Care Home: Cloneen Residential Home

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What the care home does well Cloneen does provide very homely accommodation. Residents` needs are thoroughly assessed before they move in, and their health needs are wellmanaged during their time there. The residents are treated with respect: One person said that the staff were `all very kind and understanding`. Another person said that the staff were `excellent`. A relative said `The staff are superb`. Visitors are welcomed into the home, and there are no difficulties visiting people there. Residents spoke positively about the meals at Cloneen. The home is very well-maintained, and health and safety checks and services were up to date with one exception. Staff receive a lot of training. The home currently has 50% of its staff with NVQ Level 2 and more staff are already registered to start. The home actively seeks the views of the residents and others to help its continual improvement. What has improved since the last inspection? All the actions from the last inspection have been carried out. The cellar door is now kept locked when not in use, and the name of the health and safety representative has been added to the poster. Residents who use a wheelchair when in the community can now use a minibus to get out, or suitable aids are used for them to use different kinds of transport. What the care home could do better: The home needs to review its medication procedure, and make sure that all medication kept in the home can be accurately accounted for. The complaints procedure needs to be re-written to include the name of the local funding authorities. Staff need to receive more regular supervisions with their line manager. Also, the home needs to record the whole staff team`s training needs to make sure that training offered is sufficient. Regarding the recruitment of new staff, the Registered Manager needs to make sure that two written references are received for all staff and that they include all necessary details. The home has begun work with the local Fire Brigade to resolve the issue of fire drills. This work needs to continue so that appropriate and timely fire drills do take place. CARE HOMES FOR OLDER PEOPLE Cloneen Residential Home Albion Terrace Saltburn-by-Sea TS12 1LT Lead Inspector Mrs Ann Ferguson Key Unannounced Inspection 8th March 2007 09:30 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 Cloneen Residential Home DS0000064897.V330856.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. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cloneen Residential Home Address Albion Terrace Saltburn-by-Sea TS12 1LT 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) 01287 622832 P/F 01287 622832 Mr Justin Ignatius Lawrence Russi Mr Justin Ignatius Lawrence Russi Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2006 Brief Description of the Service: Cloneen is a large period terrace overlooking a woodland park close to the town centre. The house has been adapted to provide accommodation and residential care for 15 men and women over the age of 65. Accommodation is on three floors and presents homely, family-style living. The house has 13 single bedrooms and one shared double bedroom. None have en-suite facility. Communal facilities available to residents are: one dining area and one main lounge. The kitchen is domestic in size and style. There is a private patio area used by the residents in the summer. The cost to stay at Cloneen Residential Home is currently £340 per week. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced at 9.30am and lasted for six and ¾ hours. Three residents, three staff members, and the Registered Manager were spoken to during the inspection. Four residents were case- tracked with the inspector looking at their records including individual plans of care, medication records, personal allowance records and overall health care support. Five members of staff were case- tracked too. Their records were looked at, including recruitment details, staff training and supervision. House records, health and safety records, and policies and procedures were examined. The pre-inspection questionnaire was received before the inspection. A tour of the home was carried out. Five questionnaires were given out to the residents, and five comment cards were given to relatives and visitors. All of these were returned to the home. What the service does well: Cloneen does provide very homely accommodation. Residents’ needs are thoroughly assessed before they move in, and their health needs are wellmanaged during their time there. The residents are treated with respect: One person said that the staff were ‘all very kind and understanding’. Another person said that the staff were ‘excellent’. A relative said ‘The staff are superb’. Visitors are welcomed into the home, and there are no difficulties visiting people there. Residents spoke positively about the meals at Cloneen. The home is very well-maintained, and health and safety checks and services were up to date with one exception. Staff receive a lot of training. The home currently has 50 of its staff with NVQ Level 2 and more staff are already registered to start. The home actively seeks the views of the residents and others to help its continual improvement. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. Residents move into the home after a full assessment of need has been carried out. They know that their needs can be met. EVIDENCE: There is an admissions policy in the home that is followed thoroughly in all cases. When a referral is made, the Registered Manager or the deputy manager visits the person and carries out an assessment. In the four resident’s files that were looked at, there was a detailed assessment in each of the files, which covers all the areas detailed in the National Minimum Standard. The service users’ guide describes a 4-week trial period available to all prospective residents. As well, prospective residents are offered the opportunity to visit the home and stay for a meal, and then have a trial stay there. The residents all had an up-to-date contract. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 9 A member of staff confirmed the process of assessment carried out by the manager or deputy. They said that the process was good and staff all got the information they needed to support new residents first hand. The home will provide some short-term, respite care if they have vacancies. In these situations, the deputy manager said that they firstly rely on the information provided to them by Social Services and then begin to make their own assessments when the person is in the home. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. An examination of records and discussion with staff indicates that the overall needs of the residents are recorded thoroughly in the individual plans of care. Residents’ health needs are met. The home overall has a robust medication procedure although some changes need to be made. An observation of interaction between residents and staff, and discussion with residents, indicates that the residents are treated respectfully and their privacy upheld. EVIDENCE: The four individual plans of care examined contained all the necessary information to ensure that staff supported the individuals fully. The support plans had been reviewed monthly to make sure that any changing needs were picked up on. There was a risk assessment for each resident and these were up-to-date. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 11 The residents have access to a wide range of different professionals to maintain their health. Within the individual files there were examples of contact with dieticians, opthalmologists, dentists, GPs, and chiropodists, for example. Some of the health professionals visit the residents in their homes, for example, the dentist and the chiropodist. The staff provide opportunities within the week for the residents to do simple exercises to maintain their health. One resident said that staff respond to any medical issues ‘straight away’. The home has a medication policy that covers all the required areas. The inspector did not see a date on it, and did think that it looked quite old. The Registered Manager should look at the policy again and make sure that it is still accurate in all areas. Staff administer almost all the medication to all the residents. They have asked residents if this is what they want and it is. The inspector did find one instance where a resident administers their own medication. This process was documented clearly. The inspector looked at the medication charts for four residents kept in their individual files and they were all thorough and accurate. One of the individual medication charts could do to be re-written and dated because there have been a number of changes to their medication and the chart is not easy to follow. Six members of staff have received training in the Safe Handling of Medication, and a further five members of staff are booked to undertake the course. In addition, qualified staff provide on-the-job training and observation of medication administration by the newer staff members. The MAR sheets examined by the inspector were found to be accurate for all the medication that comes into the home via the MDS system (this is where the pharmacist puts each medication into blister packs for the home). However, the medication that is taken as and when (this is called PRN) or tablets that started to be taken before the start of the new MAR sheet are not recorded accurately on the MAR sheets. It was therefore not possible to check the number of tablets that were held in these cases. The home needs to identify a way to record all medication that comes into the home so that an accurate audit can be done on all the medication. The home does hold and administer controlled drugs. The storage of this medication and the records kept were appropriate. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 12 The inspector observed residents being treated respectfully. When the inspector arrived, there was just one person having breakfast in the dining room. The staff knew her preferences. She was encouraged to do as much for herself and was unhurried. One resident said that staff were ‘all very kind and understanding’ and that they knock on the door before they come in. Another person said that the staff were all ‘excellent’. A visitor to the home who completed a comment card said that ‘the staff are always very nice to the ladies and gents who live there’. A relative described the staff as ‘superb’. The values that underpin the homes are ‘respecting people as individuals’. This information was found at the front of the staff induction file for new staff to consider from the very beginning of their employment at Cloneen. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 13 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. An examination of records and discussion with residents and staff indicates that the lifestyle of the residents does match the majority of residents’ preferences and needs. Contact with other people is encouraged and facilitated by the home. The residents are encouraged to make their own choices in their lives. The diet provided by the home is balanced and appealing. EVIDENCE: On the day of the inspection, there were a number of visitors to the home and varied activities going on. One resident watched a DVD of her choice before lunch, and in the late afternoon a group of residents played dominoes with each other. Residents chose if they wanted to take part. The hairdresser was in the home that day too and each resident was asked if they wanted their hair doing. At least two of the residents had family members visit to take them out or to chat. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 14 Residents choose where they want to eat. Some residents take their meals in their rooms. Staff are aware of their preferences and accommodate them. The home has arrangements in place for clergy from different faiths to visit the home and the residents. Within the individual care plans, residents are asked about any spiritual needs they may have and how the home can maintain these for them. There is a weekly timetable of activities displayed in the hallway of the home. Each week the residents can play dominoes, bingo, cards, have a sing-song and a sherry, do chair exercises, or get their nails done, for example. Whilst it was a busy day on the day of the inspection, two residents who spoke to the inspector did indicate that they did a little ‘too much sitting’ and they would like more activities or events to be organised. One person said that there were ‘not enough things to do to occupy the mind’. This point was discussed with the Registered Manager and deputy manager at the end of the inspection for them to give thought to. A member of staff also felt that they would welcome time just to spend chatting with a resident, to give them the opportunity to chat or reminisce. Visitors are encouraged at the home, and visiting times are unrestricted. Residents told the inspector that it is easy for people to visit, and this is reiterated in the service users’ guide. The home keeps thorough records in the individual files of any contact with family and friends, either in person or by phone. Examples of these were looked at by the inspector. The staff had positive relationships with family members. They knew them all and made time for a quick chat when they were there. One relative did say, through a comment card, that they ‘experience great warmth and care both for our mother and ourselves’. Members of the community are welcomed into the home, for example, the hairdresser and a lady who did people’s nails. The manager of the home has recently provided the residents with a meal out, joining up with people from another home. The residents spoke of this with the inspector, and really enjoyed it. The residents do exercise choice within their life at Cloneen. All the bedrooms were personalised by the individual. The residents do choose where they wish to have their meals, and what they want to do in the day. All of the residents still control their financial affairs, although some of them have asked the home to keep hold of their cash until they need it. Access to residents’ monies is restricted to the Registered Manager, deputy and senior staff member. The inspector checked the balances for cash held for two of the residents and there were no discrepancies. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 15 A varied, balanced diet is provided for the residents. Whilst mealtimes are set, residents can get drinks and snacks throughout the day. If they do not feel like eating then they can get something else later in the day. The inspector did sample lunch and thoroughly enjoyed it. One resident who spoke to the inspector said ‘I can’t fault the meals’. Mealtimes were observed by the inspector to be unhurried. Staff knew not to give some people too much, and menus took into account people’s preferences. Cloneen Residential Home DS0000064897.V330856.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 18 Quality in this outcome area is good. An examination of records indicates that, whilst there haven’t been any complaints since the last inspection, the home does take complaints seriously and will deal with them appropriately. Staff receive training to enable them to identify abuse and respond accordingly. EVIDENCE: The home has not received any complaints since the last inspection. It does have a complaints procedure, which details the necessary timescales for responding to any complaints. This procedure does need to be updated to include the name of the local funding authority. Relatives too are aware of the complaints procedure, although they have not needed to see it. Staff are provided with training in ’No Secrets’ to help safeguard the residents from abuse. At the inspection the deputy manager confirmed that all the care staff had completed this training. This training provides them with overall abuse awareness. Staff are employed after a suitable PoVA check. Within the home safeguards are in place to protect the residents from financial abuse. As explained previously, access to residents’ monies held by the home is restricted to the Registered Manager, deputy, and senior staff member. The inspector checked two balances and they were both correct. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 17 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 and 26 Quality in this outcome area is excellent. A tour of the home and a discussion with staff indicates that the service users live in a safe and well-maintained environment that is clean and hygienic. EVIDENCE: Cloneen provides a very homely environment, which is well-maintained. The home was found to be in very good decorative order throughout. The communal walls have a number of pictures and mirrors hung on them. Fresh flowers and plants were evident as well. There has been a lot of re-decoration since the last inspection; the hall and landing areas, bathrooms and the dining room. Bedrooms are re-decorated before a new resident moves in, as necessary. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 18 A handy man is employed at the home to make sure that regular maintenance is carried out at the property. The home has a very attractive area to the front of the house, which residents sit out in, in good weather. There are plans to make alterations to the area at the rear of the property for the residents to make use of too. On the day of the inspection the home was found to be very clean and hygienic. The home smelt pleasant and fresh. The home employs domestic staff to clean the home. In their absence, the care staff are responsible for maintaining the cleanliness of the home. The laundry facilities were adequate for the type of home and the number of residents. Staff have access to protective clothing to minimise the spread of infection. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 19 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. An examination of records and discussion with staff indicates that residents’ needs are met by the appropriate mix of staff. Staff receive a lot of training to enable them to support the residents appropriately. The recruitment processes are generally thorough although some gaps were found in the information kept for some staff. EVIDENCE: The home has adequate numbers of staff on to support the residents. There is a manager in post, supported by a deputy. The home has a senior staff member, and care staff. In addition, there is a cook, domestic staff and a handyman. The home does not have any vacancies at the moment. There is a rota in the home showing the names and times of people working at the home. The recruitment details received for five members of staff were looked at by the inspector. In all cases an application form was present, and then either one or two written references. In four cases the references were not signed or dated to indicate when they had been written and for whom. All the five people had received a satisfactory CRB check at an enhanced level, and four people had a PoVA check too. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 20 At the time of the inspection 50 of all staff held an NVQ at level 2 or above. A further four members of staff are registered for their NVQ level 2 and two members of staff are working on their NVQ level 3. Five staff files were looked at and they all had an individual training record. They had all received an induction into their role too when they started working. Areas covered in the induction include abuse awareness, how to support people, and communication, for example. Training provided since the last inspection includes: • • • • • • • Safe Handling of Medication Health and Safety Dementia Registered Managers’ Award NVQ level 2 Stroke training First Aid Staff who spoke to the inspector confirmed the training that they had received in the last year. The home does not have a training and development profile which shows the overall training received within the team, and identifies the overall training needs. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 21 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, 36 and 38 Quality in this outcome area is good. An examination of records and discussion with residents and staff indicates that Cloneen is run and managed by a person fit to be in charge. The home is run in the best interests of the residents and any financial interests are safeguarded. Staff do not receive appropriate supervision. The health and safety of the residents and the staff are promoted and protected. EVIDENCE: The Registered Manager and the deputy manager are both suitably qualified for their roles. The deputy manager has recently completed her Registered Managers’ Award and NVQ Level 4 in Care. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 22 The Registered Manager of the home is committed to seeking the views of the residents regularly to influence the continual improvements within the home. Each year the residents are asked to complete a questionnaire giving their views on the quality of care provided at the home. The service users’ guide seeks the different views of residents, families and friends to continually improve the service. The inspector looked at a sample of questionnaires from residents received last year. The manager needs to collate all the information he receives and compile a summary, which can then be used by CSCI and other stakeholders, or to prospective residents, to evidence the quality of care provided by the home. In addition, the staff have regular staff meetings to inform them of any changes and ask for their input in some matters. A staff meeting agenda was already up for the next week and staff were encouraged to add to it. The residents too have house meetings to get their views and ideas. No minutes of these meetings were examined by the inspector. The financial procedures in place within the home are adequate and protect the residents – see Daily Life and Social Activity, and Complaints and Protection. Staff do not receive supervision as frequent as that detailed in the National Minimum standard. Five staff files were looked at and one person had the required number of written supervisions. One person had received three supervisions in the last year; two people had received just one supervision since the last year, and one person had had two supervisions. All of the files examined except one contained an up-to-date appraisal. In spite of this, staff who spoke to the inspector made reference to the support that they received from the Registered Manager, the deputy and the whole staff team. One person said that you could bring your problems to the management quickly and they will listen to them. Another person said that one got ‘good support’ with anything you struggled with. In the area of Health and Safety, on the day of the inspection a number of key maintenance checks had been carried out within the recommended timeframe. These included: • • • • • Bath hoists Lift maintenance Portable Appliance Testing Gas safety check Fire extinguishers The manager did confirm that the fire alarm and emergency lighting has recently been serviced but that they are awaiting the certificates. The fire drill was last completed, according to the records, in March 2005. The Registered Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 23 Manager discussed with the inspector the difficulties of carrying out a full drill given the needs of the residents. He said that he is in contact with the Fire Brigade to work together and involve them in some fire drill simulations to minimise the distress or disturbance to the residents. The home’s risk assessments were all reviewed and up to date. A sample of water temperatures was taken by the inspector and these were all below the maximum temperature recommended. The handy man ensures that a full weekly check of the home is carried out each week. Examples of these were looked at. The deputy manager did say that any repairs or maintenance are speedily carried out at the home. Cloneen Residential Home DS0000064897.V330856.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 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Cloneen Residential Home DS0000064897.V330856.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 OP9 Regulation 13 (2) Sch 3 (3) (i) Requirement The Registered Manager must ensure that the existing medication procedure is reviewed and that the recording of all PRN medication and medication not included in the MDS is accurate. The Registered Manager must ensure that fire drills are carried out on a regular basis. The Registered Manager must ensure that two written references are received for all staff prior to starting work. Timescale for action 30/04/07 2 3 OP38 OP29 Sch 4 (14) Sch 2 (5) 30/04/07 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP12 OP16 Good Practice Recommendations The Registered Manager should discuss with residents the activities they would like to do, and try and accommodate these. The Registered Manager should review the Complaints DS0000064897.V330856.R01.S.doc Version 5.2 Page 26 Cloneen Residential Home 3 4 5 6 OP38 OP36 OP30 OP33 Procedure to include the names of the local funding authorities. The Registered Manager should ensure that the servicing certificates for the recent fire alarm services are received by the home. The Registered Manager should ensure that all staff receive written supervision in accordance with the National Minimum Standard. The Registered Manager should ensure that there is an overview of staff training in the home. The Registered Manager should produce a summary report based on the views of the residents and other stakeholders that covers the requirements detailed in the National Minimum Standards. Cloneen Residential Home DS0000064897.V330856.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 Cloneen Residential Home DS0000064897.V330856.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. 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