Care Home: Palmersdene

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What has improved since the last inspection? A pictoral service user guide has been produced for easy reading to help people with cognitive and sensory impairment. A programme is in place for all staff to complete training to work with people with memory loss. The doors in the dementia setting are colour coded and organised themed areas are available for people to sit along the corridors and observe items of interest. A patio area has been provided with appropriate seating along with a summer house and raised garden bed. A social committee has been set up to share ideas for fund raising, trips out etc. A training programme is in place to assist staff to become more confident and competent in person centred care. The manager and deputy manager have completed training in Dementia Care Mapping to help them fully meet the needs of people living in the home. People living in the home no longer have to pre-order their meals but can make a choice at each mealtime. What the care home could do better: No requirements were made as a result of this inspection. The home has good quality assurance systems in place which are effectively used to continually review the quality of the service and make changes as necessary. Key inspection report CARE HOMES FOR OLDER PEOPLE Palmersdene Grange Road West Jarrow Tyne And Wear NE32 3JE Lead Inspector Anne Brown Key Unannounced Inspection 9:30 16 and 17th April 2009 th DS0000000248.V374986.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. Palmersdene DS0000000248.V374986.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 Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Palmersdene Address Grange Road West Jarrow Tyne And Wear NE32 3JE 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) 0191 428 0660 0191 483 7726 maureen.curry@anchor.org.uk keri.sherwood@anchor.org.uk Anchor Trust Mrs Maureen Curry Care Home 40 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (40) of places Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of care 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, maximum number of places: 40 Dementia, over 65 years of age - Code DE(E), maximum number of places: 20 The maximum number of service users who can be accommodated is: 40 3rd May 2007 2. Date of last inspection Brief Description of the Service: Palmersdene is a purpose built home, which was built in 1990 in a location that could be described as the centre of the local community. It is a two-storey building and is close to local shops, bus and metro services. There is also a range of community services such as G.P and religious places of worship. The home has its own driveway and private entrance to the front. There are some garden areas with bench seating and a goldfish pond. A patio area and summer house is available at the rear of the building. The home is registered to provide personal care for 40 older people over the age of 65 years. The home is registered to provide care for up to twenty people who suffer from memory loss. The home has 40 single person rooms, which are referred to as flats all with their own en-suite toilet facility. A range of communal lounges, dining facilities and bathing facilities are evenly distributed over the two floors. Palmersdene does not provide nursing care or intermediate care. However, where people require nursing intervention, suitable arrangements are made with GP practices so community nurses can ensure needs are met. The current fees range from £434 to £445. Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 5 Information about the home and previous inspection reports are readily available. Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means that the people who use this service experience excellent quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. How the inspection was carried out. Before the visit: We looked at: • • • • • Information we have received since the last key inspection on 3rd May 2007. How the service dealt with any complaints and concerns since the last visit. Any changes to how the home is run. The provider’s view of how well they care for people. The views of people who use the service and their relatives. The visit. • An unannounced visit was made on 16th April 2009. A further visit was made on 17th April 2009 to complete the inspection. During the visit we: • • • • • • Talked with people who use the service, staff and the manager and deputy manager. Looked at information about the people who use the service and how well their needs are met. Looked at other records that must be kept. Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. Looked around the building to make sure it was clean, safe and comfortable. Checked what improvements had been made since the last inspection. We told the manager what we found. Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 7 What the service does well: The staff team are committed to ensuring the health, rights, welfare and safety of the people living in the home. All areas in the home are clean, pleasant and decorated and furnished to a high standard. Bedrooms are comfortable, well maintained and suit the individual needs of the people living in them. There is a homely and lively atmosphere around the building. Good relationships were observed throughout the home and staff were observed to be talking to the people living in the home and seeking their opinions. There are systems in place to review quality, which ensures consistent good care practices. Comprehensive policies and procedures are in place and reviewed on a regular basis. The management are committed to staff training and development to help make sure the individual needs of the people living in the home are met. The health care needs of people living in the home are very well met and recorded. The menus are varied and nutritious and alternatives are always available. The people living in the home stated that the food is very good and special diets are catered for. People living in the home knew how to complain and felt their complaints would be taken seriously. One relative who was present said they knew how to complain but had not had reason to. There is a range of activities taking place in the home and outings are arranged on a regular basis. People have the opportunity to pursue their religion if they wish to. Feedback from people living in the home and their relatives was positive. Comments included:“They are very good and helpful with anything I need”. “I’m quite happy here, wouldn’t move anywhere else, always happy atmosphere with staff”. Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 8 “Girls are all nice, help me lots”. “Doctor comes when I need him”. “My mum is very happy here and well looked after”. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 9 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. Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 10 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 Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Good information is available for people who are considering using the service and needs are fully assessed before anyone is admitted to the home. This helps ensure their individual needs can be met. EVIDENCE: The service user guide provides people with good information about what the home has to offer and what they can expect if they decide to live there. The manager has produced a shorter version of the guide which may be more suitable for some people who have memory loss. She also confirmed that the Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 12 guide can be produced is other formats according to people’s needs, e.g. Braille, audio, other languages etc. A copy of the guide which contains information about how to make a complaint is available in every bedroom. The surveys returned by the people living in the home confirmed they had received enough information about the home before they moved in. One person stated they came for a look around with their family. The service user guide also states that people can spend trial periods in the home before they decide to move in permanently. This helps ensure they are confident that their needs can be met. The home operates an open visiting policy and relatives are encouraged to join in any events that are taking place. The home continue to ensure comprehensive assessments are carried out by care managers from the Local Authority. They also carry out their own baseline assessment which helps ensure individual needs can be fully met. The assessment form refers to gender, culture, religion and social histories. There are also risk assessments for pressure sores, nutrition, falls and moving and handling. The home does not provide intermediate care. Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care plans give staff very good information about the needs of the people living in the home and guidelines on how these needs must be met. This helps to ensure effective and consistent care is provided. EVIDENCE: The care plans sets out detailed care needs of the people living in the home and action plans are formulated to address them. The staff record information on a daily monitoring form which is evaluated monthly to help ensure any changing needs are fully met. Reviews are held on a regular basis or when it Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 14 is necessary and all interested parties are invited to attend, with the permission of the person living in the home. The majority of staff have received training on the care planning system. The manager has a programme in place for all care staff to receive training on an individual basis. Two staff members said they found the training very helpful and had given them more confidence. There are good arrangements for meeting the healthcare needs of the service users. There are individual record of contacts with healthcare professionals, including GPs, psychiatrist, chiropody service, dentist, optician and other healthcare services. The home uses community nurses for advice and treatment of pressure area care, tissue viability, and other medical support. The people living in the home confirmed that their healthcare needs are met and they receive medical support when needed. Risk assessments have been carried out on all aspects of people lives. The risk assessments are followed by risk management plans to help ensure that all staff are aware of how best to manage a particular risk. Each person in the home has their nutritional needs assessed and this is fed into the menu planning with the chef manager. Fluid balance and food charts are filled if necessary. Fresh jugs of juice and water are placed around the home so they are freely available to people. If anyone spends time in their bedroom and are capable they have fresh juice or water every day. Baths and showers are offered on a daily basis and if people decline the staff are instructed to return later in the day to ask them again. The staff on duty were fully aware of the individual needs of the people living in the home. They were observed to be treating them with respect and good relationships were apparent. People are able to access their own bedrooms at any time and can choose how to spend their time. One visitor confirmed that their relative’s privacy and dignity was always respected. All staff who are responsible for the administration of medicines have had safe handling of medication training. The home has proper arrangements for the storage and administration of medicines in the home. The administration system for medications was examined and were no discrepancies. The effective drugs administrative system promotes the health and welfare of the people living in the home. A number of staff commented that the dementia awareness courses they completed have been useful in helping them to understand the needs of the people living in the memory loss unit. Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A good variety of activities are available to people living in the home and they are supported to maintain contact with family and friends as they wish. EVIDENCE: An activities co-ordinator is employed in the home. In her absence activities are organised by the staff. These include dominoes, arts and crafts, afternoon dancing at the local community centre, visiting local shops, pubs and cafes. Outings are also arranged to local places of interest. Lots of social events are held in the home when relatives and friends are invited to attend. Recent events include Burns Night, Family Night, Fish and Chip Supper, Grand National Day and Golden Years of Music Night. The staff work very hard to raise money for these events. Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 16 Entertainers are booked to perform in the home on a regular basis and one lady is going to the theatre in the near future. Activities take place on each unit and people can decide which activities they prefer to join. During the inspection two ladies were enjoying arranging flowers which are purchased for the home each week. The activities co-ordinator has completed an Armchair Fitness Course which means she can deliver more tailor made exercise sessions. She also works two evenings a week when the bar is open and people can enjoy a drink and some like to play dominoes. A music therapist visits the home once a week to deliver music therapy to individuals and groups. South Tyneside college are also attending to offer a twelve week course in Community Singing. After the course the home are hoping to form a choir. A social committee has recently been set up and families are invited to join this. This helps people to share ideas for activities, trips out and fund raising events. Residents Meetings take place on both units in the home on a regular basis to discuss day to day issues in the home. Social interaction and activities are outlined in the care plans and a programme of activities is displayed in the home. They are also listed in the monthly newsletter is also produced to help ensure everyone is aware of what is going on. Representatives from all religious denominations are encouraged to visit the home. A monthly Songs of Praise Evening is arranged by the local Baptist Church. Two visitors confirmed that they can visit at anytime and are able to see their relatives in private. Seating is provided in the garden areas and a sensory garden with a summerhouse is now available for people living in the home and their visitors. Comments included:“Lots of activities. I like to be doing something”. Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 17 “I enjoy what is going on”. “There are things going on but my relative prefers to spend time on his own”. The staff have introduced themes with memorabilia in the hallways and communal areas of the first floor to help with orientation of people with memory loss. Themes include the beach, royal family, football, the garden, nautical and train station. A small lounge has been made into a bar and another lounge is a reminiscence room. Alternative meals can be requested if someone does not want to choose from the menu. People do not pre-order their meals but can choose at the time. Lunch was being served during the inspection. The food was well presented and the portion sizes were ample and second helpings were offered. The atmosphere was relaxed and unhurried. The staff working on the memory loss unit were showing people the meals on offer to help them make an informed choice. If they do not like the choice on offer pictures of alternative meals are available so they can choose something else. Drinks and snacks are available throughout the day and night. Staff are told that if people ask for a drink, they must prepare this immediately in case it gets forgotten. Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 18 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. Complaints are taken seriously and the people living in the home are protected from abuse. EVIDENCE: The home’s complaints procedure is available in the service user which is given to each person living in the home. This procedure is also displayed in the home so it is available to relatives and visitors. The home also have the complaints procedure is available on audio tape and other formats can be accessed as necessary. A record of complaints is kept by the manager which includes details of the investigation and the outcome. Seven complaints have been received and satisfactorily dealt with since the last inspection. Seven compliments had been recorded and several thank you cards have been received since the last inspection. Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 19 The surveys confirmed that people knew how to make a complaint. Comments included:“There is a sign up in my room explaining this but usually staff deal with anything”. The manager confirmed that all staff have received training on the protection of vulnerable adults. The staff on duty confirmed that they had attended this training and were aware of the procedure to follow if they observed any bad practice within the home. Anchor has now appointed a specific person within the organisation to ensure a consistent approach is taken with regard to adult protection and to ensure assurance processes are in place to monitor themes and lesions learnt. Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 25 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People enjoy living in a homely, comfortable and safe environment that is clean and hygienic. EVIDENCE: Access into the home is good and meets the needs of the people living there who have mobility problems. People who have walking aids such zimmer frames or wheelchairs are able to move around the home with ease. There are specialist bathing facilities and shower rooms to meet people’s needs. Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 21 All areas were very comfortable, well decorated with a very good standard of hygiene. There is a programme for redecoration and improvements around the home. A handyman/gardener is employed to address any problems on a daily basis. The people living in the home all have their own bedrooms with en suite facilities. They are encouraged to bring personal belongings and to individualise their bedrooms with small items of their own furniture if they choose to. Some people confirmed they could spend time in their own room and see their visitors in private. Tea and coffee making facilities are available for people living in the home, where appropriate, and their visitors. The surveys returned by the people living in the home confirmed that the home was always fresh and clean. One person said “It’s kept spotless”. The manager and staff make every effort to ensure the unit for people with memory loss is suitable to meet their needs. Tactile boards have also been placed at various locations in the corridors for people to experience. Name plates have been placed on the bedroom doors which include photographs of the person who occupies the room. Signage is appropriate to help people find their way around the home. A team leader is responsible for carrying audits on infection control within the home. Some staff have completed a 12 week distance learning course and others have been identified to complete this. Infection control standards also form part of the daily health and safety check. The laundry machines have facilities for sluicing and washing foul linen at very high temperature to avoid the spread of infection. Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 22 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. There is a robust recruitment policy and procedure in place to help protect people living in the home. The staff are competent, skilled and committed to meeting individual needs. EVIDENCE: On the day of the inspection the following staff were on duty:Manager Deputy Manager Administrator Senior care assistant. Six care assistants. Activities coordinator Two domestic assistants Laundry assistant Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 23 Deputy chef Kitchen assistant Four staff files were examined. Criminal Records Bureau checks had been carried out and two written references obtained. This helps to protect the people living in the home. The majority of staff have obtained a National Vocational Qualification (NVQ) Level 2 or above. Three staff in the home are qualified NVQ assessors. Training programmes are in place to ensure all staff receive regular mandatory health and safety training and specialist training to meet the individual needs of the people living in the home. The deputy manager is currently running a training course with the staff on dementia called ‘Yesterday, Today, Tomorrow’. There are three staff in the home trained to act as Dementia Dignity Champions. The Chef Manager and Deputy have completed a training course called “Cater Craft” and the Kitchen Assistant is in the process of completing this. The staff on duty confirmed that they receive appropriate training to carry out their roles efficiently. Two members of staff said they had completed training on “Dine with Dignity” which they had found very informative and useful. The people living in the home were very complimentary about the staff. Comments included:“They are very good and helpful with anything I need”. “I’m quite happy here, wouldn’t move anywhere else, always happy atmosphere with staff”. “Girls are all nice, help me lots”. “Everything is really fine”. Comments from relatives included:“The staff are good and well trained and the food is very good”. “My mother is very happy here and well looked after”. Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 24 “My relative does not mix in very much but he is happy and I have never had to make a complaint”. Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is very well run and managed for their benefit and their health and safety is promoted. EVIDENCE: Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 26 The registered manager is experienced in managing care homes and holds appropriate qualifications. She is committed to providing good care and putting the needs of the people living in the home first. She promotes an ethos amongst staff of involving them in the decision making process. The staff and residents confirmed that the manager is supportive and very approachable. A newsletter is produced each month to inform people of things that are taking place and any changes that are being considered. A social committee has been set up and families are invited to share ideas for fund raising, trips out etc. Residents Meetings are held on a regular basis so people can express their views and suggestions. Comprehensive health and safety policies and procedures were in place. Health and safety checks are carried out by the maintenance person on a regular basis. Appropriate maintenance contracts are in place. All accidents are recorded and analysed on a monthly basis and appropriate action is taken if necessary. The home has a management quality system in place to help ensure good standards continue to be met. Systems are in place for the review and development of the service. A programme is in place to ensure formal supervision sessions are kept up to date. The staff on duty confirmed that they receive regular supervision. Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 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 3 3 X 3 3 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 3 3 4 X 3 3 X 3 Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 28 NO Are there any outstanding requirements from the last inspection? 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 Palmersdene DS0000000248.V374986.R01.S.doc Version 5.2 Page 29 Care Quality Commission Yorkshire and Humberside St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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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