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Inspection on 05/07/07 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 5th July 2007.

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 service provides a warm welcome for all visitors and attentive care for the people who live in the home. The care assistants, trained nurses and other health care professional attend to the health care needs of the residents and their personal needs. An activities organiser ensures that there are activities that provide stimulation and interest are arranged every day in which residents can choose to participate if they wish. Any needs relating to culture and faith are addressed. The staff are well recruited and receive training to provide the individual care needed and protect the residents. This elegant building provides a comfortable and interesting environment in which to live. Adaptations have been made and equipment provided to assist those who have needs in this area. The attractive garden is spacious and has superb views. Level paths are being laid to help improve access. The home is well managed and health and safety structures are in place to protect everyone in the home.

What has improved since the last inspection?

Since the last inspection repairs had been made to the laundry floor. Unfortunately these had failed and an alternative floor cover is now being tried to improve the protection from cross infection. A strong quality assurance system has been introduced and is assisting the home to discover areas of the service that can be improved and developed. A great effort had been made to obtain information regarding residents` end of life wishes. This enables the service to provide the individual care needed throughout the residents` stay.

What the care home could do better:

Residents, and /or if they wish their representatives should be given opportunities to be involved in the forming of their care plans so that they are happy and agree with the care they receive. More care needs to be taken in some areas of medication recording to ensure safety at all times.

CARE HOMES FOR OLDER PEOPLE Astley Hall Nursing Home Astley Hall Church Lane Astley Stourport-on-Severn Worcestershire DY13 0RW Lead Inspector Yvonne South Key Unannounced Inspection 5th July 2007 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.V339853.R02.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.V339853.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Astley Hall Nursing Home Address Astley Hall Church Lane Astley Stourport-on-Severn Worcestershire DY13 0RW 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 providing nursing 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.V339853.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home may also accommodate a maximum of three people with a physical disability whose age is between 50 and 65 years. 20th July 2006 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 disability may be between 50 and 65 years of age. 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 registered providers. The registered manager is Mrs Carol Wallington. The email address for the home is carisastley@aol.com On 05.07.07 the manager stated that the current scale of charges were between £1584 per month and £2200 per month. 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.V339853.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection that incorporated information received by the Commission for Social Care Inspection since the previous key inspection, which took place on 20.07.06 and the information obtained during fieldwork on 05.07.07. The fieldwork took place over eight and a half hours, during which the inspector spoke to residents and five staff. Documents were assessed and a partial tour of the premises was also undertaken. Prior to the fieldwork the home was sent a copy of the Annual Quality Assurance Assessment (AQAA) document by the Commission for Social Care Inspection (CSCI) to complete and return. Questionnaires were sent to fifteen residents, their representatives and their GPs seeking their views of the service provided. Eight responses were received from the residents, four from relatives and three from GPs. The focus of this inspection was on the key National Minimum Standards and requirements and recommendations that arose out of the previous inspections. As part of the fieldwork and to obtain a broad view of the care provided, the inspector assessed the care of three residents. One person was from another country, one person was an emergency admission and the third person had multiple nursing needs. What the service does well: The service provides a warm welcome for all visitors and attentive care for the people who live in the home. The care assistants, trained nurses and other health care professional attend to the health care needs of the residents and their personal needs. An activities organiser ensures that there are activities that provide stimulation and interest are arranged every day in which residents can choose to participate if they wish. Any needs relating to culture and faith are addressed. The staff are well recruited and receive training to provide the individual care needed and protect the residents. This elegant building provides a comfortable and interesting environment in which to live. Adaptations have been made and equipment provided to assist those who have needs in this area. Astley Hall Nursing Home DS0000004094.V339853.R02.S.doc Version 5.2 Page 6 The attractive garden is spacious and has superb views. Level paths are being laid to help improve access. The home is well managed and health and safety structures are in place to protect everyone in the home. 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. The summary of this inspection report can be made available in other formats on request. Astley Hall Nursing Home DS0000004094.V339853.R02.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.V339853.R02.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): 3 (Standard 6 was not assessed as the home does not provide this service.) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who are seeking a place in the home for themselves or a relative are provided with information and opportunities to visit and inquire about the service. A place is not offered unless an assessment has indicated that the necessary care can be provided. EVIDENCE: Information is readily available in the Statement of Purpose and Service Users’ Guide concerning the service. The manager, staff and relatives confirmed that opportunities are given to visit and look around the home and questions can be asked and answered. Astley Hall Nursing Home DS0000004094.V339853.R02.S.doc Version 5.2 Page 9 During the fieldwork the care of three residents was assessed in depth. It was observed that an assessment had been carried out by a competent person before a place was offered in the home. The information was of sufficient detail to enable an initial care plan to be drawn up to provide the staff with information and guidance explaining how it had been agreed the care needs would be met. Astley Hall Nursing Home DS0000004094.V339853.R02.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): 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. Residents receive the personal and health care they need. Their prescribed medication is administered and managed safely. The staff relate to them with respect for privacy and dignity. EVIDENCE: Three care records were assessed during the fieldwork. These were detailed and informative. Risk assessments had been undertaken and care plans had been drawn up. These had been regularly reviewed and updated when necessary. There was very little evidence that the residents or, with their consent, their representatives had been offered opportunities to be involved in the care planning process. Astley Hall Nursing Home DS0000004094.V339853.R02.S.doc Version 5.2 Page 11 The records indicated that wound care had been very well managed with excellent outcomes. Good links were maintained with other health care professionals such as doctors, nurses, chiropodists and opticians. Responses to the surveys from the Commission for Social Care Inspection had been received from three doctors and they all gave positive answers to the questions regarding the service that was being provided. Residents confirmed that they were well cared for. One resident said in the questionnaire response ‘Not often need medical support from doctors but staff get it sorted.’ A relative said ‘The patients’ welfare seems to be top priority’. Communication needs had been considered when a resident came from another country. Relatives said that they were kept well informed about events that concerned their ‘resident’. One questionnaire response said ‘I discuss any time I notice a change in my husband. It’s important to have peace of mind.’ Another said ‘If I have any queries I always go upstairs and speak to the people at the nurses station. I find them very helpful.’ Medication was generally well managed. Storage and security was acceptable. Some hand written amendments to the medication administration records had not been signed and some medication had not been recorded when checked in. Otherwise medication records were well maintained. It was observed that residents were related to kindly and with respect. If they wished to remain in their bedrooms with the door open so that they did not feel isolated, they were able to use a safety gate so that unwanted visitors (residents) did not intrude on them. Good detail had been obtained regarding individual resident’s wishes regarding end of life care and death especially in relation to their faith. Therefore the recommendation made in the previous report had been accepted. Astley Hall Nursing Home DS0000004094.V339853.R02.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): 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 make choices relating to matters that affect their daily lives. They enjoy receiving their visitors and links with faith groups are maintained according to the wishes of the people concerned. A choice of food is available that the residents enjoy and meets their needs. EVIDENCE: In the AQAA completed by the manager it was stated that the • Daily routines and activities were flexible and varied to suit the SU expectations, preferences and abilities. • Visitors were welcome at any reasonable time and may use the resident’s private room or the communal areas. • Meals and mealtimes were designed to meet the needs of each person. Since the last inspection activities had been allocated to and are being overseen by an experienced carer who has taken on the role of activities coordinator with enthusiasm. Astley Hall Nursing Home DS0000004094.V339853.R02.S.doc Version 5.2 Page 13 New entertainment within the home has been introduced including music therapy, which had proved highly rewarding and beneficial to the residents. It was planned to expand on this improvement with such occupations as gardening and art therapy. Menus were being evaluated and new recipes included. It was observed during the fieldwork that residents on one floor were entertained during the morning with music and singing and on the top floor during the afternoon a small group participated in a throwing game that exercised alertness and dexterity. The activities organiser maintained records that reflected the residents’ participation and an event was on offer every day. A resident commented in the questionnaire response that he/she enjoyed the singers best. A relative commented in a questionnaire response that there was a need for more activities and stimulation. Also that there was too much TV that only the carers watched. The manager said that the activities organizer generally worked Monday to Friday leaving weekends, commonly a restful time for most people and often the only time that some relatives and friends were able to visit, free for social occasions. There was an attractive garden that was being further developed to provide opportunities for activities and quiet enjoyment for the residents. It was observed that meals were well prepared according to the needs of the individual and the cook confirmed this. Lunch looked and smelt appetising and residents were enjoying what they had chosen. Choice was discussed with the manager in relation to those who had difficulty making a selection. The inspector was told that staff took advise from family members concerning likes and dislikes. To this they added their own observations of what the residents enjoyed. The questionnaire responses from residents indicated that they usually enjoyed the meals and one person commented that he/she liked to choose his/her own meals. It was observed that staff were helping the residents where necessary with their meals in a sensitive manner. Astley Hall Nursing Home DS0000004094.V339853.R02.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): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have the information they need to enable them to raise their concerns in confident expectation that they will receive an appropriate response. Staff are well recruited and trained so that the safety and welfare of the residents is safeguarded. EVIDENCE: The manager stated in the Annual Quality Assurance Assessment that all complaints were dealt with following the home’s procedure and the procedure was clearly identifiable and on view in the main entrance to the home. The importance of the residents’ rights and protection is addressed at all times and all staff were made aware of the protection of vulnerable adults thorough training. This was incorporated in induction training and updates. The complaint procedure was seen to be available in the Statement of Purpose and the Service Users’ Guide and it was observed that these were available in the residents’ bedrooms. Astley Hall Nursing Home DS0000004094.V339853.R02.S.doc Version 5.2 Page 15 Two complaints and a concern were received by the Commission for Social Care Inspection and these were passed to the registered provider to investigate. They had concerned matters relating to personal care practice, a lack of daily activities and risk assessments, and a relationship matter. Documentation demonstrated that thorough investigations had been carried out, all regulations had been met and action was being taken where necessary to improve the service. The records in the home indicated that no further complaints had been received by them since the last inspection. The inspector interviewed three members of staff and it was clear that they were aware how to respond if in receipt of a complaint and if they had concerns regarding the safety and welfare of a resident. The staff records demonstrated that an acceptable recruitment process had been used and appropriate checks had been made prior to a post being offered. Training records indicated that induction training had been undertaken and training was update at suitable intervals. Astley Hall Nursing Home DS0000004094.V339853.R02.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in clean, pleasant surroundings that suit their needs and wishes. Structures, training and systems are in place that protects the residents by managing the risks of cross infection. EVIDENCE: In the AQAA the manager said that a new laser beam curtain had been installed in place of the old lift door system and this had been a sound investment and improvement. In future it was planned that bathrooms on the middle floor would be refurbished, partial landscaping of the garden would be undertaken to improve the residents’ enjoyment of the views. Astley Hall Nursing Home DS0000004094.V339853.R02.S.doc Version 5.2 Page 17 Redecoration would continue, the purchase of new furniture was under consideration, and following feedback from relatives investigation of the need for a visitors room was to be undertaken. Funding was in place to provide an easy access garden room for the residents. A partial tour of the home and gardens was undertaken. It was observed that bedrooms were well decorated and personalised. Lounges and dining rooms were well furnished and a variety of seating was available to meet the individual needs of the residents. The décor on the middle floor was somewhat damaged due to heavy wear from the residents who lived there. However the manager said that this would soon be addressed through the ongoing programme. It was also said that a rolling programme to totally refurbish all the residents’ bedrooms in the home was planned. It was observed that the conditions in the laundry had not improved since the last inspection. The floor had been repaired as required but had since become worn again and difficult to keep clean. There was discussion relating to alternative floor coverings and the Commission for Social Care Inspection has since been informed that this work had been carried out. The space in the laundry remained cramped and access to the hand basin was obstructed. A risk assessment had been drawn up to address the carrying of loads up and down the stairs to the facilities. The residents’ questionnaires indicated that they thought the home was always fresh and clean and one person commented that she liked her bedroom kept tidy. Relatives stated that the home was ‘very clean’, ‘The dinning room looked homely.’ and ‘The home provided secure accommodation in pleasant grounds and surroundings.’ The grounds were attractive and well laid out for the use of the residents. Work was still in progress improving the view, the pathways and the flowerbeds. Raised beds and vegetable plots were being developed. Seating was available and bird feeders were hung to provide added interest and stimulation. The manager stated in the documentation that an infection control policy was in place and staff had received training. This was conformed by the staff and their records. It was observed that personal protective equipment was appropriately available and all communal facilities were equipped with liquid soap and disposable towels. Astley Hall Nursing Home DS0000004094.V339853.R02.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient staff who are well recruited and trained to provide the care the residents need and protect them from risks. EVIDENCE: In the AQAA the RM state that the Skills for Care web site was being used to update existing training manuals, there were appropriate staffing levels and a good skill mix. Discrepancies were efficiently addressed as needed. Recruitment and induction procedures were in place and there had been the introduction and implementation of Common Induction Standards (Skills for Care) for new recruits. National Vocational Qualification training was available and promoted. One of the Registered Nurses was working towards achieving the Registered Manager’s Award. It was observed from the data supplied that there was a good age range in the staff team and there were five male carers and thirty-five female carers. The residents’ records indicated where that person had a preference for a carer of the same gender and the team was able to meet this requirement and did so. Astley Hall Nursing Home DS0000004094.V339853.R02.S.doc Version 5.2 Page 19 All catering staff had relevant qualifications. The staff team were very diverse, including staff from England, Ireland, Holland, Poland Czechoslovakia, and India. The manager said that all except one person spoke good English and the one person was able to make himself understood. Several people were attending English classes at the local college and many were doing NVQ training. The need for preferred times off for religious services was addressed in the duty roster when required. There was no additional support needed relating to faith or culture. The majority of questionnaire responses were positive. A resident commented that ‘My contact with the staff has always been friendly and helpful’. Relatives said ‘Staff are always friendly and helpful.’ and ‘Very caring and helpful’. Only one negative comment was received from a relative that; ‘Some staff have very poor English, they don’t understand and can’t hold a conversation.’ He/she also believed that there was a high turnover of staff although the statistics for a home of this size did not support this view. The samples of duty rotas seen indicated that the home was staffed to meet the current needs of the residents and this was confirmed by the staff that spoke to the inspector. The manager said that there were currently no staff vacancies. Agency staff were only used as a last resort as the residents benefited from familiar staff that knew their needs and they were comfortable with. Although thirteen staff had left the home in the past twelve months all posts had been filled and the home retained a strong, sound core of staff. Data provided indicated that thirteen care staff had National Vocational Qualifications (NVQ) at levels 2 or 3. Two people were awaiting their certificates and five people were working towards NVQ level 2. Staff recruitment, work and training achievement records were well maintained. Astley Hall Nursing Home DS0000004094.V339853.R02.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is well managed so that the residents receive the care they need and the safety of those is the home is addressed. EVIDENCE: The registered provider and manager of the home remained unchanged. The manager had the relevant experience and qualifications for her role and managed the home efficiently and effectively. A requirement was made following the previous inspection that a quality assurance system should be implemented. This had been met. Astley Hall Nursing Home DS0000004094.V339853.R02.S.doc Version 5.2 Page 21 The Mulberry House quality assurance system was in use and an audit of the service was in progress. This system was comprehensive and thorough. Areas in need of improvement were attended to as they were identified. Good feedback had been received from the home’s questionnaire and the manager said that this had stimulated thought and actions for further improvements. A ‘comments’ file contained many appreciative letters from relatives and friends concerning the quality of care provided. These included; ‘appreciation of time and understanding’, ‘kindness and sympathetic professionalism’, ‘great dignity’, ‘enabling individuals their own personalities’, ‘never regret our decision to move into Astley Hall’. Personal monies held for residents in safekeeping and managed for residents were stored securely and records were well maintained. The AQAA stated that policies and procedures were reviewed this year. An estates manager maintained all maintenance records including fire precautions, health and safety and COSHH (Care of Substances Hazardous to Health). Systems and equipment were appropriately monitored and serviced. It was observed that the maintenance manual was well managed. Risk assessments relating to the service were well documented and had been recently reviewed. Fire safety systems were well maintained and monitored, and staff had received appropriate training. Staff and also received training in other relevant health and safety matters. This was confirmed by them and their records. Astley Hall Nursing Home DS0000004094.V339853.R02.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 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 Astley Hall Nursing Home DS0000004094.V339853.R02.S.doc Version 5.2 Page 23 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 OP9 Good Practice Recommendations Residents and/or with their consent their representatives should be given opportunities to be involved in the care planning process. A record should be made of all medication checked into the home and all handwritten amendment to the administration records should be checked and double signed to ensure accuracy and safety. Astley Hall Nursing Home DS0000004094.V339853.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Worcester Area Office The Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell, Worcester WR3 7NW 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 Astley Hall Nursing Home DS0000004094.V339853.R02.S.doc Version 5.2 Page 25 - 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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