Care Home: Murray House

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What the care home does well This is, in general, a well run home were residents have their needs well met. There is a lively, friendly atmosphere with people coming and going; there are notices up in areas, which encourage visitors, who are always made to feel welcome. Comments received from the residents via the questionnaires included, `I`m happy here at Murray House, when I feel I do downstairs to join in with other residents`, `it is home from home. Everybody is friendly and helpful` and `perfect, 100%`. The staff team are well supported with regular supervision and appraisals; there is a range of training and courses available. This ensures that the staff team are equipped with the knowledge and understanding to provide residents with good quality care. The home has adopted the `Eden alternative`, which focuses on residents and what they want to do on a daily basis. A full time activities co-ordinator supported by two volunteers who come into the home twice a week, support residents in providing activities that they want to do. The management team strives to provide positive leadership in all areas of administration in the home, care of the environment, staffing arrangements and catering thereby ensuring that residents receive a high quality of care. What has improved since the last inspection? All Requirements that were set at the last inspection of the home have been met within agreed timescales. In particular, this has focused on the administration of medication so that residents receive the medication that is prescribed to them and that there is a clear record of medication given. In addition, all staff undergoing the induction process now have a clear record of the training that has occurred. Two other requirements and one recommendation were made at the last inspection have been met, and were relatively minor in nature. CARE HOMES FOR OLDER PEOPLE Murray House Royal Borough of Kingston Community Care Services Acre Road Kingston Upon Thames Surrey KT2 6EE Lead Inspector Ms Rin Saimbi Key Unannounced Inspection 16th 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 Murray House DS0000033769.V362876.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. Murray House DS0000033769.V362876.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Murray House Address Royal Borough of Kingston Community Care Services Acre Road Kingston Upon Thames Surrey KT2 6EE 020 8547 6300 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) alysonpiper@kingston.org.uk Community Care Services Alyson Jayne Piper Care Home 38 Category(ies) of Dementia (38), Old age, not falling within any registration, with number other category (38) of places Murray House DS0000033769.V362876.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 38. 6th December 2006 Date of last inspection Brief Description of the Service: Murray House is a purpose built resource centre, built in 1974 and owned and operated by The Royal Borough of Kingston Upon Thames. It provides residential accommodation for up to 38 older people. The home is situated in a residential area of north Kingston, yet is close to the town centre and local transport facilities. Murray House is one of four resource centres for older people operated by the Community Care Services division of The Royal Borough of Kingston. Fees are set at £575.25 per resident/week for the year 2008/09. Residents pay for their personal requisites. The home provides information about its services in a Service User Guide, which is made available to current and potential people who use the service. Additional information can be found in the home’s Statement of Purpose. Murray House DS0000033769.V362876.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 people who use this service experience good quality outcomes. The Commission preferred way of referring to people who live in the home is ‘people who use the service’. However, people in this home wish to be referred to as ‘residents’, and therefore this phrase is used throughout the report. This was an unannounced inspection that took place on 16th May 2008 between 10.00 and 16.45. During the inspection process there was a partial tour of the premises, observations of staff interaction with residents and some discussions with residents. We case-tracked a number of people, this involves looking through all the paperwork relating to them, seeing their bedroom and if possible meeting with them. Documentation relating to specific staff was also conducted in this way; we also spoke directly to three members of staff. We talked to the manager and various staff who were on duty at the time of the inspection. In addition, residents and staff filled out questionnaires; five completed questionnaires were received from people who use the service and three from the staff group. Prior to the inspection, we reviewed all documentation relating to the service, which had been received by the Commission. In particular, this focused on the Annual Quality Assurance Assessment (AQAA), which was completed and returned in a timely manner. The AQAA was completed to a high standard, and gave an accurate picture of the home, its strength and future work needed. We would wish to thank the residents and the staff for their time and cooperation during the inspection process. Murray House DS0000033769.V362876.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? All Requirements that were set at the last inspection of the home have been met within agreed timescales. In particular, this has focused on the administration of medication so that residents receive the medication that is prescribed to them and that there is a clear record of medication given. In addition, all staff undergoing the induction process now have a clear record of the training that has occurred. Murray House DS0000033769.V362876.R01.S.doc Version 5.2 Page 7 Two other requirements and one recommendation were made at the last inspection have been met, and were relatively minor in nature. 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. Murray House DS0000033769.V362876.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 Murray House DS0000033769.V362876.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): 3,4,5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home conducts pre-admission assessments so that the needs of potential residents are identified. This means that each resident can be reassured that the home has taken into account their individual needs, and feels that it can meet them; and the staff in the home can be as familiar as possible with residents, and have an understanding of what specific service they will need to provide. This should assure residents that they are not just being slotted into an existing vacancy. EVIDENCE: Murray House DS0000033769.V362876.R01.S.doc Version 5.2 Page 10 Information concerning prospective people coming into the service is initially obtained via referrals from Social Services and other relevant professional bodies. Senior managers within the home then complete their own assessment involving all interested parties including the person themselves. Records of the most recent admission of a person who had been admitted to the home were examined; they indicated that a thorough assessment was completed. There was a completed Functional Analysis of Care Environment (FACE) assessment; this brings together all the multi agency assessments in one place. People coming into the home as prospective residents have the opportunity to visit the home beforehand, and then have a process of gradual introductions before moving in, this includes a tea visit. It is only after a six-week trail that a review meeting takes place and makes the final decision about the move. Specialist services are available within the home, this includes services for residents with disabilities such as tracking hoists, shower rooms with wheelchair accessibility and talking books for people with a visual impairment. The home is also able to meet the needs of black minority ethnic groups, they can order Asian food from the day centre which is in the next door building, and will arrange for religious needs to be met if necessary; there is currently one resident who takes himself to the local mosque. Murray House DS0000033769.V362876.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 This outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good arrangements for care planning and residents continue to have their health, social and personal care needs well met. A strong emphasis is placed on protecting the dignity, and respecting the privacy of residents; this ensures that the well being of residents is protected. EVIDENCE: Each resident has a care plan setting out their individual social and health care needs so that staff can use this plan as the basis for the care they deliver. We looked at four residents care plans; they were drawn up in consultation with the resident and their family members and had been reviewed on a monthly basis. We also checked to see if annual reviews with the local Murray House DS0000033769.V362876.R01.S.doc Version 5.2 Page 12 authority were completed at least annually, it was positive to note that all had been within the required timescales. Manual handling risk assessments were completed and reviewed annually; other risk assessments for individual residents were written as and when necessary; environmental risk assessments were available to be examined. The care event sheets (daily recording) were examined and all found to be up to date. It is commendable that they contained relevant information, which gave a clear picture of each resident and significant events that had occurred. The home is promoting and maintaining residents health by ensuring the residents have access to health care services to meet their assessed needs; there were records of opticians, dentists and chiropodists appointments. In recent months, the home in conjunction with the local GP practice has started a weekly drop-in surgery, for those residents that wish to make use of the service. There is a general expectation within the home that every resident should have their weight monitored on a monthly basis, this is also recommended as good practice as a way of monitoring the well being of individuals. However, it was noted that one resident had had their weight checked in September 2007 and then not until April 2008, during which period according to the records, the resident had put on five kilograms in weight. A requirement is therefore being made in this regard. The home has in place procedures for ensuring the safe management of medicines. This includes, where appropriate, support and risk management for residents who wish to be responsible for their own medication so that they may do so safely; in fact no one is currently self-medicating. We examined medication, it was stored in a trolley which is secured to the wall; this trolley is kept in locked cupboard. In general, it appears that medication is stored and administered appropriately. Medication Administration Records (MAR) were checked and no omissions were found. The deputy manager stated that she conducts a mini audit of medication almost daily; there is a formal audit conducted by an outside agency twice a year. The local pharmacist has recently started completing annual reviews of medication for every resident. Care staff ensure privacy and dignity, this was observed by their practice of knocking on bedroom doors and of addressing residents by their preferred title. We also asked questions of staff regarding privacy and dignity and they were able to give a reasoned response. Murray House DS0000033769.V362876.R01.S.doc Version 5.2 Page 13 We received a number of positive comments about the care received by residents including ‘their marvellous’, ‘good girls’ and ‘ they do as well as they can’. Murray House DS0000033769.V362876.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. This judgement has been made using available evidence including a visit to this service. There continues to be a good arrangement for social and recreational activities, which ensures that residents experience a lifestyle that matches their preferences. The home generally provides balanced meals at times that suit residents; this ensures that residents have nutritious meals, which should enhance their well being. EVIDENCE: The home employs a full time activities co-ordinator, who was on annual leave at the time of the inspection. In addition there are two volunteers who come into the home on a regular basis and supplement the activities of the coordinator. The home has adopted the ‘Eden alternative’, which focuses on resident’s wishes. The co-ordinator has developed a timetable of events throughout the Murray House DS0000033769.V362876.R01.S.doc Version 5.2 Page 15 week, however these are very much a guideline and can be adapted to suit the preferences of the residents. There are a variety of recreational activities available to residents, including an arts and craft group running within the home. Community groups such as schools, musicians and actors also come into the home and there are various outings, including a five-day holiday for those residents wishing to attend. The home has recently initiated the ‘owl club’, which as it names suggests, is for residents who find it hard to sleep at night. Rather than being constantly returned to bed, they can stay up with staff, made a hot drink and have a chat. We spoke to a number of residents about the level of activities on offer, in general they were happy with the arrangements. One person stated, ‘you do what you want to do, I can’t be bothered’. In the many of the communal rooms within the home, there were lamented photographs on display of residents and their activities; in particular there was a collage of residents who had lived in the home over a period of time, this was very eye catching. The deputy manager of the home owns a dog, which she brings to work with her; the dog is elderly and quite docile. The dog has clearly become a focal point within the home; he has his own feeding area and is free to wander around. A number of residents were observed making a fuss of the dog, feeding it and being quite attentive of it when it wanted to go outside or come in. We spoke to a number of residents about the dog, all of whom were very positive of it. The dog has clearly become a discussion point, something else to focus on and care about, and gives some of the residents a feeling of normality. Friends and visitors are welcome in the home, there were various notices up which indicated this. We spoke to a number of residents who said ‘relatives could come at anytime, and that they are always offered a cup of tea or coffee’. There were photographs of this Easter, when the home had invited friends and relatives for a meal, which had ended up as being for 150 people. With regard to meals, residents were generally positive. There was a weekly menu available on each table and written on a board in the dining area. The main meal of the day was taken at lunchtime and was a hot meal; there was also a vegetarian option available. If residents preferred, there was a choice of baked potatoes, omelettes or sandwiches. Meals could be taken in the main dining room down stairs, or in smaller dining areas on the first and second floor. The tables were all laid with tablecloths and menu holders. A meal was taken with residents, which on the day of inspection was fish and chips with peas. All meals were well presented in an appetizing way, even for those residents who had their food puréed Murray House DS0000033769.V362876.R01.S.doc Version 5.2 Page 16 Murray House DS0000033769.V362876.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. This judgement has been made using available evidence including a visit to this service. There is a system in place for the effective handling of complaints and residents and their relatives are encouraged to raise any concerns they have. Residents should therefore feel that their concerns would be listened to. Arrangements are in place for handling allegations and instances of abuse thereby ensuring the well being of residents EVIDENCE: The home maintains Kingston’s policies and procedures for dealing with complaints. At previous inspections this policy has been examined, it outlines how complaints, concerns and suggestions should be made and how they can be dealt with; this includes a timescale for dealing with any issues The home has a complaints log, which outlines all complaints made. The complaints log was viewed, and it contained two complaints since the last inspection, both of which it appears were dealt with in a timely and appropriately manner. We talked to a number of residents about who they would talk to if they had a problem. Comments received included, ‘if I had a problem I’d talk to them in Murray House DS0000033769.V362876.R01.S.doc Version 5.2 Page 18 the office’, or ‘I’d talk to my key worker or at a residents meeting’. One person did state, ‘I don’t talk to anyone’. With regard to the protection of vulnerable adults, training records were checked and confirmed that staff had all received recent training in this area. We talked to a number of staff about a fictional scenario of adult protection and what they would do; all were able to give an appropriate answer. Murray House DS0000033769.V362876.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): 19,20,22,24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally maintained, decorated and furnished to a good standard, which ensures that residents live in a pleasant, homely and comfortable environment. EVIDENCE: Murray House is on three floors; the ground floor compromises of a large dining room; there are two separate lounges, known as the T.V. lounge and the quiet lounge. There is an activities room and a licensed bar, and various other communal rooms, there are also four ground floor bedrooms. There are two other floors which compromise of bedrooms, a small lounge/dining room and kitchen. The building is serviced by a lift. Murray House DS0000033769.V362876.R01.S.doc Version 5.2 Page 20 In general the home is well maintained and in a reasonable decorative order. There is a rolling programme of redecoration, which was evident during the inspection. The inspector conducted a tour of the building including the communal areas and some of the bedrooms. Each bedroom had its own sink, wardrobe, chest of drawers and easy chair. There was also a lockable space provided in each bedroom. In the majority of the bedrooms, there was a pleasing degree of personalisation with residents bringing in their own ornaments and photographs. The home has a well-maintained garden with access via ramps for those residents who use wheelchairs. The home has recently purchased a large range of good quality garden furniture. Adaptations and equipment for the use of residents with a disability was present throughout the home. The laundry facilities are suitable for the size of the home, and the flooring finishes are impermeable as required by the National Minimum Standards. Sluicing facilities are available. Murray House DS0000033769.V362876.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. This judgement has been made using available evidence including a visit to this service. Staff members are provided in sufficient numbers and the procedures for the recruitment of staff are robust and provide the safeguards to offer protection to people living in the home. There is a staff training and development programme that provides staff members with skills necessary for meeting the needs of residents. EVIDENCE: Staffing levels as detailed in the staff rota, and in the numbers on shift at the time of this inspection are appropriate, and in line with the needs of residents. Rotas for several other weeks were also checked to ensure that the staffing levels were constant. There were six staff on duty in the mornings, four in the afternoon and then five in the evening; there are two waking night staff. In general, residents felt that there were sufficient numbers of staff on duty, although one person did indicate ‘they do as well as they can’ feeling that they were sometimes very rushed. Murray House DS0000033769.V362876.R01.S.doc Version 5.2 Page 22 The home currently has one full time and four part-time vacancies. The manager explained that the homes own bank staff covers vacancies, and when these staff are not available then agency staff are used. It was noted that amongst the staff team there was only one male, although there are five male residents. This is disappointing although not unusual in care home settings. The staff team comprises of approximately fifty percent from black minority ethnic groups. Three files were chosen at random to check recruitment and selection processes. All files were in good order; the application form, job description, references and forms of identification and enhanced Criminal Records Beaux checks were all present. There is a good training programme for staff within the home. Once staff have completed an induction period and training, there are then mandatory courses that they are required to do on an annual basis these include manual handling, medication, fire and protection of vulnerable adults. Courses are then undertaken as necessary or if staff have a particular interest. All staff had completed the minimum level of training, that is to say, at least three days training per year; this was confirmed directly by staff and evidenced by their certificates of attendance. Ninety five percent of care staff within the home have now achieved National Vocational Qualification level 2 or 3. This level of qualification is to be commended and therefore the scoring of the outcome groups reflects this. Murray House DS0000033769.V362876.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): 31,32,33,35,36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff members continue to receive good support and guidance from the manager and there is an effective quality assurance system, this ensures that the home is run in the best interests of the residents. In general, issues regarding health and safety matters are taken seriously, though there were a number of shortfalls in this area, which needs to be addressed. EVIDENCE: The registered manager for the home, Ms. Alyson Piper, has worked within a senior role for some six years. She holds a Diploma in Management and an Murray House DS0000033769.V362876.R01.S.doc Version 5.2 Page 24 NVQ Level 4. The manager continues to demonstrate good practice and competence in running the home. Both staff and residents felt that the manager was approachable and positive in her interactions, thereby creating an atmosphere that was open. With regard to the supervision of staff, this has been delegated down the lines of managerial responsibility with an expectation that staff receive supervision on a monthly basis. Three staff files were viewed and indicated that supervision was taking place at the required level, staff confirmed this. There are a number of tools for self- monitoring. Residents and their family members and staff members are surveyed on a regular basis about their views on the home. There are residents meetings, minutes of which were available. The Registered Manager continues to carry out ‘spot checks’ in the home, this includes nighttime visits. The home was also able to provide copies of the Regulation 26 visits; an individual who is not directly involved in the day-today running of the home completes these on a monthly basis. Matters regarding health and safety were checked; Records indicated that there are regular safety checks on water temperatures, fridge and freezer temperatures, and the fire alarm. Certificates were provided for gas and electricity safety checks, portable electrical appliance safety checks and testing for Legionella. Servicing records were examined for the lift, wheelchairs, hoists and bath seats. However there were a number of shortfalls in health and safety matters. Firstly, fly screens in the kitchen were unclean; bleach was stored in the laundry room; the CoSHH cupboard was left unlocked; there was clutter in the stairwell and the first aid boxes had out-of-date items. A single requirement is made regarding these shortfalls, however, each must be treated separately. Financial checks were made regarding residents individual monies. A running total is kept as well as receipts for every transaction. It was noted however, that resident’s monies are nonetheless pooled together, rather than being stored separately. This practice contravenes the National Minimum Standards. The Commission recognises that the system does function adequately and that resident’s finances are safeguarded. Therefore a recommendation is made that the current practice is reviewed, and that the Commission is sent an outcome of the review. Murray House DS0000033769.V362876.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 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 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 3 3 X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 2 Murray House DS0000033769.V362876.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. OP8 2. OP38 12(1)(a) Standard Regulation 12(1)(a) Requirement The home must monitor the weight of residents on a regular basis to ensure that there nutritional needs are being met The home must address issues regarding health and safety i) ii) iii) iv) v) the fly screens in the kitchen must be cleaned bleach must be stored away appropriately the CoSHH cupboard must be locked when not in use excess items must be removed from the stairwell all out of date items in the first aid boxes must be removed Timescale for action 16/06/08 16/06/08 Murray House DS0000033769.V362876.R01.S.doc Version 5.2 Page 27 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 OP35 Good Practice Recommendations The home should conduct a review of how resident’s monies are handled, and provide the Commission with a report of the outcomes. Murray House DS0000033769.V362876.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Murray House DS0000033769.V362876.R01.S.doc Version 5.2 Page 29 - 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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