Care Home: Half Acre House

What the care home does well What has improved since the last inspection? All the good practice recommendations made at the last key inspection had been addressed either fully or in part. Improvements to the fabric and furnishings in the building were on going. The owner also reported improvements to their internal monitoring and ways of seeking `feedback` from service users and relatives. CARE HOMES FOR OLDER PEOPLE Half Acre House Roch Valley Way Rochdale Lancashire OL11 4DB Lead Inspector Steve Chick Unannounced Inspection 23rd June 2008 10:30 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 Half Acre House DS0000025474.V366173.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. Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Half Acre House Address Roch Valley Way Rochdale Lancashire OL11 4DB 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) 01706 861098 01706 649066 Mrs Anita Lewis Mrs Lesley Rider Lynne Kowalski Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 25 service users, to include: Up to 25 service users in the category of OP (Older People) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 10th July 2007 Date of last inspection Brief Description of the Service: Half-Acre House is a care home providing personal care and accommodation for 25 older people. Nursing care is not provided. The home is located approximately 1.5 miles from the centre of Rochdale and has good transport links to the motorway and several bus routes. Half-Acre House is a large 2-storey building, which has been converted and extended into a residential care home. Bedrooms are located on the ground and first floor and all are single occupancy with en suite facilities. A passenger lift is provided. A variety of communal space is available. The home is situated in its own grounds with ample parking available. A copy of the most recent Commission for Social Care Inspection report is available in the manager’s office. The current (July 2008) weekly fees range from £ 352.00 to £ 440.00 dependent on the package of care required. Further details regarding fees are available from the manager. Half Acre House DS0000025474.V366173.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 star. This means the people who use this service experience good quality outcomes. We (the Commission for Social Care Inspection) undertook a key inspection, which included an unannounced visit to the home. This meant that no one at Half Acre House knew that the visit was going to take place. All the key inspection standards were assessed at the site visit. For the purpose of this inspection three service users were interviewed in private, as were four relatives of service users and three carers. Additionally discussions took place with one of the managers and the owner. We undertook a tour of the building and looked at a selection of service user and staff records as well as other documentation, including staff rotas, medication records and the complaints log. We also looked at information we have about how the service has managed any complaints, what the service has told us about things that have happened in the service, these are called ‘notifications’ and any relevant information from other organisations. One allegation in connection with the possibility of a safeguarding issue had been received by us. This was passed to the Local Authority for investigation and was found not to be a safeguarding issue. Before the site visit, we asked for surveys to be sent out to residents, relatives and staff, asking what they thought about the care at the home. Eight residents, four relatives and five staff returned their surveys. Comments from these surveys are included in the report. We also asked the management of the home to fill in a questionnaire, called an Annual Quality Assurance Assessment (AQAA). This is a legal requirement. The AQAA told us what they thought they did well, what they need to do better and what they have improved upon. Where appropriate, some of these comments have been included in the report. This questionnaire indicated that the owner was not complacent about the quality of care and was identifying ways to improve. What the service does well: Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 6 The significant majority of comments received from service users, relatives and staff were positive about the care offered at Half Acre House. Comments from relatives included :“this home is 100 caring and supportive in every way.” – “the home is very warm, welcoming and very loving. The staff are fantastic with my mum and all residents.” – “the staff do their utmost to maintain a happy atmosphere for the residents” - “friendly atmosphere” and “[the] managers are very approachable and friendly.” Staff comments on what they do best included:“Half Acre House is well run and organised home, which makes it a pleasure to come to work, there is always a nice warm happy feeling amongst residents and staff alike, also there is good rapport with relatives and staff and managers and Mrs Lewis are very supportive and encourage staff to maintain high standards of care.” Service users have their needs assessed before moving to the home. People receive appropriate medical support when needed. Staff provide a welcoming atmosphere for visitors and are perceived as being friendly and approachable. Good food is provided. Service users are confident that complaints will be dealt with, and feel safe at Half Acre House. What has improved since the last inspection? What they could do better: Several areas of recording and administration could be improved. These mainly related to some aspects of care planning, staff vetting and medication. While this did not present as having an immediately detrimental impact on service users it did have a negative impact on the management’s ability to be accountable for their care and safety. Half Acre House DS0000025474.V366173.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. Half Acre House DS0000025474.V366173.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 Half Acre House DS0000025474.V366173.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): 3 and 6. Quality in this outcome area is good. Service users’ needs are assessed before moving to the home to ensure that their needs can be appropriately met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) which was sent to us before this key inspection informed us that an assessment was always carried out before anybody was admitted to the home to ensure that staff could meet the individual needs of any resident. A selection of service users’ files was looked at. All had a copy of an assessment undertaken before they moved to the home. Some of the assessments seen, may have benefited from more detail. Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 10 A visiting relative confirmed that she had been given good information about the home before making a decision on behalf of her relative to move there. Half Acre House does not offer intermediate care. Half Acre House DS0000025474.V366173.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. Service users’ health, personal and social care needs are met by the staff’s implementation of appropriate policies and procedures. Staff practices also serve to promote the dignity of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A selection of service users’ files was inspected. All had a written copy of a care plan and there was documentary evidence that the plan was reviewed at appropriate intervals. Although the care plans are regularly reviewed, there was some evidence that changes to the planned support were not always documented as thoroughly as they could be. For example one record indicated that a continence assessment needed to be carried out but there was no Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 12 subsequent record of this having been done. Discussion with the owner and staff indicated that this was because the assessment had changed (the service user no longer having a continence management problem) but this had not been effectively documented. The AQAA reported that the need for care plans to be updated more meticulously was an issue which had been identified for action, by the management. As with the written care plans there was room for some improvements in the daily records. For example, one entry noted that a service user had a condition which indicated some follow-up was necessary, but there was no subsequent record of the issue having been followed up. Discussion with the manager indicated that this action would have been taken and the error was in connection with the administration, not the care. Staff who were asked at interview reported that the overall system, including verbal handovers at shift change and information documented in the handover book” was effective in keeping them up to date with the individual needs of service users. A significant majority of service users who responded to the survey said they either always or usually received the care and support they needed. All relatives who responded to the survey said that they felt the home either always or usually met their relatives needs, with one respondent saying this home is 100 amazing. All staff respondents to the survey felt that they were either always or usually kept up to date regarding service users and that information was passed on well, either always or usually. One member of staff reported that all staff are encouraged to read all care plans. Another member of staff responded to the question, what does the service do well, by saying cares very well for all residents needs and wishes. Pass on important information that we need to know. All service users, relatives and staff who were asked confirmed that appropriate medical support was obtained in a timely manner. A selection of records was looked at relating to contact with medical professionals. These presented as being appropriately maintained. Medication presented as being stored appropriately. The system in use for recording the administration of some medication was unusual. Although it did appear to maintain accurate records to confirm that medication had been administered in an appropriate dose at the correct time, more straightforward and robust systems do exist. There was documentary evidence that the medication administration records were regularly ‘audited by staff. Discussion with the owner and some staff members indicated that the management was actively pursuing improvements to the service received from the pharmacist. This was particularly in connection with the systems for recording the administration of medication. Observation during the site visit indicated that service users were treated with respect and dignity. No information had been received, through any of the surveys, to indicate that service users dignity was not maintained. Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 13 Interviews with service users and visiting relatives indicated that good quality care was provided by the staff. One service users said she was very well looked after and another said [the staff] look after them well … [and they] keep a close eye on me. Other quotes from visitors included care very good and very good care. One member of staff, when asked what the best thing about Half Acre House was replied care always there to help around the clock. Half Acre House DS0000025474.V366173.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. An appropriate range of activities was available for service users, and visitors are welcome in the home, which enhances service users’ fulfilment and social stimulation. The provision of food to maintain service users’ health and well-being is good and service users are able to maximise their autonomy within the context of communal living. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Visitors who were asked, reported that they were made to feel welcome when they visited Half Acre House. Service users, staff and visitors who were asked confirmed that visitors are welcome at any reasonable time. One relative who was interviewed said that they liked Half Acre House because it was “informal, like a family and familiar”. Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 15 People who were interviewed during the site visit were positive about the level of social activities available for people to take part in if they wished. One service users cited the Easter bonnet parade as being something she had particularly enjoyed. Another visitor confirmed that service users had been invited to a local school for a concert and afternoon tea which was enjoyed by those who attended, and was aware of a planned trip to Southport. There was some evidence on service user files that individuals hobbies and interests were documented. In the files seen information varied in detail. Respondents to the service user survey, when asked about there being activities in the home, did not give a consistent picture. Two said always, three said usually and three said sometimes. One service user said I dont take part but this is my choice. I enjoy watching the activities. All respondents to the relative survey said that residents were supported to live the life they choose either always or usually. One, when asked what the home does well reported entertainment and outings are organised for the residents on a regular basis and another in reply to the same question said entertainment. The AQAA reported that there was a wide range of activities and interests for residents and that staff were working to encourage relatives to accompany and support them on certain outings. The AQAA also identified the potential for improvement in staff training to increase the provision of interests and activities and to make better use of the more interesting stimulation materials they had bought. A record of activities undertaken by individual service users is maintained. As with several other pieces of documentation maintained by staff, these may be improved by including more detail. Service users and staff who were asked, confirmed that service users were able to exercise autonomy and choice within the context of communal living. Service users confirmed they were able to get up and go to bed when they chose and were free to either use the communal areas or go to their own rooms when they wished. Some visitors were observed to be meeting with their relatives in the privacy of their relative’s own room. During the unannounced visit to the home one meal was sampled. This was pleasantly presented, tasty and people were observed to have good portions. There was a choice which included a vegetarian option and ample drinks were provided. The meal was taken in a pleasant and relaxed atmosphere and staff were observed to be assisting service users in an appropriate and dignified manner. Staff reported that menu choices were regularly discussed at residents meetings. Five of the eight respondents to the service user survey said they either always or usually liked the meals provided. One service user commented if they[ the cooks] hear from residents they like something different then this meal gets made. Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 16 Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. Service users are protected from abuse or exploitation by the home’s policies and practices and are confident that any complaint would be dealt with appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The management of the home have produced a complaints procedure which has been found to be appropriate on previous visits to the home. The written policy and procedure was not looked at again on this visit. The record of complaints was looked at and presented as being predominantly appropriately maintained. One complaint had been received by the CSCI which had been passed to the local social services department to investigate. The owner of Half Acre House reported that they had not recorded this complaint as it had not come to them in the first instance. It was recommended that a record is kept of all complaints, including the outcome, regardless of the routes by which the owner or manager became aware of them. Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 18 All service users who were asked during the visit said they would be confident about making a complaint. One service user said you can complain and people do listen. Similarly, relatives who were interviewed, expressed confidence that complaints would be dealt with appropriately. One visitor said [a complaint] wouldnt fall on deaf ears. Staff who were asked were confident that the management would respond to complaints appropriately. The AQAA reported that management listened carefully to residents needs and that action was taken when there was a problem. The AQAA also reported that the owner and managers put effort into maintaining an open and approachable atmosphere in which residents and relatives are encouraged to speak out if they are unhappy in any way. All respondents to the service users survey confirmed that they knew how to make a complaint. All respondents to the relative survey reported that they knew how to make a complaint and that the home appropriately responded to concerns. All respondents to the staff survey similarly reported that they knew what to do if any concerns were expressed to them. One allegation of potential abuse had been made since the last key inspection and had been investigated under the appropriate safeguarding adults procedures by the local authority. This investigation concluded that no abuse had taken place. All service users spoken to were very positive in saying that they felt safe at Half Acre House. Visitors who are interviewed were also very positive about the safety of the service users, with one saying when I leave I know my mum is happy and well cared for. All staff who were interviewed were aware of the importance of maintaining vigilance in connection with the protection of vulnerable adults. They were all aware of the whistleblowing procedures and were confident they would use them if necessary. There was documentary evidence that most staff had received training in the protection of vulnerable adults. Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. The home is appropriately maintained, decorated and cleaned to enable service users to live in a pleasant, safe and hygienic environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information in the AQAA indicated that the owner had moved forward with the decoration of bedrooms and had refurbished the upstairs bathroom including the provision of specialist equipment. Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 20 During this unannounced visit a tour of the building was undertaken. This included a selection of service users’ own rooms. No serious remedial issues relating to the maintenance of the building were identified during this visit. A maintenance record is maintained where staff can record any defects to the fabric of the building, furnishings or equipment which need attention. This record is then ‘signed off’ when the work has been completed. Respondents to the service user surveys all stated that the home was either always, or usually fresh and clean. One respondent to the service user questionnaire and one respondent to the relatives questionnaire suggested the carpet in the dining room and lounge would benefit from being replaced. One visitor also commented that this area was looking a little tired. Observation indicated that this was not an urgent matter. Information supplied in the AQAA and discussion with the owner indicated that those communal areas would be addressed as part of a rolling programme of refurbishment. All service users who were asked, said that they liked their room. Visitors spoken to also reported positively on service users’ bedrooms. One specifically said that one of the best things about the home was the “lovely setting and the nice rooms”. Visitors confirmed that their relative had been able to bring in pieces of their own furniture. The tour of the building confirmed a good level of personalisation in each bedroom. The home presented as clean and tidy, with no unpleasant odours. This was confirmed as the usual state of the home by service users, visitors and staff who were spoken to. Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. The numbers and skills mix of staff on duty promotes the independence and well being of service users. Recruitment and vetting procedures are usually effectively applied to minimise the risk to service users of inappropriate staff being employed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff rota for the week beginning 21/06/08 was looked at. The owner reported that the rota is usually fixed, with changes tending to be because of annual leave and sickness. The rota indicated that staffing levels were usually provided on the basis of: - three carers between 08:00 – 14:00, with an additional carer to cover the peak morning time of 08:00 – 11:30. The afternoon shift is two carers working from 14:00 – 20:00, who are joined by a third carer to cover peak time between 15:00 and 21:00. This carer’s hours straddle the afternoon and night shift. The night shift consists of two carers working between 20:00 – 08:00. The owner reported that these staffing levels were appropriate to meet the needs of the service users. Additionally the Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 22 home employed cooks and domestic staff. The managers hours were in addition to those identified above. Respondents to the service users survey varied in their response to the question of staff being available when needed. One replied always, six replied usually and one replied sometimes. Comments from these respondents included staff are always lovely and thoughtful to my needs, residents are treated with care and consideration and I am well cared for and the staff I cannot fault. Respondents to the relative survey were predominantly positive about the staff attitude and included comments such as the staff do their utmost to maintain a happy atmosphere for the residents . One of these respondents thought that the home could improve by having more staff at times . Information from the AQAA indicated that over 70 of the care staff held an appropriate NVQ qualification. A small, random selection of staff who were recorded as holding an NVQ qualification was chosen and the owner was able to provide certificates confirming their achievement. A selection of records, relating to recently recruited staff, was looked at. These demonstrated that the required pre-employment checks with the criminal records bureau (CRB) had been undertaken. Most of the other preemployment vetting procedures and required checks had been undertaken. However some examples were seen where the applicant’s full employment history was not fully recorded. Discussion with the owner and manager demonstrated that they had a better understanding of these people’s employment history than was recorded. The owner was reminded of the minimum legal requirements in connection with records relating to preemployment checks. All staff who were interviewed confirmed that new staff received induction training. Respondents to the staff survey all confirmed that induction either very well or mostly, covered everything they needed to know and all reported that they were given training which was relevant to their role and helped them to understand and meet the individual needs of service users. There was documentary evidence that staff were able to access a range of appropriate training. Staff who were asked at interview, confirmed that training was encouraged and good quality support was available to them from their colleagues and managers. Interviews with visitors on two separate occasions identified that they believed that the carers were amongst the ‘best’ thing about the home. Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. The managers are competent to run the home, use the quality audit systems and implement the health and safety procedures for the benefit of service users and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager role is shared between two people on a job share basis. Previous inspections have provided evidence that they hold appropriate qualifications and experience. Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 24 The AQAA identified that quality assurance and audit systems were in place. Some documentary evidence to support this was looked at. A comprehensive quality assurance assessment involving questionnaires to service users had been undertaken by the owner in August 2007. There was documentary evidence of an analysis of these questionnaires and an action plan based on the outcomes of that analysis. A selection of records relating to money held on behalf of service users was looked at. This documentation presented as being appropriately maintained to safeguard the interests of the service users and included receipts for purchases made on behalf of service users. Staff who were asked, confirmed that appropriate basic health and safety training was provided. Similarly staff confirmed the availability of personal protective equipment such as disposable gloves and aprons. The owner also confirmed that these were always available. Previous site visits to Half Acre House have confirmed good standards of the maintenance of equipment for health and safety purposes. Similarly there has been a regular routine of testing fire alarm and detection equipment which was appropriately recorded. The owner reported that she was maintaining all appropriate health and safety testing and compliance. A small sample of this documentation was looked at and indicated these standards were being maintained. These documents included servicing of the lift, the hoists and the fire alarm and detection equipment. Half Acre House DS0000025474.V366173.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 X X 3 X X 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Half Acre House DS0000025474.V366173.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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations The manager should ensure that care plans are updated when there is a change in the assessed need This will ensure care needs are met consistently and efficiently. The manager should ensure that effective aids to the safe recording of medication administration are used to ensure that staff can demonstrate that service users receive the correct dose of the correct medication at the correct time. The manager should ensure that prospective employees always give a full employment history which is recorded. There should also be a written record of any gaps in employment or full time education, together with a satisfactory explanation of those gaps. 2. OP9 3. OP29 Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection 3rd Floor Unit 1, Tustin Court Port Way Preston PR2 2YQ 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 Half Acre House DS0000025474.V366173.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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