Inspection on 18/07/08 for Winscombe Hall Care Home

This inspection was carried out on 18th July 2008.

CSCI found this care home to be providing an Good service.

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

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Poldhu

Queensmount

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Belma

Hunters Care Centre

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Extracts from inspection reports are licensed from CQC, this page was updated on 28/10/2008.

CARE HOMES FOR OLDER PEOPLE Winscombe Hall Care Home Winscombe Hill Winscombe North Somerset BS25 1DH Lead Inspector Juanita Glass Unannounced Inspection 10:30 18 and 23rd July 2008 th 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 DS0000071367.V363971.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. DS0000071367.V363971.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Winscombe Hall Care Home Address Winscombe Hill Winscombe North Somerset BS25 1DH 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) 01934 843553 Cedars Care (Winscombe Hall) Ltd Mrs Susan Jane Welsh Care Home 39 Category(ies) of Dementia (17), Old age, not falling within any registration, with number other category (39) of places DS0000071367.V363971.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with Nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) Dementia (Code DE) - maximum number of places is 17 The maximum number of service users who can be accommodated is 39. 2. Date of last inspection Brief Description of the Service: Winscombe Hall is registered with the Commission for Social Care Inspection to provide care for 39 older people requiring nursing care. The home is owned by The Cedars Care Group, which is a family owned company. They specialise in dementia and nursing care for older people and run various homes throughout England. Winscombe Hall admits male and female residents over the retirement age, which requires personal and nursing care. Part of the home also allows for 17 residents who have dementia and may require nursing. These rooms are located in a separate wing over two floors. They can also provide short-term respite care. The Statement of Purpose says they aim to provide a stimulating atmosphere in which service users can extend their quality of life through social activities, visitors and stimulating surroundings, whilst preserving their independence and choice for as long as possible. The registered manager is Miss Susan Welsh who is a qualified Registered General Nurse with many years experience managing care homes and working in the nursing home sector. A team of qualified nurses, and care assistants supports the manager in the provision of care. Winscombe Hall is an attractive 18th-century converted building retaining many of its original features and character in six acres of ground close to the Somerset Levels and Cheddar. Several of the rooms have en-suite facilities, there are two passenger lifts enabling disabled access to upper floors, however five bedrooms have restricted access, as they are only accessible by stair. The DS0000071367.V363971.R01.S.doc Version 5.2 Page 5 home has three comfortably furnished lounges and two dining rooms. Limited care parking is available for visitors outside the entrance to the home. Current fees are. Residential £369.34 - £425 Dementia residential £428.05 - £450 Nursing £545.86 - £570 Dementia Nursing £580.90 - £605 DS0000071367.V363971.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection took place over two days in the presence of the manager Miss Susan Welsh a total of 8 hours were spent in the home. Evidence to support the findings of this inspection was obtained through written surveys from people living in the home and their relatives. Reponses to our written survey were received from 6 people living in the home and 3 relatives. An Annual Quality Assurance Assessment (AQAA) was completed by the home manager and forwarded to the Commission for Social Care Inspection (CSCI). We The Commission also carried out a review of documentation in the home. This included documents in peoples care plans, staff personnel records and records maintained for the day-to-day running of the home. Whilst in Winscombe Hall we discussed the care provided with 6 people living there on a one to one basis and as a group. We also observed staff working practices and spoke to 5 staff members over the two days. Although the outcomes for people living in Winscombe Hall are Good we will recommend a further inspection be carried out in 6 months rather than the standard two years. This will give the Dementia wing chance to become established and staff to settle into the new routines recently introduced by the manager. What the service does well: Whilst at Winscombe Hall we noticed that staff had a very friendly but professional rapport with people living in the home. There was cheerful chatter between staff and residents with a relaxed and homely approach. On both days of our visit to the home we saw people enjoying various activities being provided by staff. People told us that they were looking forward to the afternoon quiz, which was a regular event. We also saw people taking part in a newspaper discussion group where they were looking at the current news. The surveys we received from people living in the home and their relatives showed that people were happy with the care and support being provided by staff. One survey stated, ‘I have seen a real improvement in the way my DS0000071367.V363971.R01.S.doc Version 5.2 Page 7 relative is being looked after.’ Another survey said, ‘I’m very happy with the way the staff respond to my relatives needs, they are always polite cheerful and respect their dignity, which I think is very important for people this age.’ One person living in the home said they were really happy, enjoyed the quizzes and liked their room. People we spoke to were also relaxed and happy and said staff were cheerful and helpful. One person on respite care said they would be happy to come back next time their relative needed a break. They also said the meals were a pleasure and there was plenty to do if you wanted to join in. What has improved since the last inspection? What they could do better: As a result of this visit we made one requirement about care plans and five recommendations to improve best practice in the home. When we looked at care plans held for people living in the home we noticed that although very good detailed pressure area care plans were in place they did not contain any mention of the type of pressure relief in use and the setting needed for individual pressure relief mattresses. As a result of a complaint received by the manager we have recommended that the qualified staff need to direct care staff so that residents can be observed all times. We also recommended that following the dementia care training staff are currently undertaking, the manager needed to provide some training in managing challenging behaviour. This is not an issue in the home at the DS0000071367.V363971.R01.S.doc Version 5.2 Page 8 moment but it would be best practice if staff have received training before it may become an issue when the dementia care wing is fully occupied. We recommended that the manager follow up the recommendations made by their recent pharmacy inspection carried out by Boots. We also recommended that they draw up an, as required (PRN) medication protocol for people who are on as required medication. This should show what triggers they should be aware of, any intervention they should carry out before giving as required medication and when to use. People living in the home need to have access to well maintained outdoor areas such as the lawned area at the rear of the building or the proposed courtyard area that had still not been commenced at the time of this inspection. 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. DS0000071367.V363971.R01.S.doc Version 5.2 Page 9 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 DS0000071367.V363971.R01.S.doc Version 5.2 Page 10 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, 3, and 5. 6 does not apply Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents benefit from adequate written information, a chance to visit the home and a full assessment of their needs. This means they can make an informed decision before moving in and their needs are fully met. EVIDENCE: We the Commission requested a copy of the homes Statement of Purpose and Service user guide. This was readily available and provided immediately. We saw that it was well written and contained all the information a person would need to tell them about what care the home can and cannot provide. It also states clearly the fees and what they pay for with a list of extra charges clearly mentioned. We spoke to one resident who said they had a ‘book’ that told them all about the home and what they could do. DS0000071367.V363971.R01.S.doc Version 5.2 Page 11 We asked the manager about how they would assess a person who wished to move into the home. She said they would visit the person either at their home or in hospital. They would talk to them, a relative or advocate and staff at the hospital or a social worker. They would also look at existing care plans for the person. We then looked at the records held in the home for people who had not lived there very long. They all had completed assessments and community or hospital care plans. We spoke to the people living in the home; one person said they had felt everything had run very smoothly others did not comment. People wanting to move into Winscombe Hall can visit and spend some time to meet other people living there and staff who will be looking after them. This is often done by a relative or advocate on their behalf. If the manager and staff feel they can meet the needs of the person they will offer a trial period when both the person moving in and staff can decide whether the home is really the best placement for them. DS0000071367.V363971.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from personal and specialist healthcare support that is provided in a person centred way respecting their privacy and dignity. They benefit from and are protected by the homes policies and procedures for the administration of medication which staff follow. EVIDENCE: We looked at the care records for four people living in the home. We saw that the manager had reviewed the care plans so they were person centred and reflected the personal likes and dislikes of the person rather than task led roles for staff to follow. The care plans in place were relatively new and staff said they gave them a full picture of the persons needs. They were easy to read and meant you could tell very quickly when reading them how a person preferred to be looked after. All residents had been given a named nurse and DS0000071367.V363971.R01.S.doc Version 5.2 Page 13 key-worker that was responsible for gathering information and making sure the care plans were kept up to date. All staff spoken to understood the diverse needs of the people in the home. They knew what they liked and how they liked to be cared for. They were also aware of the need to recognise cultural differences and a work manual for anti discriminatory practice supported this, promoting good working practices between staff as well as for residents. When looking at the care plans we saw very clear risk assessments for people these included risk of falling, manual handling and pressure area assessments. We found that they gave very clear guidance to staff. However the pressure area assessments did not state what type of intervention was being used to prevent pressure sores and how they should be managed, for example the care plan needs to state clearly what settings a pressure relief mattress should be set at for the individual. We observed the way staff spoke to people and helped them in their daily activities. They were very respectful and were aware of the need for privacy and dignity when carrying out procedures. We heard staff with a cheerful and friendly rapport talking to residents. We spoke to people living in the home and asked them about the way they were looked after. Everybody said they felt well cared for, one person said they found all the staff very caring and polite. We observed staff respecting people’s private space by knocking on doors and waiting before entering. People living in the home have access to health care specialists and care plans showed that the district nurse could be consulted when the home felt they needed some expert advise. Residents were helped to attend out patient appointments, the dentist and the chiropodist. Regular reviews are carried out with the GP looking at specific health needs and medication. We discussed the receipt, storage and administration of medication with the manager. Boots Pharmacist had carried out a review and inspection a few days before our visit and it was recommended that the manager and staff follow the recommendations made. Staff were observed to handle medication appropriately and they were aware of the policies and procedures in the home. The manager was in the process of arranging a homely remedies protocol with the local GPs’. This is an agreement with the doctor about what medication staff can give that has not been prescribed. We recommended that the manager write a protocol for staff giving PRN (as required medication). This needs to include the signs that staff can see that indicate a person may need medication and when to give it. DS0000071367.V363971.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 good. This judgement has been made using available evidence including a visit to this service. People living in the home benefit from the development of meaningful activities which recognises their diverse needs, likes and dislikes enabling them to maintain some control over their lifestyle. They benefit from continued contact with family, friends and the community. A well-balanced menu means people benefit from a healthy and nutritional diet. EVIDENCE: On both days of the inspection we observed people taking part in organised activities such as quizzes, newspaper reviews and general discussion groups. We noticed a full activities programme advertised on the notice board and a display of craft in the dining room. People we spoke to said there was always plenty to do. One person said they especially looked forward to the quiz and would not miss it for anything. Another person said they had been told about the various activities but preferred not to join in. They said they felt there was plenty to do for those who chose to take part. This person had their own personal radio and plenty of books and magazines they said that staff would DS0000071367.V363971.R01.S.doc Version 5.2 Page 15 come and chat and they never felt isolated. On both days there was a ‘general buzz’ of activity that residents said was an everyday event. People confirmed that they could keep in touch with family and friends’ one person said they had more visitors at Winscombe Hall than when they were at home. People can also attend a regular church service and monthly communion provided in the home. If people express the wish they can receive religious support from their own minister of religion either in their place of worship or in the home. People spoken to indicated that they could keep some control over the way they lived and spent their day at Winscombe Hall. One person said staff respected and supported their choices. Another person being helped to the lounge said they had decided to have a ‘lay in’ that morning and they were being helped to have a late breakfast. Staff confirmed that they could work flexibly to accommodate personal choices. The menu showed that people are offered a choice of healthy and nutritious meals, including fresh meat, fruit and vegetables. People spoken to said they enjoyed the meals. One person said they thought they must have put on weight as they had eaten very well during their stay. Another person said that they could have a choice and felt comfortable telling staff if they did not like anything on the menu. Staff were aware of the need to be flexible with mealtimes especially breakfast, and the need to recognise personal and cultural preferences. Any dietary requirement such as medical, personal or cultural could be accommodated. Meal times in the home were observed to be relaxed and people were offered assistance in a dignified way. Nobody was hurried to finish and one person said they were always a bit slower but no one insisted they hurry up. DS0000071367.V363971.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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from and are protected by the complaints and safeguarding procedures in the home. Staff are fully aware of the procedures to follow to protect people from abuse. EVIDENCE: We looked at the homes complaints policy and procedure. It was easy to read and when asked one resident said ‘I have a copy of it here in the book they give you. If I have got something to say I know where to go and who to talk to.’ Another resident said they knew what to do and felt it a waste of time an inspector asking them as the manager would deal with any problems they had very well. One complaint had been received by the manager, which The Commission had been copied into. The manager had made a very clear record of the complaint, how she had investigated the issues raised and her response. The home also has a robust policy and procedure for Safeguarding Adults who may be vulnerable to abuse. Staff spoken to said they knew what action to take, they were aware that there was a local authority procedure and where to access the information if they needed to. Training on the North Somerset DS0000071367.V363971.R01.S.doc Version 5.2 Page 17 policy and procedure had been provided for some staff and a further date was being arranged for the remaining staff. A Random Inspection was carried out on 28th April 2008 we found that the people living in the home were protected from possible abuse by the way the manager had acted following information she had received about a member of staff. The manager and companies Human Resources had followed the correct procedure. DS0000071367.V363971.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, 20, 24, and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People benefit from a comfortable, well-equipped and homely environment, which is well maintained and decorated. People do not benefit from going outdoors as access to outdoors areas is limited. People are protected by staff awareness of appropriate infection control guidelines. EVIDENCE: Winscombe Hall is a large listed building which has been adapted to provide accommodation for 39 people. There is a separate wing that provides care for people with dementia although this was not established at the time of the inspection. The homeowners have provided equipment and adaptations as required to meet the needs of the people living in the home. Recommendations made by the registration team have been followed. This means that window restrictors are in place and inappropriate furniture DS0000071367.V363971.R01.S.doc Version 5.2 Page 19 replaced. The provision of electromagnetic firedoor stops for individual bedroom doors was ongoing. All rooms seen were well decorated and some people had bought in their own furniture and belongings. The dementia wing has its own dedicated lounge and dining room, however these were not in use on either day of the inspection, as the wing has not been fully established. All areas of the home were clean and well maintained with planned re-decoration of rooms as they become available. One person said they had a very nice room with a good view. All rooms were bright and well lit. Another person said they had all their own possessions in their room but did not want anyone looking in. We discussed the provision of outdoor access and plans are being considered for the proposed courtyard area development. The lawn and garden area at the rear of the house does not encourage people to go out and sit, as it needs to be better maintained. People spoken to said they did not sit outside often. Staff were seen to observe good Infection Control procedures using personal protective clothing and cleaning materials appropriately. DS0000071367.V363971.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. People benefit from and are protected by the staffing levels and skill mix of staff in the home. The homes recruitment procedures and staff training further protect them from the possibility of abuse. EVIDENCE: We looked at the personnel files held by the home for some of their staff. We looked at the employment records for three recently employed members of staff. We also looked at the staffing rota and the training records for people working in the home. We found that there were appropriate numbers of staff working in the home on each shift; we also looked at the proposed staffing levels that will be in place when the Dementia wing has become more established. The manager confirmed that staffing the new wing was difficult and they would need to use agency staff until a full complement of staff had been recruited. There was a good skill mix of staff with qualified staff, senior carers, care staff and new staff who work supervised until they have completed their induction. All new staff complete an induction that is linked with the Common Induction DS0000071367.V363971.R01.S.doc Version 5.2 Page 21 Standards for Skills for Care and underpins the NVQ 2 In Health Care. Care staff are encouraged to obtain an NVQ qualification. Following a complaint by a relative we recommended that senior staff deploy care staff so that residents are not left unobserved in communal areas. We looked at employment files and found that the manager follows the homes strict policy and procedure on staff recruitment, obtaining all the required documentation before they commence work. This protects residents from the possibility of abuse by ensuring all new staff are appropriately checked. Staff training records showed us that the home supports staff in continuing to attend all mandatory training and to attend training that is specific to their role in the work place or to the identified needs of the people living in the home. The manager has ensured that all outstanding training has been bought up to date. Staff have also attended training in Dementia Care and the home has obtained the Alzheimer’s Society training package ‘Yesterday, Today and Tomorrow.’ We recommended that staff should also attend training in Managing Challenging behaviour. This was not an issue in the home at the time of the inspection, but it would be good practice to have staff trained before any issue is raised when the Dementia wing is fully established. Staff said they felt well supported in attending training and in the staffing levels in the home, they said there was plenty to do but enough staff to ensure residents had one to one attention as well as meeting their activities of daily living. DS0000071367.V363971.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, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from living in a well run home with an appropriately qualified manager and supervised staff. They are protected from financial abuse through safe and stringent policies for managing resident’s money. Both people working and living in the home are protected by robust health and safety procedures. EVIDENCE: The registered manager is Miss Susan Welsh who is a qualified Registered General Nurse with many years experience managing care homes and working in the nursing home sector. A team of qualified nurses, and care assistants supports the manager in the provision of care. People spoken to said they felt they could talk to anybody at anytime. They felt they could go to the manager DS0000071367.V363971.R01.S.doc Version 5.2 Page 23 and speak to her in confidence. Staff also said they felt that the approach to managing the home was open and inclusive. The home does not manage money for many of the people living in the there. They encourage relatives or advocates to ensure people are protected from financial abuse. We did a random audit on the finances held for two people living in the home. A very strict procedure is followed so that income and expenditure is recorded and proof obtained through receipt or copies of payments made. The audits showed that there were no errors. The manager stated that the company does carry out relative and resident surveys, and a survey would be carried out in the near future once the new ownership was well established. The manager also stated that the Annual Quality Assurance Assessment completed for the Commission helped as a tool to looking at how they have developed and what further improvements are needed. There are also regular management reviews when any improvements and developments in the home are discussed. Quality Assurance is an area that will be followed up at the next inspection. The manager has introduced and carries out regular supervision with current members of staff. Supervision sessions include looking at working practices and identifying training needs which staff are encouraged to access either in house or through external organisations. Staff stated that they felt well supported by the management team. Health and safety within the home is generally satisfactory. The manager has carried out new risk assessments to cover the entire home and working practices. Staff are kept informed of the new assessments. The manager has also obtained contracts with companies to ensure all equipment used in the home has a service agreement. The fire log was reviewed and showed that all the relevant checks were being carried out appropriately and that all staff had attended training. The home policies and procedure for health and safety to safeguard residents and staff had been reviewed and up dated as necessary. DS0000071367.V363971.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 X 3 X 3 N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 X X X 3 X 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 3 3 3 X 3 3 X 3 DS0000071367.V363971.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 OP7 Regulation 15 (1) Requirement The manager must ensure that pressure area assessments include a description of equipment in use and the settings for mattresses. This is to ensure people benefit from well-informed staff that can deliver individualised care to prevent pressure sores. Timescale for action 01/09/08 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 2 3 4 Refer to Standard OP9 OP9 OP20 OP27 Good Practice Recommendations The manager and staff need to follow the recommendations left by the Boots Pharmacy inspector. The manager needs to develop a protocol for the administration of PRN (as required medication). The owner needs to ensure that residents have access to well maintained outdoors areas. The manager needs to ensure that qualified staffs deploy DS0000071367.V363971.R01.S.doc Version 5.2 Page 26 5 OP30 care staff so residents are not left unobserved in communal areas. The manager needs to provide training for staff in Managing Challenging Behaviour before the Dementia Unit is full. DS0000071367.V363971.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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