Inspection on 01/06/06 for Walshaw Hall

This inspection was carried out on 1st June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Walshaw Hall 08/12/05

Walshaw Hall 23/05/05

Walshaw Hall 27/10/04

Walshaw Hall 01/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Capstone Care Limited Walshaw Hall Bradshaw Road Tottington Bury Lancs BL8 3PJ Lead Inspector Grace Tarney Unannounced Inspection 10:00 1st June 2006 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 Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 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. Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Capstone Care Limited Address Walshaw Hall Bradshaw Road Tottington Bury Lancs BL8 3PJ 01204 884005 01204 883710 Telephone number Fax number Email address Provider Web address None Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Capstone Care Limited Mrs Marilyn Bates Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th December 2005 Brief Description of the Service: Walshaw Hall is situated in a semi rural setting in extensive gardens overlooking fields and farmland. It is a large detached and extended property set in its own grounds close to the village of Tottington. It is approximately 10 minutes drive away from the town centre of Bury. There is ramped access to the back of the home to allow access for wheelchair users and people who have problems climbing steps. There is adequate parking to the front of the home with extensive additional parking within the grounds. The home is registered to provide 50 places for the personal (residential) care of elderly people. There are 42 single and 4 double bedrooms. 35 single and 2 double bedrooms have en-suite facilities. This accommodation is provided on three levels with a passenger lift to the first floor and a stair lift to the second floor. There is plenty of lounge and dining space and the decoration and furnishings are of a very good standard. The toilets and bathrooms have aids to assist any resident with a disability or mobility problem Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was not told that this inspection was to take place although the home was aware that an inspection was due. This was because several weeks before the inspection questionnaires were sent out to the residents their relatives and to the home itself. These questionnaires asked what people thought of the quality of the service and facilities provided. The inspector visited the home over two days and spent a total of 12 hours inspecting. During this time the Inspector looked at care and medicine records to ensure that the health and care needs of the residents were being met. She also looked at how many staff were provided on each shift to make sure the residents needs were being met, and also looked at how management recruit and supervise their staff. To make sure that the home and the equipment in it was safe, the Inspector looked at the maintenance and service records of the equipment within the home. She also looked at how the management handle the residents’ spending money. The Inspector then looked around the building at the bedrooms, bathrooms toilets and sitting areas to check if they were clean and well decorated. She then visited residents in their own bedrooms to check out the care that was being provided for them. She also spent time talking to the residents who were sitting in the lounge areas and the garden. In order to get further information about the home the Inspector also spent time speaking to 6 residents, 3 relatives, 3 care assistants and the manager. A copy of the last inspection report is available in the managers’ office. The provider informed the inspector that the fees within the home ranged from £400 to £525 per week This information was received on the 28th April 2006. What the service does well: Before residents went into the home, the manager or one of the senior carers visited them in their own homes or in hospital to make sure that the care they needed could be provided by the home. The home has exceeded the Standard in relation to meals and mealtimes. Meals and mealtimes were considered to be an important part of the residents’ day. The dining room was a very pleasant place to sit, eat and meet with other residents. The residents said that they really enjoyed their meals. They were satisfied with the choice of meals and the way they were cooked and served. Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 6 Residents feel that the home puts their needs first. Comments such as “Its an OK place” “Next best thing to home” “ They are wonderful, they fuss me to death” were made to the Inspector. Comment cards received from residents and relatives made comments such as “I feel I am settling in nicely thanks to the kindness of the staff ” “ We are getting peace of mind that she is safe and exceptionally well cared for” The residents live in a very clean and pleasant environment. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected 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. The system for ensuring that all prospective residents had a detailed assessment undertaken prior to admission to the home gave an assurance both to residents, relatives and staff that a resident was only admitted if the home could meet their needs. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Inspection of three resident care files showed that assessments had been undertaken prior to admission. Before any resident was admitted to the home a senior member of the staff from the home undertook an assessment of their needs. Assessments undertaken by other professionals requesting a residents’ admission i.e. care manager/social worker were also in place. One resident wrote in a questionnaire that he visited the home first and then the manager came to see him in his own home. Standard 6 does not apply. The home does not provide Intermediate Care. Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 9 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 good. Although the care plans contained a lot of important information they did not fully reflect the support needs of some of the residents. Despite some small areas of concern being identified, the medication system in place was safe and residents received their medicines correctly. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Each resident had a care plan. The care plans of 3 of the residents were inspected. The care plans gave a lot of good information and clear instruction and guidance on how some of the care needs of the residents were to be met when problems had been identified, but there was not enough information in relation to how to care for one of the residents with diabetes and what problems staff would need to watch out for. The care plan did state that the resident was under the care of the district nurse and was receiving insulin and the blood sugar was being monitored but there were no instructions about what to do in the event of the blood sugar levels being too low. The manager did tell the Inspector that the staff were aware that the resident had a stock of emergency glucose in the event of this Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 10 happening, however there was no record of this in the care plan. . There was not enough information about the care of the residents’ skin and the importance of the involvement of the chiropodist to keep her feet and nails healthy. There was not enough information about the care of the residents’ eyes such as regular check ups with the optician. There was an eating and drinking care plan and this did state that the residents’ food was to be “sugar and fat free”. A discussion with staff showed that they didnt have a lot of understanding about what a person with diabetes could eat although staff did inform the Inspector that there had been some training in relation to diabetes care. They staff did not write down how the residents were to be assisted with being moved around and by how many members of staff and what equipment, if any, was to be used to assist in safe moving and handling. This is called a moving and handling assessment. There was no evidence to show that either the residents or their families were involved in the drawing up of the care plan. To ensure that an accurate and agreed care plan is in place the resident and/or their families should be involved. From the care plans inspected it was evident the residents were weighed at least on a monthly basis and any weight loss identified and acted upon. The staff did not write down however, if any of the residents were at risk due to problems with their diet and fluid intake. This is called a nutritional risk assessment. Inspection of the care files identified that the residents had access to health care professionals, such as dentists, opticians, chiropodists and district nurses. Some equipment necessary for the prevention and treatment of pressure sores was readily available within the home and the Inspector was informed that the district nurses could provide more specialist equipment if needed. Comments cards received from GPs showed that the home communicated and worked in partnership with them. One GP commented that the home was very good and quick to react to any change in the condition of a resident. Overall a safe system of medication management was in place. The home does not have a designated locked medicine room. The medicines are kept in trolleys and cupboards that although kept securely locked, are situated in a staff thoroughfare close to the kitchen. To ensure that the medicines are stored at the correct temperature a room thermometer needs to be placed in this area. Some issues were identified in relation to the following: Handwritten instructions for medicines (Transcriptions) were not signed, checked and countersigned. Signing and checking transcriptions reduces the risk of drug errors. When a prescription stated that one or two tablets were to be given, staff were not documenting just how many tablets had been administered. Only suitably trained and designated staff administered the medications. Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 11 The residents said that the staff treat them with kindness and respect. During the inspection staff members spoke with residents in a kindly and respectful way. Staff spoken to gave examples of how privacy and dignity were promoted. Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected 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 excellent. The home enabled residents to exercise as much personal freedom and choice as possible and find enjoyment with the range of activities available. Great importance is attached to ensuring that the meals are varied and nutritious and that mealtimes are considered to be an important part of the residents’ day. This judgment has been made using available evidence including a visit to this service EVIDENCE: A discussion with residents indicated that they were satisfied with the personal choices and freedom they were able to exercise. One resident told the Inspector that it was “the next best thing to home”. One resident told the Inspector that the staff let her stay in her room if she doesnt want to eat in the dining room. The residents’ routines of daily living and their social interests were recorded in their care plans. On the inspection days, several residents were sitting outside, some with their visitors, enjoying the beautiful views and the sunshine. The Inspector was told that the activities person had recently left and the home were advertising to fill the vacancy. One of the residents spoken to said that she really missed the activities organiser because she was “so very good”. In the meantime the staff within the home undertake activities. Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 13 Activities such as board games, dominoes, flower arranging, arts and crafts and cake making are undertaken. Every Sunday the home has a traditional Sunday lunch and relatives and friends are invited to join them. The homes’ staff were in the process of organising a summer fair and the residents spoken to said they were looking forward to it. One relative wrote in a questionnaire about activities; “you can see everything that is going on, its not just a list on the wall” Residents told the Inspector that they are able to have visitors at any reasonable time and they can see their visitors in private. Relatives confirmed this. Residents are encouraged to bring personal possessions into the home. Many of their bedrooms were highly personalised with small pieces of their own furniture, pictures, photographs and ornaments etc. The inspector did not dine with the residents but observed lunch being served. The dining room is very large and is used by the majority of the residents, although some residents preferred to eat in their own room. The tables were nicely set with tablecloths, napkins, cruets and individual teapots, cream jugs and sugar bowls. The residents were asked the day before for their choice of menu. Staff informed the Inspector that if the residents changed their minds or did not like what was being served to them then there was no problem in giving them an alternative. The Inspector saw that the residents were served their vegetables in tureens and they were also given sauceboats for their bread sauce. This method of “silver service” showed that residents were treated as individuals, and that great importance is attached to ensuring that mealtimes are an enjoyable and social occasion. In addition it ensured that residents had what they wanted. The serving of the meals was relaxed and the staff were patient and helpful. An inspection of the menus identified that there was a choice of main meal and dessert at lunchtime and the evening meal. Staff told the Inspector that there was always a choice of a salad. Fresh orange juice and fresh fruit was available. Residents told the Inspector that they thoroughly enjoyed the food. One resident told the Inspector that her porridge at breakfast time was the best she had ever tasted. She said it was “so lovely and creamy” One resident stated that she appreciated “the effort that was put into catering for my vegetarian diet”. Staff ensure that the residents have a light snack for their supper and milky drinks, in addition to tea and coffee are always available. Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be 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. The complaint system in place enabled residents to feel that their views were listened to and acted upon. Staff had a good knowledge and understanding of what abuse was, thereby reducing the possible risk of harm or abuse. This judgment has been made using available evidence including a visit to this service EVIDENCE: A detailed complaints procedure was in place and was displayed. It was easy to understand and gave an assurance that complaints would be responded to within 28 days. The Service User Guide that is given out to all residents/families also explained the complaints procedure. It did not however, give the contact details for the Commission for Social Care Inspection. A discussion with residents and relatives indicated that there was a general awareness of how to make a complaint. Replies from the questionnaires showed that the residents knew how to make a complaint if they had to. Staff also knew what to do if someone complained. No complaints have been made to the CSCI in the last 2 years. A policy and procedure was in place in relation to the detection of abuse and neglect (including whistle-blowing) and how to respond to suspected abuse. The procedure in place that is used for NVQ care training however, states that any allegation of abuse must be referred to the CSCI. Another procedure in place (Croner) does state refer to the social services department. A discussion took place between the manager and the Inspector in relation to the correct procedure to follow. This identified that the home did not have a copy of the Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 15 local authority procedure for the protection of vulnerable adults. The manager contacted the social services department whilst the Inspector was present and requested a copy of their procedure. Once this has been received the manager and staff must ensure that the procedure for reporting any allegation of abuse is adhered to in accordance with social services requirements. A discussion with care staff identified that they were very aware of the different forms of abuse and knew that it had to be reported to their manager or other senior staff. Staff were also aware of the whistle blowing policy within the home. Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 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 21 24 25 & 26 Quality in this outcome area is good. The residents were living in a clean pleasant environment but an infection control issue needs to be addressed. This judgment has been made using available evidence including a visit to the service EVIDENCE: There is ramped access to the back of the home to allow access for wheelchair users and people who have problems climbing steps. There is adequate parking to the front of the home with extensive additional parking within the grounds. The Inspector walked around most of the building and looked at several bedrooms, the lounges, the dining room, corridors and the laundry. It was evident that there was an ongoing programme of redecoration and refurbishment. The home was very clean and free from any unpleasant smells. A relative stated that the home “ shone out as being spotless and smelling fresh” The dining room and lounge areas were well decorated and furnished, bright and welcoming. Grab rails to aid mobility were in place along several but not all corridors. Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 17 There were enough toilets and bathrooms to meet the needs of the residents. Toilets were within close proximity of communal spaces. Each toilet and bathroom had a lock on the door to ensure privacy and the facilities were all clearly marked. Most bathrooms and toilets were suitably adapted for disabled use. During the inspection it was identified that thermostatic control valves were not in place on immersion baths and showers. An immediate requirement form was issued in respect of this and the home took action very quickly. These have now been installed and the Inspector has been informed that they are also being installed on the wash hand-basins. The home has 42 single bedrooms, 33 with en-suite facilities of toilet and wash hand basin and 4 double bedrooms, 2 of which have an en-suite toilet and wash hand basin. The bedrooms were clean, suitably furnished and most were very personalised. Several of the bedrooms were without a lockable space. Some bedrooms had an overriding door lock but there were no keys to these locks. Some bedrooms had no door locks. To ensure the privacy and dignity of the residents is upheld, locks must be fitted to bedroom doors. The locks must be accessible to staff in emergencies and residents must be provided with a key unless their risk assessment suggests otherwise. The rooms were individually and naturally ventilated, they were all centrally heated and radiators were covered. The home was clean and free from offensive odours. Staff hand-washing facilities, such as liquid soap and paper towels were not available in the bedrooms. To prevent cross infection/contamination they must be provided where any resident is receiving personal care. Alcohol gel and vinyl/plastic gloves are no substitute for hand washing. The laundry was clean and looked organised. Adequate equipment was in place and protective clothing was available. Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 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. The residents were cared for by sufficient numbers of staff that were safely recruited and suitably experienced and trained, and therefore had the knowledge and skills to meet the residents’ needs. This judgment has been made using available evidence including a visit to the service EVIDENCE: Examination of the duty rotas and a discussion with staff, residents and relatives identified that there was sufficient care staff on duty to meet the needs of the residents. Resident and relative questionnaires showed that they were satisfied with the numbers of staff on duty. One relative stated “ there are always staff on hand” The duty roster did not document the full name of the staff members and did not document when the manager was working. To ensure that an accurate duty roster is in place these details must be added. Of the 34 care staff employed 18 have obtained their NVQ level 2 or above in care. 2 of the staff are presently undertaking NVQ level 4. This is a percentage of 52 and therefore the home has met the Standard. The personnel files of three staff members were inspected. All were in order and these staff had been properly and safely employed. They had a completed application form, 2 professional references, an enhanced criminal records disclosure (CRB) check and a health status declaration. Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 19 An induction training programme was in place. It was not in accordance with the National Training Organisation (NTO) specifications but it was detailed. The manager told the Inspector that she was in the process of developing it further. All members of staff receive induction training within six weeks of appointment to their post and further training within the first six months of appointment Training records were in place in the staff files inspected. training had been undertaken in the following areas: Moving and Handling. Fire Safety. First Aid. Food Hygiene. Infection Control. Health & Safety Abuse awareness. These showed Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 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 The experience and qualifications of the manager ensures there is effective leadership and guidance to the staff thereby ensuring that the residents receive consistent quality care. A satisfactory accounting system was in place that ensured the residents’ financial interests were protected. The home was safe and very well maintained thereby promoting and safeguarding the health, safety and welfare of the people using the service. This judgment has been made using available evidence including a visit to the service. EVIDENCE: The registered manager has 25 years extensive experience of providing care within the private sector and the NHS. She has been the manager at Walshaw Hall for over 5 years and has obtained the Registered Managers Award. She has recently commenced the NVQ level 4 in care. Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 21 Staff spoke very positively about the managers attitude, knowledge and experience. They said that she was very approachable and listens to any concerns that they have. The Inspector was advised that the home have not yet developed a formal quality assurance system. Questionnaires have been developed and given out to residents and relatives. Other ways of monitoring the service would be via questionnaires to other stakeholders i.e. district nurses, care managers etc and the results of any surveys should be published in the Service User Guide. The systems in place for the management of residents’ money were good. The home had a satisfactory accounting system in place. The administrator could determine exactly how much money the home was holding for each person and how the money was being spent. Receipts were retained for all financial transactions. The home had a detailed Health & Safety Policy. Regular weekly checking and testing of fire detection system, fire exits and emergency lights was undertaken and documented. A “competent person” however does not undertake the annual fire training. The manager told the Inspector that she was in the process of addressing this issue. A competent person (as defined by Greater Manchester Fire and Rescue Service ) is someone who has experience of fire fighting and subsequent fire prevention and training. The Inspector has since been informed that fire training by a competent person is being undertaken on the 17th July 2006. Any accidents that happen are properly recorded and monitored. Most of the equipment and services within the home were serviced on a regular basis in accordance with the individual requirements. The following certificates of servicing/maintenance were not available: Portable appliance testing (PAT) last undertaken March 2005. Bath and Portable Hoists (The Inspector was informed that the servicing was to be undertaken the following week) Moving and handling and infection control. Fire training was undertaken on an annual basis Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x 3 x x 2 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 2 Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement The Registered Person must ensure that a care plan is in place that details how the resident with diabetes is to be cared for. This must include the care of the skin, feet and eyes, and what to do in the event of an emergency situation, such as hypoglycaemia. The Registered Person must ensure that there is evidence of resident/representative involvement in drawing up the care plan The Registered Person must ensure that each resident has a risk assessment in place for moving and handling. . The Registered Person must ensure that each resident has a risk assessment in place for nutrition The Registered Person must ensure that a room thermometer is in place in the medication storage area. The Registered Person must ensure that the staff record the actual number of tablets being DS0000008410.V289578.R01.S.doc Timescale for action 31/07/06 2 OP7 15 31/07/06 3 OP7 13(5) 31/07/06 4 OP8 13(3) 31/07/06 5 OP9 13(2) 31/07/06 6 OP9 13(2) 01/06/06 Capstone Care Limited Version 5.1 Page 24 given. 7 OP16 22(5) The Registered Person must ensure that the contact details of the CSCi must be in place on the Service User Guide. The Registered Person must ensure that all bedroom doors are fitted with locks and residents provided with a key unless their risk assessment suggests otherwise. The Registered Person must ensure that each resident has a lockable space. The Registered Person must ensure that, to reduce the risk of cross infection, staff hand washing facilities must be provided in the residents’ bedrooms /en-suite toilets. The Registered Person must ensure that the full name of staff and the managers hours worked, are recorded on the duty roster. The Registered Person must ensure that quality-monitoring systems are introduced including the use of regular residents quality assurance surveys with a report of the findings and of any action taken produced and made available. (Previous timescale of 28/2/06 not complied with). The Registered Person must ensure that certificates of installation/maintenance and servicing in respect of portable appliance testing, thermostatic control valves and hoists are forwarded to the CSCI. 31/07/06 8 OP24 12(4)(a) 23(1)(a) 30/09/06 9 10 OP24 OP26 23(2) 13(3) 30/09/06 31/07/06 11 OP27 17 & Schedule 4 24 (1)(2) 01/06/06 12 OP33 30/09/06 13 OP38 13(4) 31/07/06 Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 25 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 OP9 OP18 Good Practice Recommendations To ensure the accuracy of a transcription, handwritten transcriptions should be checked with another member of staff, signed and countersigned The manager is strongly advised to have in place a copy of the Bury Social Services Procedure on the Protection of Vulnerable Adults. It is strongly recommended that staff receive ongoing training in relation to the care of a resident with diabetes 3 OP30 Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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. Extracts may not be used or reproduced without the express permission of CSCI Capstone Care Limited DS0000008410.V289578.R01.S.doc Version 5.1 Page 27 - 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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