Inspection on 16/09/08 for Southborough Nursing Home

This is the latest available inspection report for this service, carried out on 16th September 2008.

CSCI found this care home to be providing an Excellent 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

Southborough Nursing Home 07/02/06

Southborough Nursing Home 25/05/05

Southborough Nursing Home 22/11/04

Southborough Nursing Home 28/06/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Extracts from inspection reports are licensed from CQC, this page was updated on 17/12/2008.

CARE HOMES FOR OLDER PEOPLE Southborough Nursing Home 12-14 Langley Avenue Surbiton Surrey KT6 6QL Lead Inspector Michael Williams Unannounced Inspection 16th September 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Southborough Nursing Home DS0000026258.V372077.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. Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southborough Nursing Home Address 12-14 Langley Avenue Surbiton Surrey KT6 6QL 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) 0208 390 3366 0208 390 9394 info@lrh-homes.com www.lrh-homes.com London Residential Healthcare Limited Mrs Katherine Mary Litster Care Home 56 Category(ies) of Old age, not falling within any other category registration, with number (56), Physical disability (56) of places Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing (CRH - N) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places: 56) 2. Physical disability Code PD (maximum number of places: 56) The maximum number of service users who can be accommodated is: 56 27th September 2006 Date of last inspection Brief Description of the Service: Southborough Nursing Home is a registered care home with nursing for up to fifty-six older people who require general nursing care and who may have a physical disability. The home is situated in a residential area of Surbiton, and reasonably close to public transport, local shopping and leisure facilities. The home is owned and managed by London Residential Healthcare Limited (LRH). Bedrooms are situated on the ground and first floors of the home. Passenger lifts provide access to the first floor of the home. The main communal areas of the home are situated in the ground floor and consist of two large lounges, one small sitting room, a dining room and a large conservatory. A small sitting room is available on the first floor. To the rear of the property there is a large garden. Ample car parking is available to the front of the property. The person in charge when we visited confirmed that there have been no changes in the ownership, management or service registration details in the last 12 months and that their current registration certificate is providing the correct details. Fees as at September 2006 were from £516 to £880. Southborough Nursing Home DS0000026258.V372077.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 3 star. This means the people who use this service experience excellent quality outcomes. This inspection took place on the morning of 16th September when we visited the home; we met with people who use the service (in this home they prefer to be called residents and this is the term used in this report); we met with their visitors and with staff and management. We also toured the premises, checked residents case files and staff files and records and documents to cross-check information. We also took account of information we have received since our previous inspection and we noted the contents of the homes AQAA [Annual Quality Assurance Assessment form that each home is required to supply] What the service does well: What has improved since the last inspection? What they could do better: One requirement is made to ensure staff are aware of the protection of adults policies and procedures and in particular the whistle-blowing policy. Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 6 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. Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 7 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 Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 8 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): NMS 1 and 3: People using this service experience excellent quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be assured their needs will be assessed and they will be given comprehensive information so that their decision to reside in Southborough will be well supported. EVIDENCE: The joyful picture on the front cover of the new guide to Southborough provides a glimpse of the happy atmosphere visitors tell us they experience when they call in. This guide is their latest version and offers a comprehensive statement of purpose combined with a resident guide, which is very specific to the resident group and considers the different styles of accommodation, support, treatment, philosophies and specialist services required to meet the needs of residents. The information is provided at different levels, about the company, the specific home and information particular to the resident and is in a format suitable for their and their families’ need. The company can provide the information various ‘community languages’, pictures or Braille if this is needed. The new version is ‘person centred’ that is, the documents put the resident as the focus of the information and describes what is being offered to them individually. The inserts to be enclosed in each ‘handbook’ will be not Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 9 only specific to the home but to the individual resident so as to give specific information – about fees, contracts, catering arrangements and so forth All new residents receive a comprehensive needs assessment before admission. This is carried out by staff with skill and sensitivity. Southborough is highly efficient in obtaining a summary of any assessment undertaken through care management arrangements, and insists on receiving a copy of the care plan before admission. For residents who are self funding, the assessment is undertaken by qualified members of staff. Individuals are supported and encouraged to be involved in the assessment process. Information is gathered from a range of sources including other relevant professionals, and with the individuals agreement, carer’s interests are taken into account. The assessment focuses on achieving positive outcomes for people and this includes ensuring that the facilities, staffing and specialist services provided by the home meet the ethnic and diversity needs of the individual including the six strands of diversity are: gender (including gender identity), age, sexual orientation, race, religion or belief, and disability. This means that before agreeing admission the Southborough staff carefully consider the needs assessment for each individual prospective resident and the capacity of the home to meet their needs. Prospective residents are given the opportunity to spend time in the home. An individual member of staff is allocated to give them information and special attention to help them to feel comfortable in their surroundings and enable them to ask any questions about life in the home. Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 10 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): NMS 7 to 11: People using this service experience excellent quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. Health and social care appears to be exemplary in this care home and so residents can be assured that their care needs will be met to very high standard. EVIDENCE: Visitors describe this home as “loving and caring” and “the residents and their relatives are treated like family” Residents receive effective personal and healthcare support using a ‘person centred’, that is, a very individualised approach to care that respects residents’ expectations to be treated with dignity, equality, fairness, autonomy and respect. The new statement of purpose sets out the competencies and specialist services the home offers and delivers this effectively through a skilled, trained and knowledgeable staff group that work in this person centred way. Staff are very much aware that the way in which support is given is a key issue for older people. Individual plans clearly record people’s personal and health care needs and detail how they will be delivered. Staff in this home respect people’s preferences and have expert knowledge about individual personal needs when providing support, including intimate care. The staff group is balanced to enable choice of male, female and age Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 11 related preferences when delivering personal care. We confirmed this by checking one of the home’s AQAA forms [their Annual Quality Assurance Assessment], which provides details about the balance of male and female staff and their age range and background. This enables the home to give choice; so as an example a resident made appoint of commenting how kind and gentle the male carers were. As we toured the Southborough we were able to observe that staff respond appropriately and sensitively in all situations involving personal care, ensuring that it is conducted in private and at a time and pace directed by the person receiving the care. Aids and equipment are provided to encourage maximum independence for people using services; these are regularly reviewed and replaced to accommodate changing needs. Specialist advice is sought by the home to ensure effective use of equipment such as raisable beds, alternatingair mattresses, hoists and similar equipment. Since most residents are very frail the home arranges for health professionals to visit residents at home. The home fully respects the rights of people in the area of health care and medication. They recognise and work with the decisions made by the individual regarding any refusal to take medication, or any specific requests about how their healthcare is managed. To this end some of the visiting doctors have begun assessing residents’ wishes and in particular what might be regarded as ‘advanced directives’ for they are very ill – for example whether or not they wish to be treated with antibiotics, resuscitated, transferred to hospital at times of relapse and so forth. We saw a great many comments, in the comments book, in thank-you cards and in questionnaires, that all say how good, “excellent is the care and warmth” of Southborough. Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 12 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): NMS 12 to 15: People using this service experience excellent quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be assured that Southborough offers choices about the lifestyle they would expect including respect for their background, contact with their family and friends and offers a range of meals that are well balanced. EVIDENCE: The many residents we spoke to said that they were happy with the arrangements for social and recreational activities. A small number of residents still manage to go out and about with their family and friends and this is commended. An activities programme was displayed and there was a notice detailing that regular church services are held in the home. There was an activities coordinator who was spending who was organising a game of Bingo in the afternoon; whilst this remains a popular activity there are many other opportunities for recreational and social activities here. On this occasion we noted and commend the home’s collaboration with Age Concern in a project to introduce a regular, volunteer visitor called a ‘Buddy’. This person visits the home regularly each week and compliments the work of the activity coordinator by spending time with individual residents. As an older person and with similar life experiences as the residents this volunteer is able to share memories. The poetry reading sessions have also proved popular as well. Since many of the staff do not share the same background as the residents this Buddy project also compliments the work of carers – whose understanding of spoken English and English culture may not be so refined as the Buddy’s. Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 13 There are two large communal lounges. Some service users were reading newspapers in one lounge and others were listening to music in the second lounge. There is a television in one lounge giving residents a choice about whether or not to watch it. The home also has an upright piano – whether or not it is used it is a piece of furniture that will be familiar in the home setting to many residents. There were a great many photographs displayed of trips that have been organised recently and it was pleasing to hear that such trips are well supported by residents. The activities coordinator completes a written social ‘reviews’ for each service user. These are then made available at each review of care. Residents are able to make choices about daily living and we assess that staff members respect their wishes, so some enjoy the quietness of their rooms, some like to take a newspaper and almost all have an opinion about the choice of meal each day. Formal meetings occur on a regular basis where residents are invited to discuss daily living issues. There were menus on tastefully displayed on the dining tables and residents get a choice of two main meals each day. On the day of our visit it was choice of Steak Pie or a Prawn in fried rice dish. All service users are offered sherry, wine or beer with their meal – if they wish it and it is safe for them to have – and this ‘extra’ was very much appreciated. There was good support from staff members for those service users who needed to be assisted in eating their meal. Positive comments were received from service users about catering in the home. As we have found on previous occasions residents agreed that “The food here is very good”. Most service users had a soft drink close to hand, we noticed that drinks had been brought to the lounges early in the morning in readiness for residents using the communal areas. Hot drinks were provided at midmorning and afternoon. The chef is commended for providing meals that residents agree are very homely and tasty. We did not inspect the kitchen in any great detail since the kitchen rated 4 stars when assessed by an Environmental Health Officer. Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 14 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): NMS 16 and 18: People using this service experience good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems are in place for the effective handling of complaints and protection issues and service users and their relatives are encouraged to raise any concerns they have. So residents know that their concerns will be acted upon. EVIDENCE: There has been no change to the manner in which this standard about complaints and protection is being met and so the previous findings are restated. There are no complaints recorded since the previous inspection. There are policies and procedures in place for dealing with complaints. Information is made available in the residents’ Guide about how a compliant, concern or suggestion should be made, and how this will be handled. This information also includes details about how a complaint may be made to the Commission for Social Care Inspection. The Manager tells us that residents and their relatives are encouraged to raise any concerns with staff members before they become problematic; the comments book in the lobby demonstrates this pro-active approach. The home has a copy of the Royal Borough of Kingston Upon Thames vulnerable adult protection procedures. The Manager assured the inspector that any suspicion of abuse would be referred to the Social Services (who are responsible for investigating such matters) and our records show this to be the case. Records examined detailed that staff members receive training in the protection of vulnerable adults as part of the induction programme; however we spoke to staff who were not sure of the whistleblowing policy and need refresher training on this point. Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 15 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): NMS 19 and 26: People using this service experience excellent quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is decorated and furnished to a very good standard and facilities are accessible and clean. This ensures that service users live in a safe, pleasant, homely and comfortable environment. EVIDENCE: This is an ‘existing care home’ and is therefore not required by regulations to meet current environmental standards. Some rooms are therefore less than 12 square metres and few have ensuite toilets. Nevertheless it is a well maintained property and residents find it a comfortable place to live in. Communal areas and some service users bedrooms were viewed and these were in good decorative order. The Manager said that there are no outstanding Requirements following environmental health and fire inspections and there have been no substantive changes to the premises, other than refurbishment of room, since the previous inspection by the Commission. Closed-circuit television cameras are used in some areas of the home, but not areas used by service users. Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 16 The home has been assessed by an Occupational Therapist and there are a number of environmental aids and adaptation that are designed to promote the independence of service users. Hoists and assisted baths are available throughout the home and there were certificates detailing that these had been serviced on a regular basis. Staff members receive training in moving and handling and in the use of hoists. There are grab rails in toilets and bathrooms and in corridors. There is a passenger lift to all floors, which periodically safety tested. Call bells were available in bedrooms. There was good lighting and the home was warm and well ventilated. Windows on the first floor had restrictors and the. There is emergency lighting throughout the home and records detailing that this has been checked for safety. All sinks in communal toilets, bathrooms and service users’ bedrooms are fitted with a thermostatic value to prevent the risk of scalding. We noted that two windows on a landing were without restrictors and although not easily accessible to residents the Manager arranged for restrictors to be fitted whilst we were on the premises - again this shows the pro-active manner in which Southborough is managed, with safety uppermost in the Manager’s mind. Water temperatures we checked were at a safe temperature. The home has a risk assessment in place in relation to the risk of Legionellosis and the whole water system has been checked to ensure compliance with the Water Regulations. Water temperatures, along with many other routine safety checks such as fire doors, are being checked in rotation on a weekly basis as required. The home was clean and hygienic; cleaning staff were on duty throughout the day and they are commended for keeping the home odour free. Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 17 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): NMS 27 to 30: People using this service experience good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff recruitment, the number of staff employed and their skill mix are appropriate to the assessed needs of the current service users in this home – so this will ensure that their needs are being met. EVIDENCE: To evaluate this staffing we interviewed a range of staff including, the Manager, nurses, carers and ancillary staff. In addition to this head-office staff, now based in new building adjacent to Southborough, were most helpful in making staff files and other records available for inspection and the training officer was also briefly available to confirm the training arrangements for the home. The Manager stated and office staff confirmed that all staff have a police check [a CRB] in place and no staff are being employed without such checks in place as required by regulation. Staff recruitment is very thorough so all staff are checked and assessed prior to employment including reference checks, nursing qualification checks (P.I.N. checks), health checks, work permits and so forth are confirmed to be in place. Induction and on going training is in place for all grades of staff. The staff interview were well informed about the duties. The residents and their visitors thought the staff were kind and caring people and were complimented in many ways; for example, “Thank you for the excellent care, your kindness and warmth” and “Mum felt safe here and regarded Southborough as her ‘home’”. One criticism made by residents about staff, who were otherwise commended for their kindness, was the matter of their sometimes poor English language skills and the home’s AQAA shows that the majority of staff do not share a common culture and background with residents. Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 18 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): NMS 31, 33, 35, 37 and 38: People using this service experience excellent quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be assured that Southborough is well managed, staff receive good guidance and leadership and the management team are running this service so as to serve the best interests of the residents. EVIDENCE: The registered manager, Mrs Kathy Litster has the qualifications and experience needed, she is highly competent to run the home and meet its stated aims and objectives and has been registered by the Commission as a person ‘fit’ to run this home. The manager is able to describe a clear vision of the home based on the organisation’s values and corporate priorities and this is reflected in the new Statement of Purpose. The manager communicates a clear sense of direction, constantly strives to achieve ‘best practice’ particularly in relation to continuous improvement in customer satisfaction. Equality and diversity, human rights and person centred thinking are given priority by the manager and the way the home is run shows an understanding Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 19 of people’s needs in respect of the six strands of diversity: gender, age, sexual orientation, race, religion or belief, and disability. The manager is able to demonstrate through formal qualification, robust operational systems and or professional experience and ability that they are knowledgeable and highly competent in a range of areas. These can include service-specific good practice areas, understanding current legislation and proposed developments, and the importance and purpose of having effective quality assurance systems and in this the manager is supported by a management and administrative team who all exude the same enthusiasm and regard for the residents. The manager should at all times provide an excellent role model for other employees and this appears to be the case. Other professionals see the manager as an imaginative and effective leader who consistently provides high quality services and this is reflected in the feedback we get. Staff practice and performance is being discussed during supervision, staff training and team meetings and we have spoken to staff and checked records to confirm this. Spot checks and quality monitoring systems provide management evidence that practice reflects the home’s and organisation’s policies and procedures. The company’s Responsible Individual [RI] plays an important role here in visiting all home in the company regularly to monitor services on behalf of the owners. There is strong evidence that the ethos of the home is open and transparent. The views of both residents and staff are listened to, and valued. The AQAA, Annual Quality Assurance Assessment forms we ask for each year, contains detailed information as required. It includes a high level of understanding about the importance of equality and diversity and a wide range of evidence showing how they have listened to residents. The home has efficient systems to ensure effective safeguarding and management of residents’ money and valuables, including record keeping. Residents are supported to manage their own money where possible. They have access to their records whenever they wish. Record keeping is of a consistently high standard. Records are kept securely and staff are aware of the requirements of the Data Protection Act. Residents can gain access to their records and contribute to them. They are always told when a significant new entry has been made and what it says. All the working practices in the home are safe and there are no preventable accidents, or there are clear trends indicating a steady reduction in the number of preventable accidents, evidenced by good monitoring and record keeping systems. The home has a comprehensive range of policies and procedures to promote and protect residents’ and employees’ health and safety. Staff are trained, understand, and consistently follow these. There is full and clearly written recording of all safety checks and accidents, and there is no evidence of a failure to comply with statutory reporting requirements and other relevant legislation. The home proactively monitors its health and safety performance and this again is monitored by the Responsible Individual [RI]. Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 20 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: Excellent Standard No Score 1 2 3 4 5 6 ENVIRONMENT: good Standard No Score 19 20 21 22 23 24 25 26 4 X 4 X X N/A HEALTH AND PERSONAL CARE: Excellent Standard No Score 7 3 8 4 9 3 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES: Excellent Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION: Good Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING: Excellent Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION: Excellent Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X 4 4 Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 21 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 OP18 Regulation 13(6) Requirement Protection: must receive regular refresher training in the policies and procedures, including the whistle-blowing procedures so as to ensure residents are protected from abuse. 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. Refer to Standard Good Practice Recommendations Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Southborough Nursing Home DS0000026258.V372077.R01.S.doc Version 5.2 Page 23 - 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. 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