Care Home: Bhajan Kaur Rai Hall

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What the care home does well What has improved since the last inspection? Staffing levels have been improved to provide additional support for residents who require assistance at meal times. A new satellite kitchen has been installed in response to suggestions made at the residents meeting. All corridors have been redecorated. Sitting rooms on both floors have new, flat screen televisions. There were new chairs in the ground floor sitting room. There were recorded fire drills, as required following the last inspection. The Registered Manager said that she felt that there was better team cohesion and that the implementation of a new training programme enabled staff to access training without disruption to staffing rotas. What the care home could do better: Requirements: (what the home must do to improve the service) Care staff who undertake nursing tasks, such as blood pressure monitoring, must receive adequate training to ensure that they are aware of irregularities which may require medical intervention. Recommendations: (what the home should do to improve the service). Staff should proactively seek health professionals` advice to assist with possible issues regarding monitoring health, continence care and medication management before they become of concern. Staff should ensure that residents are provided with a choice of planned, appropriate and varied activities that reflect their specific needs. The Annual Quality Questionnaires should be collated and actioned and written feedback provided in the Statement of Purpose and Service Users Guide to show that comments from residents and others help to improve the service. CARE HOMES FOR OLDER PEOPLE Bhajan Kaur Rai Hall Epinal Way Care Centre Hospital Way Loughborough Leicestershire LE11 3GD Lead Inspector Mrs Carole Burgess Unannounced Inspection 14th April 2008 09:00 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 Bhajan Kaur Rai Hall DS0000001655.V362387.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. Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bhajan Kaur Rai Hall Address Epinal Way Care Centre Hospital Way Loughborough Leicestershire LE11 3GD 01509 216616 01509 262710 surjit@rushcliffecare.co.uk 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) Rushcliffe Care Limited Mrs Karen Joy Wragg Care Home 33 Category(ies) of Dementia (12), Dementia - over 65 years of age registration, with number (22), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (12), Old age, not falling within any other category (21), Physical disability (21), Physical disability over 65 years of age (21), Sensory Impairment over 65 years of age (21) Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. BKR Hall care home is registered to provide personal care to male and female service users who fall within the following categories:Physical disability over 65 years of age (PD(E)) 21. Physical disability over the age of 55 years (PD) 21. Old age, not falling within any other category (OP) 21. Sensory impairment over 65 years of age (SI(E)) 21. Mental disorder, excluding learning disability or dementia - over 65 years of age (MD(E)) 12. Dementia - over the age of 65 years (DE(E) 22, Dementia over the age of 55 years (DE) 12. Dementia, over the age of 65 DE(E) 12. Persons accommodated at BKR Hall under the categories of DE and DE(E) should be accommodated on the first floor only. The maximum number of persons to be accommodated on the first floor of BKR Hall under the DE and DE(E) categories is 12. Persons accommodated at BKR Hall under the categories of PD, PD(E), OP, MD(E) and SI(E) should be accommodated on the ground floor only. No one falling within the category MD(E) should be accommodated at BKR Hall when there are 12 persons in total of this category already accommodated within the home. The maximum number of persons to be accommodated on the ground floor at BKR Hall is 21. The maximum number of persons to be accommodated at BKR Hall in total is 33. 17th May 2007 2. 3. 4. 5. 6. 7. Date of last inspection Brief Description of the Service: Bhajan Kaur Rai Hall Care Home provides personal care and accommodation for 33 people with physical and mental health needs. It provides separate accommodation for those people with dementia. It is located next to the Loughborough Hospital, and approximately one mile from the centre of Loughborough and easily is accessible by public transport or car. There is parking for visitors. The home is purpose built with all the adaptations needed to support the residents. There is a good standard of decoration throughout the home and all of the bedrooms have en-suite facilities. Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 5 There are bedrooms and communal space on two floors with large dining rooms and comfortable sitting rooms with televisions, videos and books. Both floors are accessible by stairs, or a passenger lift that is suitable for wheelchair users. The home has a garden and patio area to the front and back of the building, which is well maintained, that residents can use in the better weather. The Statement of Purpose, Service Users Guide & Inspection Report are available on request (these provide information on how the home is organised and what services they provide). The Statement of Purpose and Residents’ Guide are provided for all new residents. At the time of the inspection the Registered Manager said that the weekly fees were within social service banding or £433 to £456 per week depending on care needs. There are additional costs for individual expenditure such as hairdressing. Bhajan Kaur Rai Hall DS0000001655.V362387.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 stars. This means the people who use this service experience good quality outcomes. The focus of the inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. The site visit was unannounced and took place over six and a half hours. The Inspector selected three residents and tracked the care they received through a review of their records, discussion with them (where possible), other residents, relatives, the care staff, and observation of care practices. The Inspector spoke with staff members regarding training and support. Planning for the Inspection included assessing notifications of significant events and a review of the Annual Quality Assurance Assessment (AQAA) sent to the CSCI by the home. The Registered Manager and other staff spoken with were positive and helpful during the inspection. What the service does well: BKR Hall provides a good standard of care within a bright, spacious, and homely environment and has a cheerful and busy atmosphere. The home maintains a good standard of décor and cleanliness throughout. The home and garden are well maintained and provide a safe environment in which residents can be supported to maintain as much independence as possible. Food is nutritious and well-presented, individual diets and preferences are catered for, and the cook and staff are very flexible to ensure that residents’ requests are accommodated. Residents confirmed that staff are very caring and respectful, ensuring their privacy and dignity at all times, and are always welcoming and supportive to relatives. Visitors are made very welcome. A relative said that, ‘Karen (the Registered Manager) and all of the staff are just out of this world. We couldn’t ask for anything more’. Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 8 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. Bhajan Kaur Rai Hall DS0000001655.V362387.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 Bhajan Kaur Rai Hall DS0000001655.V362387.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, 2, & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with good information about the home, and have their health, welfare and social care needs assessed, so that staff have the necessary information to enable them to meet the resident’s needs once they move into the home. EVIDENCE: The home provides prospective residents and their relatives with a Statement of Purpose and Service Users Guide (both give information about the home) to help them decide if the home is the right one for them. These documents, and the complaints policy and procedure, should also include social services contact Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 11 details and the new contact details of the CSCI when next reviewed and updated. Copies of contracts (terms & conditions) were kept in residents’ files and residents, or their relatives, could be provided with a copy. The three residents’ care plans reviewed contained a detailed pre-admission assessment to show that the home could meet their specific health, welfare, and social care needs. It included personal details, relative and GP contact numbers, past and present medical history, current health care requirements and medications, personal preferences, social interests and hobbies to ensure that the home could meet all of a prospective residents needs. The home does not provide intermediate care. Bhajan Kaur Rai Hall DS0000001655.V362387.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): 7, 8, 9, & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well looked after in respect of their health to ensure that their health and personal care needs are met, but attention to detail would demonstrate a proactive approach to managing potential healthcare issues. EVIDENCE: Residents’ care plans were detailed and gave carers good information about the health, personal and social care needs of the residents. Residents said that they could see their GP when they needed to and were supported by staff to access healthcare services. Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 13 The residents and/or their reptresentaive had signed to say they agreed with their plan of care. The care staff had reviewed all care plans regularly so that residents’ care needs continued to be met. Contact with healthcare professionals such as GP’s, District Nurses, hospitals, and Chiropodists were recorded to ensure that healthcare needs and treatments were addressed. However, it was noted that a resident who had regular blood pressure checks had a raised blood pressure on one occasion. This had not been re-checked or followed up with the resident’s GP, and could have put the resident at risk. Carers who perform this task need to be given adequate training to ensure that they can recognise changes that need to be followed up by a healthcare professional to ensure that the resident’s health is protected. Medication policies and procedures were sound. Residents were able to continue to self medicate following a risk assessment to ensure that they were safe to do so: no one was self medicating at the time of inspection. Medications is administered by carers who receive annually updated training to safeguard the residents, and ensure that they receive their medication as prescribed. It was noted that a resident who had ‘once-a-day’ tablets had refused to take them, and these had been kept to try again later. It is recommended that the pharmacist or GP’s advice should be sort on how this should be best managed to ensure that a medication mistake does not occur. Observation during the inspection showed that staff have a good awareness of how to protect residents privacy and dignity. Staff spoke to residents and visitors in a respectful, friendly, quiet and supportive way. Five, residents spoken with during the inspection, said that they were very well looked after and that staff were kind, caring and respectful. Bhajan Kaur Rai Hall DS0000001655.V362387.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff work hard to ensure that residents experience a safe and homely life style although more could be done to identify and support personal preferences, and provide appropriate activities for the residents. EVIDENCE: There is an activities organiser who provides 15 hours per week, in addition to her care hours. The provision of activities tended to be patchy with no weekly or ongoing plan in place. There were no activities taking place on the day of the visit although some of the residents were seen to be watching the television. Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 15 The Registered Manager said that residents in the dementia care unit had enjoyed recent art and craft sessions and other residents had occasional bingo and foot spar sessions, which they had also enjoyed. Information regarding residents’ past and present hobbies and social activity could be improved to provide a more rounded picture of what activities residents now preferred, and responded to, especially for those residents with memory loss or dementia. Such details are important to residents and attention to them can either add or detract from the quality of life that they are entitled to enjoy. Although staff had received specific training in the care of people with dementia there was little evidence within the home that such things as memory boxes, daily diaries and specific activities had been introduced to actively address and improve the daily lives of residents with dementia. Residents said that they would like more activities and more trips out. They specifically mentioned shopping and canal boat trips but felt there was insufficient staff to accommodate this. The Registered Manager said that the provision of entertainers was expensive but she was looking into this and into the possibility of arranging a boat trip. Religious and cultural needs are supported although there is no longer a regular Church of England. The Registered Manager is to contact the local church to try to arrange for the re-introduction of regular visits to ensure that residents receive the religious support they need. The Roman Catholic priest visits regularly, as do other denominations on an individual need basis. Nevertheless, staff do support residents with making choices in their everyday lives. All residents spoken with said they got up and went to bed when they wished, were able to choose what they wanted for their meals, choose how to spend their time and were able to have visitors at any time. All meals were prepared in the home’s kitchen by the cook. The kitchen looked clean and well maintained. A cooked breakfast was available every day if required. There were choices at all main meal times. Drinks and biscuits were provided mid morning and afternoon. Special diets such as diabetic and soft diets were catered for. The food provided for lunch looked nutritious and well presented in two pleasant dining rooms. Following the last inspection there were now two staff to assist residents who require help at meal times to ensure that they can enjoy their meals in an unhurried and dignified manner. Staff said that this had improved meal times for residents who required help, as they were able to now spend more time assisting them. Most residents spoken with said that the food was very good and that choice and personal preferences were catered for. One resident said that the food was Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 16 ‘variable’ at lunch times but another said that the food had much improved over the last six months since the new cook was in post. Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for receiving and responding to complaints were satisfactory and the home’s policies and procedures protect residents from abuse. EVIDENCE: The CSCI has not received any complaints about the service since the last inspection. Residents’ and staff comments showed that people feel that they could discuss concerns with the Registered Manager and staff. Residents spoken with said that they had no complaints and that they were well cared for. The home had received four complaints since the previous inspection that were satisfactorily resolved. Information regarding advocacy services was available in the entrance hall for residents and relatives who may require independent support and advice. Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 18 The home’s complaints process reflected the local agreed procedures for Safeguarding Adults ‘No Secrets’ policies. Staff were able to show that they were aware of the correct procedures to follow to ensure the safety of the residents. Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 19 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, 22, 23, & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of accommodation is good and provided residents with an environment that is clean, well maintained, comfortable and homely. EVIDENCE: The home was safe and well maintained with many adaptations to suit residents’ specific needs. It was decorated and furnished to a high standard that creates a comfortable and homely environment, and there was a system of maintenance and refurbishment. Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 20 All residents’ rooms had en-suite facilities and all had a ‘nurse call’, and were clean and well decorated. Residents were able to bring items of their own furniture and possessions with them to personalise their rooms. All residents’ rooms were personalised and some had brought in items of home furnishings. Residents also had access to attractive, safe gardens. There were sufficient additional toilets, bathing and assisted bathing facilities. On the day of the site visit the home was clean, pleasant and hygienic except for one room, which the Registered Manager was aware of and had arranged to address. It was agreed that hourly checks, fluid intake monitoring and the advice of the Continence Nurse might provide additional help and assist the resident and staff better cope the problem. The home’s health and safety arrangements such as regular maintenance and servicing of equipment, two recently recorded fire drills and monitoring heat control valves on hot water taps throughout the home, show that the Registered Manager was mindful of her responsibilities to make sure that residents live in a safe environment. Following the last inspection it was noted that some residents found the ‘tannoy’ communication system intrusive. A small number of residents said that it was annoying but most said that they did not really notice it. It is recommended that its use should be kept to a minimum in support of those residents who do find it intrusive. Residents said that the home was always kept clean and tidy and they felt safe. Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 21 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff at the home are adequate in number to meet the current residents’ basic care needs, but staffing levels should be re-considered to ensure that staff have sufficient time to support residents’ preferred activities. EVIDENCE: At the time of the site visit there were 29 residents. Staffing levels were in accordance with those suggested by the Department of Health Residential Forum Guidelines and appeared to be sufficient to meet the residents’ basic care needs. There were four care staff on duty throughout the day, and the Registered Manager who was supernumerary, and two care staff at night. In addition there were domestic staff, catering and caretaking staff. A Senior Manager was always available. There was evidence of a good skill mix of staff and the rota reflected the number of staff on duty to ensure that the residents care needs were met. Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 22 The residents and staff spoken with said that there were usually enough staff on duty to provide for their care. However, it appears that current staffing levels do make it difficult for staff to engage in and provide support for residents’ activities. This was borne out by comments made by the residents, who would like more activities, but felt that there were insufficient staff to support this, especially for those residents who would like to go shopping or on trips out. Extensive ‘in house’ training supports staff in meeting the residents’ health and welfare needs. The implementation of a new training programme will enable staff to access training without disruption to staffing rotas or the care of residents. Three staff files were checked during the inspection and showed that there is a satisfactory recruitment process to ensure that residents are well protected. Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 23 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 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager provides the standard of leadership that residents and staff require and manages the home well, which ensures that the residents’ rights are protected. Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 24 EVIDENCE: The Registered Manager has many years of experience in care and was undertaking National Vocational Qualification (NVQ) Level 4 in Care and the Registered Mangers Award (RMA). She manages the home well for the benefit of the residents, their relatives and the staff. There was an ethos of openness in the home that demonstrates an inclusive, open and constructive management style, which is well supported by senior management. The Registered Manager has an ‘open door’ policy and holds meetings with the residents and their families as well as one to one discussions both to pass information on and to listen to their views and opinions. There were annual quality questionaires sent out to residents and their families to gain their views about the home. It was recommended that these, once collated, should be published with the Statement of Purpose and Service Users Guide to show how these help to improve the quality of care for the service users. All new care staff had received a comprehensive induction with additional mandatory, specific ‘in house’, and were supported to attain NVQ’s in Care. Three staff currently held an NVQ level 2 and others were undertaking the training. The Registered Manager said that all staff receive annual appraisals and supervision (a regular review of staff’s personal and training needs in relation to their work – seen in staff files). The implementation of the new programme of training, and regular, recorded supervision, should ensure that staff have their training needs identified and that they have the necessary skills to provide a good service for the residents. Residents’ personal allowances were appropriately managed and recorded to ensure that residents’ financial interests were safeguarded. There was a designated senior manager, who acts as Fire officer and will be updating all fire policies and procedures to comply with current legislation. Health and Safety Policy and Procedures, such as regular recorded fire alarm tests and fire drills had been completed to ensure the health and safety of the residents and staff. Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 25 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 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 4 3 3 3 3 X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 26 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 OP8 Regulation 13 (1) (b) Requirement The Registered Manager must ensure that care staff who undertake nursing tasks, such as blood pressure monitoring, receive adequate training to ensure that they are aware of anomalies which may require medical intervention. Timescale for action 14/05/08 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 Refer to Standard OP8 Good Practice Recommendations It is recommended that staff proactively seek health professionals’ advice to assist with possible issues regarding monitoring health, continence care and medication management before they become of concern. It is recommended that staff ensure that residents are provided with a choice of planned, appropriate and varied activities that reflect their specific needs. 2. OP12 Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 27 3 OP38 It is recommended that Quality Questionnaires are collated, actioned and written feedback provided in the Statement of Purpose and Service Users Guide to show that comments from residents and others help to improve the service. Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Bhajan Kaur Rai Hall DS0000001655.V362387.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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