Care Home: Eversfield House

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What the care home does well The paperwork within the home has improved over time; it was notable that the daily recording log was up to date and pertinent for people who use the service. The recording and administration of medication was also accurate with no errors found.Eversfield HouseDS0000007172.V376111.R01.S.docVersion 5.2The monthly quality assurance visits completed by the trustees are generally of good quality. This ensures that there is an arms length overview and scrutiny of the service. People who use the service were positive about the meals on offer; there was a range of food and if they did not like what was available then an alternative was offered. The only complaint about the food was that sometimes there was too much. What has improved since the last inspection? The manager and trustees of the home take seriously their responsibilities under the Care Standards Act, and therefore it is positive to note that all requirements made at the last inspection have been actioned. What the care home could do better: There are broadly two main areas that the home needs to focus on over the coming months. Firstly, the area of daily life and activities; there is very little on offer to the people who use the service. This is particular unfortunate given that the majority of people who use the service are physically and mentally fit and able. There are some limited activities which are offered within the home. However, there are few links with community groups and only one outing offered over the summer period. People who use the service told us ‘we want more excitement’. This issue was raised and commented upon at the previous inspection, although at that time not made into a requirement. The lack of progress in this area has made this a requirement at this inspection and needs to be actioned for with. A recommendation has also been made that the home gives consideration to employing an activities co-ordinator to arrange activities. The second issue which needs action is regarding the supervision and training of night staff. Currently it appears that the night staff are working with neither sufficient training nor supervision; this issue must be addressed with someEversfield HouseDS0000007172.V376111.R01.S.doc Version 5.2 degree of urgency as they work in isolation and are therefore leaving themselves and people who use the service vulnerable. Key inspection report CARE HOMES FOR OLDER PEOPLE Eversfield House 45 Mulgrave Road Sutton Surrey SM2 6LJ Lead Inspector Ms Rin Saimbi Key Unannounced Inspection 09:30 20th August 2009 DS0000007172.V376111.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eversfield House Address 45 Mulgrave Road Sutton Surrey SM2 6LJ 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) 020 8642 6661 020 8642 6747 evers-field@btconnect.com Sutton & Cheam Elderly People’s Housing Association Carole Margaret Harradence Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories 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: 2. Old Age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 24 31st August 2007 Date of last inspection Brief Description of the Service: Eversfield house is a registered charity owned and run by Sutton and Cheam Elderly Peoples Housing Association. It has a Board of Trustees and a management Committee. Eversfield House is situated a short distance from Sutton town centre on a quiet residential street. The home compromises of the original detached property, and a 1950’s extension known as Ely Wing. A further extension has recently been built as part of a programme to upgrade all the bedrooms so that they all have en-suite facilities. The accommodation is based on the ground, first and second floor. A lift has been fitted into the property to allow easier access to all people who use the service. The communal facilities on the ground floor include a dining room, a large main lounge, a smaller lounge, a hairdressing room and a conservatory. There is an enclosed large garden with flowerbeds and a greenhouse to the rear of the property. At the front there is a tarmac driveway with parking for a number of cars. The people who use the service at Eversfield House are generally fit and able, and are free to come and go as they wish. Eversfield House charges from September 2009 are £455 per week, and £480 Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 5 for respite care. Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means people who use the service experience good quality outcomes. This was an unannounced inspection that started at 9.30 am and took approximately seven hours to complete. During the inspection we met and talked to the people who use the service. We looked in detail at paperwork relating to three people who use the service; this is known as case tracking. We looked at documentation about the running of the home this included looking through some staff files and the health and safety records. We talked to the staff and manager, and had a partial tour of the home. Information received by the Commission throughout the year was also considered. The home has recently been re-registered as a new wing was built and renovation of some of the existing bedrooms, all of which now have en-suite facilities. We would like to thank all the people who use the service and staff for their time and co-operation during the inspection process. What the service does well: The paperwork within the home has improved over time; it was notable that the daily recording log was up to date and pertinent for people who use the service. The recording and administration of medication was also accurate with no errors found. Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 7 The monthly quality assurance visits completed by the trustees are generally of good quality. This ensures that there is an arms length overview and scrutiny of the service. People who use the service were positive about the meals on offer; there was a range of food and if they did not like what was available then an alternative was offered. The only complaint about the food was that sometimes there was too much. What has improved since the last inspection? What they could do better: There are broadly two main areas that the home needs to focus on over the coming months. Firstly, the area of daily life and activities; there is very little on offer to the people who use the service. This is particular unfortunate given that the majority of people who use the service are physically and mentally fit and able. There are some limited activities which are offered within the home. However, there are few links with community groups and only one outing offered over the summer period. People who use the service told us ‘we want more excitement’. This issue was raised and commented upon at the previous inspection, although at that time not made into a requirement. The lack of progress in this area has made this a requirement at this inspection and needs to be actioned for with. A recommendation has also been made that the home gives consideration to employing an activities co-ordinator to arrange activities. The second issue which needs action is regarding the supervision and training of night staff. Currently it appears that the night staff are working with neither sufficient training nor supervision; this issue must be addressed with some Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 8 degree of urgency as they work in isolation and are therefore leaving themselves and people who use the service vulnerable. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 and 5 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information is gathered from a variety of sources before a decision is made regarding the suitability of the home. It is only after a trail period and then a final review meeting that a decision is made about the placement. In this way, people who use the service can feel assured that the placement is able to meet their individual needs, rather than they are being slotted into a vacancy. EVIDENCE: Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 11 Information is gathered from a variety of sources including the people who use the service, family and other professionals before a decision is made regarding the suitability of the home. There is then a period when people who use the service have the opportunity to visit the home and live there for six weeks or longer if necessary before a final review meeting is held to consider the suitability of the placement. People are encouraged to visit the home if at all possible. If this is not possible, then a senior within the staff team will visit people at hospital or within another home. Eversfield House then completes their own needs assessment within 24 hours of admission. We case tracked three people who use the service, this means that we looked at all information relating to them; this included someone who had just moved into the home. The needs assessment included information on mobility, medical needs, and dietary requirements. This assessment was then translated into an individual care plan, which outlined the day-to-day care that is to be given. There was evidence that the person who uses the service and the key worker had both signed the original care plan. From the documentation seen, all people who use the service had a contract stating their terms and conditions, which had been signed appropriately. We viewed the service user’s guide and statement of purpose both of which had been reviewed in May 2007, these documents included details of how to make a complaint. Currently, the majority of people who use the service are white/European with only three males in residence. The staff group is ethnically mixed with only one male member of staff. Whilst this is not unusual in a care home, it is unfortunate that there are not more male members of staff. The home does have various aids and adaptations that would assist people who use the service in their daily lives; these include a lift, grab rails and specialist bathing equipment. Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are encouraged whenever possible to maintain their own health needs. However, assistance is available should they require it. The health and personal care that people who use the service receive is based upon their individual needs. Care plans are reviewed monthly between the key worker and people who use the service to ensure that needs are accurately recorded. EVIDENCE: We looked at a number of files of people who use the service; all had an assessment, which was then translated into a care plan. These care plans were reviewed on a monthly basis by people who use the service and their key Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 13 worker, both then signed the document as confirmation of the care that would be provided. In one example, the care plan had been divided into eight tasks with the need, aim and course of action defined. Risk assessments were in place for people who use the service; they were reviewed on a monthly basis. In addition, there is then evidence of an annual review for each person within the service. We looked at the daily recordings; they were completed for each person with information about what activities each person had undertaken. People who use the service have access to domiciliary dentists or opticians should they require. A private chiropodist is available to people who use the service at a minimal charge. A district nurse visits on a daily basis for a specific person within the home. With regard to medication, it is stored in metal cabinets which are secured to the wall. The recording of medication was checked and no errors or omissions were found. The home has an external audit by a local chemist on an annual basis, the last report was seen and no major concerns were identified. Each person within the service had a medication profile which has photographs of the individuals and a list of allergies. There are two people who use the service who self medicate. There is an expectation that people who use the service are weighted on a monthly basis, this is a way of ensuring their well being. It was noted that on several sets of records, weight was not being monitored monthly but was ad hoc; for one person they were weighted in August 2009 and then not again until February 2009. A recommendation has therefore been made that all people who use the service should have their weight monitored monthly. We looked at issues of privacy and dignity by talking to a number of staff and found that they had an understanding of the issues involved. From observations we saw that staff knocked on bedrooms doors before entering, people received mail unopened and people have plenty of clean clothes to choose from. . Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 14 Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are offered some limited activities; they are not offering a range of activities to suit the majority of people who use the service. The importance of mealtimes is recognised by the home, thereby ensuring that people who use the service maintain their health and well being. There is a social element to mealtimes whereby people are encouraged to take their meals in the dining area EVIDENCE: Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 16 There some limited weekly leisure activities such as bingo and an ‘exercise lady’ who does chair exercises with the people. On occasions there is also arts and crafts, and music on offer. The number of organised outings has lessened considerably, from six over the summer months to a day trip to Brighton this year. We discussed this with the manager who stated that it was because they did not have a driver for the minibus anymore. In discussions with the people who use the service, one person stated there is ‘not enough to do, an exercise lady and a (religious) service once a month’. Another person said, ‘we want more excitement’. The home is clearly not meeting the leisure and recreational needs of the people who use the service, who are in the main physically able and mentally alert. Staffing levels do not allow for care staff to undertake activities themselves within the home and therefore a recommendation is being made that the home gives consideration to employing an activities co-ordinator. This issue was raised at the last inspection and highlighted in the report, since then the range of activities has in fact lessened. A requirement is therefore being made that the home provides a wider range of leisure and recreational activities. People who use the service were able to confirm that family and friends were able to visit whenever they wished and were always made welcome by the staff. People could choose where to receive visitors, and often the home would lay out meals in the conservatory for them to enjoy in privacy. A meal was taken with people who use the service in the dining area; the setting was congenial and relaxed. People were generally positive about the meals provided, with an alternative on offer if you did not like what was on the menu. Main meals were served a lunchtimes with a much lighter evening meal. Meals were cooked on a four-week rota basis. The chef does not currently have to cater for any specific dietary needs. Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. In general, the home appears to have an ethos of openness whereby suggestions are encouraged and complaints are taken seriously. This in part ensures that people, who use the service, feel that their views are taken seriously. There are procedures in place regarding the protection of vulnerable adults to ensure that people who use the service are kept safe. EVIDENCE: People spoken to at the time of the inspection knew who to talk to if they had any problems or complaints about their care, namely the manager. One person stated ‘I’ve no complaints they are very good here’. The home does have a complaints log, which we looked at; it contained one complaint in the last year which appears to have been dealt with in a timely fashion. Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 18 The home does have a whistle blowing policy and a copy of Sutton’s vulnerable adult’s procedure. In discussions with staff we gave them a fictional scenario and asked them what they would do in the situation. Staff in general were able to give an appropriate response. Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24, and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. In general the home meets the needs of the people who use the service, it is homely and comfortable; people have their own bedrooms and there is some specialist equipment available for those who have mobility difficulties. There is ample communal space so that people can choose to be with others in the main lounge, or be in quieter rooms. EVIDENCE: The home has been undergoing major renovation works in recent times so that all the bedrooms now have en-suite facilities. In addition, part of the foyer has been renovated so that it is more accessible and provides a more homely environment. Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 20 People who use the service all have their own bedrooms, with a single bed, wardrobe and chest of drawers. People all have keys to their bedrooms and a space provided, usually a drawer, which they can lock if they so wish. Not all the bedrooms were viewed, although selections were chosen at random from the three floors. Of those viewed, all were naturally ventilated and had domestic style radiators. Furniture was of reasonable quality and domestic in style. Rooms had been personalised to reflect peoples interests and with photographs of family and friends. People are free to bring into the home any furniture they wish. The home also has a large lounge, separate dining area and conservatory; there is also a second small lounge which is used by people who wish to be in a quieter area. There are a number of aids and adaptations evident in the home. There is a call system, a lift, ramps and grab rails. There are also hoists and medi-baths available. It was noted that the ground floor bathroom which contained the medibath was in need of refurbishment. A recommendation is therefore being made in this regard. The home is in general clean and hygienic; there is a sluice room and a laundry room which is equipped with washing machines that can wash at higher temperatures. It was noted that the office had a filthily carpet, particularly around the area that the medication was being administered. In addition, the carpet was uneven and could cause a tripping hazard. A requirement is therefore been made that the condition of the carpet must be reviewed. The home has a large well-maintained garden to the rear of the property, which can be accessed via a ramp for those who are frail. A requirement made at the previous inspection regarding the installation of fencing has been completed and therefore this requirement has been withdrawn. Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. In general, it appears that there are sufficient staff on duty to provide adequate care of people who use the service. Not all care staff are sufficiently equipped with the knowledge and experience required to provide a high level of care to the people who use the service. EVIDENCE: The management structure of the home is of a manager, deputy and a senior member of staff on duty during each shift. The aim of the home is to have four members of staff on duty in the mornings; with some overlap, a maximum of five in the afternoons and three in the evenings; In addition, there are two waking night staff. Samples of the duty rota were taken and found that the staffing levels were being met. The home does not use agency staff; instead any vacancies on the staffing rota are either met internally, or by the use of bank staff. This is considered positive in terms of consistency of care for the people who use the service. Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 22 There is a range of experience and age within the staff team; the staff team is predominately women although ethnically mixed. There is a staffing establishment of thirty in the home with only one vacancy. Staff personal files were checked at random, we looked at three files in particular; they contained completed job applications, notes from interview, references, terms and conditions and Criminal Records Beaux checks. Discussions with staff indicated that there is an induction process in place, whereby new staff ‘shadow’ a more experienced worker for a month before undertaking any work on their own. Training records were viewed, they indicated that staff undertake core training on an annual basis; this included manual handling, vulnerable adults, fire and food hygiene. The exception to this was the night staff who had undertaken no training at all over the last year. It is clearly of concern that night staff have not undertaken any training given that there are only two of them working in isolation. A requirement has therefore been made that night staff must receive the same level of training as care staff and this must be actioned for with. All care staff have undertaken National Vocational training Level 2, with some care staff having achieved Level 3. Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has some quality assurance monitoring systems, which in general ensure that the safety and well being of people who use the service is maintained. There are some shortfalls in this area which could compromise the welfare of people who use the service. EVIDENCE: Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 24 The manager Mrs Carol Harradence has been in post since 2005; initially she was acting up and then made the manager in August 2008. Mrs. Harradence has completed her NVQ level 4 and has also become the registered manager of the home. People who use the service and staff felt that the manager had an open, inclusive style and felt if they had any problems they could approach her. One person within the service said ‘if I had a problem I’d talk to Carol’. With regards to quality assurance, the trustees of the home complete regulation 26 visits on a monthly basis. These visits are undertaken by individuals not involved in the day to day running of the home as a way of monitoring quality. We looked at a number of regulations 26 reports and found that they were up to date and detailed. We checked a number of health and safety certificates, those for portable appliance, landlord’s gas, and Legionella and employers liability were all up to date. It was noted however that the First Aid boxes contained out of date items, a recommendation is therefore made that the home instigate a method of checking items held. Monies for people who use the service were checked at random for three individuals no inaccuracies were found. In general day care staff are supervised at the required level, that is to say six supervision sessions per year. There was a shortfall for night staff who did not receive any supervision. As stated previously, with regard to lack of training, night staff are vitally important in that they work in isolation. Lack of training and supervision could seriously compromise the welfare of people who use the service, and affect the development of staff. Therefore a requirement is being made that night staff must receive the levels of supervision Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 2 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 X 2 Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. OP12 2. 3. OP19 OP30 23(2)(b) 18(1)(c) Standard Regulation 12(1)(a) Requirement Timescale for action 20/10/09 4. OP30 18(2) The home must ensure that a range of leisure and recreational activities are available to people who use the service. The condition of the carpet in the 20/08/09 office must be reviewed Night staff must receive 20/11/09 mandatory training and attend other courses relevant to the work that they undertake Night staff must receive 20/09/09 supervision at the required levels 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 3 Refer to Standard OP8 OP12 OP21 Good Practice Recommendations People who use the service should have their weight monitored on a monthly basis to ensure their well being Consideration should be given to employing an activities coordinator to broaden the range of activities available to people who use the service The condition of the bathroom on the ground floor should DS0000007172.V376111.R01.S.doc Version 5.2 Page 27 Eversfield House 4 OP38 be reviewed. A system should be initiated so that the First Aid boxes do not contain out of items Eversfield House DS0000007172.V376111.R01.S.doc Version 5.2 Page 28 Care Quality Commission National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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