Care Home: Hallgarth

What the care home does well People are only offered a place at the home following a thorough assessment of their needs, and if it is then considered that their assessed needs can be met. Residents are encouraged and supported to live their chosen lifestyle and to take part in appropriate activities. Residents told us that they like the meals at the home, and a relative told us that they are invited to stay for a meal.The home is well maintained, clean and hygienic; health and safety practices are good. Staff take part in training programmes that equip them to meet the needs of residents accommodated at the home. The quality assurance system gives residents and others the opportunity to affect the way that the home is operated. What has improved since the last inspection? No improvements were required as a result of the last key inspection of the home. However, there is an on-going programme of refurbishment that includes the provision of en-suite facilities for residents. Those bedrooms that have been refurbished provide a high standard of accommodation for residents. CARE HOMES FOR OLDER PEOPLE Hallgarth Hallgate Cottingham Hull East Yorkshire HU16 4DD Lead Inspector Diane Wilkinson Key Unannounced Inspection 13th May 2008 10:00 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 Hallgarth DS0000019678.V364332.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. Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hallgarth Address Hallgate Cottingham Hull East Yorkshire HU16 4DD 01482 842115 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) Hollyfield Limited Michael Everard – not yet registered Care Home 40 Category(ies) of Dementia (40), Old age, not falling within any registration, with number other category (40) of places Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP and Dementia - Code DE. The maximum number of service users who can be accommodated is: 40 16th May 2006 2. Date of last inspection Brief Description of the Service: Hallgarth is a care home that is registered to provide care and accommodation for up to forty people, including those with dementia. It is a detached two storey building situated in the centre of Cottingham, close to local amenities and transport links. Communal accommodation is arranged on two floors with a lift providing easy access for the residents. Private accommodation is also provided on both floors but most is situated on the first floor, and all but two rooms are for single occupancy. There is an ongoing programme of redecoration and renewal and those bedrooms that have been refurbished offer en suite facilities. There are pleasant gardens to the front of the building and a patio area to the rear; both offer easy access for residents. Fees charged by the home are from £350.00 to £436.50 per week. Additional charges are made for chiropody, hairdressing and newspapers. Hallgarth DS0000019678.V364332.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. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last Key Inspection of the home on the 16th May 2006, including information gathered during a site visit to the home. The unannounced site visit was undertaken by one inspector over one day. It began at 10.00 am and ended at 6.10 pm. On the day of the site visit the inspector spoke on a one to one basis with three residents, three members of staff, a community nurse and a relative, as well as the registered manager, the training manager and the administrator. Inspection of the premises and close examination of a range of documentation, including five care plans, were also undertaken. An annual service review was undertaken on the 11th January 2008. In preparation for this, the registered provider and registered manager submitted information about the service by completing and returning an Annual Quality Assurance Assessment (AQAA) form. As part of the annual service review, surveys were sent to residents, staff, relatives and care managers. The information gathered at this time was also used to inform this key inspection. Comments from surveys and discussions with residents and others were mainly positive, for example, ‘The staff at the home are always kind and gentle with the residents – sometimes under great difficulties and from what I have seen, show great patience’, ‘the staff are fabulous – they are patient, pleasant and caring’ and ‘This residential home provides a good level of care and support to both it’s residents and also their family and friends’. Other anonymised comments are included throughout the report. What the service does well: People are only offered a place at the home following a thorough assessment of their needs, and if it is then considered that their assessed needs can be met. Residents are encouraged and supported to live their chosen lifestyle and to take part in appropriate activities. Residents told us that they like the meals at the home, and a relative told us that they are invited to stay for a meal. Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 6 The home is well maintained, clean and hygienic; health and safety practices are good. Staff take part in training programmes that equip them to meet the needs of residents accommodated at the home. The quality assurance system gives residents and others the opportunity to affect the way that the home is operated. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 was not assessed, as there is no intermediate care provision at the home. 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. Residents are assessed prior to their admission to the home and only admitted if it is considered that their assessed needs can be met. EVIDENCE: The registered manager confirmed that people are visited by staff at their current place of residency prior to their admission and that this is when the initial assessment of needs commences. We examined five care plans and all included a thorough care needs assessment, plus a moving and handling assessment, a nutritional needs assessment and a pressure care assessment. This information, along with a community care assessment undertaken by care management (where people are funded by a local authority), had been used to develop an individual plan of care for residents. There is evidence that family Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 9 members and health/social care professionals are consulted as part of the initial assessment of needs. There is evidence that people are only offered a place at the home if it is believed that their current assessed needs can be met, and in some instances, a period of respite care is arranged to assist people in making a decision about permanent care. Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 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. Care planning documentation evidences that health care needs are met in a way that respects a person’s privacy and dignity. EVIDENCE: We examined the care records for five residents; these included an individual care plan that was based on the needs assessment undertaken by the home as well as information gathered from care management and family members. Care plans include risk assessments for moving and handling as well as those for more specific risks to the individual resident, such as ‘leaving the home unaccompanied during the night’, ‘the use of stairs’ and ‘using a kettle’. Care plans record a person’s strengths and needs and detailed information about the level of need regarding assistance with personal care and continence care. Daily records include information on food/fluid intake, a person’s sleep pattern and how and where they choose to spend their day. A monthly Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 11 monitoring form is then used to summarise the daily records for each month. We saw records on the day of the site visit that evidence that care plans, assessments and risk assessments are reviewed and updated on a regular basis. Care plans include a record of a person’s nutritional requirements, such as a diabetic diet and any allergies; people are also weighed on a regular basis as part of nutritional screening. There is a record of any visits from or contacts with health care professionals, including the reason for the visit, and detailed information is held regarding advice given by health care professionals following surgery or hospital visits. Relatives told us that they are kept informed about health care issues concerning their relative. One relative told us in a survey, ‘My relative has been taken into hospital a few times from the home, and I have been told in time to get to the hospital before she does’. Care plans include a record of a person’s current prescribed medication, as well as risk assessments to record a person’s wishes and capabilities regarding selfmedication. Some care plans included information about medication reviews undertaken by their GP. On the day of this site visit we observed the administration of medication by a senior carer; this was carried out in a satisfactory manner. There is evidence that staff that administer medication have undertaken accredited training; this has been done via various training providers and the registered manager told us that staff will be attending refresher training to ensure that their knowledge is up to date. There are no sample signatures for these members of staff to enable signatures on medication administration records to be checked for authenticity. Medication records, including those for controlled drugs, had been completed accurately. We checked the records held for the administration of controlled drugs against the actual number of drugs held and these were accurate. Medication, including controlled drugs, is stored securely and there is a fridge in the medication room to enable medication to be stored at the correct temperature, where needed. Staff told the inspector that they used to record the fridge temperature but that this practice has ceased; this needs to recommence. We observed on the day of the site visit that residents are spoken to sensitively with regard to personal care, and that staff respect a person’s privacy by knocking on bedroom doors and by closing doors when people were using the toilet and bathroom. A relative told us that they had always heard staff speaking nicely and with respect to residents. We observed that resident’s are treated as individuals, with consideration given to their personal relationships and particular lifestyle choices. Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 12 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 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. Residents are encouraged and supported to maintain their chosen lifestyle and to continue with their hobbies and interests, and visitors to the home are always made welcome. Residents and visitors told us that the meals are good. EVIDENCE: Care plans include information about a person’s life history and previous lifestyle, including details of family and friends, their interests and their religion, including their wishes about attending a church service. Care plans record information about a person’s preferred time to get up and go to bed and about likes and dislikes regarding their diet. Residents confirmed that they can get up and go to bed as a time chosen by them, and that this can vary from day to day, depending on their preference. There are various areas of the home where residents can sit and we observed that residents were able to choose whether to sit in one of the communal areas of the home or in their own room. There are private areas of the home Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 13 where residents can meet with visitors to give them privacy. Visitors told us that they are able to visit the home at any time, and are always made welcome; they told us that they are invited to stay for a meal. We spoke to the activities coordinator who explained about the activities available to residents; it was noted that this includes one to one time being spent with those residents who prefer to remain in their room. Residents confirmed that there are activities that they are able to take part in, such as chair exercise, quizzes and craft activities. One resident said in a survey, ‘Happy with activities arranged’. Care plans evidence that some residents go out into the village themselves or with family, and that others are accompanied by staff. Some people went out with relatives on the day of the site visit. Some residents have had a telephone installed in their own room; they told us that this helps them to remain in contact with family and friends. Information about advocacy services is not displayed in the home; this would enable people to access these services without having to ask someone for the information and promotes privacy and independence. Training plans evidence that staff are in the process of undertaking training on the Mental Capacity Act and it is clear that there is an understanding of the implications of this legislation for residents living in care homes. Care plans record a person’s likes and dislikes regarding food. On the day of the site visit we observed that the menu was displayed outside the dining room, and that there were two choices of meal on offer. Residents seemed uncertain about there being two choices of meal on offer at lunchtimes although records and the menu evidence that this is the case. We saw that special diets are catered for. People were offered fruit juice to have with their meal, and were encouraged to have more that one glass of juice. One resident told us, ‘They vary the meals. I am happy with the choice’. We observed that people were allowed to take their time when eating their meal and that staff offered appropriate assistance where needed. One resident was seen to assist with the serving of drinks and told us that they liked to ‘make themselves useful’; we observed that they wore protective clothing. Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 14 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 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. Residents and others know how to use the complaints procedure and residents say that staff listen to them. Residents are protected from the risk of being abused by the training and skills of the staff group. EVIDENCE: There are appropriate complaints policies and procedures in place, and the complaints procedure is displayed in the entrance hall. Residents and relatives told us that they know how to make a complaint and that they know who to speak to if they are dissatisfied with any aspect of care. They told us that they were confident that their complaints would be listened to and acted upon. One resident recorded in a survey, ‘If I am not happy I speak to my key worker’. One complaint has been made to the CSCI since the last key inspection of the home. This was passed to the registered provider and a satisfactory investigation was undertaken. Other complaints had been made directly to the home; these were recorded in the complaints log and information about the investigation and the outcome were included. There are appropriate policies and procedures in place regarding the protection of vulnerable adults from all forms of abuse. We spoke to three members of Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 15 staff and all were able to explain about possible types of abuse and about the purpose of whistle blowing. The training manager told us that staff undertake training on safeguarding adults annually, and that it is one of their mandatory training courses. All staff that we spoke to told us that they had undertaken training on safeguarding adults from abuse. Since the last key inspection, the home has reported five allegations of abuse to the local authority; it is good practice for the home to refer any allegations or incidents of abuse to the local authority Social Services department for consideration. In most instances, the CSCI were also informed of these events, sometimes via notifications under Regulation 37 of the Care Homes Regulations 2001 and sometimes by a direct telephone call from the home. All allegations have been investigated by the local Social Services team and the CSCI were kept informed of events and the conclusion of the investigations. Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 16 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 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 home is clean, well maintained and well furnished and provides comfortable surroundings for residents. EVIDENCE: There is a repairs book and a maintenance book in place and these record the work undertaken by the maintenance person. We spoke to the maintenance person on the day of the site visit and were told that there is an on-going programme of redecoration; additional staff have been employed to ensure that this work is completed as quickly as possible. We observed that the home is well maintained and there is evidence that equipment is replaced as necessary. Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 17 Bedroom accommodation is in the process of being refurbished. Those bedrooms that have already been refurbished now include en-suite facilities and are decorated and furnished to a high standard. The bedrooms that have not yet been refurbished are small and do not have en-suite facilities, but are decorated and furnished to an acceptable standard. There are various communal areas, both on the ground and first floors. All provide a light and bright atmosphere for residents. Bedrooms are furnished and decorated to reflect the needs of the resident concerned, and many residents have brought small items of furniture from their own home. Laundry facilities at the home are satisfactory. A laundry assistant is employed so care staff do not have to undertake laundry work alongside care tasks; this reduces the risk of cross infection. The inspector observed good hygiene practices being used by staff on the day of the site visit. Some comments had previously been made about a smell of urine in the home. The registered manager told us that he had recognised that this was a problem when he was first appointed and took steps to alleviate this. There were no strong odours identified on the day of the site visit and the home was seen to be clean and hygienic. Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 18 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 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. Care staff are recruited in a safe way and receive induction and on-going training to ensure that they are qualified and skilled to care for the residents living at the home. EVIDENCE: There is a staff rota in place that records the role of each member of staff and we observed that, on the day of the site visit, the staff rota was a true reflection of the actual staff on duty. Catering staff, domestic staff and laundry staff are employed in addition to care staff; this allows care staff to concentrate on personal care duties and enhances infection control at the home. Twelve care staff have completed NVQ Level 2 in Care and a further seven staff are working towards this award. Due to staff changes, the home does not currently meet the requirement for 50 of care staff to have achieved this award. This will be achieved when the staff who are working towards this award complete their training. The training manager told us that nine staff (care managers and senior carers who work nights) are due to commence NVQ Level 3 in Care, and that ancillary staff are also undertaking NVQ training. Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 19 The inspector examined the recruitment and selection records for three members of staff. These evidenced that a satisfactory application form that includes details of a person’s employment history, their previous experience and their training achievements is completed in most cases; one application form was seen to include only brief information. The registered manager told us that he would not accept such an application form now. In all instances, a POVA first check and two written references had been obtained prior to the person commencing work at the home. The registered manager was reminded that, in normal circumstances, a satisfactory CRB check should be obtained prior to staff commencing work at the home, and that a POVA first check should only be used in exceptional circumstances. One reference addressed ‘to whom it may concern’ had been accepted. The registered manager told us that he would not accept such a reference now. We examined the training plan for 2008/9 – this is very detailed and evidences that new employees have induction training when they are first in post and that this meets Skills for Care standards. The organisation have identified core training needs for staff and have made this training mandatory – staff confirmed that they undertake this training annually. This includes fire safety, health and safety, food hygiene, moving and handling and safeguarding adults. In addition to this, staff undertake more specialised training such as the Mental Capacity Act, oral hygiene, nutrition and challenging behaviour. Training achievements are recorded in individual staff records; we recommend that a training and development plan be developed that records the date that staff have undertaken training so that it is easy to identify the overall training needs and achievements for the full staff group, and the date that refresher training is needed. The training provided by the organisation equips staff to meet the needs of the residents accommodated at the home. A relative told us, ‘The staff are fabulous – they are patient, pleasant and caring’ and a care manager said, ‘The staff at the home are always kind and gentle with the residents – sometimes under great difficulties and from what I have seen, show great patience’ Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 20 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. 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 home is well managed and the health, welfare and safety of residents and others are protected by the systems in place. EVIDENCE: The new manager has recently had an interview with the Commission for Social Care Inspection to assess his suitability to become the registered manager, and is still awaiting an outcome. He is a qualified nurse and has undertaken management training whilst working for the National Health Service. He is new to the field of social care but the discussions we had with him on the day of the site visit evidence that his years of experience working in a hospital setting have provided him with the skills needed for his current post. Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 21 Staff, residents and relatives told us that they have a good relationship with the manager, and this was observed on the day of the site visit. The home has achieved the Investors in People award and the Quality Development Scheme (QDS) Parts 1 and 2, the quality scheme operated by the local authority. The quality assurance systems in place at the home enable residents and others to affect the way in which the home is operated. Surveys are distributed to residents and others and the results of these are evaluated. These are discussed at residents meetings, staff meetings and managers meetings; a copy of collated QA information should also be forwarded to the CSCI. There is evidence that policies and practices at the home have been changed as a result of the outcome of quality surveys. Resident/relative meetings and staff meetings take place, and there is a suggestion book in operation. There is a QA calendar in place and this records the audits, meetings and reviews that will take place each month as part of the quality assurance system. We examined the records for monies held on behalf of residents and crosschecked these with actual monies held - both were found to be accurate. Receipts are obtained for any purchases made on behalf of residents and for money handed to residents. We recommend that a receipt be given to relatives when they hand money to staff for residents for safe keeping, to protect all parties concerned. Staff were reminded that, ideally, individual receipts should be obtained to ensure that the Data Protection Act is not breached when recording financial transactions. We examined health and safety documentation held at the home. There is evidence that weekly fire tests take place as well as regular fire drills. All other health and safety documentation was seen to be in order, such as a gas safety certificate and maintenance certificates for mobility hoists, bath hoists and the passenger lift. The maintenance person undertakes a weekly audit of the premises to ensure that they are safe. Staff undertake appropriate training on health and safety topics, and this training is updated on a regular basis. On the day of the site visit we saw evidence that water temperatures at outlets accessible to residents are tested on a regular basis to reduce the risk of scalding; a different sample area is tested each day. Temperatures were seen to be consistently between 40 – 43°C; 43°C is the recommended temperature to ensure safety for residents. There has also been a test to detect the presence of Legionella in the water supply and the result of this was negative. Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 22 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 2 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 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 Requirement There must be a sample signature held for each member of staff that administers medication to enable medication records to be checked. Timescale for action 13/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP9 OP14 OP30 OP35 Good Practice Recommendations Fridge temperatures should be checked and recorded every day to ensure that medication is stored at the correct temperature. Information about advocacy services should be displayed in the home; this would enable residents and others to access these services without having to ask for assistance. There should be a record of the overall training needs and achievements for the full staff group; this would assist with identifying refresher training. Receipts should be issued to relatives when they hand money to staff for residents for safe keeping. Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 24 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 Hallgarth DS0000019678.V364332.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!