Care Home: Saxondale

What the care home does well The management and administration of the home was based on openness and respect. The registered manager had a wealth of experience and knowledge and was able to demonstrate her ability to manage the home. The home had a warm, friendly and welcoming atmosphere. The environment was comfortable with pleasant lounge areas. People who lived at the home were relaxed and happy. People who may use the service and their representatives had the information they needed to choose a home that would meet their needs. They were invited to visit the home before admission, to assess the quality, facilities and suitability. On the whole staff treated people with respect, courtesy, privacy and dignity. People and their representatives were able to express their concerns and had access to a complaints procedure. Adult safeguarding policies and procedures were in place to uphold peoples` rights and protect people from abuse. Staff were trained, skilled and in the main in sufficient numbers to support people who used the service and to support the smooth running of the service. They received training on dementia care and how to communicate with people who have dementia. What has improved since the last inspection? The admission assessment provided more detailed information and was sufficient to formulate the plan of care for daily living. The recording of accidents/incidents was clear, reflecting what had happened and what action had been taken with no room for ambiguity. There was no personal information that was publicly displayed that could compromise peoples` privacy. When people were moved in the hoist it was done without compromising their dignity by exposing their underclothes. The meal time experience had been reviewed to make it a more pleasant occasion for people. The staff files now demonstrated gaps in employment were being explored, a further safeguard to ensure people are safe.The quality assurance system had included consultation with representatives, via questionnaires to gain their opinions of the quality of care provided and make improvements where necessary. CARE HOMES FOR OLDER PEOPLE Saxondale Clarke Street Barnsley South Yorkshire S75 2TS Lead Inspector Jayne White Key Unannounced Inspection 5th August 2008 09:00 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 Saxondale DS0000038017.V369441.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. Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Saxondale Address Clarke Street Barnsley South Yorkshire S75 2TS 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) 01226 207705 01226 713409 saxondale@bondcare.co.uk None Bestquest Limited Mrs Mary Ackroyd Care Home 36 Category(ies) of Dementia - over 65 years of age (36), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (36) Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One service user may be aged 55 to 65. Appropriate staffing levels must be maintained. The care staff, qualified nursing staffing levels and the manager supernumerary time must be maintained as agreed with the previous registering authority. The staffing requirement is highlighted on the Section 25(3) Registered Homes Act 1984 Notice dated 20th February 2001. 8th August 2007 Date of last inspection Brief Description of the Service: Saxondale is a care home providing nursing or personal care and accommodation for 36 older people with dementia or a mental disorder. Bestquest Limited owns the home. The home is situated off Huddersfield Road, Barnsley and is less than a mile from Barnsley town centre. It is close to a bus route and within a ten-minute walk of shops including grocers, hairdressers, chemist, post office and newsagents. The home is a two-storey building. There is a passenger lift. The home has 32 single and 2 double rooms. Communal space includes four lounge areas and a dining room. There is a commercial kitchen and laundry. Sufficient bathing facilities are provided. Information about the home, including the service user guide is available in the entrance hall. This includes the most current CSCI report about the service. The manager said the fee was £380. The National Health Service nursing care contribution is in addition to these fees and ranges from £72.00 to £93.00 dependant on the level of National Health Service assessed need. Additional charges are made for hairdressing and chiropody. Saxondale DS0000038017.V369441.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 that the people who use this service experience good quality outcomes. We visited the home on the 5 August 2008 between 09:00 and 13:00 and 18 August 2008 between 8:30 and 14:45 without giving them any notice. Before the visit we took into consideration other information the Commission for Social Care Inspection (CSCI) had received. This included: • An Annual Quality Assurance Assessment (AQAA). An AQAA is a document completed by providers. It gives them the opportunity to tell the CSCI how well they think they are meeting the needs of people using their service. Information contained in notifications from the home about any deaths, illnesses and other events, which affected the health and well being of people living there. A complaint that had been received by CSCI. • • During the visit: • • We spoke with people that lived there, a relative, staff, the manager, looked round parts of the building and read some records. Conducted a ‘Short Observational Framework for Inspection (SOFI). This involved us observing 5 people who used the service for approximately 2 hours and recording their experiences at regular intervals. This included their state of well being, and how they interacted with staff members, other people who used the service and the environment. This is because people with dementia are not always able to tell us about their experiences and this is a formal way to observe people to help us understand. We would like to thank the people, their relatives and friends, staff and the manager for their time and co-operation throughout the inspection process. Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The admission assessment provided more detailed information and was sufficient to formulate the plan of care for daily living. The recording of accidents/incidents was clear, reflecting what had happened and what action had been taken with no room for ambiguity. There was no personal information that was publicly displayed that could compromise peoples’ privacy. When people were moved in the hoist it was done without compromising their dignity by exposing their underclothes. The meal time experience had been reviewed to make it a more pleasant occasion for people. The staff files now demonstrated gaps in employment were being explored, a further safeguard to ensure people are safe. Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 7 The quality assurance system had included consultation with representatives, via questionnaires to gain their opinions of the quality of care provided and make improvements where necessary. 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. Saxondale DS0000038017.V369441.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 Saxondale DS0000038017.V369441.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): The outcome for standard 3 was inspected. Intermediate care was not provided by the service (standard 6). People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who may use the service and their representatives had the information they needed to choose a home that would meet their needs. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) stated prospective users of the service and their representatives were encouraged to visit, without appointment before they came to live there. The purpose was to assess the quality, facilities and suitability and ask questions about the service provided. This was confirmed when we spoke to representatives. Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 10 In addition, the AQAA stated a brochure and service user guide was provided, which gave information to people and their representatives about the service that was provided. We saw this information in the entrance to the home. The AQAA also stated, people were assessed prior to admission to ensure their needs could be met. This was confirmed when we looked at the file of a person who had been recently admitted. Saxondale DS0000038017.V369441.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): The outcomes for standards 7, 8, 9 & 10 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people received was based on their individual needs, which were identified in the plan of care. The principles of respect, dignity and privacy were put into practice. EVIDENCE: Relatives said staff always kept them informed about any changes to their relative’s care needs. They felt the people whom they represented were well cared for and that staff ‘cared’. When we observed staff working there was clear and respectful communication between people and staff and staff treated people in a kind manner. We looked at four care plans. Overall, the plans contained good information. Personal and healthcare needs including specialist health, nursing and dietary Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 12 requirements were clearly recorded in each person’s plan. They gave a comprehensive overview of peoples’ health needs and acted as an indicator of change in health requirements. The plans were reviewed regularly and daily records identified the care that was provided to people. Records of healthcare visits were maintained and this confirmed doctors, chiropodists and other healthcare professionals visited people when necessary. Risk assessments were in place to provide people with appropriate support, whilst remaining safe. However, the action taken to reduce any risks must be done involving appropriate professionals, particularly where there is an invasion of someone’s privacy. When we spoke to staff they were very alert to changes in mood, behaviour and general wellbeing of people and were clear and fully understood how and when they should respond and take action. All medication was looked after by the home because of the person’s diagnosis of dementia. Trained nurses gave out the medication. The manager said she undertook regular management checks of medication to monitor compliance and the nurses competence in dealing with the administration of medicines. When we looked at the medication records they were fully completed, contained required entries and were signed by appropriate staff. On the whole, medication storage, including medication requiring refrigeration and controlled drugs was satisfactory. However, the medication delivery from the pharmacy for administration the following month was not placed in appropriate secure storage. Saxondale DS0000038017.V369441.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. JUDGEMENT – we looked at outcomes for the following standard(s): All of the above standards were inspected. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People were assisted to make some choices and decisions in their daily life and social activities, but this could be improved. EVIDENCE: When we entered the home there was a warm and friendly atmosphere, with a pleasant ambience in the lounges. We did a SOFI observation between 9:45 and 11:55 on the 5 August 2008 on five people. We found that for four people during that time their main state of well-being was sleep. When awake their state of well-being was either positive or passive. When we discussed this with staff they said there was only one person where there was a valid reason for them to be asleep. This was confirmed when we looked at their medication record. There were no reasons highlighted in the other peoples’ care plans as to why they might be sleeping in the day. Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 14 Clearly, during the time people are asleep they have no contact with staff or other people, which can have a negative affect on their well-being. Because four people were asleep it meant that there were only 21 staff interactions with all of the people during the observation. Of these, two were recorded as good interactions, the rest neutral. In the main, this was because the majority of the interactions with people were carried out either prior to or during care delivery. At these times, however, staff spoke clearly to people and at a pace where they could understand what was being asked or told to them. Staff therefore, need to make efforts to include as many people as possible in conversation and day-to-day life and encourage people to be active in their own activity. There were no social activities that morning, as the staff member that provided activities was on leave. We had been told the lounge where the SOFI was carried out was the ‘quiet lounge’ where people did not like a lot of noise or activity such as television or music. When we spoke to staff they confirmed this and that this was the reason activities were not carried out as much in that lounge. We looked at three peoples’ social care plans who had been included in the SOFI. They did not identify what activities might be carried out with those people to engage them in meaningful daytime activities of their own choice, interests and capabilities to enhance their well-being. The dining room was bright and clean. Apart from the first morning when we arrived there were tablecloths on some of the tables, which created a more pleasant setting for people to eat meals. The menu for the day was displayed. We spoke to the manager about making it clearer and easier for people to see and understand by only advertising the current meal that was being served. In addition, to use pictures of the meal as another way of explaining to people who no longer recognised words or the meaning of words what the meal was that was being offered. We saw the breakfast and lunchtime meal being served. The meals were served directly from the kitchen to the dining room via a serving hatch. The cook and staff did have a good understanding of peoples’ dietary needs. Carers were attentive to people, offering them different choices and asking if they would like some more. When the meal was served, it was leisurely and relaxed, staff were patient and helpful and allowed people time to finish their meal comfortably. We saw care staff being sensitive to the needs of those people who found it difficult to eat and needed support to eat their meal. They were aware of the importance of assisting at the pace of the person, making them feel comfortable and unhurried. The service had retained the silver award from Food Award Barnsley as a result of offering a well balanced and nourishing diet. We spoke with the manager about ensuring the menus that had been presented to retain the award were always available. This was because menus stated fruit was served mid morning but this wasn’t observed when conducting the SOFI. Saxondale DS0000038017.V369441.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. JUDGEMENT – we looked at outcomes for the following standard(s): The outcomes for standards 16 & 18 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People and their representatives were able to express their concerns and had access to a complaints procedure. Adult safeguarding policies and procedures were in place to uphold peoples’ rights and protect people from abuse. EVIDENCE: Representatives could access the complaints procedure because it was displayed on the notice board in the outside entrance for them should they wish to make a complaint. It was clearly written and easy to understand and explained what the procedure was and how long the process would take. People and their representatives that we spoke with were pleased with the service provided. One representative said they would raise concerns because “Mary (the manager) was approachable”. We looked at the history of the service, which told us that when complaints were made these were investigated and complainants made aware of the outcome of their complaint. When we spoke to staff they were aware of the complaints procedure and were aware of the importance of listening to and then acting on people’s concerns. Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 16 Adult safeguarding policies and procedures were in place that promoted the protection of people from harm or abuse. The AQAA confirmed there were some policies/procedures/codes of practice in place to protect people from abuse. At the last inspection we recommended these were improved to include bullying and racial harassment that may occur between people living at the home or staff, by staff and by people living at the home on staff. The reason for this is so that appropriate and consistent action may be taken should this occur. This had not been acted on and was raised again with the manager. Adult safeguarding training was regularly arranged for staff, to keep their knowledge up to date of the action to be taken should they suspect abuse or an allegation of abuse is made. This was confirmed when we spoke with them and looked at their training records. An allegation of abuse had been made. The manager worked with social services, acting on their advice, to investigate the allegation and take action to keep people safe. The outcome of the allegation has not yet been formally concluded. Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 17 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): The outcomes for standards 19 & 26 were inspected. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There was a clean, adequately maintained and comfortable environment for people to live. EVIDENCE: There was a selection of communal areas, which meant people had a choice of where to sit, meet with family, sit quietly or engage with other people that lived there. One of the lounges was being redecorated at the time of the inspection. A new carpet had been fitted. The lounges were well decorated and maintained in a Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 18 comfortable and welcoming manner. When they were all in use they offered sufficient space for the number of people that used them. Furniture and fittings, on the whole, were of a good standard. It was noted, however, during the SOFI that when people were given drinks in the lounges they had to hold their cup or balance it on their legs or chair arm. This would be even more difficult when fruit is served with the morning drink. The manager was asked to look at providing something for people to place their drinks on. When we spoke to relatives they said, “the home always looks clean and tidy”, “it smells less of urine than some I’ve been in” and “mum’s happy with her room and she’s had her bedding and curtains changed since she’s been here”. Access around the home was good and the home looked and smelt clean. People were able to personalise their rooms with pictures, photographs, ornaments and furniture. Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 19 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): The outcomes for all of the above standards were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff were trained, skilled and in the main in sufficient numbers to support people who used the service and to support the smooth running of the service. EVIDENCE: When we spoke to people and their representatives they had confidence in the staff that cared for them. They said, “they care” and “they keep you well informed”. The AQAA told us approximately a third of staff had left in the last 12 months. The manager confirmed this and said most of them had done so as a result of the adult safeguarding investigation. We observed how staff worked during the visit. This told us there were good relationships between staff, people and their relatives and on the whole, they responded in a timely way when people needed assistance. When we spoke to staff they said in general, there were enough staff on duty, but they didn’t always have the time to engage people in conversation as they were busy doing physical tasks. Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 20 We looked at three staff recruitment files to check the recruitment and selection process was sufficient to safeguard people. On the whole, it was. The files demonstrated relevant recruitment information including an application form, two written references, criminal records disclosure and where applicable a POVA first check and written evidence that gaps in employment had been explored. Documenting this separately from the application form would make this much easier to follow. We spoke with the manager about documenting how and by whom staff were being supervised when staff commenced work in exceptional circumstances with only a POVA first check, until a full CRB is received. When we spoke to staff they told us they had opportunities for training and this had included an induction programme, health and safety, moving and handling, fire, emergency aid, dementia and control of substances hazardous to health. Training files were kept and certificates were in place that confirmed training had taken place and what the content of the training was. Observation of staff practice, however, identified the training they had received was not always put into practice when moving and handling people. This was because during the SOFI staff were seen lifting a person with a moving and handling belt from a chair to their wheelchair and vice versa. This is unsafe and can lead to injury of both the person being moved and the member of staff. On the second visit the move had been reviewed and the person was moved using a hoist, which was safer. It was discussed with the manager that staff must take action immediately once a move becomes unsafe. The manager provided information that told us 50 of care staff held NVQ Level 2 or 3 in Care. She said a further 29 were working towards the qualification. Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 21 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): The outcomes for standards 31, 33, 35 & 38 were inspected. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management and administration of the home was based on openness and respect and there were quality assurance systems in place. EVIDENCE: The history of the service told us the registered manager had a wealth of experience and knowledge and was able to demonstrate her ability to manage the home. It enabled her to contribute to the care of people and communicate a clear sense of leadership to staff. She had a good knowledge of the needs of people and was committed to providing a good quality service. She operated Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 22 an open door policy to ensure she was accessible to staff, people and their representatives. Questionnaires had been sent to representative seeking their views about the quality of the service provided. The manager was disappointed with the response, but once collated this would give the service some areas where the service could be improved, if acted on. The manager said she was going to produce an action plan. The provider conducted a monthly report of their opinion of the quality of the service provided, but this did not provide comprehensive information, as the format was a tick box system with a comment box. The AQAA contained clear and relevant information. It let us know about changes the service had made and where they still needed to make improvements. On the whole, the data section of the AQAA was accurate and fully completed. We looked at the financial transactions made on behalf of three people that lived there. This included the date monies were deposited and returned, the purpose for which the money was used, a receipting mechanism and two signatures that confirmed the transaction. On the whole, working practices were safe (see staffing). Accidents were evidenced by good monitoring and record keeping systems and staff were trained to understand and consistently follow these. The AQAA told us maintenance and service records were up to date and current to the services provided. We looked at the fire risk assessment. This had been reviewed as satisfactory on 6 March 2008. We also checked to see if the service had appropriate checks in place so that staff had sufficient training in first aid to help people should an accident occur. The manager said all nurses were trained in emergency first aid, but she hadn’t conducted a risk assessment to determine whether this would be sufficient. Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP28 OP30 OP38 Regulation 13 (4) (c) Requirement Staff must not lift people with a moving and handling belt because this places the person and themselves in a situation that is unsafe and presents an unnecessary risk to people’s safety. Timescale for action 18/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations When conducting risk assessments, the knowledge and skills of relevant health professionals should be used so that the most appropriate action is taken to reduce the risk of harm to people. Additional storage for medication should be provided so that all medication is stored safely. Document the arrangements to engage people in their social interests within the plan of care, in conjunction with their representative. This focuses the attention on each person’s needs as well as informing the programme of activities to be arranged. DS0000038017.V369441.R01.S.doc Version 5.2 Page 25 2. 3. OP9 OP12 OP14 Saxondale 4. OP12 OP14 5. OP18 6. OP29 7. OP33 8. OP38 To improve peoples’ state of well being staff should make efforts to include as many people as possible in conversation and day-to-day life and encourage people to be active in their own activity. Implement a policy/procedure for bullying and racial harassment that may occur between people living at the home or staff, by staff and by people on staff. This should ensure appropriate and consistent action is taken should this occur. To demonstrate appropriate action has been taken to keep people safe, records should be made of the staff member who is appointed to supervise the new worker pending receipt of the outstanding information in relation to their criminal record certificate and ensure the new worker does not escort people away from the care home premises unless accompanied by the staff member. The quality assurance processes should be analysed and a development plan implemented to demonstrate the action the service are going to take to improve the quality of the service provided for people. To assess whether staff are sufficiently trained to help people in the event of an accident, a risk assessment should be conducted to determine this. Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Saxondale DS0000038017.V369441.R01.S.doc Version 5.2 Page 27 - 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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