Care Home: Comfort House

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What the care home does well People considering moving into this home, are given time and good information, to help them decide if the home will meet their needs. A resident who completed a survey said, `everyone was very supportive and helpful`. Residents` health care is looked after well. Relatives of a resident, who had poor health, said that the staff of the home looked after her very well. A visiting community nurse said that the staff of the home provided very good care to the people living here. A resident said, `they let you do what you want when you want`. Comments were received from two residents who completed surveys. One said, `staff look after me` and the other said, `I`m happy here`. Residents enjoyed the social activities that are provided. Most of the residents spoken to like the food provided, although some thought improvements could be made. Relatives of a resident who was in poor health said that the staff and cook did all they could to ensure that she received good nutrition. There is a very warm and friendly atmosphere in the home and residents feel comfortable about expressing their opinions. What has improved since the last inspection? The garden is being improved with new planting areas and a sensory garden is to be created. Care plans are recorded in fuller detail, which helps the care staff know what help residents need. Care staff understand about `whistle blowing` if they have concerns about the safety of residents. Records are kept to show when prescribed creams are administered, which helps to safeguard residents. What the care home could do better: Whilst generally residents receive the help they need with their personal care, there are some lapses. Some service users said that staff sometimes forgot to come back to provide the help they had asked for. The staffing levels must be reviewed to make sure there are sufficient staff on duty at the time residents need them.Training for care staff about the prevention of falls, will help them to put more effective care plans in place to help protect residents at risk of falls. Some staff may also need more training about the nutritional assessment tool that is used to identify people at risk of malnutrition. A full and accurate record of the advice given by doctors needs to be kept, including any advice about medication. This helps that staff know when and for how long medication has to be given. CARE HOMES FOR OLDER PEOPLE Comfort House Middlegate West Denton Newcastle Upon Tyne NE5 5AY Lead Inspector Janine Smith Key Unannounced Inspection 15th April 2008 9:35 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 Comfort House DS0000071014.V362893.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. Comfort House DS0000071014.V362893.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Comfort House Address Middlegate West Denton Newcastle Upon Tyne NE5 5AY 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) 0191 264 4455 0191 264 4455 comforthouse@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross BC OpCo Ltd Mrs Jayne Appleby Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Comfort House DS0000071014.V362893.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 41 The maximum number of service users who can be accommodated is: 41 21st August 2007 2. Date of last inspection Brief Description of the Service: Comfort House provides a home for up to 41 older people who require residential care. Nursing care is not provided. Fees are from £373 to £424 weekly. The fees do not include hairdressing, private chiropody, toiletries, newspapers or charges for dental and optical examinations and treatment. The building is large with a ground and upper floor. All of the bedrooms are single and have an en-suite toilet and shower. There is also an assisted bathroom on each floor and the home has aids and adaptations for people with disabilities. There is a garden at the rear of the home with a pleasant sitting area and planted areas all around the building. Comfort House is located in West Denton, Newcastle and is reasonably close to local shops and public transport. There is a regular bus service and in addition, a U Call bus, which people with disabilities can request. Information about the service, including inspection reports, is readily available. Comfort House DS0000071014.V362893.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. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit on 21st August 2007. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 15th April 2008 and further visits on 16th and 23rd April 2008. During the visit we: • • • • • • Talked with eight people who use the service, three sets of relatives, four staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager what we found. In November 2007, the ownership of the home changed to Southern Cross (OpCo) Ltd., What the service does well: Comfort House DS0000071014.V362893.R01.S.doc Version 5.2 Page 6 People considering moving into this home, are given time and good information, to help them decide if the home will meet their needs. A resident who completed a survey said, ‘everyone was very supportive and helpful’. Residents’ health care is looked after well. Relatives of a resident, who had poor health, said that the staff of the home looked after her very well. A visiting community nurse said that the staff of the home provided very good care to the people living here. A resident said, ‘they let you do what you want when you want’. Comments were received from two residents who completed surveys. One said, ‘staff look after me’ and the other said, ‘I’m happy here’. Residents enjoyed the social activities that are provided. Most of the residents spoken to like the food provided, although some thought improvements could be made. Relatives of a resident who was in poor health said that the staff and cook did all they could to ensure that she received good nutrition. There is a very warm and friendly atmosphere in the home and residents feel comfortable about expressing their opinions. What has improved since the last inspection? What they could do better: Whilst generally residents receive the help they need with their personal care, there are some lapses. Some service users said that staff sometimes forgot to come back to provide the help they had asked for. The staffing levels must be reviewed to make sure there are sufficient staff on duty at the time residents need them. Comfort House DS0000071014.V362893.R01.S.doc Version 5.2 Page 7 Training for care staff about the prevention of falls, will help them to put more effective care plans in place to help protect residents at risk of falls. Some staff may also need more training about the nutritional assessment tool that is used to identify people at risk of malnutrition. A full and accurate record of the advice given by doctors needs to be kept, including any advice about medication. This helps that staff know when and for how long medication has to be given. 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. Comfort House DS0000071014.V362893.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 Comfort House DS0000071014.V362893.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): 2, 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who may use the service and their representatives have the information needed to choose a home that will meet their needs. EVIDENCE: The home’s Statement of Purpose and a Guide for Service Users was openly displayed in the foyer. Copies of the guide are also put in bedrooms. They intend to produce an audio version of the Service User Guide but this has not been done yet. The care records of three service users admitted within the past year were looked at. These showed that information had been gathered about each service user’s needs and then used to draw up a care plan. Enquiries are Comfort House DS0000071014.V362893.R01.S.doc Version 5.2 Page 10 made about each person’s spiritual beliefs on admission so that appropriate religious services can be arranged if required. A resident said they had chosen this home after making a visit to look round. They commented that the standard of care could be improved given the amount charged in fees. Examples given were: staff ignore what you say and say they are busy, other peoples clothing had been put in their wardrobe and staff had ignore requests to return it to the rightful owner, towels and flannels were removed for washing but clean replacement items were not always provided. He also said the food was good but he was sometimes ignored when he asked for a cup of tea in the dining room. Relatives of another resident said they were very happy with the quality of care provided at this home, which they chose after visiting and viewing this and several other homes. They said that they had been given plenty of information about the home before they chose it. Another visitor said they had chosen this home for their relative, as it was the best they had seen and there were more male residents living in this home than in the others they had visited. Contracts were also seen on two of the four care files looked at. Comfort House DS0000071014.V362893.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health care needs are being met well, but not all of the residents are receiving the help they need from time to time with their personal care, which affects their dignity and could put them at risk. There are some gaps in the handling of medication, which could lead to mistakes being made EVIDENCE: Four service users’ care records were looked at. Assessments are carried out regularly to determine the risk of falls, pressure ulcers and malnutrition. Dependency and moving and handling needs are also assessed. It is questionable whether care staff are completing the Must Nutritional Assessment accurately by assessing all three risk factors. The BMI factor was the only part scored on the assessments looked at. Comfort House DS0000071014.V362893.R01.S.doc Version 5.2 Page 12 The information from these assessments are generally used well to draw up comprehensive care plans, but care plans for the prevention of falls are narrow in scope, focussing on obstacles, rather than taking account of wider factors such as effects of medication, visual impairment, etc. Meetings take place with residents at intervals to review their care and a resident confirmed that their review meeting was to take place the following week. Residents spoken to confirmed they were being weighed regularly and records supported this. Care staff monitor the skin condition of service users and seek professional advice about this when necessary. Pressure relieving equipment is provided through the Community Nursing Services for those service users at risk. A visiting Community Nurse commented that the staff of the home provided very good care to the residents. Service users spoken to confirmed that they have regular check-ups from opticians and dentists. They also said that doctors were always sent for, if they were unwell. Three visitors said the staff kept them well informed about their relatives’ wellbeing. One resident said, via a survey, that she always received the care and medical support she needed. A completed survey was received from a relative who said that the home always met the needs of their relative and always provided the care they required. Mixed views were received from residents and relatives spoken to during the inspection. One resident and his relative said he was very well cared for. Another resident also said she was very well looked after and got the help she needed in the morning and at night. Two visitors said that the staff team provided very good care for their relative who needed a lot of help. Two residents said they tried to look after their own personal care themselves, but that when they needed extra help, this was not always provided. Both said when they have asked for help staff have often said they are busy and will come back but don’t. One said the manager had told her to always ring the bell for assistance if she needs it, but she was reluctant to do this and would feel happier if staff asked her if she wanted help. One was at risk of falls. An example she gave, was asking staff in the evening for help with a wash down but no one came back so she did not get the wash she wanted. Relatives of another resident said that whilst the care he received was generally fine and he was very happy living at Comfort House, on occasions they found him still unshaved late in the dress and wearing dirty clothing. Residents seen during the inspection were well groomed and staff were respectful of their privacy and dignity. Staff were observed to take time to Comfort House DS0000071014.V362893.R01.S.doc Version 5.2 Page 13 help residents walk with the aid of staff or walking aids about the home, rather than use wheelchairs for quickness. A resident spoken to said that they were happy for the home to manage medication on their behalf and that they got their medication when they needed it. Two visitors said that their relative got the medication they needed from the staff. A carer described appropriate action being taken when residents refuse medication. The system for storage, handling and administration of medication was looked at and found to be generally in order, except for the following:The brought forward stock of medications had not been recorded on handwritten medication administration records for two residents. o The records for one person had not been as fully completed as they should have been which caused confusion about the medication prescribed. o Medication audits are carried out. Certificates were seen on staff records to show that they had received training in handling medication. The new company is to provide further training shortly. Comfort House DS0000071014.V362893.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to make choices about their lifestyle, and enjoy variety and choice in social activities and food. EVIDENCE: A carer said that staff organise social activities twice a day. An artist who runs an art class makes visits. Entertainers and singers also visit. A resident said there were opportunities to go for drives in the country. The manager intends to increase the range of social activities to reflect residents’ personal interests. Improvements are also being made to the garden, including the creation of a sensory planting area. Religious services take place in the home. Residents said their relatives and friends were welcomed in the home and there were no restrictions on when they could visit. Comfort House DS0000071014.V362893.R01.S.doc Version 5.2 Page 15 Residents choose when they want to get up and go to bed. Staff described how they gave people choices about when they wanted to go to bed or get up in the morning. They also choose whether they want to participate in the social activities. Most residents spoken to said they liked the food and said they always got a choice at mealtimes. One said she loved the cottage pie with cheese on the top. Another resident said that she loved the homemade soup, describing it as ‘beautiful’. One resident said that the soup was too cool when served. Another said that the quality of food had deteriorated since the new company took over and said that no one could eat the beef supplied a few days before. Two residents said that they had been refused a cup of tea at a mealtime because staff said they were busy. Another said that meals were served hot enough although if meals were taken in the bedroom, they would have cooled by the time they arrived. Relatives of a resident, who had a poor appetite, said that the cook provided foods that would provide extra nutrition for her, for example, by adding butter and cream. The cook was aware of the specific dietary needs of residents. Residents were offered hot drinks through the day and provided with pieces of fresh fruit, which a carer said was done daily. Dining tables were laid with serviettes, condiments, cups and saucers, and a small vase of fresh flowers. Menus were displayed on the tables. Staff helped those residents who needed assistance with their meals. On the second day of inspection, residents were offered a choice at lunchtime of mince and dumplings with vegetables or a vegetarian alternative. This was followed by apple crumble and custard. There were plenty of stores and a supply of fresh fruit and vegetables and whole milk is obtained. Comfort House DS0000071014.V362893.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. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: The complaints procedure was displayed and easy to understand. The manager said that no complaints had been received since the ownership of the home changed. Residents are encouraged to give their opinions or raise any concerns in their personal review meetings, or at residents’ meetings. The manager also now works one late night a week so that she is available outside of normal office hours if relatives/visitors want to see her. Residents and relatives spoken to said they would happy about discussing any concerns with the manager or staff. There was a very warm, relaxed atmosphere in the home. There were also lots of visitors to the home. Staff are currently being given updated training about the protection of vulnerable older people. Staff spoken to were aware of what they must do, if they have any concerns that a resident may be abused. Comfort House DS0000071014.V362893.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, 20 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The home was toured and a small sample of bedrooms seen. Each resident has a single bedroom with an en-suite. There are several comfortable lounge areas. Some refurbishment is needed to update the décor of the home, which the Operations Manager said is in hand. In the meantime, the handyman has been asked to touch up some parts of the home. Comfort House DS0000071014.V362893.R01.S.doc Version 5.2 Page 18 The passenger lift was in working order. The premises were accessible. Lighting was adequate and the home was very warm. The temperature of hot water delivered to a bath was tested and found to be safe. A sample of privacy locks were tested and found to be in working order. Window opening restrictors are fitted to safeguard residents. The home was clean and smelled pleasant. A cleaner described the tasks she carries out routinely. The laundry assistant described her duties. Both had protective clothing available to them. The laundry assistant had a system to help ensure clothing was returned to the owner, but that some items had not been labelled and these were kept aside until the owner could be identified. A resident said that staff ignored requests to remove items of clothing belonging to another resident and they stayed in his wardrobe for weeks. Another said, on occasions, clean flannels and towels are not supplied after used ones are removed for washing. Some visitors said their relative’s bedroom smells of urine. Some other visitors said their relative’s room was kept very clean. Comfort House DS0000071014.V362893.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 adequate. This judgement has been made using available evidence including a visit to this service. There are enough qualified, competent and experienced staff to meet the health and welfare of people living in the home, but there are gaps in the training of some staff which, when addressed, will help them provide more person centred care. EVIDENCE: There were 34 residents living in the home, and a new admission was expected shortly. Discussion with the manager, staff and examination of the rotas showed that the home is normally staffed as follows:8 am to 8 pm 5 8.00 pm to 8 am 3 Staff said that they were able to provide the care residents need as well as spend time with them to have a chat or enjoy a social activity. Some residents said that staff on occasions said they were too busy or forgot to provide the help they had requested. Comfort House DS0000071014.V362893.R01.S.doc Version 5.2 Page 20 Residents who made comments during the inspection said they were treated well by the staff, although one said some were not as helpful as others. A relative commented that the manager had worked there a long time and there was low staff turnover, which was a good thing. Currently less than 50 of staff have a National Vocational Qualification (NVQ) at Level II or above but the new company has its own training team, which should help. The manager hoped to have 80 of the staff through NVQ Level 2 by May 2008. All care staff are to have updated manual handling training with the company’s training provider. The manager was arranging infection control training for all care and ancillary staff. The staff team were also to undertake more advanced courses in the protection of vulnerable adults (pova) and safe handling of medicines. Evidence of training was seen on three of the staff records viewed and included health and safety training as well as relevant care practice training. A carer confirmed that they had received essential basic training and would be starting an NVQ. The files of two staff recruited in the past year showed that appropriate vetting checks had been carried out. A recently employed carer said that she was receiving induction training. Comfort House DS0000071014.V362893.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager provides clear leadership, which ensures that the home is well run and the staff team are fully aware of their roles and responsibilities. EVIDENCE: Mrs Jayne Appleby, has managed the home for a number of years and is registered by the Commission. She has obtained the National Vocational Qualification in Management and Care at Level 4 and the Registered Manager’s Award. She was also updating her training in a number of important areas at the time of inspection. Comfort House DS0000071014.V362893.R01.S.doc Version 5.2 Page 22 She is well known to service users who would readily discuss any concerns with her. The comments of staff give confidence that she provides good leadership throughout the home and has an ‘open door’ policy, which encourages good communication. The home has a quality assurance programme in place, which includes seeking the views of service users to provide feedback on the quality of care provided. The company and the manager carry out internal audits to check on quality. There are regular residents’ meetings. A service user confirmed that he attended these meetings and been able to give his views. The system for the handling and storing of money held on behalf of service users was looked at and found to be appropriate. A sample of records and receipts were also looked at. Evidence of maintenance and servicing of essential equipment used in the home was seen. The company has a training programme in place to ensure that the staff team are given training in moving and handling skills, fire safety, first aid, food hygiene. Evidence of training was seen on the staff files looked at. Two of the carers spoken to confirmed the training they had had. Comfort House DS0000071014.V362893.R01.S.doc Version 5.2 Page 23 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 3 X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 Comfort House DS0000071014.V362893.R01.S.doc Version 5.2 Page 24 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(2) Requirement Care staff must make a full and accurate record when doctors give advice/instructions about medication. This ensures that residents receive the correct medication when needed. Carry out a review of the staffing levels provided, which should include seeking the views of residents and staff, to ensure that all residents’ personal care needs can be met. Timescale for action 30/06/08 2. OP27 18(1)(a) 30/06/08 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 Obtain training for care staff about the prevention of falls, which will help them to put plans of care into place that are more effective when residents are at risk of falls. Advice could be sought from the local Falls Prevention Service who may be able to help with this. DS0000071014.V362893.R01.S.doc Version 5.2 Page 25 Comfort House 2. OP8 Ensure that staff fully understands how to assess the risks of malnutrition when using the MUST tool, which will help ensure that this is used correctly. A system should be put in place to record all medication kept in the home and carried over from the previous month. This helps to confirm that medication is being given as prescribed and assists in checking stock levels. Comfort House DS0000071014.V362893.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Comfort House DS0000071014.V362893.R01.S.doc Version 5.2 Page 27 - 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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