Inspection on 26/03/08 for Shepley House

This is the latest available inspection report for this service, carried out on 26th March 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Shepley House 15/11/05

Shepley House 16/05/05

Shepley House 10/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Shepley House Eyam Road Hazel Grove Stockport Cheshire SK7 6HP Lead Inspector John Oliver Unannounced Inspection 09:00 26 March 2008 th 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 Shepley House DS0000008588.V358238.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. Shepley House DS0000008588.V358238.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shepley House Address Eyam Road Hazel Grove Stockport Cheshire SK7 6HP 01625 874711 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) shepleyhouse@boroughcare.org.uk Borough Care Limited Mrs. Lesley Ridgway Care Home 40 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (40) of places Shepley House DS0000008588.V358238.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 40 OP and up to 4 DE(E). Date of last inspection 18th October 2006 Brief Description of the Service: Shepley House is a large, purpose built home situated in a quiet residential area in Hazel Grove. The home can accommodate up to 40 older people; all have single bedrooms. The home provides day-care facilities on four days each week and a luncheon club is run on Sunday. There are various communal lounges and dining rooms on both floors. Facilities are available for visitors to make their own drinks and snacks when visiting. There are gardens to the rear of the home, offering residents outdoor seating areas in fine weather. The home is located on the outskirts of Stockport. Shepley House is one of the homes owned by Borough Care Limited. The home is equipped with aids and adaptations and there is a lift, which serves both floors, enabling residents with diminished mobility to move around the home as independently as possible. The home has a statement of purpose and service user guide which were reported to be given to prospective service users or their families when they visit the home to look round. The fees for staying at the home were reported to be between £346:00 and £358:00 per week. Shepley House DS0000008588.V358238.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. The inspection was undertaken as part of a key inspection, which includes an analysis of any information received by us (the Commission for Social Care Inspection) in relation to the home prior to the site visit. This inspection, which the manager did not know was going to happen, took place over the course of six and a half hours on Wednesday, 26th March 2008. During the course of the site visit we spent time talking to the residents, the registered manager and staff on duty to find out their view of the home. Before the site visit we sent the manager of the home an Annual Quality Assurance Assessment (AQAA) document for them to complete and return to us with information about the service they provide. This was returned before the visit took place and contained a lot of information that helped us to assess the service being offered by the home. Again, before the site visit, we sent questionnaires to residents, relatives, staff and other healthcare professionals, such as doctors and district nurses, for them to complete and return to us to tell us what they think of the service being provided. A number of these were returned before the visit took place and contained information that helped us to assess the service being offered by the home. We also spent time examining various files and written information and spent some time looking around the building. What the service does well: The management and staff team work hard to promote the health and well being of the people living in the home. Some of the residents have lived in the home for a number of years and in survey questionnaires returned to us told us “I am very happy here”, “Been here five years and have been very happy”, “I am very happy living here and I don’t have to worry about getting my medication” and “Quite happy as I am and I can’t complain about anyone. I can talk to anyone here, and I find it easy to do so”. Shepley House DS0000008588.V358238.R01.S.doc Version 5.2 Page 6 The atmosphere in the home is welcoming and relaxed, and both residents and staff were happy to actively contribute to the inspection process. The management and staff team actively promote the services of the home and ensure that prospective residents and their families/advocates are provided with opportunities to visit the home, ask questions about the service and are provided with a lot of written information such as Service User Guide, brochures and other relevant information. Feedback received in questionnaires returned to us by relatives was very complimentary about the overall service provided by the home and comments included “I would give Shepley House 100 - all members of staff are dedicated, caring and nothing is too much trouble – even if they are busy they will still make time to answer any questions you may have. I could not wish for a better home for mum” and “Minor little problems have always been dealt with straight away”. What has improved since the last inspection? The large rear garden has been fully landscaped and a new, high quality summer house been purchased. This will be beneficial to all residents during the nicer weather. A number of bedrooms and communal areas have been redecorated and this was ongoing at the time of the inspection. The format used for care planning has been reviewed, updated and improved and is now in an electronic format. This means that care plans can be reviewed and updated when necessary and staff have access to updated information much quicker. All staff employed in the home have now received training in the Protection of Vulnerable Adults (POVA). This will reduce the risk of inappropriate action being taken in the event of any allegation of abuse being made. The management team now monitor the quality of the services being provided and produce a quality report to evidence their findings. This should enable any areas of concern identified to be addressed much quicker. Shepley House DS0000008588.V358238.R01.S.doc Version 5.2 Page 7 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. Shepley House DS0000008588.V358238.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 Shepley House DS0000008588.V358238.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 and 6 Quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Prospective residents are provided with a lot of information regarding the service prior to admission and receive a full assessment of their needs. EVIDENCE: Each person receives an assessment of his or her needs prior to moving into Shepley House and a member of the management team will carry out this assessment. Information about the person’s needs is collated into a document called a ‘Care Planning Assessment Tool’. This document is then used to develop an initial care plan along with any other information provided about the prospective resident by relatives or other healthcare professionals. Shepley House DS0000008588.V358238.R01.S.doc Version 5.2 Page 10 We looked at the files of three recently admitted residents and all contained relevant pre-admission assessment information. Wherever possible, a Key Worker is allocated to the prospective resident prior to their admission and, if possible, arrangements will be made for a introduction to take place during the pre-admission assessment process. Once the pre-admission process is completed, arrangements are then made for admission into the home. Again, wherever possible, the same Key Worker will be put on duty in order to be available when the new resident is admitted. This is good practice. Each prospective resident is given a lot of information about the service/home prior to their admission and this includes brochures, statement of purpose and ‘Welcome’ details. This information is clearly written and also comes in large print. During our visit a lady called into the home unannounced to enquire about the services available as she was looking for a residential placement for her relative. A care supervisor took this lady around the home and provided her with relevant brochures and other information. This lady was very complimentary about the home and said that she was “very impressed”. The home does not provide an intermediate care service. Shepley House DS0000008588.V358238.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Care plans were in place that detailed the needs of the individual resident and supporting policies and procedures were in place to ensure the safe handling and administration of medication in the home. EVIDENCE: Each person living in the home has an individual care plan that is kept in a file in his or her bedroom and since the last key inspection visit in October 2006 improvements have been made in the way in which care plans are developed. Care plans are produced from a computerised system and can now be updated with information as soon as necessary. Both care plans and risk assessments are reviewed every 28 days by a care supervisor and on the files we looked at we saw that these reviews had taken place. Shepley House DS0000008588.V358238.R01.S.doc Version 5.2 Page 12 Each care plan is also checked on a daily basis by the care supervisors during their handover to night staff at the end of the day. Each plan is read through to see how each resident has been throughout the day and that relevant information has been recorded and acted upon, where necessary. This is good practice. Daily records kept on each resident indicated how that person had been during any 24-hour period and, of those records we examined, we noted that some recording was better than others. For example, statements such as ‘acp 1 & 3 – slept well’ (as care plan 1 & 3…) do not give enough information about the actual care delivered to the individual. This is mainly recorded this way by night staff and we explained to the care supervisor the importance of enough detail being recorded to evidence ‘service delivery’ in accordance with meeting agreed identified needs. We spoke to one resident about care plans who told us “I know there is paperwork in the office about what I need – I do get asked about it” and “Staff are very very good – not a thing to complain about”. We received nine survey questionnaires from people living in the home. Seven stated that they ‘always’ received the care and support they needed and two stated ‘usually’. All nine stated that staff listened and acted on what the resident said they needed. We also received six survey questionnaires returned to us by relatives of people living in the home. Comments in these included “Mum is quite difficult to care for as she has many serious health problems but all the staff understand her condition and make sure all her needs are met at all hours of the day” and “The care home looks after every aspect of mum’s care and well being extremely well and ensure that I am informed with regard to mum’s health. Mum is always treated with respect and dignity”. A record is maintained of visits or appointments made to health care professionals, such as General Practitioners, district nursing services, chiropodist and opticians. In conversation with staff it was very clear that they understood how to promote and maintain the privacy and dignity of each resident when carrying out personal tasks and our observation of staff carrying out their duties confirmed this. All bedrooms have lockable doors that can be overridden in an emergency and all residents have been offered a key to their room. Shepley House DS0000008588.V358238.R01.S.doc Version 5.2 Page 13 We observed a care supervisor administering breakfast time medication. The home uses a Monitored Dosage System (MDS) that is provided by a local pharmacy. Only the manager and care supervisors have the responsibility for administering medication and it was confirmed that all staff with this responsibility had received training in the safe handling of medication. Each Medication Administration Record (MAR) contained a photograph of the resident for ease of identification. Staff clearly understood that some residents needed certain medication before food, with food or after food. Staff kept the care supervisor informed as each resident came into the dining room for breakfast and reminded certain residents not to start their breakfast until they had taken their medication. We randomly selected to check some medication prescribed to a number of different residents. In the main, all were found to be correct with appropriate signatures recorded on the MAR. Where necessary, MAR’s were highlighted to indicate specific directions, e.g. ‘Avoid eating grapefruit and/or drinking grapefruit juice during treatment with this medicine’. All staff who are involved in preparing and delivering food are also provided with this information. This is good practice. Shepley House DS0000008588.V358238.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Daily routines in the home demonstrated that residents were encouraged to maintain control over their lives, were encouraged to maintain contact with the community and, are provided with a wholesome and well balanced diet. EVIDENCE: A care supervisor has the overall responsibility for arranging activities in the home. This is done on a daily basis and staff are allocated to be involved. Residents spoken to told us “I enjoy doing my Wordsearch and crossword puzzles – that’s enough for me” and “Activities do take place but not everyone wants to join in – but staff do try to encourage people”. Watching the day-to-day routines in the home indicated a relaxed and informal atmosphere and one resident told us “I get up and go to bed when I want to and I get a choice of the food I want – the staff will come around and ask us what we would like for dinner”. Shepley House DS0000008588.V358238.R01.S.doc Version 5.2 Page 15 We observed breakfast being served in the upstairs dining room. One member of care staff has direct responsibility for making sure that everyone receives a breakfast of their choice and all food is served fresh as the person gets up. A breakfast menu was displayed and included the choice of having a cooked breakfast of egg and bacon, which a number of residents chose to have. Staff were observed to sit at the side of those residents who required help and this was done with discretion and sensitivity whilst meeting the individuals’ needs. Menus were in place on each table, which enabled residents to be reminded of what meals are planned and available for the day. In the surveys returned to us before the visit took place, seven residents stated that they ‘always’ liked the meals, one stated ‘usually’ and one stated ‘sometimes’. Comments also included “There could be a little more variety in the meals”, “Excellent food”, “I do not have a good appetite, I do like some meals and some I don’t like” and “… enjoys a good appetite and is very happy with the choices”. Visitors are made welcome to the home and residents are able to see visitors in private should they wish to do so. Residents spoken to told us “My family visit regularly and are always made to feel welcome” and “My daughter comes to see me, all the staff know her”. Shepley House DS0000008588.V358238.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Policies, procedures and training measures were in place for staff to support residents to raise any issues of concern and to protect residents from neglect and abuse. EVIDENCE: A complaints procedure is displayed throughout the home and is also included in the Service User Guide provided to all residents. This procedure gives relevant information about how to make a complaint or raise a concern and includes timescales for responses. Residents spoken to said that should they have any worries or concerns they would “go to the manager” or “I would see Dan or Fran (care supervisors)”. Staff spoken to were confidant that most residents and their relatives/ advocates would know how to make a complaint and that staff would support any resident who wished to do so. In the nine survey questionnaires returned to us by residents living in the home, all nine stated that they knew how to raise any concerns they may have. Comments included “I know how to make a complaint but there is not a thing to complain about” and “Staff are very good, they would help me if I needed them to”. Shepley House DS0000008588.V358238.R01.S.doc Version 5.2 Page 17 Records were maintained of concerns raised by residents/relatives but the format used to record them did not detail sufficiently enough the processes used when investigating a complaint and did not record the final outcome from any investigation that may have been carried out. This was fully discussed with the manager/care supervisors. Staff spoken to during our visit confirmed that they had all received training in the protection of vulnerable adults and when asked were able to clearly demonstrate what action they would take in the event of an allegation of abuse being made. In the eight staff survey questionnaires returned to us before this visit took place, all eight indicated that staff were very clear about how to support a resident and/or their relative should a concern be raised about the home. Shepley House DS0000008588.V358238.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The environment was clean, tidy and comfortable with systems in place to protect and monitor the health and safety of those residents living there. EVIDENCE: The home is set in attractive, well kept gardens and grounds and, since the last inspection visit, the rear garden area has been fully landscaped and a new high quality summer house built. This has given residents an excellent outdoor space to use in the nicer weather. On entering the home the atmosphere was found to be very homely and welcoming. We looked around most the premises, which we found to be well maintained throughout, and provide appropriate and very comfortable accommodation for those people living in the home. Shepley House DS0000008588.V358238.R01.S.doc Version 5.2 Page 19 The home also provides a day care service for up to ten people and this is facilitated in a large downstairs lounge/dining area and is staffed separately to the rest of the home. This additional service provides community contact, with many residents living in the home knowing people using the day care service. Also, many of the people using this service use the respite service also provided by the home, which means that people are then supported by a staff team they have already got to know. Furnishings, such as lounge chairs and dining tables and chairs, are domestic in style and are of good quality, adding to the comfort of residents. All parts of the home were clean, tidy and bright and were free from any unpleasant odours. Those bedrooms seen had been personalised to varying degrees and reflected the character of the person whose room it is. We saw that a number of residents like to spend time in their own rooms watching television or reading and residents also had the choice of having a key to lock their rooms for added privacy. The home also benefits from having a visitors lounge and kitchen area on the first floor, which means that residents can entertain relatives and friends and also enjoy carrying out routine tasks such as making a cup of tea (risk assessments in place). Residents also have access to a fully fitted hairdressing room/salon and the manager has recently purchased new hood style hairdryers. A visiting hairdresser comes to the home once per week or residents can choose to visit a hairdresser of their choice in the community. Shepley House DS0000008588.V358238.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, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff are employed in the home, with staff training and development helping to ensure staff are competent to carry out their jobs. A robust recruitment and selection process helps to protect residents from unsuitable people working in the home. EVIDENCE: Staff spoken to told us that “generally there are enough staff on duty and there are always enough staff to meet the residents’ needs”. We looked at staff rotas and these indicated that enough staff were employed throughout the home to meet the needs of the people currently living in the home. In the nine survey questionnaires returned to us by people living in the home four stated that staff were ‘always’ available when needed and five stated ‘usually’. In the six survey questionnaires returned to us by relatives of people living in the home, all stated that their relative ‘always’ received the support expected and agreed. Shepley House DS0000008588.V358238.R01.S.doc Version 5.2 Page 21 Each member of the staff team has an individual training record that is held on a computerised system. This system is in place to ensure that training is regularly updated and each staff’s training needs can be closely monitored by the management team. In the eight staff survey questionnaires returned to us all stated that they received training that was relevant to their roles, helps them to understand and meet the individual needs of residents and keeps them up to date with new ways of working. All staff receives mandatory training in topics such as moving and handling, food hygiene and fire procedure awareness. The majority of care staff working in the home hold the National Vocational Qualification (NVQ) level II in care or are working towards this award. Examination of a sample of staff files confirmed that staff recruitment was thorough and robust, including receipt of appropriate references and Criminal Record Bureau (CRB) enhanced disclosures. Shepley House DS0000008588.V358238.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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents living in the home benefit from having the support of a manager and management team with skills to provide a good quality service and procedures in place to promote their interests and well being. EVIDENCE: The management team of the home consists of a registered manager, a deputy manager (post currently vacant) and three care supervisors. The registered manager has over ten years’ experience in a management capacity and holds a number of relevant qualifications and regularly attends training appropriate to her job role. Shepley House DS0000008588.V358238.R01.S.doc Version 5.2 Page 23 There was evidence to demonstrate that all care supervisors are taken through a comprehensive induction programme that covers all main aspects in the management and support of residents, staff and dealing with general issues relating to the management of the home. Staff spoken to told us that they were happy with the management team at the home and comments included “Managers are very good – I am happy with the management – every month we have supervision” and “The manager is very supportive – helped me to develop my skills and knowledge”. In the returned staff surveys, comments included “My manager always has a senior meeting every month to let us know what is going on. I feel I get a lot of support, not just with the manager but with the rest of the team”. The manager told us that regular quality audits of the service are carried out in order to obtain feedback from residents and other people involved in the service such as relatives and other visiting professionals. We saw that questionnaires had also been developed for new residents/relatives to find out about their experiences prior to and during the admission procedure into the home. Borough Care Limited then produces an annual quality report showing the performance by the home in caring for its residents and the methods by which the organisation measure this performance, taking into account any internal and external reports and comments made about the service. The manager told us that she had no involvement in managing residents’ finances: this remained the responsibility of the resident and/or their relatives/ advocate. Small amounts of money were held for residents to purchase small items and systems were in place to ensure the safe handling and storage of residents’ monies. Regular residents’ meetings are held and the majority of residents attend and contribute to the meeting, sharing their views and opinions. The manager told us that the maintenance and servicing of equipment used in the home had been carried out and a random selection taken from the service records during our visit confirmed this. Shepley House DS0000008588.V358238.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 4 x 4 x x N/A 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 3 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 Shepley House DS0000008588.V358238.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. 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 2 Refer to Standard OP7 OP16 Good Practice Recommendations Information recorded about each resident should be detailed enough to evidence ‘service delivery’ in accordance with meeting agreed identified needs. Information recorded about any concern/complaint should also include details of any investigation process used and the final outcome from that investigation. Shepley House DS0000008588.V358238.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local Office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shepley House DS0000008588.V358238.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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