Care Home: Amphion Lodge

What the care home does well Pre-admission assessments are thorough and make sure the home can meet people`s needs. The staff understand the needs and preferences of all the people who live at the home. People`s health is looked after and one healthcare professional said they feel the home looks after their patients well and staff usually have the skills and experience they need to do this. Everyone said that staff listen to them, and act on what they say. Visitors said they are always welcomed. The medicines administration procedure, observed during the inspection, was careful, safe and accurate. People said they enjoy their meals and there were drinks available throughout the day. The cook is aware of people`s dietary needs and preferences. The kitchen and the rest of the house is clean, safe and well maintained. The complaints and adult protection systems work well and everyone said they know and understand what to do if they have a concern. The laundry is well organised and people`s personal clothing and the other linen is well cared for and hygienically washed. What has improved since the last inspection? All the requirements and recommendations made at the last key inspection have been met. The medication records and administration systems have improved and, although further work is needed, they are safer and more accurate than at the last inspection. The home`s refurbishment programme throughout the house and gardens is making the home more attractive as well as improving the facilities. Since the last inspection a lot of work has been put into improving the management of the home. This has resulted in the home being at full occupancy, better care and support for the people who live at the home and improvements for the staff. The staff recruitment process is more thorough and makes sure all staff have had a Criminal Records Bureau and Protection of Vulnerable Adults register check before starting work. The staffing levels have been increased to meet the needs of the people who live at the home. Two thirds of the staff now have a National Vocational Qualification in care. The rest of the staff have either begun the course or are soon to start. The training records are up to date and a regular programme of staff training has been put in place. All staff are now having regular one to one supervision with their line manager. People`s personal money, which is looked after for them by the home, is managed better, to make sure all the transactions are accurately recorded. The registered provider visits the home regularly and monthly reports, as required by Regulation 26 of the Care Standards Act, are now being produced. What the care home could do better: The recording and accounting procedures for controlled drugs and medicines supplied in the original packaging need to be improved, to make sure the systems are safe and people are receiving their medication as prescribed. An improved programme of activities would be beneficial to the well-being of the people who live at the home. To make sure that people`s needs are being met and any potential risks are minimised, the care plans need to include more detailed risk and health care assessments. People`s personal information is stored in an office, which is not always locked when it is not being used. As this information is confidential, it is important that staff make sure these files are securely stored at all times. Refresher training in moving and handling practice would benefit staff, as well as making sure people are being assisted safely. The acting manager must apply to us for registration without further delay. Some relatives commented that they would appreciate it if there were `Better communication...` with them from the home. CARE HOMES FOR OLDER PEOPLE Amphion Lodge 2-4 Auckland Road Doncaster DN2 4AG Lead Inspector Liz Cuddington Key Unannounced Inspection 10:35 7th March 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 DS0000063969.V349794.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. DS0000063969.V349794.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Amphion Lodge Address 2-4 Auckland Road Doncaster DN2 4AG 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) 01302 326050 01302 366001 NONE Amphion Lodge Ltd Care Home 30 Category(ies) of Dementia - over 65 years of age (30) registration, with number of places DS0000063969.V349794.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2007 Brief Description of the Service: Amphion Lodge is registered as a care home for up to thirty older people who have a diagnosis of dementia and who need residential care. Bedrooms are on ground, first and second floors. The upper floors are accessed by a shaft lift. The home benefits from well-tended, secure gardens at the rear of the house. The home is located in a residential area approximately one mile from Doncaster town centre. A regular bus service on Thorne Road is a short distance from the home. Cars can be parked on Auckland Road. The weekly charges are the Local Authority rate of £416.15p. Personal expenses such as chiropody and hairdressing are not included. DS0000063969.V349794.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 2 stars. This means the people who use this service experience good quality outcomes. The purpose of this inspection was to assess the quality of the care and support received by the people who live at Amphion Lodge. The visit to the home was carried out over one day by one inspector. The last key inspection was in January 2007. Since the last key inspection one complaint has been made to us about communication with relatives and the care of someone who lives at the home. These concerns have been investigated and appropriate action taken by the home and Doncaster Social Services. Since the last key inspection the registered manager has left and a new manager has been appointed. During this period, one adult protection matter has also been referred to Doncaster Social Services. The matter did not refer to the home or its staff and was resolved satisfactorily with the help of the home’s management and Doncaster Social Services. The methods used to gather information included conversations with the people living at the home, their relatives and the staff, as well as looking at care plans and examining other records. We sent questionnaires to the people who live at Amphion Lodge, their relatives and healthcare professionals. We received four questionnaires back from people who live at the home, two from relatives and one from a healthcare professional. We also received the home’s self-assessment questionnaire. These questionnaires provide a lot of valuable information to help us form a judgement about the quality of the care and support the home provides. We would like to thank the people who live at the home, their relatives and the staff, for their welcome and hospitality and for taking the time to talk and share their views during the visit. What the service does well: DS0000063969.V349794.R01.S.doc Version 5.2 Page 6 Pre-admission assessments are thorough and make sure the home can meet people’s needs. The staff understand the needs and preferences of all the people who live at the home. People’s health is looked after and one healthcare professional said they feel the home looks after their patients well and staff usually have the skills and experience they need to do this. Everyone said that staff listen to them, and act on what they say. Visitors said they are always welcomed. The medicines administration procedure, observed during the inspection, was careful, safe and accurate. People said they enjoy their meals and there were drinks available throughout the day. The cook is aware of people’s dietary needs and preferences. The kitchen and the rest of the house is clean, safe and well maintained. The complaints and adult protection systems work well and everyone said they know and understand what to do if they have a concern. The laundry is well organised and people’s personal clothing and the other linen is well cared for and hygienically washed. What has improved since the last inspection? All the requirements and recommendations made at the last key inspection have been met. The medication records and administration systems have improved and, although further work is needed, they are safer and more accurate than at the last inspection. The home’s refurbishment programme throughout the house and gardens is making the home more attractive as well as improving the facilities. Since the last inspection a lot of work has been put into improving the management of the home. This has resulted in the home being at full occupancy, better care and support for the people who live at the home and improvements for the staff. The staff recruitment process is more thorough and makes sure all staff have had a Criminal Records Bureau and Protection of Vulnerable Adults register check before starting work. The staffing levels have been increased to meet the needs of the people who live at the home. DS0000063969.V349794.R01.S.doc Version 5.2 Page 7 Two thirds of the staff now have a National Vocational Qualification in care. The rest of the staff have either begun the course or are soon to start. The training records are up to date and a regular programme of staff training has been put in place. All staff are now having regular one to one supervision with their line manager. People’s personal money, which is looked after for them by the home, is managed better, to make sure all the transactions are accurately recorded. The registered provider visits the home regularly and monthly reports, as required by Regulation 26 of the Care Standards Act, are now being produced. 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. DS0000063969.V349794.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 DS0000063969.V349794.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): 3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed before they are admitted to the home, to make sure their needs can be met. EVIDENCE: People said that they were given enough information about the home before deciding to move in, and they had also received a contract. Where possible the home encourages people and their families to visit the home and talk to the people who already live at the home and their relatives. The home invites them to come and spend time at the home, share a meal and maybe take part in the day’s activities. This means that the home can get to know the person’s needs and the individual has the information he or she needs to make a decision. DS0000063969.V349794.R01.S.doc Version 5.2 Page 10 The care plans included pre-admission assessments completed by the home. Before moving into Amphion Lodge, people’s needs are assessed to ensure that the home is able to meet their needs. This assessment forms the basis for the individual plan of care and support. DS0000063969.V349794.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 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s personal and healthcare needs are met. People generally are protected by the medication administration systems. Staff treat people with respect, care and consideration at all times. EVIDENCE: From observation and discussions with staff and people living at the home, it was clear that the staff are aware of each person’s needs and preferences. The staff make sure they provide the help people need in the way they prefer. People said that they always receive the medical and healthcare support they need. The healthcare professional who returned a questionnaire, said that the home always seeks advice about people’s health & acts upon it and that they meet individuals’ care needs and respect people’s privacy and dignity. DS0000063969.V349794.R01.S.doc Version 5.2 Page 12 People said the home has improved over recent months, they said the care is good and the staff are kind and helpful. Relatives said they are very satisfied with the care. Three care plans were looked at, to make sure that people’s health and personal care needs are being met in the way the person prefers. The plans cover each area of the individual’s care needs. They all contain enough information to guide staff in how to care for and support each person. The general manager said that the care plans are to be improved, to make them clearer and easier to use. Not all of the plans contain healthcare assessments, such as assessments for skin integrity or nutrition. Some plans need to include more risk assessments to show that potential risks had been considered and ways to minimise risk had been identified. The care plans are reviewed regularly and showed that, where possible, the individuals and their families are involved in developing and reviewing their plans. The general manager said that the home is working on making sure all the plans include a ‘pen picture’ of the individual. The daily records are kept up to date and include brief information on significant occurrences. There is a system for highlighting information that needs to be passed onto the next group of staff, including staff handover meetings. The medicines are kept safe and secure and the Medicines Administration Record (MAR) charts are securely stored. For security, the medicine cabinet was locked during the time between giving each person their medication. Most of the medicines are supplied by the pharmacy in a monitored dosage system, but some is kept in the original packaging. The MAR charts, which must show clearly the quantities of medicines received and in stock for each person, were examined. The medicines supplied in the monitored dosage system appeared to be administered and recorded accurately. There were signatures to confirm that staff had administered the medicine. During the inspection the member of staff administering medication observed each person taking their medicine and signed the chart immediately afterwards, to confirm this. This member of staff was meticulous in the way she administered and recorded the medication. The records of amounts received, administered and in stock of some medicines that were supplied in their original packaging, did not always agree. For example, five of the six records examined showed different numbers of tablets in stock than there were in the packages. It is important that the records are completely accurate, so that staff can account for all the medicines received and administered and people are confident they are receiving their medicine exactly as prescribed. DS0000063969.V349794.R01.S.doc Version 5.2 Page 13 When controlled drugs were being administered, a second member of staff observed and also signed the MAR chart to confirm the dose had been taken. In addition, it is a legal requirement to keep a separate controlled drugs book. This is to keep an up to date record of the quantities received, administered and in stock of each controlled medicine for each person. The controlled drugs book was not of a suitable type, was not properly laid out and had not been kept up to date. Within two hours of bringing this to the attention of the general manager a suitable book had been purchased and training for staff had been arranged. During the visit, all the staff were seen to treat people with respect and maintain their dignity. The people who commented said that they receive the care they need and are supported to maintain their independence for as long as they are able. People’s relatives confirmed this. Everyone said the staff listen and act on what they say. DS0000063969.V349794.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 & 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to take part in a range of activities. People are offered a good choice of meals to make sure their dietary needs and preferences are met. EVIDENCE: The staff provide a range of activities for people to take part in, if they wish. These are usually recorded in an activities diary, although there was not much information for the last month. People said there were things to do, but would like more. The management is aware that this is an area for improvement and are considering appointing someone to take responsibility for co-ordinating activities and outings. At present a member of staff is doing this as part of her duties. She explained what activities had taken place recently and the home’s plans to meet people’s preferences. During the visit people were listening to relaxing music in one lounge and in the other lounge people were listening to and singing to a recording of songs they know. DS0000063969.V349794.R01.S.doc Version 5.2 Page 15 At present the activities include arts and crafts, singing and dancing, armchair exercises, games, discussion sessions and visits to a local pub for drinks and a meal. A local church group visits once a month. Relatives said they would like to see the home ‘Doing more activities with the residents’ and ‘Having more outings with residents.’ Two of the people who live at the home said there are usually activities available, one person said there sometimes are. The garden has been extensively re-designed with level pathways and raised beds. This will make it possible for people to do some gardening, if they wish. The general manager said they are including people in choosing what they would like to grow and planning the planting. Two people said they always like the meals and two people said they usually do. One person said they are ‘Very good’. The cook explained how the meals are planned, to include the wishes of the people who live at the home and to meet any special dietary needs. Drinks are available throughout the day. People seemed to be enjoying their meals and staff were on hand to discreetly assist people who needed some help and to gently encourage people to finish their meal. The tables were laid with tablecloths and cutlery and drinks of juice and tea were provided. Some of the tablecloths need replacing as they had holes or scorch marks on them. Visitors are always welcomed to the home. One person said ‘They try and make you feel welcome at any time’. DS0000063969.V349794.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 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Most people are aware of how to raise a concern or make a complaint if they are dissatisfied with the service. Staff have received suitable training and understand the adult protection policies and procedures, which makes sure that people at the home are safe. EVIDENCE: Any complaints or concerns are recorded in a complaints file. The actions taken and the outcomes are recorded. Staff said they know what to do if anyone has concerns. The relatives said the home always or usually responds appropriately to any concerns. Most people who live at the home said they know what to do if they have a concern or complaint. One relative said that any concerns they have are dealt with and said that the home has improved over the past year. Newly employed staff are made aware of the home’s ‘whistle blowing’ policies and procedures, to be used if they suspect abuse or see examples of poor practice. The majority of care staff have had adult protection training, and further training is planned. All the appropriate policies and procedures are in place to guide staff. DS0000063969.V349794.R01.S.doc Version 5.2 Page 17 Since the last key inspection there has been one adult protection referral. This was not about the home or its staff. The matter has been resolved by the home, the people involved and Doncaster Social Services. We were kept informed and are satisfied that the issues have been handled correctly and any action needed has been taken. DS0000063969.V349794.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, 21 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a safe, comfortable and well-maintained environment. EVIDENCE: The home is clean and generally well maintained and there is an ongoing refurbishment programme. New flooring has been laid in the dining rooms. Everyone said the home is always kept fresh and clean. One of the bathrooms has been updated and there are plans to improve another bathroom. A new hairdressers room is to be created from a small former bedroom. This may also be a treatment room for use by the chiropodist and other health professionals. DS0000063969.V349794.R01.S.doc Version 5.2 Page 19 The top floor lounge is used for people to have private parties and receive visitors. It is also used for staff training and other events. Since the last inspection a lot of work has been done on the rear garden. There are now paved level walkways leading to large raised beds, which will be used for growing shrubs, flowers, fruit and vegetables. They have been designed so that people can enjoy gardening or just have a pleasant place to sit. New handrails are to be fitted to make it safer for people to walk around the garden. There are plans to build a conservatory, with an entrance from inside the house as well as from the outside. DS0000063969.V349794.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 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff are employed to meet people’s needs. People are protected by thorough recruitment procedures, which ensure that staff are suitable to work with people who live at the home. Suitable training is provided to make sure staff have the skills and knowledge they require to meet people’s needs. EVIDENCE: The staff rotas confirmed our observations that there are enough staff on duty to meet people’s care, social and leisure needs. The home is now at full occupancy and there are three care assistants and one senior care assistant on each shift. The manager’s hours are supernumerary to this. Staff confirmed that staffing levels are adjusted to meet people’s needs. All new staff complete an application form and provide two written references. Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register checks are obtained and no new staff begin work until these checks have been completed satisfactorily. Staff have a copy of the terms and DS0000063969.V349794.R01.S.doc Version 5.2 Page 21 conditions of their employment. The staff files are well organised and all the information needed was clear and easily available. Staff confirmed that they have plenty of training opportunities to support them in their roles. Staff said their training was relevant, helped them understand their role and kept them up to date. Two thirds of the care staff have completed a suitable National Vocational Qualification (NVQ) in care at level 2 or above. The other staff are either taking the course, or will be doing so soon. All new staff take induction and foundation training which meets the Skills for Care criteria. This gives them good training to help them do their job effectively, and provides a sound basis for taking an NVQ course. The organisation has appointed a highly qualified and experienced person to set up a training company to provide training for its own staff, as well as to offer training to staff from other organisations. Currently all staff take the mandatory health and safety and adult protection training, and have regular refresher training to keep their knowledge and skills up to date. In addition staff have training which includes infection control, the Mental Capacity Act, medicines administration, dementia care and the principles of care and person centred planning. DS0000063969.V349794.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 & 38 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is safe and well managed. EVIDENCE: Since the last key inspection the manager has left and a new manager has been appointed. The new manager has the experience necessary to manage the home effectively and is currently taking the Registered Managers’ Award. The manager has not yet applied to be registered with the Commission for Social Care Inspection. This should be done without further delay. DS0000063969.V349794.R01.S.doc Version 5.2 Page 23 The home also employs a General Manager and other support staff to make sure the home is managed efficiently and effectively. One of this team is responsible for making sure people’s personal monies are properly accounted for and securely stored, as well as handling the home’s financial transactions. Another member of the office staff is responsible for quality assurance and is to re-organise the care planning system. The records and the staff confirmed that all staff are now having regular one to one supervision meetings with their line manager. This supports staff to plan their personal and professional development and gives them the opportunity to discuss any areas of concern in a confidential setting. People’s personal information is stored in an office, which is not always locked when it is not being used. As this information is confidential it is important that staff make sure the door is locked when the room is not occupied. The downstairs office is kept locked when unoccupied. The home’s policies and procedures are kept up to date; to make sure they provide relevant information to guide staff on how to act in every situation. All the regular health and safety checks for the home are carried out in a timely manner. These measures make sure that the health, safety and welfare of the people at the home is promoted and safeguarded. The home’s kitchen has recently had an Environmental Health Officer’s inspection. The kitchen was awarded four stars and, when we looked, the kitchen was clean and hygienic. The laundry is well organised and the laundry assistant makes sure that people’s personal clothing, as well as bedding and towels, are properly cared for. People’s clothes are beautifully ironed and all the bedding is ironed before use. There is an integral infection control system in place to make sure that all soiled laundry is washed hygienically. To support the home’s infection control measures soiled laundry should be kept separate, preferably in dissolvable bags which are then placed in the washing machine without staff having to handle these items any more than necessary. The general manager said this had been happening and would check why this system seemed to have stopped. One example of poor moving and handling practice was seen. This was discussed with the senior member of staff on duty. The registered provider keeps in close contact with the home and there is a monthly report on progress. DS0000063969.V349794.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 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 X 18 3 3 3 3 X X X 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 DS0000063969.V349794.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 14(2)(a) Requirement To make sure that people’s needs are fully assessed and understood, all necessary healthcare and risk assessments must be completed and included in each person’s care plan. To keep accurate stock controls, medication records must be completed accurately, so that staff can account for all the medicines received and administered and people are confident they are receiving their medicine exactly as prescribed. To make sure people’s leisure needs are met, an improved programme of activities must be implemented. To confirm that the home’s manager has the necessary skills and experience, the registered provider must apply for the manager to be registered with the Commission for Social Care Inspection. Timescale for action 31/05/08 2. OP9 13(2) 31/03/08 3. OP12 16(2)(m) (n) 7(2)(3) 31/05/08 4. OP31 30/04/08 DS0000063969.V349794.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP38 Good Practice Recommendations To make sure all staff are assisting people safely, moving and handling refresher training is recommended. DS0000063969.V349794.R01.S.doc Version 5.2 Page 27 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 DS0000063969.V349794.R01.S.doc Version 5.2 Page 28 - 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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