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Inspection on 25/01/08 for Winnie Care (Ashbourne Lodge) Limited

Also see our care home review for Winnie Care (Ashbourne Lodge) Limited for more information

This inspection was carried out on 25th January 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

There is now a permanent manager appointed at the home who has applied to the Commission for Social Care Inspection so that she can be assessed to see if she is fit to run the home.

CARE HOMES FOR OLDER PEOPLE Winnie Care (Ashbourne Lodge) Limited Ashbourne Lodge Care Home The Green Billingham Stockton on Tees TS23 1EW Lead Inspector Steve Tuck Key Unannounced Inspection 11:15 25th January and 4th February 2008 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 DS0000058608.V358568.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. DS0000058608.V358568.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Winnie Care (Ashbourne Lodge) Limited Address Ashbourne Lodge Care Home The Green Billingham Stockton on Tees TS23 1EW 01642 553665 01642 558662 ashbournelodge@btconnect.com 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) Winnie Care (Ashbourne Lodge) Ltd Vacant Care Home 55 Category(ies) of Dementia - over 65 years of age (17), Old age, registration, with number not falling within any other category (38) of places DS0000058608.V358568.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th December 2006 Brief Description of the Service: Ashbourne Lodge is a care home which can provide personal care and accommodation for up to 55 older people, 32 of whom have a dementia type illness. Nursing care is not provided, however, the support of District Nursing services can be obtained if this is needed. The home is owned by Winnie Care (Ashbourne Lodge) Ltd which is a private organisation. There are 2 floors of accommodation where people live and includes the main kitchen, laundry area and staff rooms. The home has been specifically designed to provide accommodation for older people and has been open for about ten years. There is a level entrance into the home, and good access once inside because of wide corridors. There is a passenger lift which goes to the first floor, where there are two parts of the building one which provides accommodation for older people who have dementia, the other for older people who are frail or ill. The home provides single bedrooms, each with their own toilet facilities and there are several lounges and dining areas on each floor. There is a parking area at the back of the home and there is a reception area at the entrance of the home. The home is located in the Billingham Green Area, close to shops, pubs, and community facilities. The weekly fees for living at this home are £345 - £380. The costs of newspapers, hairdressing, private chiropody and toiletries are not included in the fees. Further details of fees can be found in the homes Service User Guide. DS0000058608.V358568.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people using this service experience adequate quality outcomes. This was a pre-planned inspection which took place over two days. The manager of the home was not informed that this inspection was to take place. Before the visit: We looked at: • Information we have received since the last Key Inspection. • How the home has dealt with any complaints & concerns since then. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service, their relatives and staff by questionnaire. The Visits: Two unannounced visits were made on 25th January and the 4th February 2008. During the visit we: • Talked with the people who live at the home, the staff and the manager. • Observed life in the home. • Looked at information about the people who use the service & how well their needs are met. • Looked at other records, which must be kept. • Checked that staff had the knowledge, skills & training to meet the needs of the people they care for. • Looked around parts of the building to make sure it was clean, safe & comfortable. • Checked on what improvements had been made since the last visit. We told the manager what we had found. This report represents the key findings at the time of the inspection. It is acknowledged that some work may have commenced to address some of the findings highlighted within this report DS0000058608.V358568.R01.S.doc Version 5.2 Page 6 People who live at Ashbourne Lodge or their relatives gave a variety of comments about their experiences of care at the home. Comments included: “I am kept well informed at all times.” “The care at Ashbourne lodge is wonderful.” “Staff are lovely when I visit they take time to chat to us” What the service does well: What has improved since the last inspection? There is now a permanent manager appointed at the home who has applied to the Commission for Social Care Inspection so that she can be assessed to see if she is fit to run the home. DS0000058608.V358568.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. DS0000058608.V358568.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 DS0000058608.V358568.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): 1,2,3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of information about what life is like at the home is available to help people to decide if they want to move there. And people have contracts in place to protect their rights and help them to make informed choices. The acting manager finds out and understands the needs of people who want to move there. This information helps to make sure that peoples needs can be met and agree the ways that the homes staff are to support them. EVIDENCE: Relatives and people living at the home have information that gives them details which they need to tell them what they can expect. Copies are also available at the reception. Although some of the information is being updated, DS0000058608.V358568.R01.S.doc Version 5.2 Page 10 it tells people who is responsible for the home, who to speak to and how they can make a complaint if they are unhappy. People who live at the home have a signed agreement about the purpose of their stay, proposed length of stay, and fee levels. This should help them to understand their rights and the homes responsibilities but they are not written in plain English and could be difficult for everyone to understand. By looking at the records kept at the home we could see that each persons needs are assessed before they move to the home, either by a local authority social worker, the manager, or by both. This is so that the acting manager can be sure that the home is suitable for meeting the needs of people who are going to live there. The acting manager also finds out the cultural and lifestyle needs of people who wish to move to the home to make sure that these can be met. She does this by asking about their backgrounds and how they expect that the home will meet their cultural needs. The acting manager has completed training so that she is able to carry out these assessments. As a result of these measures, all of the people living at the home at present have been properly placed there and the home is able to meet their needs. One person living at the home said, “I was finding it hard to live at home as I hadn’t been well, they came and asked me lots of questions about what I could do for myself and what I like.” There are some people at the home who have specialised needs or they are already having treatment. The manager asks for advice and guidance from healthcare specialists to make sure that these needs are best met. The home does not provide care for those people who have been admitted on a short-term basis to get special therapy while they recover from injury or hospital treatment. No one has been admitted to the home with these needs. The acting manager was clear about her responsibility only to admit people who can be successfully supported, and about the number and type of care that the home is registered to provide. This helps to make sure that only people whose needs can be met are admitted but she does not currently write to people to confirm that their needs can be met. DS0000058608.V358568.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each person has an individual plan of care, which should set out in detail their preferences and how their assessed needs will be met. But these do not fully describe the measures which staff are to use therefore making it difficult for them to consistently meet peoples’ needs. Peoples’ health care needs are generally met by the home but the way that staff at the home store and give out medication does not make sure that people living at the home receive the medical treatment they have been prescribed. People who live at the home feel that they are well treated and their privacy is respected which helps them to stay confident and in control of their lives. DS0000058608.V358568.R01.S.doc Version 5.2 Page 12 EVIDENCE: All people who live at the home have a plan of care which gives a description of how their needs are to be met. Staff write about some events or what they have seen into these records. However the care plans themselves did not match the actual support and intervention which staff currently carry out. Staff have a variety of knowledge and experience of caring for people living at the home but this information is not yet successfully combined in the care plans so that these can be used to consistently provide fully co-ordinated care. All of the staff interviewed could describe peoples’ needs, preferences and histories, however the potential areas of good practice were not generally shared with colleagues nor were these written down in care plans. People living at the home are not generally involved in their care planning and people don’t sign them. One relative said, “ I didn’t know my mother has a care plan, I don’t think anyone has shown her it.” Additionally for some people who have lived at the home for a number of years, some of their needs and wishes have changed with time. Staffs’ knowledge and understanding of their needs had not been written into care plans. This is particularly important where for example peoples’ social or physical needs had changed significantly, for example if they had been admitted to hospital for treatment or had developed dementia type illness. The home Registered to provide care to people who have dementia. Care planning arrangements for these people do not yet reflect current best practice. For example, care plans do not specify how people who have an altered sense of time or reality are to be supported or what their personal timescales actually are. Care plans, which place the person at the centre of a network of support for their needs and lifestyle requirements, are yet to be put in place. This can be particularly important for people who become increasingly reliant on staff as their level of dementia increases. One relative said, “I really like the staff, they are very caring and I couldn’t fault their commitment, but my mum keeps forgetting things and I have to keep on reminding the staff about things that are important to her.” The manager can show that she has been careful to make sure that people living at the home are able to be successfully supported there and do not require nursing care. She shows a full understanding of the needs of the people who live at the home and works in close partnership with community based healthcare staff. Due to their levels of need, most people who live at the home are not able to organise their own medicines, and appointed staff therefore help in this area. DS0000058608.V358568.R01.S.doc Version 5.2 Page 13 Staff at the home have taken training in relation to medication administration. Medication is securely stored and records are kept which should help staff to make sure that people living at the home have the medication that they have been prescribed. But five of the six records examined had mistakes and there were a number of errors. For example, at separate times, three people had not been given their medication, one person was short of medication which could not be accounted for, one person had too much medication in stock showing that it had not been recorded when administered. Some people’s Doctors have prescribed them medication which they can take if they are upset or stressed. Where this is the case, staff have to help people who live at the home to decide when they should take their medication. At this home, staff said that they recognise when people should be encouraged to take their medication but the way that they make this decision is not agreed or written down. People who use the service and their relatives made positive comments about the approach of staff and they stated they are treated with courtesy and that staff are always polite. Those asked confirmed that staff respected their privacy and they were seen to knock on people’s bedroom doors and respect their personal space. DS0000058608.V358568.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some people who live at the home are encouraged and supported by the staff to lead fulfilling lives. But this could be improved if staff had a better way of supporting the lifestyle needs of people who are more needy or have a dementia type illness. The meals provided offer an interesting balanced diet, which helps people who live at the home to eat healthily and supports their physical and emotional wellbeing. EVIDENCE: There are regular visitors to the home and staff were seen to make them feel welcome. Contact with family members and friends are supported by where possible so that people keep up links with those outside the home. People who are able to get around the home or local community on their own talked of the things that they do both inside and out of the home, for example visiting the shops, public houses and their friends in the local and wider community. There DS0000058608.V358568.R01.S.doc Version 5.2 Page 15 are photographs around the home, which display big themed social events, which are held about once a year and have a lot of preparation and thought put into them by staff. But the home is not able to successfully support people who are more needy and require help to have their lifestyle needs met. The home has not had an activities co-ordinator in post for over a year. Some people living on the ground floor were worried about not having things to do, being disinterested and bored. One person living at the home said, “I just can’t stand watching the telly all the time.” Another person said, “I like to do puzzles but I’ve only one book and I’m frightened I run out and I’ll have nothing to do.” The home provides for the needs people who have dementia type illnesses. These people live together in one part of the home on the first floor. Although staff do spend time talking to people, which is good, there is little for people to engage in. A structured programme, specifically designed to support, interest and help to structure the lives of people with these needs is not in place. People living at the home are encouraged to make choices about their diet. Although not everyone found the food to their taste, most said that they like the meals at the home and that they are asked what they would like to eat. Staff were seen asking people about their choice of meal, size of portion to make sure that they had their choice of meal. Comments from some of the people living at the home were, “The food’s OK, I like it.” “The cook tries hard to keep everyone happy.” Some people have specific foods that they wish to eat or have a particular condition which restricts the foods that they can eat. When these diets were discussed with staff and the cook they had a general idea of the types of food that people could eat, but this was not written down so that everyone would be clear about their food choices. Records in peoples care plans did show that staff monitor peoples weight to make sure that they are not suffering from an illness. Staff are available during meals to offer support and assistance where needed. The cook describes her meals as “good home cooking” and uses fresh ingredients including a variety of fresh vegetables to improve their nutritional value. The cook said that she talks to people who live at the home about the food they like to eat. DS0000058608.V358568.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints system which people who live at the home or their families can use if they are unhappy, have a grievance or dispute. They also give feedback when they are happy with the service. This helps them to have control over their lives and shows that their views are valued. People who live at the home have support to access advocacy services which can help make sure that their best interests are represented. There are measures in place which protect people who live at the home from being harmed which helps to promote their safety and security. EVIDENCE: There is a clear procedure in place at the home which tells people how to complain and the length of time a response will take. Observations of the acting manager’s and staff’s day-to-day practices show that they ask for peoples’ views and promote choice and decision making. People living at the home and their visitors said that they would feel comfortable about approaching senior staff if they had any concerns, and most were confident that these would be dealt with. DS0000058608.V358568.R01.S.doc Version 5.2 Page 17 People living at the home are encouraged to take part in local or national elections and to maintain their roles as citizens in any democratic process. Whilst there have been no instances where abuse has taken place, the home has an adult protection procedure which has been used where abuse has been suspected. This has helped to make sure that the people who are vulnerable and living at the home are properly protected. There is a staff guide that gives clear instructions about the actions which they must take if abuse is disclosed or witnessed. All staff spoken to are knowledgeable of these practices and have had training as part of their introduction to the home. DS0000058608.V358568.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in homely purpose built accommodation, which promotes their privacy, independence and comfort during their stay at the home. EVIDENCE: All communal areas and some of the bedrooms were viewed during the inspection. Ashbourne Lodge is a purpose built home which has been specifically designed to provide accommodation for older people with a range of needs. The building is spacious and has fairly modern offering warm, comfortable and cheerful accommodation for older people who live on two floors. The building has been designed to provide a good selection of lounge and dining areas to give people a variety of places in which they can spend their DS0000058608.V358568.R01.S.doc Version 5.2 Page 19 day. Each of the floors or areas has two lounges and separate dining areas. There are corridors with seating areas which are popular places for people who live at the home to spend their time talking to each other, staff and visitors. All areas are furnished with comfortable seating, attractive occasional furniture and floor coverings and wall decorations. There is a maintenance programme and staff to carry this out but there were several areas where remedial work was needed. For example on the first floor, the paintwork and decoration was needed to corridor areas, there were broken blinds, the shower needed to be refurbished and the extraction fan mended, plaster / paintwork damage to the stairwell needed to be repaired. These were brought to the attention of the manager who said that plans were in place to carry out remedial work. Some of the comments from people living at the home and their relatives said that it is difficult to get maintenance carried out on a weekend, for example broken light bulbs. Some of the lighting on the first floor does not have shades therefore making the lights painful to look at. Apart from not looking ‘homely’ this lighting is unsuitable for people who do not have the capacity to realise these dangers. There are several garden and patio areas around the home which people use in better weather. Overall service users were satisfied with the quality of accommodation. One person said, “I like my room I’ve made it my own.” Another said, “I can stay in my room if I want to – they will bring my meals, I have everything I need.” People who have dementia live on part of the first floor of the home. At present there are no adaptations in place which help to make sure that current best practice for people with dementia can be followed. For example, changes to signage around the home, the placing of appropriate photographs and creating distinct colour contrasts / schemes to people to find their way around. Research by experts has shown that adaptations like this help to support people with dementia who may become increasingly needy. Laundry facilities are well maintained and run to make sure that all laundry is hygienically cleaned. The laundry is well equipped and in a separate area away from peoples’ rooms. Arrangements are in place to make sure that clean clothing is always returned to their owner and mistakes are avoided. Inspection showed that one of the procedures used does not help to reduce the risks of cross infection which was brought to the attention of the manager and the practice changed. The home is inspected by the Fire Prevention Authority and the local council to make sure that the building and safety systems are suitable for the protection of those who live and work there. DS0000058608.V358568.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall there are sufficient staff working at the home to meet the needs of people who live there. The majority of staff have undertaken training to make sure that their care practice is good and the acting manager guides them to make sure that they support people properly The ways that staff are employed is robust and makes sure that people living at the home are protected from those who are unsuitable to work with vulnerable persons. EVIDENCE: The manager has organised the home so that overall there are sufficient staff available to meet the needs of people who currently live there. Staff support each other and work as a team so that people who live at the home will benefit. Over half of the staff team have now attained NVQ awards in care at level 2, the remainder are all working towards either Level 2 or 3. There is a plan in place which describes the training which staff are to undertake and is based on their personal training requirements and interests. DS0000058608.V358568.R01.S.doc Version 5.2 Page 21 The manager makes deliberate attempts to recruit staff from similar cultural backgrounds as the people living at the home. In some cases they share the same community and social links which helps to ensure that people are confident with the way in which they are supported. Examination of files for staff newly appointed in the home confirm that rigorous checks are carried out before they are employed to work in there. This includes receiving appropriate references and completing the necessary criminal record check. Staff files contain employment history, records of training and any training certificates. One person who lives at the home said, “The staff are very caring.” Another said, “The staff are very good – you couldn’t fault them.” DS0000058608.V358568.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The home has a new manager who could improve the quality of the service for the people who live there by giving staff long-term leadership and direction. Steps are in place which makes sure that people’s financial interests are safeguarded and accurate records are kept. This supports them to remain independent and helps if they or their families have a query. The way that the manager improves the quality of service provided at the home is not organised and written down. This makes it difficult for people to see how well the home is run and whether plans are in place to make it better to live there in the future. DS0000058608.V358568.R01.S.doc Version 5.2 Page 23 Arrangements to make sure that the health safety and welfare of people who live, work or visit the home are in place and are usually successful. EVIDENCE: There is a new manager at the home who has been in post for three months before this inspection took place. She has been appointed by the owners but has not yet been assessed by the Commission for Social Care Inspection to make sure that she is suitable to be the manager of the home. The manager has a National Vocational Qualification in Management and in Care both at Level 4 and was the registered manager at her previous service. The manager is supervised by a representative of the company who owns the home who also carries out monthly visits to the service. She is supported by a team of senior staff who have clear lines of accountability within the home and within the organisation. One relative said, “ If I have any problems I just see the manager, the boss.” Senior managers visit the home to collect the views of the people who live there, their families and friends so that they can check to see if the service is meeting the needs and expectations of all parties. But there is not an overall management plan for the home which shows the specific steps and timescales that are to be taken to achieve targets and make sure that the quality of service improves. The home helps some people to manage their day-to-day spending and records are kept of these transactions which were found to be accurate. There are many fire doors at the home, these are mostly people’s bedroom doors and there are safety procedures in place to make sure that people remain safe if there is a fire. There has also been a minor fire in the laundry at this home in the last six months. However, there are many people at the home who prefer to keep open their bedroom doors which means that the homes procedure to keep people safe if a fire occurs would not work and people would be at risk. There are a variety of chemicals and cleaning materials which are used at the home but the information sheets which tells, users and medical staff what treatment to give if someone has an accident with them is not available. DS0000058608.V358568.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 2 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X 2 X 3 2 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 2 X 2 X 3 X X 2 DS0000058608.V358568.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement The person responsible for the home must send a letter to service users after they have been assessed to confirm that their needs can be met by the home. This is so that people will know that their needs can be met by the home. 2 OP7 15 This is a new Requirement. The person responsible for the home must make sure that all care plans must have enough detail to show the specific actions staff are to take to support their needs preferences and lifestyle. Reviews must reflect the progress towards those goals. This is to make sure that staff plan and review how they work with people and that they write this down so that everyone in the home works in the same way. This is a new Requirement. DS0000058608.V358568.R01.S.doc Version 5.2 Page 26 Timescale for action 19/03/08 01/04/08 3. OP7 12 The person responsible for the home must make sure that all support for people with dementia follows current best practice and this is recorded in each persons care plan. This is to make sure that people who have dementia at the home are supported in ways that are most suitable for them. 01/04/08 4. OP9 13 This is a new Requirement. The person responsible for the home must make sure that there is an accurate record of all medication held at the home. This is to make sure that people get the treatment they have been prescribed. 15/03/08 5. OP9 24 This is a new Requirement. The person responsible for the home must make sure that the process for monitoring and making sure that medication is accurately administered, is effective. This is to make sure that people get the treatment they have been prescribed. 19/03/08 6. OP9 13 This is a new Requirement. Where people are prescribed medication to take only when they need it, the person responsible for the home must make sure that staff have clear guidance which show how staff have made these judgements. This is to make sure that people get the treatment they have been prescribed. This is a new Requirement. DS0000058608.V358568.R01.S.doc 19/03/08 Version 5.2 Page 27 7. OP9 13 The person responsible for the home must take steps to make sure that medication is not accidentally lost. This is to make sure that people get the treatment they have been prescribed. 19/03/08 8. OP12 16 This is a new Requirement. The person responsible for the home must make sure that there is a structured programme of activities for everyone at the home, with staff available to support people who need it. This is to make sure that peoples’ lifestyle needs are met 29/03/08 9. OP12 16 This is a new Requirement. The person responsible for the home must make sure that there is a structured programme of activities which is specifically designed for people who have dementia and follows current best practice guidance. This is to make sure that people with dementia have their lifestyle needs met. 29/03/08 10. OP19 23 This is a new Requirement. The person responsible for the home must make sure that the home is properly maintained. This is to make sure that people are able to live in a comfortable home. 29/03/08 11. OP22 23 This is a new Requirement. The person responsible for the home must make sure that adaptations to the home are in place that support people with dementia and follow current best DS0000058608.V358568.R01.S.doc 01/05/08 Version 5.2 Page 28 practice. This is to make sure that the needs of people with dementia are met. 12. OP25 23 This is a new Requirement. The person responsible for the home must make sure that lighting appliances which are suitable for service users are used at the home. This is to make sure that lighting is suitable for people who are frail or have reduced capacity. 13. OP31 8 This is a new Requirement. The person responsible for the home must make sure that there is a registered manager at the home who is suitably trained, qualified and experienced. This is to make sure that the home is run by someone who is fit to be in charge. This is a new Requirement. 14. OP33 24 The person responsible for the home must make sure that plans are written down about how the home is to be run and improvements made. This is to show how the home responds to service users comments and tells people about the measures that will be put in place to improve the quality of the service. 15. OP38 13 This is a new Requirement. The person responsible for the home must make sure that there is information available about all hazardous materials used in the DS0000058608.V358568.R01.S.doc 01/04/08 01/05/08 01/04/08 15/03/08 Version 5.2 Page 29 home. This is in case anyone is injured by them. 16. OP38 23 This is a new Requirement. The person responsible for the home must make sure that people are not at risk by keeping bedroom fire doors propped open. This is to help prevent dangers if there is a fire at the home. This is a new Requirement. 15/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 OP1 Refer to Standard Good Practice Recommendations The home’s terms and conditions of residency or contract should be re-written so that it is in plain English. This is so that it is easier for everyone to understand. DS0000058608.V358568.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 DS0000058608.V358568.R01.S.doc Version 5.2 Page 31 - 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. 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