Care Home: Emyvale House

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What the care home does well What has improved since the last inspection? The home had no previous requirements or recommendations, however, their own quality assurance processes that involved stakeholders of the service had continued to identify and act on what people and their relatives said to improve the service. CARE HOMES FOR OLDER PEOPLE Emyvale House 29 Brampton Road West Melton Rotherham South Yorkshire S63 6AR Lead Inspector Jayne White Key Unannounced Inspection 12th August 2008 08:30 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 Emyvale House DS0000040187.V368708.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. Emyvale House DS0000040187.V368708.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Emyvale House Address 29 Brampton Road West Melton Rotherham South Yorkshire S63 6AR 01709 874910 01709 087893 NONE 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) Mr Stephen John Oldale Julie Count Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Emyvale House DS0000040187.V368708.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th August 2007 Brief Description of the Service: Emyvale House is situated in the village of West Melton on the northern outskirts of Rotherham. It is near the village facilities such as the shops, public houses, public transport and the church. Located on the main road, it has the appearance of a large ordinary house and has been converted for this current use. A small car park and garden area are at the front of the building. A further small garden area leads off the conservatory at the side of the house, and this is level, and has seating for people, bird tables and other decorative features. Emyvale House is registered to provide care for 16 elderly people with accommodation on three floors comprising of 14 single and 1 double room, all with en-suite facilities. There are two bathrooms, one with a special bath to aid people with disabilities. A lift gives access to the first and second floor in addition to a centrally located staircase. There is a lounge that overlooks the conservatory and a ramped passage leading to the conservatory. The home provides information to people and their relatives prior to admission into the home. Service User Guides are available in all bedrooms or on request from the manager. The last published inspection report is available. The manager identified the fee as £350. Additional charges were made for private chiropody, hairdressing and newspapers. People may wish to obtain more up to date information from the care home. Emyvale House DS0000040187.V368708.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 that the people who use this service experience good quality outcomes. We visited the home on the 12 August 2008 between 08:30 and 14:30 without giving them any notice. Before the visit we took into consideration other information the Commission for Social Care Inspection (CSCI) had received. This included: • An Annual Quality Assurance Assessment (AQAA). An AQAA is a document completed by providers. It gives them the opportunity to tell the CSCI how well they think they are meeting the needs of people using their service. Information contained in notifications from the home about any deaths, illnesses and other events, which affected the health and well being of people living there. • During the visit we spoke with people that lived there, relatives, staff, the manager, looked round parts of the building and read some records. We would like to thank the people, their relatives and friends, staff and the manager for their time and co-operation throughout the inspection process. What the service does well: They had a manager who encouraged staff to be involved in promoting a good service. People and representatives spoke highly of her and their comments included, “you’ve seen her behaviour today. It’s never any different. I’ve never heard her raise her voice”, “she’s always positive”, “in a different situation we could be very good friends”, “she’s absolutely fantastic”, “she’s a very good manager. She has a lovely way and includes families”. The manager promoted an excellent admission process that gave people and their families reassurances they would choose a home that would meet their needs. People and their families said, “I was on respite at another home while my daughter-in-law looked round some places. We looked round here and it suited. I got the feel of it and liked the staff”, “I came for two separate weeks first”, “my mum calls it home”, “I liked that it was small and people are known as individuals”, “mum was part of the decision to move here. After a few weeks she said you’re to tell … I’m alright here” and “when we visited here it Emyvale House DS0000040187.V368708.R01.S.doc Version 5.2 Page 6 felt like a private hotel. It doesn’t feel like a hospital and after three days my mum said I could stay here”. On the whole, people received the health and personal care that was identified in their plan of care. Relatives said, “they’re really looked after. We can go on holiday and be settled”, “there’s terrific flexibility. Staff do everything to avoid confrontation”, “they know the residents’ very well” and “personal care’s brilliant. There’s a lot of expertise”. Activities were provided for people, which kept them stimulated and involved with what was happening around them. People were able to express their concerns and had access to a complaints procedure. Adult safeguarding policies and procedures were in place to uphold peoples’ rights and protect people from abuse. Relatives said, “it’s (the home) warm emotionally”, “I like the smallness and homely atmosphere and the fact they know me and my mum”, “it’s always clean. Never smelt a thing”, “room’s lovely” and “it always looks clean and tidy”, which confirmed the environment provided an excellent standard of cleanliness and was a comfortable environment for people to live. There was a stable staff group who had worked at the home for a number of years. They were motivated, enthusiastic and had received appropriate training. They treated people with respect, dignity and privacy. People who used the service and their relatives spoke highly of the staff. They said, “you can’t beat them – they’re good”, “it’s brilliant”, “they can’t do enough” and “I can’t praise them enough”. What has improved since the last inspection? What they could do better: When restraint is being used to keep people safe, involve appropriate professionals, so that the decision of the type of restraint is appropriate and of the least possible kind to keep the person safe. To fully safeguard people, they need to make sure when people are employed a full employment history is obtained. Emyvale House DS0000040187.V368708.R01.S.doc Version 5.2 Page 7 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. Emyvale House DS0000040187.V368708.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 Emyvale House DS0000040187.V368708.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): The outcome for standard 3 was inspected. The home did not provide an intermediate care service (standard 6). People who use the service experience excellent quality outcomes in this area. 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 they need to choose a home that would meet their needs. EVIDENCE: The manager spends time planning admissions to the home and manages them well. Prospective residents and their families are treated as individuals and with dignity and respect for the life-changing decisions they need to make. There is a high value on responding to individual needs for information, reassurance and support. Emyvale House DS0000040187.V368708.R01.S.doc Version 5.2 Page 10 The AQAA stated prospective residents received a needs assessment before admission. The service obtained a summary of the assessment undertaken through care management arrangements. We looked at an assessment and it focused on achieving positive outcomes for people. People and their families were supported and encouraged to be involved in the assessment process. This was illustrated by the comments that they made and included, “I was on respite at another home while my daughter-in-law looked round some places. We looked round here and it suited. I got the feel of it and liked the staff”, “I came for two separate weeks first”, “my mum calls it home”, “I liked that it was small and people are known as individuals”, “mum was part of the decision to move here. After a few weeks she said you’re to tell … I’m alright here” and “when we visited here it felt like a private hotel. It doesn’t feel like a hospital and after three days my mum said I could stay here”. Emyvale House DS0000040187.V368708.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): The outcomes for standards 7, 8, 9 & 10 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people received was based on their individual needs. The principles of respect, dignity and privacy were put into practice. EVIDENCE: Relatives’ said staff always kept them informed about any changes to their relative’s care needs. They said, “they’re really looked after. We can go on holiday and be settled”, “there’s terrific flexibility. Staff do everything to avoid confrontation”, “they know the residents’ very well” and “personal care’s brilliant. There’s a lot of expertise”. We looked at three care plans. On the whole these provided sufficient information to enable staff to meet the needs of the people, but could be better organised so the information staff needed would be easier to find. The Emyvale House DS0000040187.V368708.R01.S.doc Version 5.2 Page 12 care plans included regular evaluations and daily records identified the care that was provided to people. However, care must be taken that when a review takes place and there are changes to the plan of care the information is always transferred into the plan of care so that this information is not missed by staff. Risk assessments were in place to provide people with appropriate support so they could maintain their independence, whilst remaining safe. However, the action taken to reduce any risks must be done involving appropriate professionals, particularly where any form of restraint is used. Senior carers had responsibility for administering medication and they said they had attended training to ensure medicines were administered safely. When we looked at the medication records they were fully completed, contained required entries and were signed by appropriate staff. Another member of staff did not countersign handwritten entries that were made onto the medication administration record. Doing this would reduce the risk of a wrong entry being made and is good practice. On the whole, medication was stored securely but a lock should be provided for the refrigerator that stores medication in line with good practice guidelines. Also, a record of the refrigerator temperatures should be maintained to monitor that the medication is being stored at the correct temperature. Throughout this visit we saw staff interacting with people in a kind manner, they spent time talking to people and we saw them knocking on bedroom doors before entering. Emyvale House DS0000040187.V368708.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): The outcomes for standards 12, 13, 14 & 15 were inspected. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were able to make choices about their life style and on the whole social and recreational activities met peoples’ expectations. EVIDENCE: When we entered the home there was a warm and friendly atmosphere, with a pleasant atmosphere in the lounges. When we spoke to people they described how they were involved in meaningful daytime activities of their own choice, interests and capabilities. They said, “I can sit here all day, watching telly and reading my books”, “very little to do during day – hardly anybody goes out – they do if it’s nice”, “I like my own company”, “I keep busy tidying my draws, reading, sitting and musing and lying on my bed”, “I’ve played bingo, but I’m happy with what I do”, “I get lots of visitors” and “Julie (the manager) takes us out occasionally, in our turn. Emyvale House DS0000040187.V368708.R01.S.doc Version 5.2 Page 14 Relatives said, “there are plenty of activities – bingo, sing songs, quizzes about local area, Lost Chords band”, “we’ve been to garden centres and seen people from here”, “it’s made us happy and settled, rather than a worry” and “the weakness I feel is activities. Particularly in an afternoon, evening and at the weekends, as the activities person only works in a morning during the week”. A staff member was employed whose responsibility it was to organise activities to meet peoples’ needs. In the main, they did work on a morning during the week. We spoke with the manager about expanding or varying this to include the different times of day and weekend. In addition, we talked about developing the activities programme to include specific social and recreational on an individual basis. The dining room was very welcoming, being bright and clean. The menu for the day was displayed, but it was in small print and you needed to stand up to be able to see it. We spoke to the manager about making it clearer and easier for people to see by displaying it lower down with just the meals for that particular day displayed. We saw the breakfast and lunchtime meal being served. The meals were served directly from the kitchen to the dining room via a serving hatch. Mealtimes were well managed by staff who had a good understanding of peoples’ dietary needs. Carers were attentive to people, offering them different choices and asking if they would like some more. When the meal was served, it was leisurely and relaxed, staff were patient and helpful and allowed people time to finish their meal comfortably. People said they had enjoyed their meal of meat pie with fresh vegetables and potatoes, followed by a milk pudding. The quality was very good and plentiful. We saw care staff being sensitive to the needs of those people who found it difficult to eat and needed support to eat their meal. They were aware of the importance of assisting at the pace of the person, making them feel comfortable and unhurried. On the whole, when we spoke to people they were complimentary of the meals that were served. They said, “they’re alright, can’t grumble”, “drinking all the time really”, “marvellous”, “never waste any of mine” and “there’s always a choice and you choose”. Relatives said, “my mum eats well. This morning had cornflakes and bread and jam. She loves bread and jam”, “the cook’s aware of people’s preferences”, “they’ll always find something different if they (the people) don’t eat”, “very little fruit to balance the diet”, “they always use fresh vegetables” and “the manager chooses the food personally to make sure of the quality”. Emyvale House DS0000040187.V368708.R01.S.doc Version 5.2 Page 15 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): The outcomes for standards 16 & 18 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were able to express their concerns and had access to a complaints procedure. Adult safeguarding policies and procedures were in place to uphold peoples’ rights and protect people from abuse. EVIDENCE: People and their representatives could access the complaints procedure because it was displayed on the notice board for them should they wish to make a complaint. It was clearly written and easy to understand and explained to people what the procedure was and how long the process would take. The manager was asked to update the procedure, because of the new working and contact arrangements within CSCI. When we spoke to people and their families they said, “never any complaints”, “any problems and Julie (the manager) is one of the most caring people I’ve met” and “no complaints, only praise”. We looked at the history of the service, which told us no complaints had been made. The AQAA stated no complaints had been made to the service. Emyvale House DS0000040187.V368708.R01.S.doc Version 5.2 Page 16 When we spoke to staff they were aware of the complaints procedure and were aware of the importance of listening to and then acting on people’s concerns. The South Yorkshire Policy and Procedures for Safeguarding Adults was in place and would give clear guidance to staff should an alert be made. Adult safeguarding training was regularly arranged for staff. This was confirmed when we spoke with them and looked at their training records. However, it was discussed with the manager their knowledge and understanding needs to be checked, as although staff had the training they could not always define what was meant by the term ‘safeguarding’. Staff understood and knew what restraint was. However, where equipment is used to restrain people, individual assessments must be completed in conjunction with other professionals, so that the least form of any limitation for the person is used (see health and personal care section). Emyvale House DS0000040187.V368708.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): The outcomes for standards 19 & 26 were inspected. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There was a clean, well-maintained and comfortable environment for people to live. EVIDENCE: When we looked round the home there was a selection of communal areas, which meant people had a choice of where to sit, meet with family, sit quietly or engage with other people that lived there. The bathrooms were homely and included aids and adaptation for people to be able to use the facilities. A shower would enhance those facilities and offer people a choice of a bath or shower. Emyvale House DS0000040187.V368708.R01.S.doc Version 5.2 Page 18 When we visited people’s bedrooms they were homely, personalised to people’s tastes and clean. People said, “there’s room enough for what you want”, “my room is exactly where I want it” and “it’s clean”. When we spoke to people they said there was always plenty of hot water for washing and bathing and the home was kept warm. When we spoke to relatives they said, “it’s (the home) warm emotionally”, “I like the smallness and homely atmosphere and the fact they know me and my mum”, “it’s always clean. Never smelt a thing”, “room’s lovely” and “it always looks clean and tidy”. The AQAA stated new furniture, new accessories and alarms fitted to outside doors for security purposes have been the improvements in the last 12 months. Emyvale House DS0000040187.V368708.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): The outcomes for standard 27, 28, 29 & 30 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff were trained, skilled and in sufficient numbers to support people who used the service and to support the smooth running of the service. EVIDENCE: When we spoke to people and their relatives they had confidence in the staff that cared for them. They said, “some nice lasses – they look after you”, “they all know their job well”, “they don’t just pass you by, they always speak”, “everyone’s so kind” and “they’re kind and they care”. Discussion with the manager and staff confirmed that there was a stable staff group who had worked at the home for a good number of years. Staff said they enjoy working at the home and felt supported. When we looked at staff rotas they showed well thought out and creative ways of making sure the home was staffed efficiently, with particular attention being given to busy times of the day. The visit today and staff rotas highlighted the manager was sometimes called upon to cover in the absence of the cook. We observed how staff worked during the visit. This told us there were good relationships between staff, people and their relatives and they responded in a Emyvale House DS0000040187.V368708.R01.S.doc Version 5.2 Page 20 timely way when people needed assistance. When we spoke to people and their relatives they said in general there was always enough staff. We looked at two staff recruitment files to check the recruitment and selection process was sufficient to safeguard people. There was evidence that staff had a CRB check and two references had been received. There was not a full employment history for people. We looked at training records to see if staff had received appropriate training to give them the required skills and competencies to deliver a good service. There was a robust induction and probationary package, which was service specific. Staff had the required skills to meet the needs of people, but reinforcement is needed so that staff understand what is meant by the term ‘safeguarding’ (see complaints and protection). There was approximately 42 of staff meeting the recommended ratio of 50 of care staff to be trained to NVQ level two or equivalent. A further 3 (16 ) were working towards the award. Emyvale House DS0000040187.V368708.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): The outcomes for standards 31, 33, 35 & 38 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home was based on openness and respect and had effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The history of the service told us the registered manager had a wealth of experience and knowledge and was able to demonstrate her ability to manage the home. She had achieved the required management and care qualifications. She operated an open door policy to ensure she was accessible to staff and people. People and their relatives spoke highly of the manager and said; Emyvale House DS0000040187.V368708.R01.S.doc Version 5.2 Page 22 “you’ve seen her behaviour today. It’s never any different. I’ve never heard her raise her voice”, “she’s always positive”, “in a different situation we could be very good friends”, “she’s absolutely fantastic”, “she’s a very good manager. She has a lovely way and includes families”. Formal quality assurance systems were in place, although the last one took place in May 2007. The provider conducted a monthly report of their opinion of the quality of the service provided, however, the last report available was from May 2008. Care needs to be taken that this formal quality assurance process does not deteriorate, otherwise they may lose touch with stakeholders’ perception of the quality of the service provided and what improvements they might like to see. The AQAA contained clear and relevant information. It let us know about changes the service have made and where they still needed to make improvements. The data section of the AQAA was accurate and fully completed. People who used the service were able to manage their own finances, although most preferred the manager to assist with dealing with their personal monies. We looked at two financial transaction records, where the manager held monies on behalf of people. This showed that safeguards were in place when dealing with peoples’ finances. The working practices in the home were safe. Accidents were evidenced by good monitoring and record keeping systems and staff were trained to understand and consistently follow these. Accident reports were analysed by the manager to ensure risk assessments were developed where required. The AQAA told us maintenance and service records were up to date and current to the services provided. We looked at the fire risk assessment. This had been reviewed as satisfactory in November 2007. However, the assessment did not contain an evaluation of how often fire training or drills should be undertaken to make sure staff were competent to keep people safe in the event of a fire. It was suggested the manager do this, as currently a drill was carried out twice a year, which meant some staff had no practice, which could be critical in the event of a fire. Emyvale House DS0000040187.V368708.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 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 2 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Emyvale House DS0000040187.V368708.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 OP18 Regulation 12 (1) (b) Requirement Timescale for action 30/09/08 2 OP29 19 Schedule 2 When restraint is being used to keep people safe, appropriate professionals must be involved, so that the decision of the type of restraint is appropriate and of the least possible kind to keep the person safe. To fully safeguard people, a 19/08/08 person must not be employed until a full employment history has been obtained, together with a satisfactory written explanation of any gaps in employment. 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 OP9 OP9 Good Practice Recommendations A lock on the refrigerator that stores medication should be in place, in line with current good practice guidelines. To monitor that medication requiring refrigeration is stored at the correct temperature, there should be a record of the refrigerator temperatures. DS0000040187.V368708.R01.S.doc Version 5.2 Page 25 Emyvale House 3 OP18 That staff understand what is meant by the term ‘safeguarding’ so that they are up to date with current terminology that is being used to safeguard people. Emyvale House DS0000040187.V368708.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 Emyvale House DS0000040187.V368708.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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