Inspection on 23/05/05 for Walshaw Hall

This inspection was carried out on 23rd May 2005.

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

Walshaw Hall 01/06/06

Walshaw Hall 08/12/05

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, Lancashire BL8 3PJ Lead Inspector Keith Savery Announced 23 May 2005 09:30 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 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 F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Capstone Care Limited Address Walshaw Hall Bradshaw Road Tottington Bury, Lancashire BL8 3PJ 01204 884005 01204 883710 N/A Capstone Care Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Marilyn Bates CRH 50 Category(ies) of OP - Old Age - 50 registration, with number of places Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 27 October 2004 Brief Description of the Service: Care services at Walshaw Hall are provided in a large adapted property set in it’s own grounds close to the village of Walshaw that falls within the area of Bury.The property is situated in a pleasant, peaceful semi rural setting with large accessible garden areas.The home provides fifty places for the care of elderly people.There are forty-two single and four shared bedrooms. Thirty-five single and two shared 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.Decoration and furnishing is to a high standard. Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced. One inspector spent 8 hours at the home. Prior to this inspection the CSCI wrote to the Chief Environmental Health Officer and The Chief Fire Officer (Bury) in order to ascertain if “Walshaw Hall” currently meets requirements regarding safety in the home. Social Workers were written to, seeking their views/opinions on the quality of the service offered at the home. Views on quality of service within the home were also sought from doctors who visit the home. Questionnaires were sent out to seek the views of current residents and relatives of which 15 were returned. A tour of the building was undertaken to examine physical standards in the home. In order to obtain a broad opinion regarding the services and care offered, discussions took place with the following people: 8 residents were spoken to individually, one of whom was undergoing a period of respite care, and all of the homes residents were seen, 5 care staff, the registered manager and the homes activities co-ordinator. Visiting relatives also gave their opinion of the home. A selection of resident’s care records were examined and various records and policies were looked at. What the service does well: Standards of accommodation at the home are very good. Residents and visitors spoken to were all very happy with their bedrooms and the various communal lounges/facilities around the home. Standards and choice of food is also good The relationship between residents and staff is good. Residents described staff as ”exceptional”, “wonderful” “friendly and helpful”. Visitors commented that” residents are looked after in a “caring environment” and would have” no doubt in recommending it to other people”,” Staff are always helpful and pleasant” Residents are positively encouraged to live the type of life they choose, getting up when they like, going to bed when they like. The home offers a relaxed environment that allows its residents to come and go as they please or are able. They can have their own personal possessions in their bedrooms and choose their own furniture and bedroom decoration. They can meet friends and Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 Page 6 relatives either in their own rooms or any of the homes spacious lounges. They are enabled to make choices in what they want to wear and are encouraged to join in the activities taking place in the home, should they wish to. 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 F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4,5.Standard 6 is not applicable as the home does not provide intermediate care. The homes Statement of Purpose and Service User Guide are good providing residents, prospective residents and their next of kin with information of the services the home provides so that an informed decision about coming to live at the home can be made. The admission procedure ensures that all people receive a proper assessment prior to moving into the home in order to ensure that their care needs have been fully identified/ assessed and that the home is capable of meeting those identified needs. EVIDENCE: Walshaw Hall has a detailed Statement of Purpose and service-user guide, copies of which were available to residents and visitors alike. Discussion with 8 residents, one of whom was enjoying a short break, which was her first experience of residential care indicated that they were happy with their choice of home and the standard of care they are in receipt of. Further comments Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 Page 9 included” Since my admission to Walshaw Hall I have found the care to be excellent, the food wonderful, and the staff are exceptional” “You wont find a better staff anywhere” This was also confirmed in discussion with visiting relatives of residents, all of whom stated that the homes staff where” very supportive” during the admission process and are always “approachable” Other comments made included” residents are looked after in a caring environment and we would have no doubt in recommending the home to other people” It was noted however that some minor adjustments are required to the documentation i.e. the removal of reference to the NCSC and replacement with CSCI. The admission procedure is sufficiently detailed to guide staff on the actions to be taken to ensure that new residents needs are properly assessed and planned for. The Social Services Department assesses a large number of the residents prior to admission but examination of individual records also evidenced that self funding residents had undergone a full needs assessment by the home prior to their admission in order to ensure that their needs can be met. It is standard practice that prospective residents and their relatives are given the opportunity to visit the home prior to admission whenever possible and the homes manager undertakes hospital/home visits as appropriate. Inspection of the contract of terms and conditions issued to residents by the home indicated that this document was appropriate and was signed by either the resident or their advocate indicating their agreement to the homes terms and conditions. Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 and 11. The health and personal care needs of residents are assessed and addressed appropriately. The health needs of residents are well met, with evidence of good multi disciplinary working taking place on a regular basis. The arrangement for the management of resident’s medicines was found to be safe. Staff interact and assist residents sensitively and appropriately. EVIDENCE: Individual care plans were made available for inspection and examination of a number indicated that all aspects of resident’s health, personal and social care needs are planned for. Five individual care plans examined were found to be up to date and reviewed on a weekly basis by senior care staff and also on a monthly basis by the homes manager or sooner should a new need become apparent. Either the resident or their representative had not signed a number of care plans examined, the homes manager stated that she was aware of this, the reason being that all original care plans were being updated to the homes new care documentation system and that she was working her way through the process of discussion and obtaining signatures of agreement. All previous Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 Page 11 care plans had been signed. Progress in this area will be monitored at future inspections. There was clear evidence of access to community services such as the residents GP, Chiropody (3 monthly, or sooner if urgent treatment is needed) Eye testing and District Nursing support, advice and ongoing treatment and access to aids and adaptations that maintain the quality of life for residents. Appropriate risk assessments, which seek to protect resident’s health and safety, were also recorded in respect of resident’s risk of pressure sores, mobility, and nutrition (including weight monitoring) and other relevant areas. This was confirmed in discussion with residents and visiting relatives, one resident stated, “Being a vegetarian I appreciate very much the willingness and efforts of the staff to help me, considering this difficulty” The arrangements for resident’s medicines were secure and appropriately documented. These arrangements are operated by senior staff at the home all of who have undergone training in the management and administration of medicines. Staff have a good awareness of how to promote resident’s dignity and privacy. They were seen to knock on resident’s bedroom doors and wait for a response before entering. They were also seen to deal with individual residents in a supportive manner, i.e. doing things with them and not for them when appropriate. A resident stated, “Staff are very kind and friendly” Evidence was examined from the family of a recently deceased resident who stated that the care provided to their relative up and to the time of her death was “Wonderful” and that there mother was “Treated like a Queen”. Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 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 standard(s) 12,13,14 and 15. Residents are able to exercise as much personal freedom and choice as possible within a risk assessed framework and within the confines of the residents expressed interests, capabilities and choice. The routines of daily living are tailored to be as flexible as possible in a communal living setting. Dietary needs of residents are well catered for with a balanced and varied selection of food available that meets resident’s tastes and expressed choices. A programme of activities is prominently displayed in the home so that residents and visitors to the home can see what is available and can chose what to take part in and organise their day. EVIDENCE: Discussion with the more able and vocal residents confirmed that the routines of the home are quite flexible and they expressed satisfaction with the varied recreational activities provided by the home. Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 Page 13 An activities worker is employed for approximately 18 hours per week and a number of residents spoke highly of her input and “look forward” to her visits. The activities coordinator is very enthusiastic in her work and provided details of activities undertaken. She formulates and implements a monthly programme of events, which is displayed and keeps a record of all serviceusers who participate in the organised activities. Residents were observed taking part in a number of activities during this inspection which they stated they” enjoyed” and” looked forward to”. A resident spoken to at length had recently returned from Russia, were he had taken part in celebrations pertaining to his actions in the 2nd world war, which he had thoroughly enjoyed. He had confidently left his wife to be cared for whilst he attended this event. The providers encouraged service users to maintain contact with family and friends and a number of residents had been out recently on the ring and ride service for a pub lunch. A number of residents have their own independent telephone lines in their bedrooms in order to maintain contact with their family and friends. Residents and visitors spoken to confirmed that visitors were free to call at any reasonable time and no visiting restrictions were imposed Menus were inspected, which rotate every four weeks and were found to be balanced and interesting with alternative menu choice for both lunch and tea. The second choice needs to be clearly displayed on current menus as discussed. All residents spoken to comment favourably on the quality of the food served. The homes cooks are knowledgeable regarding resident’s likes and dislikes, which are displayed in the homes kitchen along with a list of resident’s birthdays. Detailed records are kept that indicate resident’s choice of meal is acknowledged and provided. Both cooks are currently undertaking formal NVQ training in preparation of food and cooking. Meals were served in a very elegant dining room with tables attractively set out. Staff were observed to serve and assist residents appropriately and sensitively with their lunch on the day of inspection. Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 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 standard(s) 16,17 and 18. Staff have a good working knowledge and understanding of Adult Protection issues, which protects residents from abuse. Arrangements/policies in place to prevent possible risk or harm of abuse to residents are satisfactory. EVIDENCE: The home has a written complaints procedure that is included in the service user pack and displayed clearly within the home. Also a complaints file is maintained. Two complaints has been received by the home over the past year, one was investigated by the home and found to be substantiated and appropriate action taken to the satisfaction of the complainant and one was investigated by CSCI and found to be unsubstantiated. Residents spoken to state they were very happy with the overall care and spoke very highly of the management and staff. These opinions were also expressed in a number of responses received via questionnaires issued to relatives prior to this inspection. Residents at this inspection made no complaints or described any areas of dissatisfaction with the level of service provision they are in receipt of. Policy and procedure is available for staff guidance when responding to allegations of abuse and the homes manager is aware of her responsibilities regarding POVA. Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 Page 15 Staff at the home have benefited from NVQ training which contains the component on Adult Abuse issues, which has heightened their awareness of the different types of abuse, how to recognise and report such issues and how this fits together with the policies and procedure arrangements the home has in place, to protect residents from abuse. The home has also recently liaised with its NVQ trainer regarding running an internal course on Adult Abuse Issues and has purchased 2 videos entitled “Adult Abuse, Basic Awareness” and” Abuse in the Care Home” to build on its existing knowledge and protect residents. Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 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 standard(s) 19,20,21,22,23,24,25 and 26. A high standard of comfort and accommodation is provided for the residents, providing an attractive and homely place to live. EVIDENCE: There is a homely and very comfortable standard of décor and furnishings. There is evidence of ongoing refurbishment and a programme of routine maintenance included redecoration of bedrooms and carpeting. All areas of the home designated for resident’s use was accessible to them. Grab rails, ramps, and a passenger lift are provided internally to maintain independence. It was commented, by a number of residents and relatives that the old design of the existing passenger lift doors are very heavy and difficult to operate, making it difficult for residents to move independently from floor to floor around the home. The proprietors will need to examine if the doors could Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 Page 17 be altered to facilitate ease of operation for residents in order to maintain their freedom of movement around the home. There is sufficient space for service users with walking aids to move freely around the home. Hoists and assisted toilets and baths are provided. Ample storage space is available for aids and equipment. A call system is provided in each room and was in working order. The home continues to provide sufficient sitting, recreational and dining space in the form of communal lounge areas and a separate dining room which following discussion with residents is confirmed. Residents stated that they are “more than happy” with the furnishings of communal rooms, and all felt they were suitable for the range of interests and activities, which they undertake. Toilets are accessible and clearly marked close to communal and private spaces. Residents stated that they have sufficient toilet, washing and bathing facilities to meet their needs. Radiators were fitted with guards throughout the home to prevent accidental burning. Radiators could be individually controlled in resident’s bedrooms allowing residents control over their heated environment. Valid servicing documentation is in place that states that hot water is stored and distributed at the correct temperatures and that thermostatic mixer valves are centrally fitted to regulate the safety of hot water temperatures and regular checks are carried out as part of the homes water management program. Lighting in resident’s accommodation meets recognised standards enabling residents to read adequately and is domestic in character and emergency lighting is provided throughout the home should normal power supply’s fail. Laundry facilities within the home remain sited away from areas where food is stored, prepared cooked or eaten and do not intrude on residents. Resident’s laundry is individually marked and is washed and cared for appropriately. The home has ample equipment (2 washers and 2 dryers). The home was clean and tidy on the day of the inspection. Residents and visitors consulted expressed satisfaction with the environment and visitors commented on the consistently high standards of cleanliness throughout the home “at whatever time they visit”. These high standards are consistent with those found at previous inspections. Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30. Care staff, senior care staff and the manager are enthusiastic and work positively with the homes residents to maintain and improve their quality of life. Staff are subject to an appropriate recruitment process that provides the necessary safeguards to protect residents living at the home. Staff receive a wide range of appropriate training – including NVQ training and are sufficiently skilled and in such numbers to meet the needs of the homes residents at this time. EVIDENCE: Staff stated they feel valued and supported by the management of the Home and they enjoy a good working relationship within the Home This is indicated by low staff turnover and sickness indicating a happy work environment. The homes continued commitment to training its entire staff indicates that the work force is valued and the role staff play in consistently providing a good standard of care to residents is recognised. In discussion with staff it is evident that they enjoy working at the home. Training records indicate that staff members have the requisite skills and experience to fulfil their roles with 26 out the current 33 staff having undertaken or currently training towards a recognised standard of NVQ qualification. Training is well planned and supports the staff in providing for the varied needs of the residents. Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 Page 19 Staffing levels exceed those recommended minimum levels made by the “Residential Forum”(886 care hrs) currently 931 care hours are provided. Currently the home is using Agency staff and existing staff are working extra hours to cover 2 care staff vacancies. The inspector would wish to see these vacancies filled as soon as possible. Random inspection of the most recently employed 2 staff members personnel files revealed that these contained an application form, 2 written references, a Criminal Records Bureau check (including a ‘POVA first’ check) and evidence of induction training. The homes manager has worked hard to improve the overall standard of information held on staff. Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36,37, and 38. The manager is well supported by the senior staff and provides clear leadership to all staff demonstrating an awareness of their individual roles and responsibilities in a continuous effort to maintain high standards of care to residents. There is a clear development plan and vision for the home, which the homes manager effectively communicates to residents, staff and relatives. The systems for residents/relatives consultation are good. EVIDENCE: The manager demonstrates continued committement to improving her knowledge; skills and competence by nearing the completion level 4 Registered Managers Award, which she intends to have completed by October 2005. Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 Page 21 The home is undertaking the “Investors in People award on the 1st June 2005 in a further effort to independently evaluate the standard of care provision to residents. Staff describe a continuing good team spirit and an open and trusting atmosphere. Residents and visiting relatives said they would feel comfortable to approach any carer or the manager with their views or issues and gave examples of how they had been given support previously. Feedback received in questionnaires issued prior to this inspection commented on the “excellent standards” set in the home and that the atmosphere is one of “organised, friendly, helpful and caring” Opinions are actively sought from residents through residents meetings, user satisfaction questionnaires and day-to-day communication. Examination of the minutes of the most recent residents meeting plus results of the most recent questionnaire, complete with actions taken in response to suggestions/information obtained gave examples of the ways that residents/relatives have been involved and consulted. The home is due to undertake its quality audit for this year. The proprietors monitor the business assets on a regular basis and a business plan is available for examination. An accountant audits financial records annually. The home operates on a sound financial basis. Up to date staff records were seen in respect of formal supervision and appraisal. The home continues with its formalised supervision system. The home administers a number of personal allowances of which an income/expenditure sheet with running total is maintained for each resident. Monies are kept separate and are securely stored. Secure facilities are provided for the safe keeping of resident’s monies and valuables. All accidents however minor, that occur in the home were appropriately recorded and written evidence in the homes accident log indicates that they have been appropriately managed. The following safety/servicing certificates were examined and found to be up to date; Yearly gas safety certificate, 5 yearly electrical safety certificate, servicing of passenger lift, servicing of fire safety equipment and the fire alarm system, emergency lighting and nurse call system. Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 Page 22 The last fire inspection by GM Fire service was dated 29 October 2004 when a number of recommendations were made, all of which have been complied with. Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 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 Standard No 16 17 18 Score 3 3 3 3 3 2 3 3 3 3 3 Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 Page 24 No 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 33 Regulation 24 Requirement The home must undertake its quality assurance and quality monitoring review for this year. The results should be published and made available to current and prospective residents, their representitives and other intrested parties, including the CSCI. Timescale for action 5/9/05 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 1 19 Good Practice Recommendations The home should make the minor adjustments to its statement of purpose and service -user guide and replace reference to the NCSC with CSCI The inspector would again recommend that the home give some consideration to the existing arrangements of entry and exit from the building and examine how observation of visitors to the home, inclusive of authorised or otherwise could be improved and also the unauthorised exit of service-users with higher dependency needs. The inspector would recommend that the home asses the issue identified surrounding the weight of the homes industrial type passenger lift door and look into ways of F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 Page 25 3. 19 Capstone Care Limited 4. 19 making it easier to operate for residents who wish to retain their independance when moving about the home. The inspector would recommend that the necessary repair work is carried out to the fly screen in the homes kitchen. Capstone Care Limited F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection 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 F56 F06 S8410 Capstone Care Ltd V215260 230505 Stage 4.doc Version 1.30 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. 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!