussed which included optician and audiology visits. Individuals at the home confirmed that activities take place and outside entertainers visit the home. Three people consulted stated that they preferred not to join in activities and it was their choice to read or watch the television. The arrangements for visiting is clearly stated within the Statement of Purpose and reinforce that visitors to the home are welcome. A relative visiting the home was consulted about the standards of care observed during their visits. The visitor said that the same standards of care are observed irrespective of the time and cofirmed that visitors are welcome at the home. It was further stated that their relatives bedroom can be used for additional privacy. The Statement of Purpose informs individuals about external advocates and provides the names of advocates that can be used. The deputy manager stated that advocates are not currently used. It was also stated that it is an expectation that individuals make their own financial arrangements. Also individuals can have their personal possessions in their bedrooms. Catering staff were consulted about the menus and meals provided at the home. It was stated that menus adapted to reflect the seasons and the menus are about to be amended with the changes in the season. Grocery shopping is generally done by the service provider and there is a good range of food at the home. Individuals consulted said that the food was good, there was a choice at each mealtime and alternatives were also provided. One person said that their cultural meals are provided 2-3 times per week. The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): (16) & (18) Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. The people at the home are confident that their views are taken seriously and acted upon. For individuals to be safeguarded from abuse staff must be aware of the procedures for reporting abuse and, policies and procedures must be up to date. EVIDENCE: The Annual Quality Assurance Assessment completed by the service provider about improvements made state that a new quality questionnaire which is more detailed and enables service users and families to comment in more details about the home and the service. The completed questionnaires examined confirms that residents/relatives views about concerns and complaints are sought. Complaints leaflets are in every room to ensure individuals know the procedure for making complaints. Individuals consulted said that they felt confident to approach the service provider with complaints. Complaints are seperated into serious and minor complaints A record of concerns made is maintained with the action taken to resolve the issues raised. The nature of the complaint, the investigation conducted and the outcome are recorded for concerns and complaints received at the home. The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 17 One annoymous concern was received at the Commission about the number of people that are accommodated with dementia and access to training for staff. Policies and procedures that show a commitment towards safeguarding adults were examined during the inspection. The policy on abuse must be reviewed to ensure that contact details are correct and to specify the procedure to alert alledged abuse. The Whistleblowing policy must be made available to staff at the home. Training records show that all staff have attended Safeguarding Adults training. An allegation of physical abuse was made and a Protection Planning Meeting was held to discuss the outcome of the investigations. It was not possible to substantiate allegations from the investigation. The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (19), (21), (24) & (26) Quality in this outcome area is (good). This judgement has been made using available evidence including a visit to this service. The home is well maintained so residents benefit from living in a comfortable and clean environment. The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 19 EVIDENCE: The Annual Quality Assurance Assessment completed by the service provider, about improvements undertaken, states that the patio garden at the back has been fenced off to promote safety of residents with dementia. We now have a full time gardener who has maintained the garden well, bright and light. The Worthies is located in Stapleton Village close to bus routes and fairly close to shops and library. The accommodation is arranged over three floors with bedrooms on all floors and shared space on the ground floor. Shared facilities comprise of three lounges are sited at the front of the property. Since the last inspection the carpet in the lounges was changed. In the dining room there is sufficient seating for the people living at the home to have their meals together. Bedrooms contain a combination of the home’s furniture and personal belongings and are furnished and equipped to meet the needs of the individual. Privacy is promoted through lockable doors with additional lockable space in bedrooms. Residents consulted were positive about their bedrooms. There are toilets on each floor and a bathroom on the second and third floor. Equipment and aids are provided to assist less mobile individuals with moving around the home. Individuals have access to bedrooms and shared space by the provision of a passenger lift to the first and second floor and level access into the building. The laundry room is sited away from the kitchen. The floor covering and walls are impermeable making surface readily cleanable. There is an industrial and small domestic washing machines with specific programmes for sluicing and two tumble dryers. The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (27), (28), (29) & (30). Quality in this outcome area is (poor). This judgement has been made using available evidence including a visit to this service. The recruitment process must ensure that the staff appointed are suitable to work with vulnerable adults. Training that meets the changing needs of the people living at the home must be provided. EVIDENCE: The service provider described the arrangements for improvements within the Annual Quality Auurance Assessment (AQAA). It states that staff will attend two days mental health awareness on the 14th and 15th of Feb 08. We have made contact with the In-Reach team to support staff with training. The Manager and deputy manager are attending the Mental Capacity Act course on the 18th December 07 through Avon and Wiltshire NHS Trust. The rota in place shows that three staff are on duty from 7:45 am- 9:00 pm and two staff awake at night. Ancillary staff for cooking and cleaning are also employed to cook meals and to keep the home clean. It was noted that one member of staff is rostered to work over 66 hours per week. The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 21 Working time directives and risk assessment must be completed for this individual, to establish that this person can make decisions whenever they are on duty for long periods. The home has a ratio of 1:8, a senior member of staff is on duty on every shift and staff are over 18 years. The deputy manager confirmed that over 50 of the staff employed have NVQ level 2 and three staff are registered onto NVQ level 3. The training records show that the service provider is taking steps to provide specific training for staff to meet the changing needs of the people at the home. A two day course on Mental Health Awareness training was provided in February 2008. However, four staff atteneded. As the home provides care to people with dementia, members of staff must attend relevant training to meet the specific needs of the people at the home. An annoymous phone call raising concerns about staff training at the home was received at the Commission. It was stated that staff are expected to attend training but are not paid for it and if they do not attend a fine is taken directly from their pay. National Minimum Standards recommend that all staff should receive three days paid training per year. One relative and three individuals at the home were consulted about the skills of the staff. Comments made were positive and one individuals said “The staff are good and they are used to my ways.” The staff’s personnel files were examined during the inspection. Application forms, written references, terms and conditions and and Criminal Records Bureau (CRB) checks obtained are held in the files. The service provider must ensure that the recruitment process is robust and only appoint staff that are suitable to work with vulnerable aduts. Evidence was found from the references examined that the home is not establishing the authenticity of the references received and requested. Also the sevice provided accepted a CRB from another service and not obtained a CRB for this person to work at the home. CRB’s for working at the home must be obtained for staff working at the home. The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (31), (33), (35) & (38). Quality in this outcome area is (adequate). This judgement has been made using available evidence including a visit to this service. Individuals can expect to live in a safe environment and can be re-assured that standards will be the subject of ongoing monitoring. The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Annual Qulaity Assurance Assessment completed by the service provider state that future improvments will include monitoring staff. The service provider acts as manager in day to day control of the home. A manager was appointted in December 2007 and the deputy manager said that through mutual agreement the manager has left. The service provider was not present during the inspection and staff’s feedback on the systems that ensure consistency was sought. Members of staff said that staff meetings, supervision and hanovers ensure standards of care are consitent. Staff meetings occur monthly to discuss issues and there are opportunities to make suggestions which are taken seriously by the service provider. Members of staff said that the previous unregistered manager introduced supervision and each person has attended one supervision session. Handovers take place on every shift to pass information about individuals. While the deputy manager said that facilities for the safekeeping of cash and valuable exist at the home, the cash was not accessible. Individuals at the home must have access to their cash and valuables at all times. The fire risk assessments completed by the service provider is dated April 2006. Risk assesments must be reviewed to ensure that appropriate measures are intorduced to reduce the risk of fire at the home. Service certificates for the lift, portable equipment, with heating and boiler documentation of checks conducted by contractors, indicate that people at the home and staff’s safety are promoted. The Worthies DS0000026524.V360822.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 x 2 x x x N/A 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 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 x x x 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 1 x 2 x x 2 The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 6 Requirement The Statement of Purpose must be reviewed to ensure that all gaps in information are included as outlined in Older Persons NMS 1. (Previously Required 03/05/07). 2 OP7 13 (4) (b) Risk assessments must be completed for a) individuals that at times exhibit aggressive and violent behaviours b) for restrictions imposed on cigarettes. Consult service users about their social interests and make arrangements to enable them to engage in local, social and community activities. (Previously Required 03/05/07). 4 OP29 Schedule 2.1 Regulation 19 The registered person shall not employ a person to work at the care home unless he has obtained in respect of the person DS0000026524.V360822.R01.S.doc Timescale for action 30/06/08 30/05/08 3 OP12 16(2)(m) 02/06/08 02/06/08 The Worthies Version 5.2 Page 26 the information and documents specified in paragraph 1-9 of Schedule 2 (Each member of staff must have a Criminal record bureau check completed through the home. This includes older staff members). (Previously Required 03/05/07). (The service provider must ensure that the authenticity of the reference can be validated). 5 OP30 18(1)(c) (I) Sch 2.5 All staff must have training in working with older persons with mental health needs and dementia (Previously Required 03/05/07). 6 OP35 Regulation Clear accurate records and 17 Sch receipts must be kept of 2.4 possessions handed over for safekeeping. (Previously Required 03/05/07). Care plans must be more person centred. Individuals likes and dislikes must be integrated into the care action plans. Care plans must be kept under review. Care plans must be adapted with individuals changing needs. Individual medication profiles must be devised which include a) the purpose of medications administered b) protocols for when required medications c) compatibility with homely remedies. a) Policies and procedures must DS0000026524.V360822.R01.S.doc 02/10/08 30/04/08 7 OP7 12 (3) 30/06/08 8 OP7 15 (2) (b) 30/06/08 9 OP9 13 (2) 30/06/08 10 OP18 13 (6) 30/05/08 Page 27 The Worthies Version 5.2 11 OP38 23 (4A) instruct staff on safeguarding adults from abuse. Fire risk assessments must be reviewed to ensure that appropriate steps are taken to prevent the outbreak of fire. 30/04/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP30 Good Practice Recommendations Members of staff should have three days paid training per year. The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Worthies DS0000026524.V360822.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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