Inspection on 07/09/07 for Upsall House

This inspection was carried out on 7th September 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 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

Upsall House 02/10/06

Upsall House 28/10/05

Upsall House 02/06/05

Upsall House 08/09/04

Upsall House 14/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Upsall House Guisborough Road Middlesbrough TS7 0LD Lead Inspector Brenda Grant Key Unannounced Inspection 7th September 2007 09:25 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 Upsall House DS0000000091.V347638.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. Upsall House DS0000000091.V347638.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Upsall House Address Guisborough Road Middlesbrough TS7 0LD 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) 01642 300429 Upsall House Residential Homes Limited Mrs Pamela Parry Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Upsall House DS0000000091.V347638.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd October 2006 Brief Description of the Service: Upsall House is a two storey converted private dwelling set in spacious and attractive grounds with extensive views across to the Cleveland Hills. The home is well appointed with two lounges and a dining room. Accommodation is provided in 30 single bedrooms, 24 of which have an en-suite facility. The home is registered to provide care for thirty older persons. Upsall House has a no smoking policy. On the date of this inspection the fees at Upsall House ranged from £355 to £430. All new residents pay a fee of £430. Upsall House DS0000000091.V347638.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection. We assessed the information from: the Pre-Inspection Questionnaire, surveys that had been completed by residents and relatives and we carried out a visit to the home. The visit took place over one day, six hours and fifty five minutes in total. Discussion took place with five residents, two relatives of residents, two staff, the cook and the deputy manager. We looked around the home and examined a number of records that included; residents and staff files, health and safety and maintenance checks and complaints, accident and kitchen records. The home called people who use the care service ‘residents’ therefore they are called residents in this report. The findings from the inspection were of the home providing a good care service with most of the National Minimum Standards being met. What the service does well: The home provided a pleasant, comfortable and homely environment for the residents. The relationship between staff and residents was seen to be very relaxed and it was obvious that staff enjoyed their work. Resident’s rights were respected and residents lived their lives as they wished. One resident said, “I am my own master”. Residents were protected by the homes complaint’s, safeguarding and recruitment procedures. Staff completed basic and additional training. It is commendable that 95 of care staff were qualified to at least National Vocational Qualification Level 2 in care and some staff had Level 3 of the qualification. The cook and two housekeepers also had National Vocational Qualifications at Level 2. Upsall House had appropriately trained staff to care for the residents who lived at the home. In surveys: Residents commented: “Staff listen to residents and act on what they say”. “I am very happy”. Relatives commented: Upsall House DS0000000091.V347638.R01.S.doc Version 5.2 Page 6 “Staff are very efficient”. “Staff always inform me of any changes in my mother/father’s condition and her/his health is well catered for”. “Staff are helpful and kind”. “As far as I am concerned the home does everything well”. “They try to ensure residents use the home as if it was their own”. “It is a comfortable well run home”. What has improved since the last inspection? What they could do better: The home must provide lighting, in resident’s bedrooms, that meets individual needs and is of domestic in character. The home had a Fire Risk Assessment but it could not be determined when it was written or whether it had been reviewed there for the document should be dated. Residents should be assessed whether they would be capable of looking after their own medicines, so that residents maintain their independence. The results of the quality assurance survey must be detailed in a report. That is so that people are informed of the results of the survey and what the home is doing to improve the service. Staff meetings were not held at Upsall House therefore staff did not have the opportunity to give their views on the conduct and management of the home. Upsall House DS0000000091.V347638.R01.S.doc Version 5.2 Page 7 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. Upsall House DS0000000091.V347638.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 Upsall House DS0000000091.V347638.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): Quality in this outcome area is good. This judgement has been made using a range of evidence including a visit to this service. Standards: 3 & 6 Resident’s needs were assessed before moving to the home and they were assured those needs would be met. EVIDENCE: Surveys, received by the Commission for Social Care Inspection, and residents who spoke with us confirmed residents had enough information about the home before they moved to Upsall House. Residents who were funded by the local authority had assessments, carried out by a care manager, which were shared with the home. For those and privately funded residents, the manager carried out a further assessment, so that Upsall House could determine whether the needs of the person would be met at the home. The home’s assessment included some personal details about the person’s abilities, usual routines and daily activities, diet and Upsall House DS0000000091.V347638.R01.S.doc Version 5.2 Page 10 religion. There were also extra details about the person’s health, social and personal needs. Three residents and two relatives said, they were involved with the assessment process and they had the opportunity to look around the home before the resident was admitted. The home did not offer intermediate care therefore standard six does not apply. Upsall House DS0000000091.V347638.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 7, 8, 9 & 10 Resident’s health, personal and social care needs were met and recorded in Care Plans. Residents were protected by the home’s policies and procedures for dealing with medicines. Residents were treated with respect and their right to privacy was upheld. EVIDENCE: A sample of resident’s Care Plans was examined. The home was in the process of introducing new Care Plans that gave full details of health, social and personal care needs. Risk Assessments were included with the Care Plans. Risk Assessments informed how risks would be managed; to reduce those risks to an acceptable level. The sample of Care Plans and Risk Assessments, that were examined, showed they had been regularly reviewed. Extra information, in resident’s files, included ‘my life story’, giving details about the person’s life. There was also a ‘dependency profile’ for each resident, which stated the Upsall House DS0000000091.V347638.R01.S.doc Version 5.2 Page 12 person’s care needs and how those needs would be met. The manager, on a monthly basis, reviewed the Care Plans. Residents and relatives we spoke with said, they were involved when Care Plans were developed and when the plans were reviewed. Resident’s files included healthcare visits and appointments. The records showed the regularity of visits for treatment from: doctors and District Nurses, opticians, chiropodists, dentists and other healthcare specialists. The home had equipment, to assist staff when they were moving residents. A relative who spoke with us said, “We are always informed about everything that concerns my mother/father” and a resident said, “The home always keep in touch with my family and tell them what is happening”. On a survey a relative commented, “Staff always ring me and keep me up to date”. The home took appropriate action for managing resident’s medicines. The storage and recording was found to be satisfactory. Resident’s files did not include assessment details, for whether a resident was capable to look after their own medicines. At the time of the inspection ‘site’ visit, the home did not have any residents who were in control of their medication. Staff details confirmed staff had completed ‘safe handling of medication’ training. Staff were observed being respectful to residents and knocking on bedroom doors before entering bedrooms. The relationship between staff and residents was very relaxed and residents, spoken with, confirmed they were treated with respect. In a survey a relative commented, My mother/father is very happy and content at Upsall House”. One resident said, “The staff are lovely” and another resident said, “I am safe living here and staff are very helpful”. All comments, from residents and relatives, were very complimentary about how staff looked after residents. Upsall House DS0000000091.V347638.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 12, 13, 14 & 15 Residents lived their lives as they wished and residents maintained contacts with families and friends. Residents had choice and control over what they do. The home provided an adequate balanced diet. EVIDENCE: Residents who spoke with us said, staff tried to make sure individual needs were met. The home offered different activities for residents. On the day of the inspection ‘site’ visit, residents were seen playing dominoes, doing a jigsaw and going for a walk. All resident’s activities were recorded. In a survey one resident commented, “I think staff seem to be too busy with their own jobs to bother about us. I think staff should converse with us more”. We asked residents and relatives if staff had time to talk with residents. All but one resident confirmed staff spent time talking with residents. The deputy manager informed us, each resident had a Key Worker and the deputy manager also made sure she spent time talking with individual residents, to make sure everything was satisfactory. Residents and relatives were not sure who Upsall House DS0000000091.V347638.R01.S.doc Version 5.2 Page 14 resident’s Key Workers were and Key Workers did not spend specific one to one time, with their nominated residents. The home provided for resident’s religious needs by arranging regular monthly religious services. There were also two residents who had their own church representative visiting them. The deputy manager said, “If it was not already provided for, the home would always make suitable arrangements to meet resident’s religious and cultural needs”. There were organised outings, musical entertainment, quizzes, walks out and trips to the theatre but one relative of a resident commented in a survey ““Could improve by having more outings to theatre or seaside” but another relative said, “The home ensures residents are offered mental stimulation”. Residents and staff said, relatives and friends were always made to feel welcome when they visited the home. Staff said the home had regular contact with resident’s families. In a survey a relative commented, “I visit regularly and s/he is always well cared for” and another relative wrote, “The staff are helpful and kind”. One relative, who visited the home every day, told us, “We can call any time we want and staff are very friendly”. Residents said, they felt they were in control of their lives and they lived their lives as they wished. One resident, who was sat outside doing some crochet, told us, “Staff are very caring and I am pleased I came here. I do as I please and there are no restrictions here”. Residents said, they were able to bring their personal possessions and have their bedrooms arranged as they wanted them. We saw that the home accommodated for residents who wished to: get up early or late, stay in their bedrooms or go to communal rooms. The home’s menus were examined. All residents who spoke with us said, there was a good variety of food offered to them and the food was good. In a survey a relative commented, “The food offered is first class”. On the day of the inspection ‘site’ visit, the lunch was well presented and the dining room was very pleasant. The cook told us, soups were home-made and she regularly baked cakes, scones and puddings. Most food was freshly made each day at the home. The cook also made sure residents, who had special dietary requirements, were catered for. The food stored at the home was of there being a good variety of fresh fruit and vegetables and dried, tinned and other foods. We saw fresh fruit on the dining room tables and staff peeled and cut up the fruit for the residents. The cook kept a record of the food that had been served to residents and there were completed records for: the cleaning rota, fridge, freezer and food temperatures. Upsall House DS0000000091.V347638.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 16 & 18 Residents were confident their complaints would be listened to, taken seriously and acted upon. Residents were protected from abuse by the home’s policies and procedures. EVIDENCE: The home had a satisfactory Complaints Procedure. Residents spoken with informed, they did not have anything to complain about but they were confident complaints would be appropriately dealt with. In a survey a relative informed, “Points raised with the care home management were only of a relatively minor matter but they do something about them”. A resident showed us their copy of the Service Users Guide that had details of the Complaints Procedure. The guide was available in resident’s bedrooms. Since the last inspection the home received one complaint and there was a record showing it had been properly investigated and appropriate action had been taken. The home had procedures for protecting residents from abuse. Staff records confirmed staff had completed training for safeguarding vulnerable adults. Staff we spoke with said, they knew of the procedures to follow if there was an allegation of abuse on a resident. Upsall House DS0000000091.V347638.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 19, 25 & 26 Residents lived in a safe and well-maintained environment. The home was clean, pleasant and hygienic and free from offensive odours. EVIDENCE: Upsall House provided a homely and comfortable environment for the residents. Since the last inspection, most communal areas of the home and some bedrooms had been redecorated and carpets had been replaced. There was new furniture in the dining room and the kitchen had some new units and flooring. The deputy manager told us, the lounge had a ‘loop system’; to help people, who were hard of hearing with listening to the televisions. She said arrangements were being made for residents to have hearing aids changed to those that were suitable to use with the system. The garden was well maintained and there was an area, at the back of the home, which was paved Upsall House DS0000000091.V347638.R01.S.doc Version 5.2 Page 17 and had plenty of seating, with umbrellas, for residents who wished to sit outside in warmer weather. One resident told us that s/he preferred to sit outside the front door every morning and seating was made available for him/her. The home’s maintenance records were examined. The requirements of the Environmental Health Department had been met and fire safety measures were in place. The fire alarm weekly checks were recorded and there was a Fire Risk Assessment but the assessment was not dated. We noticed some bedroom doors had been wedged open because some residents preferred not to have their doors closed. The deputy manager and staff told us that had not been identified as an issue when the fire officer last visited the home. We telephoned the Fire Service and were informed that wedges, to hold doors open in occupied rooms, was accepted a few years ago but they must not now be used. We informed the manager that all wedges, holding open bedroom doors, must be removed. If residents wished to have their bedroom doors open then the home must provide and fit ‘hold opener devises’. We saw that bedrooms had fluorescent tube lighting. They gave enough light for the rooms but they were not domestic in character. In a survey a relative commented, “Better parking would be helpful as the car park is always full”. S/he told us, if an ambulance or a delivery van was at the home that would limit access to some parking spaces. On the day of the inspection ‘site’ visit there was plenty of parking spaces for extra cars. The home was clean, pleasant, hygienic and free from offensive odours. A relative commented, “The rooms are clean and tidy”. In a survey a relative commented about the laundry, “They could see that laundry is returned to the right person. It is distressing to have to ask carers to find clothing”. Since then, the manager has employed a laundry assistant who is to make sure laundry is returned to the right people. The laundry dryer and the outside drying area was not close to the washing machine and staff needed to go around to the back of the home to get to that area. Staff seemed to manage very well, within the limitations of the laundry facilities. Upsall House DS0000000091.V347638.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 27, 28, 29 & 30 Resident’s needs were met by the numbers and skill mix of staff who were trained and competent to care for the residents at the home. Residents were protected by the home’s recruitment procedures. EVIDENCE: On the day of the inspection ‘site’ visit there was sufficient staff on duty, to meet the needs of the residents who lived at the home. We examined staffing figures and they showed there was enough staff for the number and dependency levels of residents. The new Care Plans identified resident’s dependency levels. The home had male and female care assistants therefore Upsall House offered residents a choice with having care delivered by a care assistant from either gender. In a survey a relative commented, “Staff are very efficient”. It was commendable that the number of care staff who had successfully completed the National Vocational Qualification at Level 2 was 95 . The deputy manager, senior care assistants and four care assistants were qualified at Level 3 of the qualification. The cook and two house-keepers also had National Vocational Qualifications at Level 2. The administrator was qualified to diploma level. The home had a training officer, who was qualified as a National Upsall House DS0000000091.V347638.R01.S.doc Version 5.2 Page 19 Vocational Qualification Assessor. The training officer planned and delivered most of the training at the home. Staff’s training files confirmed staff had completed basic and further training. Some staff had completed extra training specifically for caring of older people, including training for understanding dementia. Staff files confirmed the home followed the recruitment procedure and appropriate checks had been made before a person was employed at the home. Upsall House DS0000000091.V347638.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standards: 31, 32, 33, 35, 36 & 38 The home was well managed and run in the best interests of the residents. Resident’s personal monies were safeguarded by the home’s procedures. The health, safety and welfare of residents and staff was promoted and protected. EVIDENCE: Management of the home was of there being a deputy manager, an administrator and senior care assistants who supported the manager. The manager had experience running a care home for older people and she had successfully completed training of the Registered Manager’s Award, for management of care services. She had also recently gained a National Upsall House DS0000000091.V347638.R01.S.doc Version 5.2 Page 21 Vocational Qualification Level 4 in care. Staff said, they had satisfactory support from management at the home. Staff’s one to one supervisions had taken place on a regular basis and they were at least six times per year. The home had resident’s meetings, approximately every three months. It was when residents had the opportunity to give their views and discuss how the home was run. Minutes of those meetings were available in the manager’s office. The last staff meeting was about two years ago. There should be regular staff meetings, where staff would be able to give their views, about how the home was managed, in relation to matters that affected the health and welfare of residents. The home carried out quality assurance surveys where residents and/or their relatives complete a questionnaire. The results of the surveys had not been compiled into a report but the manager informed us the report would be completed within the next two months. The manager carried out regular audits of the service; records of the audits were available at the home. The provider carried out monthly monitoring visits and prepared a written report on the conduct of the care home, as a result of interviewing residents and staff and inspecting the premises and records. Residents informed us they were satisfied with how the home looked after their monies. The deputy manager told us, the administrator controlled and recorded the monies that were held on behalf of residents. When the administrator was not available at the home, money was available from the home’s ‘petty cash’ and the administrator adjusted resident’s personal money records when she returned to work. The deputy informed us there were regular audits of resident’s monies. A sample of health and safety records were examined and most were found to be in order. The manager kept an up to date record of maintenance checks that were required to take place throughout the year. There was a record of bath temperature checks but not for checks of other hot water outlets, such as wash basins. The deputy manager, on the day of the inspection ‘site’ visit, made sure those checks were carried out. She informed us, that all water temperature checks would be introduced into the manager’s monthly audit system which was already in place at the home. Staff had completed health and safety training and the home provided protective clothing for staff’s use. The home kept up to date records for: all accidents, checks of electrical equipment and there were Risk Assessments for the Control of Substances Hazardous to Health. Upsall House DS0000000091.V347638.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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 3 X 3 Upsall House DS0000000091.V347638.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 OP25 Regulation 23 Requirement The home must provide suitable lighting in resident’s bedrooms that meets individual needs and which is domestic in character. The manager must make sure staff are able to give their views, through staff meetings, about how the home was managed, in relation to matters that affected the health and welfare of residents The home must write a report on the findings of the annual quality assurance survey. The report must contain measures the home will take to improve the quality and delivery of the services, so that people are informed what actions are being taken as a result of the survey. Timescale for action 31/12/07 2. OP32 21 30/11/07 3. OP33 24 30/11/07 Upsall House DS0000000091.V347638.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. Refer to Standard OP9 Good Practice Recommendations The home should carry out an assessment to determine if a resident could be capable of looking after their own medicines, so that residents are helped with maintaining their independence. The Fire Risk Assessment should be dated and regularly reviewed. 2. OP19 Upsall House DS0000000091.V347638.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Darlington Area Office No.1 Hopetown Studios Brinkburn Road Darlington Co. Durham DL3 6DS 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 Upsall House DS0000000091.V347638.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!