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Inspection on 20/07/06 for Astley Hall Nursing Home

Also see our care home review for Astley Hall Nursing Home for more information

This inspection was carried out on 20th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a clean well-maintained environment for the residents with pleasant personalised bedrooms. It is situated in superb grounds and countryside. The staff are courteous and well trained. They relate well to the residents in a kindly and encouraging manner. Residents` personal and health needs are well attended to and a programme of activities and stimulation is under review. The management is stable and well organised. Relatives and residents comment favourably on the standard of care provided/received and the kindness of the staff.

What has improved since the last inspection?

The tasks set following the last inspection had all been carried out. An activities programme had been developed and was now under review to ensure the variety of events provided continued to be suitable and interesting to the residents. Care records were well maintained and reviewed so that staff had guidance and information to enable them to provide the care residents needed. The lounge and dining area upstairs, corridors and many bedrooms had been redecorated and a rolling programme of redecoration continued in progress.

What the care home could do better:

More detail should be available to staff so that they are able to support the residents with their religious needs. It is acknowledged that end of life care is a sensitive subject. However staff need to know the wishes of the residents and their families at this important time in order to be able to help effectively and therefore need to continuously seek their co-operation in supplying the information. The recruitment procedure must always be followed in full so that residents are protected from the appointment of unsuitable people. The laundry is in need of modernisation. In the interim the floor must be repaired to ensure all possible measures are being taken to address infection control risks and a risk assessment must be drawn up and complied with so that staff carry loads up and down to the laundry in safety. The frequency of Fire Safety Training must be increased in line with the guidance given by the Hereford and Worcester Fire Authority to ensure staff are able to protect the people in the home.

CARE HOMES FOR OLDER PEOPLE Astley Hall Nursing Home Astley Hall Off Dunley Road Astley Stourport-on-Severn Worcestershire DY13 ORW Lead Inspector Mrs Yvonne South Unannounced Inspection 20th July 2006 08:45 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 Astley Hall Nursing Home DS0000004094.V298759.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. Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Astley Hall Nursing Home Address Astley Hall Off Dunley Road Astley Stourport-on-Severn Worcestershire DY13 ORW 01299 827020 F/P 01299 827020 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) Mr Jayantilal James Bhikhabhal Patel Mrs Kakash Jayantium Patel Mrs Carol Wallington Care Home 48 Category(ies) of Dementia - over 65 years of age (29), Old age, registration, with number not falling within any other category (48), of places Physical disability over 65 years of age (48) Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The Home may also accommodate a maximum of two people with a physical disability whose age is between 50 and 65 years. A registered nurse participates in the English National Board (ENB) N 11 Course for care of people suffering from dementia. Care staff attending an external course designated in providing training in the care of service users. 13th October 2005 Date of last inspection Brief Description of the Service: Astley Hall Nursing Home, Church Lane, Astley, is a three storey; Grade II listed building, set in 20 acres of parkland and situated two miles outside Stourport-on-Severn. Astley village is a short, travelling distance away. Astley Hall is registered to accommodate up to 48 residents’ who require nursing and/or personal care needs relating to old age and physical disabilities. A maximum of 29 residents of the 48 may have dementia illnesses and 2 people with a physical disablity may be between 50 and 65 years of age. Categories 2 and 3 recorded above will be removed as the staff now have the relevant training. Accommodation is provided on all three floors of the home, and access to all floors is gained via stairs or a central passenger lift. Mr and Mrs Patel are the owners. The manager is Mrs Carol Wallington. On 10.08.06 the manager stated that the current scale of charges were £386 to £535. Additional charges were made for hairdressing, personal toiletries and newspapers where applicable. Information regarding the home was available from the reception area in the Statement of Purpose, the Service Users’ Guide and the most recent Inspection report. Copies of these documents were given to each new resident or their relatives. Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection incorporates information received by the Commission for Social care Inspection since 13.10.05 and the information obtained during fieldwork on 20.07.06. The fieldwork visit extended over eight and a half hours during which the inspector spoke to four residents, four staff, a relative and the manager. A tour of the premises was undertaken. Questionnaires were sent to the residents, relatives and health care professionals by the Commission for Social care Inspection and to date eight responses have been received. Phone conversations were held with two relatives. The focus of this inspection was on the key National Minimum Standards and the requirements and recommendation that arose out of the previous inspection. What the service does well: The home provides a clean well-maintained environment for the residents with pleasant personalised bedrooms. It is situated in superb grounds and countryside. The staff are courteous and well trained. They relate well to the residents in a kindly and encouraging manner. Residents’ personal and health needs are well attended to and a programme of activities and stimulation is under review. The management is stable and well organised. Relatives and residents comment favourably on the standard of care provided/received and the kindness of the staff. Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Astley Hall Nursing Home DS0000004094.V298759.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 Astley Hall Nursing Home DS0000004094.V298759.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives have access to the information they need about the home to enable them to make a decision regarding future accommodation and care. Everyone is assessed before admission to ensure the home is able to provide the care they need. EVIDENCE: Two residents were able to confirm that they had been visited prior to admission and their needs had been assessed. They also said that they had received all the information they needed regarding the home and were delighted with their choice. This was endorsed by two relatives. Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 9 Care documents contained detailed pre-admission assessments and initial care plans. Equality and diversity was monitored on admission records and entries made regarding race, gender, age and religion. Copies of the Statement of Purpose and Service Users’ Guide were provided to all new residents and/or their relatives and contracts were provided. This was confirmed by the administrator and a relative. Astley Hall Nursing Home DS0000004094.V298759.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have access to the information they require in order to provide individual personal and health care. Medication is well managed so that residents receive their prescribed medication safely. EVIDENCE: An assessment was made of four care plans that were detailed and informative. They provided the information necessary to advise and guide staff in their duties. Plans were reviewed monthly or more often when necessary. Some dates had been omitted and more care needed to be taken to ensure all documents were clearly dated when drawn up. Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 11 More detail was needed regarding the residents’ wishes concerning their religion and end of life care. Daily records indicated that the care needs were being met and this was agreed by residents and relatives. Staff were described as; ‘very good and kind, nothing is too much trouble’. One person credited the good care as the reason for her mother’s improvement and survival. Communication with family members was reported as very good and much appreciated. Notifications made in accordance with regulations, daily records, residents and relatives indicated that the home responded appropriately to health matters. Medication storage and documentation was assessed and considered to be acceptable. There were two medication trolleys, a stock cupboard and a cupboard for controlled drugs. There was also a medication refrigerator that was lockable and the temperature had been regularly monitored. All storage was clean and tidy. Key security was good. Records were generally well maintained. Four Medication Administration Sheets (MAR) were assessed. A few handwritten entries on the administration sheets had not been double signed and a few administration squares had not been filled in. One medication dose was unspecified. Astley Hall Nursing Home DS0000004094.V298759.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 at least once during a 12 month period. 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. Residents are able to follow the routines they prefer within their abilities and health needs. Their wishes and choices are respected and they have access and opportunities to participate in group and one to one activities if they wish. Relatives are welcome and supported. A varied menu is provided and residents are able to make choices for each meal, which they enjoy. EVIDENCE: Many of the residents were severely impaired and communication was limited. However staff were observed treating them with respect and kindness. Bedroom doors were knocked on before entry, privacy curtains were hung in double rooms, post was delivered un-opened or held for relatives. Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 13 The manager said, and it was observed, that some residents had private phones in their bedrooms and staff confirmed that arrangements were made for others to take calls in private when they were received. Bedrooms were fitted with approved door locks that enabled residents to lock their door without becoming trapped. Staff confirmed that keys were available for those who wanted them and were able to use them. One resident had broken his door lock. The pieces had been removed for safety. En-suite facilities had not been fitted with door locks. It was suggested that this be addressed when the rooms were next refurbished if suitable/safe for the room occupant. The two residents who spoke to the inspector in some detail said that the staff were kind, helpful and very very good. A relative who was visiting endorsed this. She commented that the home had done wonders for her mother. The two residents said that they preferred their own company and so spent most of their time in their bedrooms. They had patio doors onto the garden and were able to enjoy the views. One person had his own potted garden that he attended. In addition people enjoyed reading and watching the television. An activities organiser was employed and the current programme was being reviewed. Staff said that a range including bingo, arts and crafts, nail care, memory lane, flower arranging, dominos, music and movement, sing songs and keep fit, skittles, pet therapy and entertainers had all been provided. During the inspector’s visit residents were heard to be singing along with the music during the afternoon. Some of the more able residents were able to go out with relatives and the home had a minibus and was able to undertake outings on occasions. The manager said that religious needs were respected and the local priest was a regular visitor to one resident. None of the residents were from other countries and everyone spoke/understood English. The visitors’ book indicated a steady flow of people had come to the home during the day and the care records indicated that families were involved and kept informed of matters that concerned their relative (with their consent). This was confirmed by the relatives who spoke to the inspector. Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 14 Meals were served in bedrooms when this was requested/preferred. Residents said that the food was good and the choice was excellent. Relatives said that presentation was good and time and trouble was taken with people who frequently changed their minds. Staff confirmed that individual wishes were met whenever possible. Staff were observed to be sitting with residents assisting them to eat their lunch appropriately. Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Information is available and people confidently raise issues that concern them and are sure they will be addressed. Staff are now suitably recruited, trained and retained so that vulnerable people are protected. EVIDENCE: The complaint procedure was contained in the Statement of Purpose/Service Users’ Guide and every new resident received a copy. The complaint record indicated that complaints had been appropriately investigated and responded to The manager said that most issues were addressed and resolved before they became complaints. Those recorded were the formal complaints. Two had been received since the previous inspection. They concerned staff and were founded. Two had been brought to the attention of the Commission of the Social Care Inspection. Both had concerned care and were unfounded. Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 16 Records showed that checks undertaken by the Criminal Records Bureau (CRB) were being undertaken after employment not before. This had now been corrected and the manager said that all new staff would be checked before they started work. It is acknowledged that the delay can often result in the loss of promising people and formerly people had always worked in the home under supervision. However if the staffing situation warrants it, new people can commence work provided a check has been made of the Protection of Vulnerable Adults list (POVA First) and the person works under supervision until acceptable results are received of the full Criminal Records Bureau and POVA checks. The two staff records assessed only had one reference each although notes indicated two had been sent for in both cases. Staff and their training records indicated that training had been received regarding the Protection of Vulnerable Adults and the manager confirmed that unsuitable staff did not continue to work in the home. Five people had been dismissed since the last inspection for various reasons. Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. 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. The residents live in a comfortable home that is continuously maintained decorated and furnished to meet their requirements. Measures are taken to control and reduce the risks of cross infection however the location and environment provided for the laundry poses risks to the staff regarding moving and handling and working conditions. EVIDENCE: A partial tour of the building was undertaken. It was observed that the lounge and dining area on the top floor had been attractively re-decorated. One corridor area was in the process of redecoration. Approximately eleven bedrooms, several corridors, a bathroom and a training room had been redecorated since October last year. Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 18 The manager said that there was a continuous rolling programme of redecoration and refurbishment. There were some minor repairs that required attention and the manager made a note of those that were identified. Residents’ bedrooms were personalised according to taste and needs. Those seen were comfortable and attractive. One room needed re-decorating but would have been improved in the interim if the ‘blue tack’ had been removed from the walls when not in use. Many of the bedrooms in one area had door gates. This enabled the residents to have their doors open but not be disturbed by other residents wandering in. The manager was aware that this was not ideal but failing a better idea this did serve the purpose. The manager said that care was taken that residents who wished to go in and out of their own room were able to do so. The home was clean and free from offensive odours. Communal bathrooms and toilets were equipped with liquid soap and disposable towels. Staff had access to and were seen to be using personal protective equipment. Clinical waste bins were available. Staff confirmed that they had received training in Infection Control and the records endorsed this. The laundry was small for a home of this size and access was via a flight of stairs. This could have health and safety implications for staff carrying loads of linen. It was observed that linen was moved around the home in lidded wheeled bins and the staff then made frequent trips up and down the stairs carrying loads they could safely manage. The laundry was well equipped with suitable machines but the floor was damaged and the room disorganised and difficult to keep clean and tidy. Consideration should be given as to how this essential facility can be improved. In the meantime the floor must be repaired and risk assessments must be drawn up for the conveying of loads up and down the stairs. Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The recruitment and checking process has been improved to protect the vulnerable people who live in the home. The commitment to training ensures staff have the knowledge and skills they need to care for the people who live in the home. EVIDENCE: The pre-inspection questionnaire indicated that the calculation made of staffing needs did not meet those available. However the manager explained that the shortfall was made up by bank and agency staff. The number of agency staff used had recently decreased drastically as staff had returned from sick leave. Care staffing levels were maintained at 1:3 until 4pm, 1:5 between 4pm and 8pm and 1:9 at night. In addition to care staff there was always a trained nurse on each floor and during the day the manager was on duty as well. At night there was always another nurse on call. Currently these levels met the needs of the residents. Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 20 There was an acceptable skill mix of staff employed. Several people came from other countries. Those the inspector met spoke good English and their kindness and care was commented on by a relative. The administrator said that although there were currently no specific vacancies the manager was always alert for suitable care assistants. Two staff records were assessed. They demonstrated a strong commitment to training and the staff interviewed confirmed this. Eight people were qualified to NVQ level 2 in care. Five people were qualified to level 3 and two people were qualified to level 4. A further five people had just commenced the NVQ level two course. In addition staff undertook the range of mandatory courses, and others that were relevant to their work. Some training was undertaken in-house and some provided by external trainers. Since the fieldwork the manager has informed the CSCI that training was already in place towards all trained nurses undertaking a course in ‘End of Life Care’. The records contained only one reference (although two had been requested as required), and evidence that the candidate had commenced work before clearance had been received from the Criminal Records Bureau regarding their records and the Protection of Vulnerable Adults List. The manager was aware of this and the matter had been acceptably addressed. Staff who were interviewed said that they received supervision and underwent an annual appraisal. Records were maintained and these were in their files. Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The limited quality assurance system does not readily identify areas of the service that can be strengthened and developed. The personal monies held in safekeeping are managed in the best interests or the residents. However protection can be further enhanced by the provision of signed records indicating receipt of income. The management of the home ensures the residents receive the care they need and the home is well maintained and managed in a safe manner. However the safety of people working in the laundry needs to be addressed. General maintenance and servicing supports health and safety but staff receive insufficient updates of training to maintain a continuous awareness of fire safety. Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager of the home is well trained and has many years of management experience. The staff considered her to be ‘fine, helpful, approachable, good. A person who helped others to move forward’. A limited quality assurance system was in use in that regular audits were undertaken of infection control, laundry, risk assessment and the kitchen. The manager was about to undertake training on a new system and intended assessing its suitability for the home. Questionnaires were sent out by the home to relatives and health care professionals and given to those residents who were able to participate. However this was last done in 2004. The questionnaires supplied by and returned to the Commission for Social Care Inspection from health care professionals all held positive answers and comments. The owner of the home visited every week. However up to date reports were not available as required by regulations. Copies of these should be provided to the manager each month and be available to the Commission for Social Care inspection. Some money was held for residents in safekeeping and used to pay for such expenses are hairdressing and toiletries. Secure storage was available and records were maintained. The record system needed to be developed to include the source of incoming monies and signatures. Two residents had independent advocates who supported them with their finances. The manuals of policies and procedures were available to staff and it was demonstrated that they knew where they were and what was in them. Information was available regarding the protection of vulnerable adults and equality, diversity and equal opportunities. The pre-inspection questionnaire indicated that equipment and services were being appropriately checked and serviced. Certificates were seen for pest control, lift servicing, electrical installation and tests. The Fire Safety Checks were being appropriately undertaken and a Fire safety Risk Assessment was available. Staff training in Fire Safety was being undertaken on induction and yearly, and drills were being conducted. Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 23 However the Hereford and Worcester Fire Safety Authority recommends that fire safety training be undertaken with every member of staff every three months and participation in a minimum of one drill a year. The manager was given some guidance documents and an example of a monitoring document. Since the field work the CSCI had been informed that the relevant training is now on place. It was seen that a health and safety audit had been carried out and the accident book was well maintained. A risk assessment manual was available for the premises and it had been reviewed this year. Astley Hall Nursing Home DS0000004094.V298759.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 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 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 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 X X 2 Astley Hall Nursing Home DS0000004094.V298759.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 OP26 Regulation 13 Requirement Laundry floor finishes must be impermeable and these and the wall finishes must be readily cleanable. There must be continuous selfmonitoring, using an objective, consistently obtained and reviewed and verifiable method (preferably a professionally recognised quality assurance system) involving residents, and an internal audit must take place at least annually. Timescale for action 01/11/06 2 OP33 24 01/02/07 Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP11 Good Practice Recommendations More information should be available regarding residents’ religious needs and wishes regarding end of life care. Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: 0845 015 0120 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 Astley Hall Nursing Home DS0000004094.V298759.R01.S.doc Version 5.2 Page 28 - 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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