Care Home: Underhall Resource Centre

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What the care home does well Underhall Resource Centre continues to provide a homely atmosphere for people coming for short term care. There are stimulating activities and entertainment at the day centre. The home promotes people`s safety and well being. People spoken to were complimentary about the service provided, and the staff who work there: `this place is excellent`, `the staff are wonderful`, `I am more than satisfied`. Most people come on a regular basis and rotating short term care is part of a wider package of care to enable them to exercise choice and remain in the community. Everyone spoken to looked forward to and enjoyed their visits to Underhall. The management and staff demonstrate a responsive approach towards peoples` needs and provide a complaints procedure that is accessible. There is a stable and experienced staff group. Staff undertake regular training updates, to enable them to meet people`s varied needs. Staff take a real pride in their work and the services provided. Staff feel supported by managers. Supervision takes place on a regular basis, although sometimes formal supervision could be recorded more regularly. The managers are well organised and have a systematic approach to maintaining records. Both the manager and staff spoken to are committed to continuous improvement of the service provided. What has improved since the last inspection? One of the managers who `job shares` has become registered with CSCI. The requirements made at the last inspection has been met and adjustable heating valves have been provided on radiators in bedrooms. There is new flooring in the staff toilet and staff room, which have also been decorated. Other improvements, refurbishment and decoration are taking place as part of a rolling programme. CARE HOMES FOR OLDER PEOPLE Underhall Resource Centre Chesterfield Road Two Dales Matlock Derbyshire DE4 2SD Lead Inspector Denise Bate Unannounced Inspection 10th April 2008 1:30 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 Underhall Resource Centre DS0000035715.V362217.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. Underhall Resource Centre DS0000035715.V362217.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Underhall Resource Centre Address Chesterfield Road Two Dales Matlock Derbyshire DE4 2SD 01629 778511 01629 778519 vivbateman@derbyshire.gov.uk - cc annturner@ derbyshire.gov. www.derbyshire.gov.uk Derbyshire County Council 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) Vivienne Joy Bateman Ann Turner Care Home 8 Category(ies) of Old age, not falling within any other category registration, with number (8) of places Underhall Resource Centre DS0000035715.V362217.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following categories of service only - Care Home - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home fall within the following categtories: Older Persons - Code OP The maximum number of service users who can be accommodated is: 8 24th April 2007 2. Date of last inspection Brief Description of the Service: Underhall Resource Centre is a purpose built modern building situated in Two Dales, near Matlock. The registration permits the admission of up to eight older people with personal care needs. The centre admits service users for shortterm care, usually for one to two weeks duration (for respite care). The registered unit is part of a larger complex, which includes day care and sheltered housing (40 on - site flats). Charges are worked out on a means tested basis and are up to £336.42 per week at the time of inspection. Copies of the last inspection report are available in the communal lounge/dining area. Copies of the homes Statement of Purpose, Service User Guide, complaints procedure, etc. are available in each bedroom and communal areas. Underhall Resource Centre DS0000035715.V362217.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 the service is two star. This means the people who use this service experience good quality outcomes. The inspection was unannounced and took place over an afternoon. During the inspection seven people staying at the home, two visitors and two staff members were spoken with. Prior to the inspection we looked at previous inspection reports and a self assessment questionnaire (AQAA) completed by the managers of the home. Pre inspection questionnaires had been completed by people who stay at the home, their relatives and staff. Information provided by the questionnaires has been included in this inspection report. The manager was present during the inspection and provided assistance and information. A number of records were examined, including care planning documentation, minutes of staff meetings, regulation 26 visit records, and action plans, Two residents were case tracked. Case tracking involves identifying people who currently stay at the home and tracking the experience of the care and support they have received. The inspector also checked that information provided by the manager matched individual experiences of the people living at the home by talking with them and observing the care received. A tour of the building took place. What the service does well: Underhall Resource Centre continues to provide a homely atmosphere for people coming for short term care. There are stimulating activities and entertainment at the day centre. The home promotes people’s safety and well being. People spoken to were complimentary about the service provided, and the staff who work there: ‘this place is excellent’, ‘the staff are wonderful’, ‘I am more than satisfied’. Most people come on a regular basis and rotating short term care is part of a wider package of care to enable them to exercise choice and remain in the community. Everyone spoken to looked forward to and enjoyed their visits to Underhall. The management and staff demonstrate a responsive approach towards peoples’ needs and provide a complaints procedure that is accessible. There is a stable and experienced staff group. Staff undertake regular training updates, to enable them to meet people’s varied needs. Staff take a real pride in their work and the services provided. Staff feel supported by managers. Supervision takes place on a regular basis, although sometimes formal supervision could be recorded more regularly. The managers are well organised and have a systematic approach to maintaining records. Both the manager and staff spoken to are committed to continuous improvement of the service provided. Underhall Resource Centre DS0000035715.V362217.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: No requirements were made at this inspection. Derbyshire County Council have a system for issuing questionnaires to people, co-ordinating the responses into action plans, and making this information available to people. Unfortunately the information available on the day of inspection was not up to date and related to 2005/6. Information should be sought on a more consistent basis and ‘fed back’ promptly so that people who stay at the home have their views taken into account. The bathroom could be greatly improved by the repositioning of the bath and provision of a shower which would provide comfort and choice for people who stay at the home. The provision of ‘protectors’ for the lower part of the corridor walls would enhance the general appearance of the home. A number of good practice recommendations have been made including; providing more detailed personal support plans and ensuring all information kept on Framework I (the computer system) is kept up to date to ensure that information accurately reflects current needs, completing falls assessments for people to ensure their safety, making infection control training available to staff to reduce the risk of infection, ensuring that formal supervision takes place on a regular basis for all staff and is recorded to provide evidence that appropriate management systems are in place. Please contact the provider for advice of actions taken in response to this Underhall Resource Centre DS0000035715.V362217.R01.S.doc Version 5.2 Page 7 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. Underhall Resource Centre DS0000035715.V362217.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 Underhall Resource Centre DS0000035715.V362217.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): 1, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available to ensure people can make an informed choice about where they come for short term care. EVIDENCE: The AQAA stated they have a good welcome procedure and complete personal service plans and appropriate assessments, e.g. medication risk, moving and handling. They say they write to service users with confirmation of their stay and level of fees applicable. Underhall does not provide long term care and all people come for short term care, usually on a rotating basis as part of a comprehensive plan to support Underhall Resource Centre DS0000035715.V362217.R01.S.doc Version 5.2 Page 10 their choice to remain living in the community. We found that some people know the home well as they have been attending for some time and/or they also attend for day care. Copies of the statement of purpose and service user guide were given and looked at after the inspection. The Statement of Purpose is mainly corporate information that has been recently updated. The statement of purpose says that the home provides ‘effective quality assurance’. However information in communal area related to 2005/6 so was out of date. No information was included about fee levels, although this is provided separately on an individual basis. Contracts for short term care are dealt with by peoples’ care managers or social care workers, and copies of contracts are held centrally. No one reported any difficulties with these arrangements. The Service User Guide was well presented and information given that related specifically to the home and the service provided, e.g. not able to take people with need for two carers and points out that doors are not alarmed. It is in the process of being updated. Seven people staying at the home were spoken to, some of whom have been coming regularly and two of whom it was their first visit. They felt that sufficient information had been given before they arrived. Evidence of assessments and reports of pre admission visits were seen on the care planning documentation of four people case tracked. Care planning documentation provided an assessment of peoples’ needs and information from various sources (e.g. nurses) was available to enable the home to develop an up to date care plan for each service user. Most prospective short term care people visit the home prior to coming for short term care and a record is kept of this visit – these were seen on care planning documentation. The home occasionally takes emergency placements, but these are kept to a minimum. Discussions with staff and the manager indicated that they are clear on what service user needs the home could not meet because of the physical layout and location of the building, i.e. people who wandered, people with substantial disabilities. This information is made clear in the Service User Guide. The home does not provide formal intermediate care, but the philosophy of the home is to encourage people to maintain as much independence as possible and meet their individual needs and choices. Underhall Resource Centre DS0000035715.V362217.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are completed in detail and are individualised to demonstrate that people’s health, personal and social care needs are being fully met. EVIDENCE: The AQAA states that they operate a successful key worker system, work to maintain people’s independence, and have arrangements in place to meet individual’s needs. They plan to provide more specialised training, e.g. in mental health continence and sensory needs, as well as ensuring that people’s details are available on the new computerised Framework I system. The home have identified a problem with staff recruitment in the local area. Underhall Resource Centre DS0000035715.V362217.R01.S.doc Version 5.2 Page 12 Four people were case tracked. The files were neatly presented and there was evidence of assessments, some of which were quite old and related to services provided in the community. Most people had handwritten personal service plans that were not very detailed. However, these had been discussed with people and all four were signed by the worker and person staying at the home. There was evidence that the personal service plan was reviewed regularly and that each short term care visit was assessed. The home are in the process of integrating the Derbyshire County Council Framework I. This has the advantage of usually providing appropriately information quickly, but because the home only provides short term care, they have a lot of records to keep up to date. We spoke to seven people and all praised the service very highly. Amongst the positive comments were included: ‘the staff are always bright and cheerful and willing to help’, ‘excellent’, ‘the staff are always wiling to do whatever they can to help’, very friendly and 100 efficient’. One person described the help and support provided by the staff during a time of crisis as ‘marvellous’. The surveys people completed for CSCI indicated that staff listened to people and that they always received the care and support they needed. Staff were observed treating people with dignity as they were assisted in day to day tasks. Interactions were sensitive, respectful and friendly. Matters relating to medication are dealt with efficiently. Medication is kept securely in a locked room. This room is sometimes accessed by other DCC staff for training and other purposes. The manager said that people generally looked at coming to Underhall as a holiday, and usually wanted to the home to look after medication. On the day of inspection one person was keeping their medication in a locked cabinet in the bedroom. Underhall Resource Centre DS0000035715.V362217.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): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides suitable activities and the quality of catering is good which contributes to a pleasant atmosphere and the overall levels of satisfaction for people. EVIDENCE: The day centre is attended by most people staying at the home, although they are able to use their bedrooms or the residential sitting room during the day if they prefer. Most people enjoyed having a busy day at the day centre with lots of company, then being able to relax in the evening with other short term care people. At this inspection everyone staying at the home got on extremely well together and provided support and encouragement to each other. A wide variety of activities are held in the day centre that meet most people’s needs and interests. On the day of inspection there was singing and entertainment given by a community group. Everyone enjoyed this. Underhall Resource Centre DS0000035715.V362217.R01.S.doc Version 5.2 Page 14 Two visitors said they thought the standard of service provided was good. Everyone praised the food which was of a high standard and well presented. Several sources (AQAA, staff survey) said that they would like to have more day trips. Most people come to Underhall as part of a plan to maintain them in the community. Many live with relatives who are their main carers and so the stay at Underhall is often ‘respite’ care and most people are not getting visits from relatives. However, there is no restriction on visits and arrangements can be made for these to take place. Contact details are noted on care planning documentation. Underhall keep people informed of information via notice boards in the short term care unit and in the day centre. There have also been displays about particular issues of relevance to the service user group, e.g. the importance of fluids and good diet, how to reduce the risk of falls, updates on the gardening project. There is a regular newsletter. Underhall is an established part of the community and local organisations, e.g. schools, choirs, etc., often come in to entertain at the day centre. There was an excellent singing group at the day centre on the day of inspection, and everyone enjoyed the entertainment. Regular religious services are held. Most short stay people are from the local rural community or small towns. The home would make arrangements to meet the cultural needs of service users from different religious or cultural backgrounds. The home follows Derbyshire County Council’s Equal Opportunities Policy. Matters relating to equality and diversity are discussed at staff meetings and in individual staff supervision. People take lunch in the day centre; breakfast and tea are taken in the residential unit which has a small kitchen that people can use to make drinks and snacks if they wish. People are offered a choice of menu, and can discuss individual needs and preferences. People spoken to said the food was very good, and food seen on the day of inspection was of a high standard. Underhall Resource Centre DS0000035715.V362217.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): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear and accessible complaints and safeguarding adults procedures are in place to ensure people can be confident that any issues raised would be acted on effectively and promptly. EVIDENCE: The AQAA states that they display complaints information and are committed to the protection of people’s rights. They operate within Safeguarding Adults guidelines and staff have received appropriate training. At the last inspection we recommended that safeguarding adults training was made available to staff. Staff confirmed that this had taken place. Information about the complaints procedures is available in the information provided by the home, and displayed in the day centre and in the short term care unit. People spoken to said they had no complaints and would speak to staff or managers if there was something they were not happy about. Staff spoken to said that they would deal quickly with any problems that were drawn to their attention. Underhall Resource Centre DS0000035715.V362217.R01.S.doc Version 5.2 Page 16 There is a corporate complaints procedure and the procedure for this is clearly displayed, although most service users prefer to raise issues on a more informal basis. There have been no formal complaints recorded in the complaints book since the last inspection. No complaints have been made to CSCI. The home keep a record of commendations and suggestions. Derbyshire County Council has clear procedures for dealing with safeguarding people. Staff spoken to showed an awareness of safeguarding adults issues, were clear about their responsibilities and would pass any concerns on to their line manager. Underhall Resource Centre DS0000035715.V362217.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): 19, 20, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides people with an attractive and homely place to stay. EVIDENCE: The short term care unit is situated down a corridor so it is apart from the day centre. There are eight single bedrooms, a comfortable communal lounge dining area, a kitchen, two toilets and a bathroom. Everyone spoken to was happy with the physical environment which they felt was suitable to their needs. Underhall Resource Centre DS0000035715.V362217.R01.S.doc Version 5.2 Page 18 The communal lounge/dining area is pleasantly decorated and provides a relaxing environment. One person showed us their bedroom, which they said was comfortable and a ‘home from home’. Some redecoration has taken place and new flooring obtained, in staff room as well as residential areas. The bathroom would be greatly improved by changing the position of the bath and the provision of a shower. This would provide comfort and choice for people staying at the home and safety for staff who are helping people. The AQAA provided details of access arrangements and signage, as well as listing the services provided. New risk assessments for fire and COSHH have been completed. The home plan to do infection control training for staff. All areas of the home were clean, comfortable and tidy. There is a pleasant outdoor seating area that people can enjoy in fine weather. Underhall Resource Centre DS0000035715.V362217.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): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Current staffing levels meet the dependency needs of people currently accommodated within the home. EVIDENCE: Staff work across all the services provided on site, i.e. sheltered housing, day care as well as short term care. Discussions with staff, the manager, and people staying at the home indicated that, generally speaking, staff are busy but there are sufficient staff to meet the needs of people staying at the home. As well as the positive comments made by the seven people staying at the home on the day of inspection, we received 3 surveys from relatives. These also praised the staff and included the following; ‘My relative feels totally safe and secure at Underhall’, ‘Staff offer genuine friendship and humour’, ‘They care about us as a couple’, ‘In my opinion it is running to a very high standard’. Underhall Resource Centre DS0000035715.V362217.R01.S.doc Version 5.2 Page 20 The feedback from people who stay at the home, staff and the manager, indicate that current staff show expertise, initiative and a sense of responsibility. Two staff were spoken to and staffing issues were discussed with the manager. At night there is one member of waking night staff and one sleep in. There is a stable and mature care staff group with few changes of personnel. The AQAA says that they do sometimes struggle to recruit to vacant posts because the local employment market is very competitive. Staff spoken to were responsible and enthusiastic; they were proud of the standards of care they provide. The staff survey indicated that they feel well supported and trained, though sometimes courses are difficult to access. Comments included: ‘Good team work’, ‘this is a happy place to work’, ‘excellent training’. Staff comments on ‘what the service does well’ included the following:- ‘Promotes independence, providing choice’, ‘upholding people’s dignity and treating people as individuals’, ‘Helps keep service user in the community’, ‘Offers and delivers a friendly and welcoming centre’, ‘Provides warm friendly safe environment for both service users and staff’, ‘Always kept clean and tidy’, ‘Promotes independence, provides support to carers/relatives’. Underhall Resource Centre DS0000035715.V362217.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): 31, 32, 33, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager provides clear leadership throughout the home with staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: There are two managers who job share. They have joint responsibility for all the services on site. Both are registered with CSCI, and have appropriate skills and qualifications. There is a well developed staff training programme. In particular staff praised moving and handling and safeguarding adults training. Underhall Resource Centre DS0000035715.V362217.R01.S.doc Version 5.2 Page 22 The general level of support for staff is high, with confidence expressed in all the managers to provide day to day support. Some arrangements for formal supervision could be made more explicit and regular. The manager recognises that formal quality assurance and consultation systems could be improved. Information displayed in the communal lounge/dining area was very out of date. Regular regulation 26 visits (visits by the provider’s representative) take place and records are kept and were seen. They note that staff are very busy. There are regular staff meetings for main staff group and senior staff. Minutes were seen and demonstrate that matters relating to the day to day running of the home are dealt with appropriately. The home has systems in place for safeguarding people’s valuables. Information provided in the AQAA (the home’s self assessment form) indicate that matters relating to maintenance are kept up to date. Underhall Resource Centre DS0000035715.V362217.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 3 X 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 X X X 3 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 3 3 X 3 3 X 3 Underhall Resource Centre DS0000035715.V362217.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. 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 OP1 Good Practice Recommendations Information about current fees and financial assessment procedures should be available to enable people to make an informed choice about coming to stay at the home and to comply with current guidance. Staff would benefit from training in infection control to ensure service users comfort and safety. More detail should be included on care plans to ensure that people’s needs are met appropriately. Falls assessments should be carried out for anyone who might be at risk to ensure their safety is maintained at all times. Assessments, care plans, and personal support plans should be kept up to date on the computer system Framework I. Formal staff supervision should take place on a regular basis and be consistently recorded. DS0000035715.V362217.R01.S.doc Version 5.2 Page 25 2 3 4 5 6 OP30 OP7 OP7 OP7 OP36 Underhall Resource Centre 7 OP33 Quality assurance systems should be in place and kept up to date and systems should ensure that information is ‘fed back’ to people in a timely manner. Underhall Resource Centre DS0000035715.V362217.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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