Inspection on 19/09/06 for Townsend House

This inspection was carried out on 19th September 2006.

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

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

Other inspections for this house

Townsend House 15/10/07

Townsend House 20/01/06

Townsend House 30/08/05

Townsend House 28/09/04

Townsend House 25/05/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Townsend House Bayswater Road Headington Oxfordshire OX3 9NX Lead Inspector Lilian Mackay Unannounced Inspection 19th and 26th September 2006 10:05 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 Townsend House DS0000013161.V312612.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. Townsend House DS0000013161.V312612.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Townsend House Address Bayswater Road Headington Oxfordshire OX3 9NX 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) 01865 762232 01865 744681 manager.townsendhouse@osjctoxon.co.uk The Orders Of St John Care Trust Vacant Care Home 45 Category(ies) of Past or present alcohol dependence over 65 registration, with number years of age (3), Dementia - over 65 years of of places age (17), Learning disability over 65 years of age (3), Old age, not falling within any other category (45), Physical disability over 65 years of age (20) Townsend House DS0000013161.V312612.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 45. 20th January 2006 Date of last inspection Brief Description of the Service: Townsend House is situated in Headington on the outskirts of the city of Oxford. It is a care home for 45 older people managed by The Orders of St John Care Trust, a charitable organisation with a wealth of experience of providing residential care. The two-storey building has a lift and each room is linked to a call system to summon staff assistance when required. The care home provides 45 single bedrooms with several lounge areas, one of which is designated for smoking. There is a communal dining room, an attractive conservatory room and pleasant accessible grounds with seating. The fees for this service range from £484 to £650 per week. Items not covered by the fees include hairdressing, podiatry, newspapers, magazines, toiletries and Bingo. Townsend House DS0000013161.V312612.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced “Key Inspection”. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that the CSCI has received about the service since the last inspection. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The purpose of this inspection was to see how the agency is meeting the National Minimum Standards for Care Homes for Older People. This unannounced “Key Inspection” took place from 10.05 to 17.00 and 13.00 to 16.00 on two weekdays and consisted of talking to residents of the home to discuss their experience of the service provided, inspecting records including those of clients’ and staff and other documentation and talking to staff. Management contributed to this inspection by sending the CSCI full and timely pre – inspection information. Feedback was also obtained from questionnaires undertaken with residents and staff. The organisation is reconsidering the registration of this home for learning disability [LD] and alcohol [A] as no specific training to meet the needs of residents in these categories is currently provided. When changes to the Certificate of Registration are made an amended Statement of Purpose will need to be submitted to the CSCI. Questionnaires were completed with three staff. Their feedback was generally very positive. 100 confirmed recruitment procedures and induction procedures to be adequate and appropriate, 100 confirmed that they are familiar with the home’s policies, procedures and guidelines, 100 confirmed that they are fully briefed before starting work with new residents, 100 confirmed that they always work within their areas of expertise, 100 confirmed that they are familiar with adult protection procedures, 33 confirmed that they have enough time allocated to meet clients’ needs as indicated on their care plans, 100 confirmed that they meet with their manager regularly, 100 confirmed that they receive regular supervision and have regular team meetings. Feedback was obtained from eight relatives with knowledge of the home and this was generally very positive. Seven felt that staff welcome them in the home at any time, six felt there were always sufficient staff on duty, all eight confirmed that they were able to see their relatives in private, seven felt that Townsend House DS0000013161.V312612.R01.S.doc Version 5.2 Page 6 they were kept informed of important matters affecting their relative, five were aware of the home’s complaints procedure, seven had never had to make a complaint, five felt they had access to a copy of the CSCI inspection report on the home and all eight were satisfied with the overall service provided. Relatives’ commented, “X and her team do an excellent job. They are always available when I need to talk to them.” “The home is very welcoming.” Feedback was obtained from nine residents. Seven recalled receiving contracts, six felt they had received enough information about the home before moving in, seven felt they always received the care and support they need and two felt they usually did, all nine felt that staff listen and act on what they say, three felt that staff are always available when they need them and six felt they usually are, eight felt they always receive the medical support they needed and one felt s/he usually did, three felt that the home always arranged activities they can take part in and three felt the home usually did, five always liked the meals provided by the home and four usually did, seven knew who to speak to if they were not happy, seven knew how to make a complaint and eight felt the home was always kept fresh and clean by the staff. Clients’ comments included – “I am very happy here and would hate to be moved”. “I am glad I came here”. “They are all a good lot”. “I was in hospital and I did not like it. Then I came here and it was much better. I am generally pleased with everything”. “I’ve been so happy here. With living locally I know so many people”. The inspector would like to thank the Townsend House staff, relatives and residents for their courtesy, assistance and hospitality throughout this inspection. What the service does well: What has improved since the last inspection? What they could do better: Townsend House DS0000013161.V312612.R01.S.doc Version 5.2 Page 7 Care planning needs more consistency. All medication administered must be recorded, including creams and the storage arrangements for medications must be improved. The standard of nutritional screening done on admission needs improving. Complainants must be notified of the outcome of their complaint within 28 days. All first floor windows must be restricted for residents’ safety. The home must be kept fresh smelling. 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. Townsend House DS0000013161.V312612.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 Townsend House DS0000013161.V312612.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Individual care needs assessments are carried out before admission to ensure that the home can meet the individual’s needs. Prospective service users are invited to visit the home before making a decision. The home does not provide intermediate care. Respite care is provided. EVIDENCE: A qualified person undertakes individual care needs assessments using a dependency assessment tool. New care needs assessments are to be introduced in January 2006. An examination of a sample of residents’ care records indicated that care needs assessments had been carried out for all of them. Prospective residents are encouraged to visit the home in order to meet with the staff, fellow residents and view the facilities and services offered at Townsend House DS0000013161.V312612.R01.S.doc Version 5.2 Page 10 Townsend House, in order that they can make an informed choice as to whether the home is suitable for them. Clients’ comments about the arrangements for moving in included – “I didn’t want to come. I cried a lot. My daughter decided I was to come.” “My son visited six homes before he decided that this was the best for me”. “I used to come for day care and respite a week at a time.” “My friend looked for me”. “I had to find a place fast because I was in hospital”. “My daughter in law chose it because it was closest to my friends”. “My son and I came and had lunch”. Townsend House DS0000013161.V312612.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Whilst all residents have a plan of care drawn up from an assessment of needs these need to be more holistic. Residents’ nutritional needs should be more fully assessed. Residents’ health needs are well met with evidence of multi – disciplinary working taking place regularly. The medication administration procedures are generally good but the storage arrangements need improving. Residents are treated with respect and their right to privacy upheld. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. EVIDENCE: Examination of a sample of care plans indicated that whilst one resident’s care plan recorded her personal hygiene and emotional needs there was no indication of her social or spiritual needs. Residents sign to agree care plans and these are reviewed monthly. Townsend House DS0000013161.V312612.R01.S.doc Version 5.2 Page 12 An area for further improvement could be for the activity organiser to be encouraged to make entries in residents’ daily records and to input into residents’ care plans such as drawing up social histories for those residents with a dementia to assist in identifying their social care needs. Not all daily entries seen evidenced that care plans are implemented. For example, whilst one care plan identified the need for a resident to be checked two hourly the daily entries did not evidence that these checks were being undertaken. A risk assessment was not seen for one resident who had recently fallen. Also no risk assessment was seen for this resident going swimming. The risk assessments, which were seen, were being reviewed regularly. One relative commented, “My mother is hard of hearing and she does not always get told medical information in a way she can hear and understand. The nutritional screening currently being done on admission is too basic. Management acknowledge this and reported that a more sophisticated version, the MUST tool is to be introduced in October 2006. The handling, administration and recording of medications were found to be of a generally high standard. However, the storage arrangements are unsuitable as they are too small for staff to work in safely and comfortably. Management have identified this as an issue and reported that the medications would be relocated within a month of this inspection. A number of improvements are required to the medication administration procedures – food supplements should be recorded on medication profiles, self medication by residents should be recorded, no gaps should be left on medication administration records and the application of creams should be recorded. A number of examples of good practice were noted such as recording the medical room temperature, recording sample signatures of those staff designated to administer medication, having clear photos on the medication file for identifying residents, recording the special needs of individuals with regard to their medication, residents signing consent to medication forms when staff administer their medication and good recording of refused medications. Residents’ bedrooms are locked whilst they are away from the home to maintain their privacy. The inspector observed no personal and intimate belongings left out as was the case at the last inspection and felt that staff were respecting residents’ dignity better. Residents spoken to confirmed that their privacy and dignity is respected. Staff comments about the health and personal care arrangements included – “All residents are well looked after and their care plans followed. When residents have any ailments the GP is called and relatives informed”. Townsend House DS0000013161.V312612.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The daily life and social activities provided match the residents’ preferences and interests. Residents are encouraged to have visitors. Residents feel that they have the opportunity to make choices and to exercise control in their daily lives. Residents enjoy the food provided and are consulted regularly about the quality of it. EVIDENCE: The home provides a daily programme of activities in the home to suit the varying needs of the residents including seated exercises, Bingo, baking, singalongs, games, art and crafts, news discussions, films, quizzes and shopping trips on a one to one basis. The activity coordinator is trained in providing music and movement and seated exercises. Residents and the activities co-ordinator are soon to have the opportunity of attending a series of workshops with professional artists. The activities co-ordinator works with the residents both in group activities and on a one to one basis. A log is kept of participation and residents’ hobbies and interests, to ensure that the activities offered match their preferences and expectations. Townsend House DS0000013161.V312612.R01.S.doc Version 5.2 Page 14 Outside the home residents go swimming, have barbecues, go on trips out and attend a local church. The monthly newsletter informs the residents, their relatives and the staff of significant activities and events that have taken place. The home has a guest room and residents are encouraged to invite friends and family for meals at the home. Visitors to the home looked relaxed and at ease. Clients’ comments about the arrangements for activities included - “I cannot stand so I do not take part. I am better sitting or laying down.” “I love whist drives but they do not do them here.” “I would like to go out more but my family are too busy”. “I like to join in with anything that is going. I like going to church”. “I am very content in my room. I am happy by myself.” “We have lots of trips out which I enjoy.” “I enjoy the library and card games. I do my own knitting”. “I go swimming weekly to Barton swimming pool.” “I have gone shopping. A carer always comes with us.” “I would like more people to come into the home from the community. It’s a very nice home and I would not like to be anywhere else. It suits me very, very well. I would like more visitors just coming in and chatting.” “I like it. I’m left alone. I like my books and peace.” “I enjoy the knitting club and playing Bingo. I enjoy the outings”. Staff comments about the arrangements for activities included - “I end up having to take the residents to the activities which is time consuming”. “We enjoy entertaining residents, making them smile and laugh”. The residents spoken to felt they had a lot of control over their day-to-day lives. Meals are monitored monthly to gain residents’ views and comments and to ascertain their preferences and dislikes. It is recommended that staff date the fruit juices on the fridge on the wings when opened to help identify the date for discarding. Residents commented on the good quality of the food and the variety of choices available from the sweet trolley. Clients’ comments about the meal arrangements included – “If I don’t like something I tell them and they give me something else.” “I can’t speak too highly of the meals and the cooking of them”. “There are some things I do not like. I was a cook so I can be quite critical. The cakes are good.” “The food is very good.” ”I like it all”. “If there is anything I do not like they will change it.” “I have invited my son and his wife for a meal”. “Wonderful food. I’m a country girl at heart so I enjoy all country things. The chef is good. She knows what old people like and give us it.” Townsend House DS0000013161.V312612.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 inspected at least once during a 12 month period. 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. Residents are aware of the complaints procedure, and confident that any concerns or complaint would be taken seriously and acted upon appropriately. Staff are adequately trained to safeguard residents. EVIDENCE: The home has received three complaints since the last inspection and two of these were responded to within 28 days as required. Complaints are monitored monthly by the organisation and the complaints procedure is prominently displayed on notice boards in the home. No complainant has contacted the CSCI with information concerning a complaint made to the service since the last inspection. Clients’ comments about the arrangements for complaints included – “I would speak to the manager – she listens to me. I would go to the office”. “I would go to the manager but I don’t have any complaints”. “My key worker is very good. The office staff are very good. I would go to the office”. “ I have never had to complain about anything”. “I do not have any need to complain”. All staff sampled had received recent training on safeguarding vulnerable adults from abuse. Townsend House DS0000013161.V312612.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. Quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home provides comfortable surroundings and is equipped to meet the residents’ differing needs. The storage arrangements for hoists and wheelchairs have been improved to protect residents’ safety. EVIDENCE: The inspector walked around the home and saw that it was being well maintained and that the fire precautions were being observed. One window on the first floor required restricting for residents’ safety. Whilst the inspector saw one wheelchair stored in a shower room. Management have identified that storage is an issue and reported that these are going to be stored in a designated cupboard. Residents gave very positive feedback about the home’s laundry arrangements. Townsend House DS0000013161.V312612.R01.S.doc Version 5.2 Page 17 Whilst the inspector saw numerous examples of high standards of cleanliness and housekeeping on the first day of this inspection there were faint odours of urine at the front door and in the Beechwood wing. When the inspector returned a week later to provide feedback there was an odour of urine in several areas. This was attributed to the home’s cat. Management acknowledged that this is a housekeeping issue that requires to be addressed. Relatives commenting on the home said, “Sometimes they take a long time to make my bed but otherwise I am quite happy.” ” Spotless”. “My mother is very happy in the home with a lovely room.” Townsend House DS0000013161.V312612.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 at least once during a 12 month period. 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 home’s staffing levels appeared adequate to meet residents’ care needs. The home’s robust recruitment procedures ensure that residents are protected from the employment of unsuitable staff. Staff receive the training necessary to ensure competency in meeting the residents’ needs. EVIDENCE: There has been a significant turnover of staff recently with seven staff leaving. This has resulted in an increase in the use of agency staff. Whilst there are times when there are only four care assistants and a care leader on duty in addition to support staff no evidence was found at this time that this level of staffing was other than adequate. [See also staff comments]. Night staffing consists of one care leader asleep “on call” in the home and two care assistants awake on duty. In discussion with staff and an examination of staff records the inspector concluded that staff receive adequate and appropriate training. Good records are kept of staff training and of their qualifications. An examination of staff files indicated that staff recruitment procedures are thorough, and that all the required checks are carried out before employment, thereby safeguarding residents. Townsend House DS0000013161.V312612.R01.S.doc Version 5.2 Page 19 All members of staff undergo induction training, upon appointment to their posts, and are offered ongoing training, which equips them to meet the assessed needs of the residents. Staff members are encouraged to undertake the National Vocational Qualification (NVQ) in care. The inspector was informed that 12 members of staff are participating in training for the NVQ level 2 in care, with a further four participating on the NVQ level 3. Whilst the home has not met the 50 of care staff to be trained in NVQ level 2 by 2005 management have a strategy for achieving this. All care leaders either have to have an NVQ level 3 or have to agree to undertake such training. Clients’ comments about the staffing arrangements included –“Sometimes they are too busy”. “They do their best”. “I am very happy here everyone is so nice and kind and helpful.” “They work very hard.” “The staff are quite good, even the cleaners.” “The cleaners are really good.” “Some staff listen but some do not”. “Everybody is very helpful and very kind here.” Staff comments about the staffing arrangements included - “There is not enough time to do what is expected of us. I get behind with my paperwork and do it in my own time”. “I would employ more staff for the laundry. I would have six staff on the floor on each shift, particularly in the mornings. Two allocated staff on each floor and two “floaters”.” “There are some very good carers in this home who go beyond the call of duty. There is a very good team of domestics and some of them are very caring”. “Yesterday and the day before there was only one Townsend House carer and three agency staff on duty. Sometimes the agency staff have never been to the home before. There are usually four care assistants on duty from 5pm to 9pm. Sometimes we are short staffed in the mornings. They should employ staff more promptly”. Townsend House DS0000013161.V312612.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. A highly experienced and well-qualified manager manages the home. Residents are consulted regularly about the running of the home. Clear and robust systems are in place to protect the residents’ financial interests. Residents’ health and safety is promoted and protected. EVIDENCE: The manager has an NVQ level 4 and the Registered Manager Award. She is not currently registered as the manager of this home and needs to be so. An application for registration will be expected within three months of her appointment to the home. There are regular senior staff meetings. Townsend House DS0000013161.V312612.R01.S.doc Version 5.2 Page 21 The staff handover the inspector attended suffered from interruptions such as the telephone, residents, agency staff and the home’s own staff. One member of staff commented, “We should restart upstairs and downstairs meetings to discuss issues”. Regular residents and relatives meetings are held and action is taken as a result of these. The home has the ISO standard. This was audited in August 2006. The home is also Investors in People. The annual quality questionnaire conducted with residents and relatives in 2005 identified the following areas of high satisfaction - the gardens, cold food served cold, portion sizes, the friendliness of staff, the reception given to visitors by staff, the refreshments offered to visitors and the private meeting room. Another quality questionnaire was conducted in 2006 prior to this inspection but the results had not yet been collated. Once the results of these are collated a copy must be sent to the CSCI. The organisation carries out its own unannounced nighttimes inspections of the home. The home’s administrator looks after residents’ finances carefully. An inspection of records, a walk around the home and discussion with residents and staff confirmed that the health and safety of residents were being protected. Regular checks were seen to be undertaken of the home’s equipment and facilities. One resident commented, “I think it is a very well run home. We are well cared for and it is lovely”. Townsend House DS0000013161.V312612.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Townsend House DS0000013161.V312612.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13(4)c Requirement Document potential risks to all residents within a risk assessment identifying the means to eliminate unnecessary risks. Previous timescale 28/02/06 Improve the storage arrangements for medications. Ensure all medication administered is recorded. Notify complainants of the outcome of their complaint within 28 days. Restrict all first floor windows for residents’ safety. Maintain the home fresh smelling in all areas. Timescale for action 30/11/06 2 3 4 5 6 OP9 OP9 OP16 OP19 OP26 13[2] 13[2] 22 13[4] 16[k] 30/11/06 31/10/06 31/10/06 31/10/06 31/10/06 Townsend House DS0000013161.V312612.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 Refer to Standard OP8 OP37 Good Practice Recommendations Improve the standard of nutritional screening done on admission. Date personal inventories and have these witnessed and signed. Townsend House DS0000013161.V312612.R01.S.doc Version 5.2 Page 25 - Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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