Care Home: Kyffin Taylor House

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What the care home does well The staff team have worked with people who use the service, developing care plans that are unique to them so that they receive the right amount of support to meet their needs, in the way they prefer. The systems in place to consult with people about the service in Kyffin Taylor have been used well to plan for the future and develop the service in the way people want. Staff have obtained information about the social, cultural and leisure care needs of people living in the home. This means that staff have the information they need to make sure the care and support provided is right for the person. People told us they are well cared for and feel relaxed in their home. They said that staff are competent and always available to help them. A visitor said that staff let her know about any changes in her relative’s general health and that the care provided is good. We were told that when the person moved in to Kyffin Taylor, the process was well managed and they were given information about the home to help the make a decision about whether it would be suitable. People told us they like their bedrooms and think their home is comfortable. People said they had chosen colour schemes for their bedrooms and had made Kyffin Taylor House DS0000005416.V376868.R01.S.doc Version 5.2 them their own with their photographs and ornaments. People described the home as ‘Perfect’, ‘Very comfortable’ and one person said ‘It is a true home for me’. What has improved since the last inspection? A lot of work has been done to improve the way medication is managed and requirements from our last visit have been met. There are now improvements to make sure medication given to people will always be in date and that pharmacy instructions will be followed when giving out medication. For people who wish to manage their own medicines there is a system for risk assessments to be carried out to ensure each person is able to do this properly and safely. The medication management system is monitored each month to ensure that any medication queries or issues will be identified without delay and mediation will be managed properly and safely. These steps have helped to make sure that the medicines are managed well in the home to make sure mistakes do not occur and people receive their medications as prescribed by their doctors. During our last visit to Kyffin Taylor House, we recommended that visual aids be fitted throughout the home to make it suitable for people who have dementia. Advice was obtained from a specialist consultancy firm, and during this visit we saw that pictorial signs, pin boards and colour coding was in place to give prompts to people who have dementia, to help them find their way around and stay as independent as possible. What the care home could do better: We have not made any requirements or recommendations during this visit and we read the AQAA to find out what the manager thinks could be improved upon. Some of the information on service development is as follows. The AQAA tells us that consultation with people who use the service is a main way of driving improvements. This is good evidence of the importance placed on people’s opinions on their home. The manager has identified that a wider range of activities will improve variety and quality of life in Kyffin Taylor for people who have dementia and who benefit from daily stimulating activities which will engage their attention.Kyffin Taylor HouseDS0000005416.V376868.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Kyffin Taylor House Deyes Lane Maghull Liverpool Merseyside L31 6DJ Lead Inspector Mrs Trish Thomas Key Unannounced Inspection 21 August 2009 10:30 DS0000005416.V376868.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. Kyffin Taylor House DS0000005416.V376868.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 Kyffin Taylor House DS0000005416.V376868.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Kyffin Taylor House Address Deyes Lane Maghull Liverpool Merseyside L31 6DJ 0151 527 2822 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) Parkhaven Trust Margaret Kathleen O`Reilly Care Home 28 Category(ies) of Dementia (28), Old age, not falling within any registration, with number other category (4) of places Kyffin Taylor House DS0000005416.V376868.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 people of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia - Code DE The maximum number of people who can be accommodated is: 28 Up to 4 people can be accommodated in the category of: Old age, not falling within any other category - Code OP 7 August 2008 Date of last inspection Brief Description of the Service: Kyffin Taylor House is a care home owned by Parkhaven Trust. The home provides a permanent home to elderly people and a respite service for people who have dementia. The building has recently been refurbished, providing more bedrooms and en suite facilities, upgraded bathrooms and more lounge space. There is a car park at the front of the home and well-maintained and secure gardens at the rear. The weekly charges for Kyffin Taylor House are £449.00 - £464.00. Chiropody and hairdressing are charged for as extras. Kyffin Taylor House DS0000005416.V376868.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 three stars. This means that people who use this service experience excellent quality outcomes. The visit was just one part of the inspection. Before the visit took place, we (the commission) asked the manager to fill in a questionnaire that we call an annual quality assurance assessment or AQAA and return it to us. This gives us information about how the home is meeting the needs of the people who live at the home and includes future plans for further development. We used a system called case tracking. This is a way of inspecting that helps us to look at services from the point of view of some of the people who use them. We track people’s care to see whether the service meets their individual needs. During our visit we walked round the home and we checked various records to see what care people living there receive. We spoke with people who live at the home and they told us what they thought about it. We also spoke with staff and with the manager who gave us their views about Kyffin Taylor. We have included their views throughout the report. What the service does well: The staff team have worked with people who use the service, developing care plans that are unique to them so that they receive the right amount of support to meet their needs, in the way they prefer. The systems in place to consult with people about the service in Kyffin Taylor have been used well to plan for the future and develop the service in the way people want. Staff have obtained information about the social, cultural and leisure care needs of people living in the home. This means that staff have the information they need to make sure the care and support provided is right for the person. People told us they are well cared for and feel relaxed in their home. They said that staff are competent and always available to help them. A visitor said that staff let her know about any changes in her relative’s general health and that the care provided is good. We were told that when the person moved in to Kyffin Taylor, the process was well managed and they were given information about the home to help the make a decision about whether it would be suitable. People told us they like their bedrooms and think their home is comfortable. People said they had chosen colour schemes for their bedrooms and had made Kyffin Taylor House DS0000005416.V376868.R01.S.doc Version 5.2 Page 6 them their own with their photographs and ornaments. People described the home as ‘Perfect’, ‘Very comfortable’ and one person said ‘It is a true home for me’. What has improved since the last inspection? What they could do better: We have not made any requirements or recommendations during this visit and we read the AQAA to find out what the manager thinks could be improved upon. Some of the information on service development is as follows. The AQAA tells us that consultation with people who use the service is a main way of driving improvements. This is good evidence of the importance placed on people’s opinions on their home. The manager has identified that a wider range of activities will improve variety and quality of life in Kyffin Taylor for people who have dementia and who benefit from daily stimulating activities which will engage their attention. Kyffin Taylor House DS0000005416.V376868.R01.S.doc Version 5.2 Page 7 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. Kyffin Taylor House DS0000005416.V376868.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 Kyffin Taylor House DS0000005416.V376868.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 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. There are good procedures in place to help people move into the home and to check on what their needs are before they move in to show those needs can be met at the home. EVIDENCE: People regularly move in to this home for short respite breaks and we looked at the care file of a person who moved in recently. We looked at how admissions to Kyffin Taylor are arranged and at the information given to people about the home. We also looked at the information the home obtains about each person’s needs before they moved in. It is procedure for the local authority to fax a needs assessment document for each person to Kyffin Taylor before they move in and this information will form the basis of their care plan. Kyffin Taylor House DS0000005416.V376868.R01.S.doc Version 5.2 Page 10 On the day the person moves in, staff from the home sit down with them and find out about their needs and preferences, to ensure they have all the information they need and will be able to support the person properly and safely. In this way, the information they have about the person’s support needs will be up to date and will avoid them being placed at risk in situations where their needs have become more complex since last being reviewed by social services. We spoke with a visitor whose relative had moved in to the home recently on a permanent basis, having received respite breaks there in the past. We were told the person was given enough information about Kyffin Taylor to help them make a decision about whether the home would be suitable. We were informed by the visitor that when the person moved in, the process had been well managed and staff had been helpful throughout. Kyffin Taylor House DS0000005416.V376868.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 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 are treated with dignity and respect in this home. Their care plans are completely person centred so that their health care, personal care and social needs are being met in the way they prefer. EVIDENCE: We carried out case tracking of two people living in the home to find out about the support they were receiving. We found that the care plans which guide staff about how to assist people were completely person centred. This meant that staff knew exactly what they needed to do to help the person in the way they preferred. The plans focussed on what people were able to do for themselves, which helped them to stay as independent as possible. Each person’s care plan is reviewed three days after they move in and afterwards at least every month. This guides staff about how to give people the right Kyffin Taylor House DS0000005416.V376868.R01.S.doc Version 5.2 Page 12 amount of support so that they will not lose their skills. We found that the care plans for people who have dementia had been signed by a family representative as consent to the support they will be given. We found that potential risks to people’s safety (for example if they were at risk of falling), had been identified and action taken to address the risks and keep them safe in their home. There were clear records in care files that showed us that people who live in Kyffin Taylor House are registered with local doctors. There are arrangements in place for people who are staying on a temporary basis have access to local doctors if their GP is not local to the home. There are arrangements for people to attend their hospital appointments and have visits from district nurses, specialist mental health services and paramedical services. This means that people have access to the full range of community health services while they are living in this home. People living there told us they are well cared for and that staff are pleasant and helpful. A visitor told us her mother is well looked after and staff always let her know of any change in her mother’s state of health. We looked at the medication procedure and tracked the medication of two people who live in the home. Medication is blister packed and given to people by staff who are trained to do this. Medication we looked at was in date and had clear instructions about how often it should be given to the person and the dose. It is safely stored in a locked area and there is a trolley, controlled drugs cupboard and medication fridge. The records of medication given out were up to date and there are systems for returning unwanted medication to the pharmacy to give an audit trail of all medication accepted into the home. To ensure medication will be safely managed, monthly audits are carried out by staff so that any problems with medication will be identified and corrected. People told us that they get their medication at the same time each day. One person said she was glad staff keep her medication as she may forget to take it and she trusts them to look after this. Self medication risk assessments are carried out and reviewed when required, to ensure that only people are able to do so safely will manage their own medication. Those who hold their medication have a locked facility to store it safely. We asked people if they thought the privacy and dignity is respected in their home. They said they are handed their mail unopened and are given privacy with their visitors. They told us they liked having their own single bedroom and en suite shower rooms. During the visit we saw staff supporting people discreetly and respectfully and offering them choices. People told us they always get their clothes back from the laundry in good condition and they liked the arrangements in place for having their hair done regularly. One person told us everything was perfect and Kyffin Taylor is a ‘real home’ to her. Kyffin Taylor House DS0000005416.V376868.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Social activities and meals are both well managed so that people living at Kyffin Taylor House have daily variation and interest. EVIDENCE: There is an activities diary which shows a range of in house events, such as yoga, gardening, sing songs, trips out to garden centres and places of interest, art sessions and pet therapy. People appeared to be relaxed during our visit and were moving freely into the garden through french windows, where there is seating and tables with umbrellas. Others were relaxing in the lounges or in their bedrooms. People told us they were satisfied with their lifestyle as they can choose what they want to do and where to spend their time. They told us there are no undue restrictions on visiting times and visitors we spoke with said that staff are always welcoming and leave them in private with their relatives. People told us that religious ministers visit the home about every two weeks and a gospel choir sometimes entertains them. One person Kyffin Taylor House DS0000005416.V376868.R01.S.doc Version 5.2 Page 14 explained that activities are displayed on the notice board and there is a photo diary of events in the home. We visited the kitchen and spoke with the chef about how choices are offered to people for their meals. The arrangement in place is that staff take the menu to people, ask what they would like and offer alternatives. The menu is displayed in the dining room with picture aids for people who have dementia. There were good stocks of food in store, including fresh fruit, vegetables and meat, as well as chilled, frozen and dry food. The catering records were well managed and showed that food is stored and cooked safely. The kitchen was clean and well equipped and there is a service hatch directly to the dining room which is bright and well presented with surrounding views of the garden. We saw that people who need a lot of help with their food are assisted by one member of staff in a relaxed manner in a private area. People told us the food is ‘very good’, ‘very tasty’ and ‘well presented’. Another person said ‘we are not rushed, we take our time with our food’. People told us they are offered choices and alternatives to the main menu. Care records showed us that people’s weight is monitored to ensure they will be well nourished and stay as healthy as possible. Kyffin Taylor House DS0000005416.V376868.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 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. There are good procedures and staff training so that people living at Kyffin Taylor are listened to and protected from harm. EVIDENCE: There is a complaints procedure, which is given to people and displayed in the home so they know about their right to complain and that their complaints will be taken seriously. We looked at the complaints record book, which had been signed by the manager each month to confirm there had been no complaints received about this home. Kyffin Taylor has safeguarding and whistle blowing procedures and staff have received training in protection of vulnerable adults. Staff we spoke with understood the safeguarding procedures and how to report suspected abuse, which means that people will be protected in their home. Staff have received some training and have guidance on deprivation of liberty safeguarding, which means they are aware of how to promote and protect the rights of people who live in Kyffin Taylor. Kyffin Taylor House DS0000005416.V376868.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Kyffin Taylor is very well maintained so that it provides a comfortable, safe, attractive home that is suitable for the needs of the people who live there. EVIDENCE: Kyffin Taylor has been recently completely refurbished and provides a very comfortable and pleasant home for the people who live there. The recent improvements mean there is more lounge space, a hairdressing room and single bedrooms with en suite shower rooms. There are assisted bathrooms for those people who are frail and need help from staff while bathing. The home is furnished and decorated in an attractive domestic style which provides comfort and interest for people who live there. Because the home provides Kyffin Taylor House DS0000005416.V376868.R01.S.doc Version 5.2 Page 17 services for people who have dementia, expert advice has been obtained and a range of environmental prompts have been fitted, such as picture aids for toilet and bathroom doorways and memory boards and colour coding outside people’s bedroom doors. These visual aids help people find their way around their home and stay as independent as possible. People told us they chose the colours for their bedrooms and had made them individual with ornaments and photographs. There are call bells throughout the home for people to summon assistance and people said staff do not delay in arriving to help them. For staff guidance, there are procedures for infection control and COSHH (control of substances hazardous to health). Staff told us they lock cleaning materials in the safe area because they could cause a risk to the people who live in the home if left unattended. They said there is no shortage of cleaning agents and protective gloves and aprons. Domestic staff work in the home every day so that good standards will be maintained. The home was clean and odour free in the areas we visited and a visitor and people who live there said the home is always clean and staff work hard to keep it that way. Kyffin Taylor House DS0000005416.V376868.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. 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. The people living in Kyffin Taylor are supported by well trained staff who have gone through recruitment process. This means their needs are met and they are safe from possible harm or poor practice. EVIDENCE: The home has a staff roster which names the staff on duty for each shift. We think that the staffing levels were meeting the needs of the people who live in the home at the time of our visit. Staff have job descriptions and designated roles within the home and there is a clear management structure in the home and the wider organisation. We looked at the training records which show there is an ongoing training programme to ensure that staff have the skills to support people properly and safely in the home. Staff have National Vocational Qualifications in care and have done a course in dementia. All mandatory training was up to date and staff said they think the training is useful and relevant to the needs of the people they support. People told us the staff were pleasant, helpful and they Kyffin Taylor House DS0000005416.V376868.R01.S.doc Version 5.2 Page 19 have the skills to look after people properly. They said, ‘Nothing is too much trouble for them’ and ‘When you need them they are there’. To ensure that only people who are suitable will be employed, we looked at the recruitment procedure and checked staff files. We saw that applicants for vacant posts are always interviewed and they fill in an application form giving employment history, qualifications and experience. We looked at two staff files and saw that there was evidence of satisfactory criminal records bureau checks and references. These checks help to make sure that staff are suitable to work with the people who live at Kyffin Taylor. The staff files were well organised and are kept in a secure cabinet to ensure confidentiality. Kyffin Taylor House DS0000005416.V376868.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Kyffin Taylor is well run and a high level of consultation with people who use the service meant they could contribute to its development. EVIDENCE: The manager is qualified and has many years experience managing and overseeing care services. To support the management role in Kyffin Taylor there is a deputy manager and supervisory care staff, to take over when the manager is off duty. We saw evidence of good communication between the management team and care and ancillary staff during our visit. A visitor said Kyffin Taylor House DS0000005416.V376868.R01.S.doc Version 5.2 Page 21 there is a good team and staff are helpful. The manager follows the organisational procedures for monitoring of the quality of policies, procedures and practice in the home and information gathering. This is done through monthly audits of care plans, medication and health & safety. There are regular staff and residents’ meetings and ongoing quality assurance monitoring. The trustees of the organisation visit Kyffin Taylor each month, carry out checks, speak with the people who live there and write a report on their findings. An annual quality audit of the service is carried out by a care consultancy firm and this includes seeking the views of those who work and live in the home in and their representatives through questionnaires. Where shortfalls in the service are identified by any of these methods, action is taken to put things right. This mean that people’s opinions on their home will be at the heart of planning future developments and improvements in the home. There is a good system in place to manage people’s money which is held in safekeeping. We looked at the accounts of two people, chosen at random, and their accounts were in order and had been regularly audited. This means that people will be protected by the procedure and their money will be accounted for at all times. To ensure the home will be safe for people to live and work in, a series of checks on the building and equipment is carried out. We looked at the records and certificates and found them to be up to date. Health & safety training is provided for staff to guide them in safe working practice. Kyffin Taylor House DS0000005416.V376868.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 3 X 3 X X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X 4 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Kyffin Taylor House DS0000005416.V376868.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. 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. Refer to Standard Good Practice Recommendations Kyffin Taylor House DS0000005416.V376868.R01.S.doc Version 5.2 Page 24 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA 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. 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