Care Home: Warren Farm Lodge

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What the care home does well The collects good information about people before coming into the home and this is added to by the completion of the baseline assessment shortly after admission. The information collected includes details of the persons ethnic background, lifestyle and religion and this helps the home provide care in the most appropriate way.The home ensures that each person has a care plan that details how their health and social needs are to be met. We found that all the people`s health care conditions had care plans to say how these were going to be managed. Health-care professionals that visit were satisfied with how the home manage peoples health care. A person living in the home said "I always get GP visits on the day requested." People appeared to be well looked after with their personal hygiene needs met and details such as jewellery and makeup were attended to where people wanted this. Staff are working well with health-care professionals to provide a service to people who are terminally ill and attention is given to ensuring people`s last wishes are met. The management of medication was good and this helps to protect people`s health and well-being. People are treated with dignity in respect, the expert by experience noting good interactions between staff and residents during the day and records of compliments showed there is a good atmosphere in the home. A coordinator is employed to ensure that people have activities and this enhances people`s lives. People can have visitors when they want and have freedom to move around the building or have their care in their room if they wish. People said that the meals were good. Efforts were made to ensure that people have meals that suited them and meets their lifestyle. People have the opportunity to raise concerns either in meetings, with staff or can write these in a complaints book in the reception area. The home has a good warm friendly environment for people to live and this enhances their life. Staff were friendly and helpful, people spoke of them warmly as did visitors to the home. Arrangements for assisting people with the management of their money were safe and safeguarded people`s interests. Health and safety checks were undertaken and this means that people have a building safe to live in. What has improved since the last inspection? The home has increased the number of hours the activities coordinator is spending the home. All but his staff have received protection of vulnerable adult training except for the two newest. All staff have received dementia training and are receiving support from the dementia specialist. There are new soft furnishings in the lounge and dining areas and the home has a new patio area. What the care home could do better: We found on the day of the inspection that a number of bedrooms had cleanliness and odour issues, it is recommended where this is a problem more regular checks are undertaken. It was clear there was some fluctuation in the staffing levels of the home throughout September, and the needs of some residents were increasing. The management must review the staffing levels to meet the needs of the residents. Although the home were recruiting staff appropriately it is recommended that records of interviews be kept to ensure that equal opportunities in recruitment are maintained and that a full staff file is maintained. CARE HOMES FOR OLDER PEOPLE Warren Farm Lodge 123 Warren Farm Road Kingstanding Birmingham West Midlands B44 0PU Lead Inspector Jill Brown Unannounced Inspection 24th September 2008 08:00 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 DS0000016920.V372263.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. DS0000016920.V372263.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Warren Farm Lodge Address 123 Warren Farm Road Kingstanding Birmingham West Midlands B44 0PU 0121 382 3752 0121 382 2173 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) www.anchor.org.uk Anchor Trust Ms Janet Bennett Care Home 30 Category(ies) of Learning disability over 65 years of age (30), registration, with number Old age, not falling within any other category of places (30) DS0000016920.V372263.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2006 Brief Description of the Service: Warren Farm Lodge is a purpose built two-storey home, which is situated close to a local health centre, shops and public transport in the Kingstanding area of Birmingham. The Home provides accommodation for thirty residents for reasons of old age and learning disability. Accommodation is provided in single flats each with kitchenette and en-suite facilities consisting of toilet and wash hand basin. There are communal assisted bathing/shower and toilet facilities strategically placed in the Home and staff are available to provide assistance in these areas as required. A passenger lift gives access to the first floor. There is a lounge, conservatory and dining room situated on the ground floor and there are smaller quiet seating areas located throughout the Home. The main kitchen is adjacent to the dining room and is well equipped. Parking is available to the front of the property and attractive enclosed gardens are situated to the rear with access through the conservatory. The Home and gardens are well maintained and provide a warm homely atmosphere and there is a no smoking policy within the building. Aids and adaptations are provided for residents with physical disabilities. There is a notice board displaying forthcoming events and other information of interest to residents and their visitors. The most recent CSCI inspection report is available in the reception area of the Home. The weekly fee to live at Warren Farm Lodge is £368 with an additional top up of £15. Hairdressing is not included within this fee. DS0000016920.V372263.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 visited the home without notice on a day in September 2008 and spent about 9 hours in the home . During the inspection two people’s needs were case tracked. This case tracking involved looking at all the records and information about them, looking at their medication and their rooms and observing their care. This assists us to make a judgement about the care given. We also looked at parts of the care of a further two care plans. We received 20 comment cards about the service. Other documents about the running of this home were examined and parts of the building were looked at. We also took into account of information we had received from all sources about the home since the last key inspection. Services are required to complete an Annual Quality Assurance Assessment (AQAA) on a yearly basis; information from this was used in this report. During this inspection an expert by experience, Dorothy Stubbs, accompanied us. An ‘expert by experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in or use the service. The expert by experience had the opportunity to speak to a large number of people in the lounge and at mealtime. The inspector also spoke with 2 people in the home. We have had no complaints about the service. What the service does well: The collects good information about people before coming into the home and this is added to by the completion of the baseline assessment shortly after admission. The information collected includes details of the persons ethnic background, lifestyle and religion and this helps the home provide care in the most appropriate way. DS0000016920.V372263.R01.S.doc Version 5.2 Page 6 The home ensures that each person has a care plan that details how their health and social needs are to be met. We found that all the people’s health care conditions had care plans to say how these were going to be managed. Health-care professionals that visit were satisfied with how the home manage peoples health care. A person living in the home said I always get GP visits on the day requested. People appeared to be well looked after with their personal hygiene needs met and details such as jewellery and makeup were attended to where people wanted this. Staff are working well with health-care professionals to provide a service to people who are terminally ill and attention is given to ensuring peoples last wishes are met. The management of medication was good and this helps to protect people’s health and well-being. People are treated with dignity in respect, the expert by experience noting good interactions between staff and residents during the day and records of compliments showed there is a good atmosphere in the home. A coordinator is employed to ensure that people have activities and this enhances peoples lives. People can have visitors when they want and have freedom to move around the building or have their care in their room if they wish. People said that the meals were good. Efforts were made to ensure that people have meals that suited them and meets their lifestyle. People have the opportunity to raise concerns either in meetings, with staff or can write these in a complaints book in the reception area. The home has a good warm friendly environment for people to live and this enhances their life. Staff were friendly and helpful, people spoke of them warmly as did visitors to the home. Arrangements for assisting people with the management of their money were safe and safeguarded peoples interests. Health and safety checks were undertaken and this means that people have a building safe to live in. What has improved since the last inspection? DS0000016920.V372263.R01.S.doc Version 5.2 Page 7 The home has increased the number of hours the activities coordinator is spending the home. All but his staff have received protection of vulnerable adult training except for the two newest. All staff have received dementia training and are receiving support from the dementia specialist. There are new soft furnishings in the lounge and dining areas and the home has a new patio area. 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. DS0000016920.V372263.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 DS0000016920.V372263.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is collected about the needs and abilities of people before admission to this service and this helps the home ensure that they can meet the person’s needs. EVIDENCE: The home stated in their annual quality assurance assessment (AQAA) that they gives information to people who are thinking of coming into the home. Information was available on the day of the inspection; this was not looked at but had not been a problem at previous inspections. We look the assessment information collected on two people who had recently been admitted to the home. We found that the home undertakes a preadmission assessment and collects good information on a person’s circumstances. This includes information about their skills and abilities as well DS0000016920.V372263.R01.S.doc Version 5.2 Page 10 as information about their health and personal care needs. This preadmission assessment can take place two or three months before admission however, in addition to this the home undertakes a baseline assessment, which includes what else they have discovered about the person following admission to the home. This assessment was completed within days of the person being admitted. We also found information about the person from an assessment undertaken by a social worker. People place by social workers have any three-way agreement which acts as own contract outlining the terms and conditions of their stay. People living in the home have details about their religion and ethnic origin recorded; this helps to ensure that these needs are met. The home has an allfemale staff and this means that male residents do not have the option of personal care from a male member of staff. The home has a culturally diverse staff group and this meets the needs of the people in the home. DS0000016920.V372263.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&11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People in this home have care plans that instruct staff how to meet care needs in the way that people want. Peoples health and medication needs are met and this means that people are kept as well as possible. People are treated with respect and efforts are made to meet their wishes and this means that people are happy with the care they receive. People can be assured that if they need terminal care that this home will try and provide it. EVIDENCE: We looked at the care plans for three people living in the home and look at parts of other plans. We found that these plans were detailed and gave good instructions to staff about how to care for people. DS0000016920.V372263.R01.S.doc Version 5.2 Page 12 Care plans showed how to manage peoples health conditions; daily records showed that people received visits from health professionals if needed. One person commented I always get GP visits on the day requested. Four healthcare professionals gave very positive comments about the home including in this care home everything is done to the highest standard. Care plans were in place for people with epilepsy, mobility, and personal hygiene. A number of the details in the care plans ensured that people receive the care that they wished for example she likes jewellery and rings, has no teeth and this is her choice, likes make up. An expert by experience joined the inspector at the home and found that female residents were wearing jewellery and make up if they wished. One gap was found in one care plan relating to their health care need, this was rectified immediately. The expert by experience spent time in the lounge and noted some inconsistency in moving and handling but their conclusion about the service was ‘I have to say that I was pleasantly surprised at the high standard I found at this Home, and I would have had no hesitation in placing my own mother there. The staff ware friendly, polite and had considerable pride in the work and the residents. All the residents appeared happy and contented.’ We looked at the medication arrangements for the people case tracked and sampled some other peoples records and found that the medication and arrangements were good. One member of staff takes the responsibility for the ordering and clerking in medication. It is recommended that two people undertake this task to ensure that any mistakes can be spotted. However, we found that medication was stored, administered, recorded and disposed of appropriately. We found the person responsible for medication had a good knowledge about what medication was for and any contra indications. During the day the expert by experience noted that people were treated with dignity and respect. She stated During the morning the staff brought around a tea/coffee trolley, it was very pleasing to see that “normal” cups and saucers were used, except for one lady who used a feeder plastic mug, but this was due to her disabilities and gave her independence. A health professional commented As I have seen, people are treated the way I would like a member of my family to be treated. People have keys to their flats however many leave their doors open one person said to the expert by experience “ they can come and check me every two hours during the night to make sure I am OK”. This home is working in partnership with the local health services to provide terminal care for people placed by them. On the day of the inspection there were a number of people receiving terminal care who had been resident at the home for some time. Specific care plans were in place to meet the persons terminal care needs. Appropriate pain relief was available, people were talked DS0000016920.V372263.R01.S.doc Version 5.2 Page 13 to about their wishes and arrangements were made to try and meet these wishes. DS0000016920.V372263.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People in this home have activities routinely and have good, suitable, wholesome meals and this ensures their well-being. People are not unduly restricted and this enables them to make choices about their life. EVIDENCE: This home employs a coordinator who attends the home four times a week to provide activities. On the day of inspection the expert by experience observed a record being played with the old time music hall songs with a member of staff encouraging people to sing-a-long. There was a lady having her nails filed, whilst others were happy to chat or just sit a listen to what was going on. There was a lot of staff interaction with people who were spoken to with respect. Comment cards from people said they were happy with the activities provided. People spoken to occasionally went out of the home for appointments or to the local shops. The manager on duty said that that there hadnt been able to do as many outings as in previous years. We received a DS0000016920.V372263.R01.S.doc Version 5.2 Page 15 comment card that said more staff time was needed to assist people into the garden. Peoples interests are recorded on their care plan and it helps the home ensure that people have activities that are meaningful to them. The homes annual quality assurance assessment recognised that they could develop activities further. During the inspection there were a number of relatives visiting, there appeared to be no undue restrictions on visiting. People were seen to move around the building without any restrictions. People were able to get up and spend time in their rooms. The expert by experience spoke to a number of people who confirmed they were able to get up and go to bed when they wished. The expert by experience had a meal with early people living in their home and spent time in the dining area. She found that Meals are served by staff. Vegetables are served in tureens so that residents can help themselves. On the day of inspection there was leek soup, a choice of gammon or fish finger, mash potatoes, cabbage and Carrots, white sauce (gravy was available if required), four choices of sweet, fresh fruit salad, tined fruit salad, cherry pie, crumble with either custard or fresh cream. She observed two ladies being assisted to eat this was done very discreetly and the staff member helping one person at a time, all the time talking quietly to them. We spoke to the cook about the meals provided and found that they were knowledgeable about peoples health conditions and how that affected the meals provided. The home has people from the white Irish and African Caribbean backgrounds and meals reflecting their culture are occasionally made. The cook likes to ensure items such as cake are home-made. Although the home stated that they do have menus available that can be easily read these were not on display on the tables on the day of the inspection. We looked at the menu for 4 weeks and found that people had a choice at all three main meals and this always contained a hot food option. There was also supper available of sandwiches if people wanted. DS0000016920.V372263.R01.S.doc Version 5.2 Page 16 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. People living in this home are encouraged to raise concerns and these are listened to and responded to. There is good staff understanding of their role and procedures protects people in this home. EVIDENCE: On entering the home we found that the home had books for people to raise their concerns and to comment on the service provided. The outcome of the concerns is also recorded. This demonstrates that the home has an open attitude to concerns and tries to resolve any issues brought to them. The homes AQAA states that ‘ Complaints are seen as a way of improving best care practice.’ A number of concerns were raised the only theme that we could find was about the laundry service and the manager on duty advised us of this before we looked at the records. We have received no complaints about this service. We also noted in the compliments book a number of comments about the good atmosphere in the home, the friendliness of staff, the good food and care that people received in the home. We have received no referrals about issues where people living in the home needed to be safeguarded. Staff are recruited appropriately and any concerns raised about staff checks are investigated and risk assessed. Staff spoken to DS0000016920.V372263.R01.S.doc Version 5.2 Page 17 were clear about their responsibilities in ensuring people living in the home were safe and not the victim of abuse. DS0000016920.V372263.R01.S.doc Version 5.2 Page 18 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in this home have a good homely environment that is designed to meet their needs. EVIDENCE: The entrance to the home is level access making it accessible for wheelchair users, there is a lift to the first floor. There is car parking at the front. There is a large lounge, dining room and kitchen. The “flats” are on the ground and first floors. There is a large conservatory and small garden area with outside tables and umbrellas. The home has identified in their AQAA that this could be improved by making the garden more wheelchair friendly with raised beds. The home was in good order and was warm and inviting. All the communal areas were clean and fresh with a good range of furniture and areas for people to sit. Two flats did have issues with odour management and processes should be put in place to check these rooms more regularly. Staff spoken to had DS0000016920.V372263.R01.S.doc Version 5.2 Page 19 undertaken infection control training and were able to discuss the way they manage control of infection in the home. The flats in the home are en suite having a toilet and sink. All flats had a number on the door and some had other identifying features to assist people to identify their room. There are adaptations to bathing and showering areas so people can be assisted if it is needed. DS0000016920.V372263.R01.S.doc Version 5.2 Page 20 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): 27,28,28&30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The needs of the people in this home are increasing and the home isn’t consistently ensuring that there is enough staff to meet all their needs. Staff are trained appropriately to ensure that needs of home are met. EVIDENCE: The staffing rotas showed that there was one senior carer and three care assistants on duty during mornings, one senior carer and two care assistants during afternoons and two care staff overnight with on call support from a senior member of staff. In addition to this there was management staff during the week and the home has domestic cooking and maintenance staff. Staffing appears to have been difficult at the beginning of September and more staffing has been put in place more recently due to the increasing dependency of some residents. A number of staff comment cards indicated that more staff were needed to ensure that all the peoples needs are met. The home ensures that the majority of staff have a National Vocational Qualification Level 2 in care. Currently 68 staff including bank staff have this qualification. This helps to ensure that staff are aware of the care older people need. DS0000016920.V372263.R01.S.doc Version 5.2 Page 21 the people in the We looked at the recruitment records of two recently employed staff and found that they had the necessary checks undertaken before employment. We found that staff had completed an application form, references were applied for and at a minimum a Protection of Vulnerable Adults check was completed before they person started work. A full Criminal Records Bureau check was received later. We noted that there had been interview but a record of the interview, to ensure that equality issues in employment and that any future performance concerns could be checked, should be maintained. The home showed us its training matrix and we spoke to some staff about their training. wW found that the home was ensuring that training such as Fire safety were repeated on a regular basis to ensure the safety of the residents. DS0000016920.V372263.R01.S.doc Version 5.2 Page 22 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): 31,33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in this home can be assured that their interests, safety and well being are taken into account in all aspects of running the home. EVIDENCE: There was a stable and effective management team at Warren Farm Lodge and each member had their own designated responsibilities in respect of the running of the Home. The manager of the home has taken extra responsibilities as part of the organisation and the deputy was taking on some extra responsibilities. Comment cards from staff showed that the management of the home was seen as helpful. DS0000016920.V372263.R01.S.doc Version 5.2 Page 23 The annual quality assurance assessment (AQAA) was completed well, it demonstrated that the management understood the strengths of the home and where it could make improvements. The home has a process at selfassessment this is yet to be completed we were told this was because of the increase metres people living in the home recently. People living in their home have meetings to discuss how the home could be improved and what activities they would like. At a recent meeting people asked for a WII and a DVD and these have been bought. Some people wanted to go to Spain for a holiday others wanted to go to Weston-super-Mare these have not been arranged as yet. We looked at the financial records for some people who received assistance in managing their money. The home tries to ensure that people remain as independent with money as they can. If people need help managing their personal allowance, families can request a statement from Anchor Housing at any point. A lot of relatives bring in money for people, and number of solicitors are involved in managing Peoples money and one persons money comes in from Birmingham city council. There are three points, which confirm how much money people have. There is an individual account, the daily account of transactions and the computerised account. The accounts we looked at seem to have appropriate spending. People living in the home have access to their money. Some people manage their own money. The home was able to demonstrate that they had different ways of managing money to meet the needs and wishes of the people living in the home. We looked at a small selection of maintenance records and found that the health and safety records for electrical, gas, asbestos safety were in place. The home produces its own internal health and safety report and this was completed in August. DS0000016920.V372263.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 X X X X X X 2 STAFFING Standard No Score 27 2 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 DS0000016920.V372263.R01.S.doc Version 5.2 Page 25 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 OP27 Regulation 18(1) Requirement The home should review their staffing to ensure that the levels, skills and roles are available in sufficient numbers to meet the needs of people living n the home. Timescale for action 30/11/08 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. 2. Refer to Standard OP9 OP15 Good Practice Recommendations All medication received in to the Home should be checked by two staff members Menus should be available on dining tables for residents to refer to. Outstanding since last inspection Where a person’s room are likely to be require cleaning more than once a day a system must be put into place to monitor them. It is recommended that records of recruitment interviews of staff are retained DS0000016920.V372263.R01.S.doc Version 5.2 Page 26 3 4 OP26 OP29 DS0000016920.V372263.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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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