Care Home: Summerhill

Similar services:

• Fairfields Country Rest Home
• Poldhu
• Queensmount
• Trevaylor Manor
• Didsbury Court Rest Home
• Belma
• Hunters Care Centre
• Manor Lodge

What the care home does well Prospective residents have their needs assessed before being offered a placement at the home. This procedure makes sure that the home only admits people whose needs it can meet.SummerhillDS0000026878.V377939.R01.S.docVersion 5.2Summerhill provides a ‘homely’ and comfortable environment for its residents. Residents spoken with told us that they were very satisfied living at the home. They told us that their personal care and health needs were being met and that they were treated with respect and dignity by the staff. Residents social, leisure and recreational needs are met through provision of activities and outings. Residents are supported in meeting their spiritual needs. Residents are able to maintain contact with friends and relatives. Residents are able to make suggestions concerning menus and they were satisfied with the standard of food provided at the home. The home has well publicised complaints procedures and residents were satisfied that their complaints would be looked into and responded to. What has improved since the last inspection? Care planning has improved and now reflects needs of residents and how these will be met by the staff. There has been an improvement concerning medication administration. There have been improvements to the physical environment that will make the home safer and reduce the risk of cross infection. Staffing levels have been increased in the mornings. Staff recruitment procedures have been improved with all new staff being recruited in line with the Regulations. The home has now achieved a level of above 50% of the staff trained to NVQ level 2 or above. Improvements have been made in respect of staff training. Now all the staff have received core mandatory training. There has been improvement concerning management of the home and action taken to address all the concerns raised at the key inspection in April 2009. Summerhill DS0000026878.V377939.R01.S.doc Version 5.2 What the care home could do better: As agreed at this inspection, one of the thermostatic mixer valves in one of the communal bathrooms should be serviced by an engineer, to make sure water temperatures to do cause unnecessary risk to residents. A recommendation remains in place that hand entries on medication administration records are checked and signed by a second member of staff to make sure there are no errors in transcribing information. Key inspection report CARE HOMES FOR OLDER PEOPLE Summerhill 46 Glenwood Road West Moors Ferndown Dorset BH22 0ER Lead Inspector Martin Bayne Key Unannounced Inspection 28th September 2009 09:00 DS0000026878.V377939.R01.S.do c Version 5.3 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. Summerhill DS0000026878.V377939.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 Summerhill DS0000026878.V377939.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Summerhill Address 46 Glenwood Road West Moors Ferndown Dorset BH22 0ER 01202 870935 NONE summerhillwestmoors@hotmail.com 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) Mrs D K Farrar Manager post vacant Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Summerhill DS0000026878.V377939.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th April 2009 Brief Description of the Service: Summerhill residential home is registered to provide personal care and accommodation to 15 people older people. The home is situated in a quiet residential area of West Moors with a level walk to the local shops and bus routes to the nearby towns of Poole and Bournemouth. The home is a detached property with a car park to the front and a secluded garden to the rear. All of the bedrooms are for single occupancy and are provided with en-suite WC facilities. A passenger lift provides access to the first floor. Residents share communal areas of a large lounge that leads to the garden and a small conservatory. The home has a separate dining room. Mrs Farrar, the registered provider lives in a property adjacent to the home. In August 2007, the weekly fees were between £495 -£520. Additional charges are made for hairdressing, chiropody, etc. and are detailed within the Terms and Conditions of Residence. Summerhill DS0000026878.V377939.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. We, the Commission, carried out a key inspection of Summerhill residential home between 9:30am and 2:30pm. The inspection was carried out by two inspectors, but throughout the report the term ‘we’ is used, to show that the report is the view of the Care Quality Commission. The aim of the inspection was to evaluate the home against key National Minimum Standards for older persons, and to follow up on eight requirements and three recommendations made at the last key inspection of the home in April 2009. Following the inspection in April, a Statutory Enforcement Notice was served on the home concerning the recruitment of new staff. A random inspection of the home was carried out in June 2009 to monitor compliance with the Statutory Enforcement Notice. We found at that inspection that the home had complied with the Notice but had failed to comply with a requirement concerning maintaining accurate staff duty rosters. Throughout this inspection we were assisted by Mrs Farrar, the Registered Provider. At the time of our visit, there were 12 residents living at the home. We spoke with seven of these residents about their experience of living at the home. We looked at the personal care files for three residents who had been admitted to the home since April 2009, using these as examples to track the records and paperwork that the home is required to keep up to date under the Care Homes Regulations 2001. We also carried out a tour of the premises. Additional information that helped form to the judgements contained within this report was obtained from the Annual Quality Assurance Assessment (AQAA) document that was completed by Mrs Farrar earlier in the year. What the service does well: Prospective residents have their needs assessed before being offered a placement at the home. This procedure makes sure that the home only admits people whose needs it can meet. Summerhill DS0000026878.V377939.R01.S.doc Version 5.2 Page 6 Summerhill provides a ‘homely’ and comfortable environment for its residents. Residents spoken with told us that they were very satisfied living at the home. They told us that their personal care and health needs were being met and that they were treated with respect and dignity by the staff. Residents social, leisure and recreational needs are met through provision of activities and outings. Residents are supported in meeting their spiritual needs. Residents are able to maintain contact with friends and relatives. Residents are able to make suggestions concerning menus and they were satisfied with the standard of food provided at the home. The home has well publicised complaints procedures and residents were satisfied that their complaints would be looked into and responded to. What has improved since the last inspection? Care planning has improved and now reflects needs of residents and how these will be met by the staff. There has been an improvement concerning medication administration. There have been improvements to the physical environment that will make the home safer and reduce the risk of cross infection. Staffing levels have been increased in the mornings. Staff recruitment procedures have been improved with all new staff being recruited in line with the Regulations. The home has now achieved a level of above 50 of the staff trained to NVQ level 2 or above. Improvements have been made in respect of staff training. Now all the staff have received core mandatory training. There has been improvement concerning management of the home and action taken to address all the concerns raised at the key inspection in April 2009. Summerhill DS0000026878.V377939.R01.S.doc Version 5.2 Page 7 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Summerhill DS0000026878.V377939.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 Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents benefit from their needs being assessed prior to being offered a placement at the home, to make sure that the home can meet their needs. EVIDENCE: We looked at the pre-admission assessment documentation for the three residents we tracked through the inspection. Each of these residents had been admitted to the home since the last key inspection April 2009. We saw that Mrs Farrar had visited the residents concerned and recorded a detailed preadmission assessment of their needs. We saw that once a decision had been made to offer a placement at Summerhill, a letter had been sent to the Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 Page 10 resident or their relatives informing that their needs could be met at the home and an offer of a placement had been made. The home does not provide an intermediate care service. Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. Care planning and medication administration has improved since the last key inspection and residents’ health care needs were being met at the home. EVIDENCE: At the last key inspection we found that the care plans did not adequately inform staff on how to meet the assessed needs of residents. At this inspection we looked at the personal files for the three residents we tracked through the inspection. We saw that there was a photograph of the resident concerned at the front of their care plan, so that staff could easily identify that person. We found that residents’ personal files contained detailed assessments relating to their personal care needs, personal preferences, nutritional needs, moving and handling requirements and skin care needs. We found that the Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 Page 12 care plans that had been developed from these assessments were much improved on those we saw at the last key inspection. They now reflected how residents’ needs were to be met by the staff at the home. The care plans were also supported by risk assessments, put in place to minimise the risk of any harm to residents when meeting their personal care needs. We also saw that the care plans were being monitored each month and updated if necessary. There was evidence that residents had been involved in developing care plans, by their signing their care plan. During the inspection we spoke with seven of the residents. Generally there was very positive feedback about the home and we were told that their health and social care needs were being met. One resident commented,’ We are well looked after here, I couldn’t find fault with it; they always say it is horrible in homes but it’s lovely here’. At the last key inspection requirements were made concerning medication administration, as we found evidence that procedures were not always been followed. We also found that insulin was being administered by staff untrained to carry out this procedure and that medicines were not been returned timely to the pharmacist when no longer required. At this inspection we found there were no residents to whom insulin had been prescribed. We saw that the home had got suitable storage facilities for medication and that medicines were being stored correctly and locked away safely. We looked at the medication administration records for all of the residents. We saw good practice of a photograph of the resident concerned at the front of their records, together with information concerning any allergies. We found that medication administration records had been completed in full with no gaps in the record. We saw that the home had a book to record returned medications to the pharmacist and that surplus medication was being returned every 28 days. We saw that the pharmacist had visited the home in August and was satisfied with medication arrangements in the home. At the last key inspection we recommended that where staff have to make hand entries to medication administration records, a second person signs and checks that the record has been made correctly. Generally we found that this practice had been adopted but there were some occasions where a second person had not signed the record. The recommendation therefore remains in place. Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents benefit from activities being provided that meet their social and recreational needs and from being able to maintain contact with friends and families. They also benefit from being consulted about food provided. EVIDENCE: Residents we spoke with told us that they were happy with the level of activities provided within the home. We saw that regular residents meetings are held at which they could put forward suggestions for outings and activities. The home has a minibus for taking residents out of the home into the community. Residents told us that they had choice of newspapers provided each day. The home also provides a quarterly news letter for residents. One person told us that they liked to help around the home and would help the staff lay up the dining tables. We saw that activities were more formalised with activities taking place on set days of the week. Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 Page 14 Residents’ spiritual needs are assessed and one person told us how they are supported to attend a church service every week. There were no restrictions on visiting times and residents told us that visitors were made welcome and could come to see them at any time. Generally there was satisfaction amongst residents about the standard of food provided at the home. Residents are able to bring forward suggestions and feedback about the food at residents’ meetings. We were given examples of where some of the suggestions had led to changes in the menu. At the last key inspection we detailed the improvements made in the record keeping concerning food provided to residents. Records now provide details of what each resident has eaten. Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents benefit from well publicised complaints procedures and through staff at the home from having received training in the protection of vulnerable adults. EVIDENCE: Since the last key inspection in April 2009 there have been no complaints made to the management of the home and none had been brought to the attention of the Commission. No more safeguarding of vulnerable adult issues have been raised with the Commission or the local council. Residents we spoke with were confident that should they make a complaint, management would investigate and action be taken. Relatives and residents are well informed of how to make for a formal complaint, as the complaints procedure is detailed within the Service User Guide and within the terms and conditions of residence. The complaints procedure includes contact details for the Commission. Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 Page 16 We saw from looking at samples of training records that staff are provided with training in the prevention of abuse and safeguarding of vulnerable adults. As found at previous inspections, the home has the necessary copies of policies and procedures relating to the protection of vulnerable adults. Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents benefit from the management having taken action to make the improvements identified at the last key inspection concerning infection control and health and safety. EVIDENCE: On the day of our inspection the home was found to be warm, clean and in good decorative order. At the last key inspection in April 2009 requirements and recommendations were made in respect of infection control and health and safety matters. Improvements in the following areas were identified at this inspection, meeting requirements and recommendations made at the April inspection. Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 Page 18 • • • • • • • We saw at this inspection that mattresses had been checked for wear and tear and six new mattresses had been purchased. We saw that the laundry room had been repainted so that wall surfaces could be easily cleaned. We also saw that new fridges and freezers had been bought with guidance to staff on the front on how foodstuffs should be stored. We saw that wardrobes had been fixed to the wall, eliminating the risk that they could be pulled over. We found that plinths missing at the base of kitchen units had been ordered and that the kitchen had been redecorated. Liquid soap and paper towels were now also provided. We saw that communal bathrooms now provided liquid soap, paper towels and foot operated lidded bins. We saw that staff were making sure that resident’s personal toiletries and creams were not left in communal bathrooms. We found some other improvements with some other areas of the home having been redecorated. We saw that residents were able to personalise their rooms with their own furniture and possessions. Residents’ bedrooms are situated on the ground and first floor and there is a passenger lift to assist residents to access the first floor of the home. All bedrooms have ensuite bathroom facilities. The home provides communal areas of a large lounge, dining room and sun lounge. Residents are able to access the garden and patio area from the sun lounge at the back of the home. There is car parking and garden landscaping at the front of the home. As reported a previous inspections, risk assessments had been carried out concerning uncovered radiators. We saw at this inspection that two more radiator covers had been fitted to uncovered radiators. Thermostatic mixer valves have been fitted to hot water outlets of baths and showers to protect residents from scalding water. We tested the water in one of the bathrooms and found that the valve needed adjustment, as the hot water temperature was 48°C. It was agreed that an engineer would be called to service this valve. Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents benefit from improvements having been made concerning staff recruitment, provision of mandatory training and higher staffing levels being provided in the mornings. EVIDENCE: At the key inspection in April 2009 and also the random inspection in June 2009 we found poor compliance in terms of duty rosters being in place to inform who had been working at the home. At this inspection we were shown a copy of the roster for the previous two weeks and the current week. These clearly identified who was to work shifts that week and who had worked at the home in the previous two week period. The requirement was therefore met. From the duty rosters we saw that there were two care staff on duty between 8am and 10pm at night. During the night-time period the home provides one awake member of staff and one member of staff who carries out a sleep-in duty. Since the last key inspection the staffing levels have increased in the mornings. At the previous key inspection one of the care staff was taken from care duties to assist with domestic tasks. We were told at this inspection that Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 Page 20 the home now provides dedicated domestic staff so that there are always two care staff on duty available to assist residents. There was very positive feedback from residents about the staff. Since the last key inspection in April 2009, one new member of staff has been recruited to the staff team. We looked at the recruitment records for this member of staff. We found that there had been compliance with the Statutory Enforcement Notice and the requirement made at the last key inspection; as all of the required checks and records were in place, and the staff member did not start work until the return of the check against the register of adults deemed unsuitable to work with vulnerable adults. At the last key inspection a requirement was made that all staff should received induction and core mandatory training. We saw that since that time there has been a big improvement in the provision of staff training. We saw that the new member of staff who had been recruited had been through a programme of induction that complied with Skills For Care induction standards. We also saw that training had been provided to staff since April 2009 in respect of; health and safety, first aid, client handling, infection control and the Mental Capacity Act 2005. We saw that in each staff member’s file, a training matrix recorded the date that they had received core training and date for when refresher training was due. The home has now achieved a level of 60 of staff team trained to the standard of NVQ level 2 or above. Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents benefit from improved management of the home and action taken to address concerns made at the last key inspection. EVIDENCE: Mrs Farrar, who is the registered provider of Summerhill, has the necessary qualifications and many years experience of running the home. We found at this inspection that there had been significant improvement and action taken to address requirements and concerns raised at the last key inspection in April. We also found that there was high resident satisfaction with the way that the Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 Page 22 home was run and evidence that residents are involved and consulted in how the home was run. During the inspection we also spoke with a member of staff who had worked at the home for many years and they also had confidence in the way that the home was managed. At the last key inspection we had concerns that the management had not informed the Commission of incidents and events that should be reported. Since that time all necessary incidents had been reported under Regulation 37 as required by the Care Homes Regulations 2001. The home safe keeps small sums of money on behalf some residents. We looked at the records and the balance of money held in respect of two of the residents. We found that there were detailed and accurate records that tallied with the monies being held. We looked at the fire logbook and found that tests and inspections of the fire safety system were being carried out to the required timescales. We saw a report from the Environmental Health Officer’s visit to the home in June 2009 confirming that the home was meeting all the necessary standards. We also saw a range of certificates demonstrating that the home was having equipment in the home’s serviced to necessary timescales. Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 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. 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. 1. Refer to Standard OP9 Good Practice Recommendations We recommend that where hand entries have to be made to the medication administration records, a second member of staff checks and signs that the record has been completed correctly. This recommendation is repeated. Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 Page 25 Care Quality Commission Care Quality Commission South West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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. Summerhill DS0000026878.V377939.R01.S.doc Version 5.3 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!