Inspection on 11/05/07 for Boarbank Hall Nursing Home

This inspection was carried out on 11th May 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.

Other inspections for this house

Boarbank Hall Nursing Home 21/12/05

Boarbank Hall Nursing Home 21/09/05

Boarbank Hall Nursing Home 14/01/05

Boarbank Hall Nursing Home 07/07/04

Boarbank Hall Nursing Home 13/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Boarbank Hall Nursing Home Allithwaite Grange Over Sands Cumbria LA11 7NH Lead Inspector Marian Whittam Unannounced Inspection 11th May 2007 09:20 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 Boarbank Hall Nursing Home DS0000006136.V333563.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. Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Boarbank Hall Nursing Home Address Allithwaite Grange Over Sands Cumbria LA11 7NH 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) 015395 32288 015395 32288 The Canonesses of Saint Augustine Sister Eileen Anne Pollard Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27), Physical disability (4), Terminally ill (4) of places Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st December 2005 Brief Description of the Service: Boarbank Hall Nursing Home is owned and managed by the Augustinian Canonesses of the Mercy of Jesus, a Catholic Religious Order dedicated to caring for others. They provide long term and respite care for up to 27 residents including terminal care and convalescent nursing care. Boarbank is located at the edge the Lakeland village of Allithwaite, facing south and overlooking Humphrey Head and Morecambe Bay. The home is a short distance from the village of Allithwaite and its amenities, such as the public house, bus routes into Grange and the local post office/shop. Alongside the nursing home is the Sister’s own religious community, a guest house and a Chapel. Relatives and carers can stay in the community’s guesthouse and use their amenities. Accommodation in the home is on two floors and there are two passenger lifts and the home has a fully equipped physiotherapy suite on site. The home has large gardens with a terraced area that is accessible to wheelchair users and has a children’s play area in the grounds. The home also has its own kitchen gardens and grows some of its own vegetables for use in the home. There is ample car parking space at the rear and side of the home. The fees charged by the home range from £500.00 to £510.00 per week for an en suite room as at the date of the inspection. Information about the home, its facilities and the range of services on offer are found in the Statement of Purpose and service user guide which are available in the home. An additional charge is made for a private telephone, personal toiletries, newspapers, magazines, hairdressing, and chiropody. There is also a charge of £2.50 a week for personal laundry. Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit, which forms part of the annual key inspection, took place over seven hours. Pre- inspection information on residents, fees, staffing and services provided by the home, requested in advance by CSCI, was returned before the visit. Time was spent looking around the home talking with residents in their bedrooms and lounges. Several people living in the home, both permanent and respite were happy to talk about their experiences of living in the home. The manager was spoken with at length and also members of nursing staff. Care plans, assessments and policies and procedures were also examined. An inspection of medication handling and records was carried out during this visit. What the service does well: Boarbank Hall provides a safe and comfortable environment in a building suited for it’s stated purpose. People living there commented on how peaceful and calm the home is and that they were never rushed or pushed into doing anything. More than one resident commented on the “feeling of belonging and” and the cheerfulness and kindness of the staff. The home is comfortable, well furnished, well maintained and has a very homely, relaxed atmosphere for the people living there and their visitors. The people living there benefit from the well trained, experienced and stable staff team who, together with the manager and other members of the senior team, deliver an extremely high standard of care. The manager and staff take great care to maintain a high nurse/carer to resident ratio so that standards of care remain high and staff can spend as much time with residents as they need to. There is a very good social programme that includes activities in the community that help people keep up their friendships and outside contacts. In house activities and outings are also provided. The home takes care to make sure that resident’s particular religious needs are catered for including multi denominational services. The standard of catering and choice of food is appreciated by the people living at Boarbank. Different dietary needs are well catered for with a balanced and varied selection of good quality food and home cooked meals. The Provider and manager promote a supportive, learning culture evident in the support given to staff in their work or when dealing with terminal care and Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 6 those with family commitments. Staff working in the home said they felt they had the time and resources to give a high standard of care to the residents and so had a high level of job satisfaction. What has improved since the last inspection? What they could do better: There were no requirements or recommendations made at this inspection and the provider, registered manager and staff continue to review the services the home has to offer in order to ensure a very high standard of care is provided for those living in the home. Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 7 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. Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 1, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an admission procedure that ensures a full assessment of needs is completed prior to admission. Information provided about the home ensures all that use the service know the home can meet their needs EVIDENCE: Clear and comprehensive information is available about the home for prospective residents and their families in the statement of purpose and service users guide. Both of these documents have recently been updated and can be provided in different formats, as people’s needs dictate. This documentation ensures all interested parties know what the home can provide for them including clear environmental information. The registered manager assesses all new residents prior to their admission and this is used as a basis for the plan of care. Information is gathered from other professionals and care settings to get a full picture of people’s needs before they come in. Where appropriate other care agencies and professionals Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 10 including the local palliative care team are involved in advising and making assessments of the individual needs to be met. It is the policy of the home that respite residents are assessed with regard to the current workload of staff and the level of existing resident dependency. This is good practice as it prevents the existing good nurse/ carer to resident ratio being affected. Prospective residents and their families are invited and encouraged to visit the home and many people get to know the home by regular respite visits before they make the decision to go there permanently One person staying for respite care said they had been coming back for 4 years and always looked forward to coming to stay for 2 weeks. A resident who comes to the home for respite care said how welcome they felt and that staff made you feel “like one of the family straight away”. The home, although run by a community of Catholic Sisters, has residents from different faiths and care plans show that different social, cultural and religious needs are assessed and planned for individually. Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7, 8, 9, 10 and 11 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The care planning records and assessments provide staff with the information they need to meet resident’s healthcare, personal and social care needs. The systems for the administration of medicines promote safe practice for the people living in the home. EVIDENCE: All people living in the home have a clear and easily followed individual plan of care, based on their initial individual assessment. Each plan is based on core care planning and sets out the health, personal and social care needs of the residents. Relevant and clear risk assessments are in place and reviewed to make sure they reflect the individuals needs. Much work has been done on the plans to make sure that they also allow them to be personalised. Nursing staff spoken with during the visit were very clear about the need to make care planning person centred and how they worked to achieve this. Some staff are involved in helping people living there with their own personal profiles, to give Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 12 greater insight into the individual and their aspirations. This level of information ensures staff are aware of the individual needs and personal preferences of people living in the home. The home anticipates and respects the needs of people from different cultures and has provided translation for a person in the home who had problems communicating in English. The nursing staff review all care plans monthly and many aspects of care, such as pain relief and wound management, are evaluated at each shift and any identified changes are acted upon and updated in the plans. There was evidence of prompt referral to health services and support agencies such as intermediate care teams and effective working with such agencies. Doctors from the local surgeries visit the home every week in order to monitor the healthcare needs of the people living in the home. There is also a physiotherapy department seeing people who live there two days a week free of charge. A spot check was made of the medicines storage, handling and records and showed evidence of a very well organised system. There was evidence of good practice with regards to the receipt and disposal of medication and controlled drugs are handled and recorded in a safe and appropriate manner. All medication records were correctly completed and these together with the medicines held are checked on a regular basis. A risk assessment for those wanting to keep and take their own medicines has been developed. This can help people keep their independence with medicines if they want to. There are policies and procedures on caring for the dying and providing physical, spiritual and emotional support. The manager has specialist nursing qualifications in Palliative care and one of the registered nurses has a particular interest in palliative care, and symptom control. They act as a link nurse and attend the appropriate training courses to develop this including counselling skills. The home has a guesthouse attached and visitors and families of the people living or staying in the home can also stay there and be close by if needed. Observations during the visit showed that staff treated the residents with care and consideration and personal dignity is being maintained. Staff were observed spending time with residents chatting with them and reassuring them if needed. Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 13 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, 13, 14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home are able to make choices about their life style and social and cultural needs to retain their independence for as long as they can. EVIDENCE: The home promotes the individual resident’s right to live a life that is fulfilling and meaningful. Residents have a choice of activities that are varied and stimulating. Regular outings are arranged in the homes minibus on a daily basis and staff also take residents out for walks in the large gardens. People staying in the home did comment on the peaceful and quiet surroundings and on the birdlife they enjoyed watching from their room. Additionally there are varied activities people can make use of if they wish, concerts by local groups and amateur dramatics, craft and cookery sessions or just following individual interests, reading, listening to music in their rooms. Resident’s hobbies and interests are recorded and individual interests and capabilities are given consideration in planning and carrying out the activities. The home makes good provision for the religious and cultural preferences of residents, including monthly Anglican Communion that also involves the local Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 14 community. All the local ministers of various denominations will visit if asked or arrangements can be made to visit people’s own church. The home has its own Roman Catholic chaplain who is available for support and general chat with anyone that wants it. There are several private, quiet rooms and chapels where people of any faith may go for prayer or reflection. The main chapel has a loop system and is also used for concerts and people living in the home commented on the beauty and tranquillity of the main church. Residents said that they could come and go as they please, take their meals where they preferred and see whom they want to. Meals are prepared in the main kitchen, some of which is grown in the homes own gardens and greenhouses. It is transported around the home in heated trolleys to keep the food hot. All of the people living in the home who spoke with the inspector thought the quality and variety of the food provided was “excellent” and one said that “ the meals are so good, lovely home made cakes and biscuits” and another that, “you just ask for what you want and get it”. Resident’s comments emphasised that they have a choice of food at all of their meals and drinks and snacks when they want them. All agreed there was a choice of food each day and that there was plenty of it. One person joked,” is overfeeding abuse?” Special diets, including diabetic and vegetarian are available when required. There is also a small shop that carries toiletries, sweets, cards and small daily items and provides a place where people stop and chat. It was noticeable during the visit that the atmosphere in the home was warm friendly and open with lots of chitchat and social banter. Boarbank Hall Nursing Home DS0000006136.V333563.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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16, 17 and 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home are able to express their concerns through an effective and accessible complaints procedure and are safeguarded by an efficient adult protection procedure. EVIDENCE: The home has a clear complaints procedure and logs complaints for investigation using a four stage process and the procedure is available to people living in the home. The complaints procedure is displayed in the home and information is in the statement purpose. All the people spoken to who lived in the home expressed confidence that the staff and manager would listen to them and deal with any complaints they made. One resident said that they had no complaints but they saw the manager everyday to talk to and all the staff asked if everything was all right and if there was anything they needed. Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 16 Residents spoken with felt confident that any complaints or issues they raised would be dealt with quickly. All the residents spoken with said that they had never had reason to complain. One resident said that, “If anyone grumbles in this place well they must be hard to please”. Matters raised by people living in the home are recorded in their plan as well, for example a comment about food and so it can be monitored. Records show that training on abuse and adult protection has been given to staff and the Cumbria multi agency guidance is available in the home. A member of nursing staff conducts training within the home on safeguarding adults following training from social services on this. The home has clear policies and procedures in place for adult protection; identifying and reporting abuse, POVA procedures and whistle blowing. There is also information on advocacy services and where to get help and support outside the home. Staff who spoke to the inspectors confirmed that training is given and are aware of what to do should abuse be suspected and expressed confidence in the manager to support them in raising any issues about care. There was one adult protection referral made that was fully investigated with social services using the homes procedures in line with multi agency guidance. This was completed and actions taken to change policies and procedures on accepting gifts and additional training where needed. Additionally the home reviewed all procedures around adult protection to ensure they offered full protection to people who use the service. Boarbank Hall Nursing Home DS0000006136.V333563.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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables the people living there to live in a safe, well-maintained and comfortable environment that encourages independence EVIDENCE: The home is well maintained, warm and comfortable with a staff team that encourages all residents to see the home as their own. Repair and maintenance is well planned and ensures the home remains attractive and safe for those living there. Three lounges and dining rooms provide communal areas that give ample space for enjoying organised activities and for sitting quietly reading or chatting with friends. The home has extensive and well-kept gardens, which provide an excellent amenity for the people living there and their visitors, including a playground for children. There are pleasant views from all bedrooms and those at the front of the building have spectacular views Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 18 across Morecambe Bay and Humphrey Head. Boarbank Hall has twenty five bedrooms for single occupation, fourteen of which have en-suite facilities. Two more en suite bathrooms have been created in bedrooms as well as refurbishment of bathrooms and bedrooms as part of the general maintenance. There is one double bedroom that allows a carer or relative to stay close at hand if needed. The people who are living there permanently have personalised their rooms with their own furniture, pictures and photographs brought from their own homes and some had brought soft furnishings as well. There is a range of moving and handling equipment, nursing beds, two passenger lifts and adaptations in the home to help residents make the most of their independence and to get about the home. Laundry facilities are provided and situated away from the main living and food preparation areas. One resident said that the laundry service was, “excellent” and returned quickly. All those living in the home who spoke with the inspector said how clean the home was and that their rooms were thoroughly cleaned each day. One person said “the cleaner was very good” and another commented that having worked in hospitals and homes themselves what they noticed immediately when they came in was “there is no smell here like you always get in homes, no bad smells either just flowers and cakes”. There is a range of equipment, nursing beds, two passenger lifts and adaptations in the home to help residents make the most of their independence and to get about the home. Boarbank Hall Nursing Home DS0000006136.V333563.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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The levels of skill and training for staff in the home and the robust recruitment procedures in operation mean the safety and wellbeing of people living in the home are promoted. EVIDENCE: The home had a stable staff group of registered nurses and carers providing continuity for residents and a high standard of care and support. Boarbank hall has a full recruitment and selection procedure overseen by the administrator and registered manager. The registered providers consider the recruitment of good quality staff as essential to the delivery of an excellent service. Staff working in the home said that they were well supported professionally and personally by the management team. Application forms are completed, all necessary references taken up and interviews arranged. All new staff have been appointed after all the required Criminal Record Bureau (CRB) and Protection of Vulnerable adults (POVA) checks have been completed. Nursing staff have their professional registration checked at recruitment and periodically thereafter. The staffing ratio is excellent, with the home maintaining good staffing levels. There is a good skill mix of qualified nurses and care staff and there are, Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 20 currently over 50 of the care staff trained to National Vocational Qualification (NVQ) levels 2 and 3. There is an ongoing staff training programme and training and development is given a high profile in the home with records of training completed and updates due. All mandatory training is up to date, including manual handling and risk assessment covering environmental issues. Training planned for the future includes the new mental capacity legislation. That will affect the interests of people living in the home. The nursing and care team are enthusiastic with individual areas of interest and expertise, including palliative care, counselling, wound care and care planning. They present as a highly motivated staff team that has the balance of skills and experience to meet the needs of people living in the home. Discussions with the staff evidenced that they all work as a team and support each other, although they are aware of their own roles and responsibilities. Boarbank Hall Nursing Home DS0000006136.V333563.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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 31, 32, 33, 35, 37 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed with procedures, systems and practices in place that promote the personal and financial interests of the people living there and their safety and well being. EVIDENCE: Residents spoken to said their views and opinions were asked for and acted upon to affect the way the service is run. This is usually done on a one to one basis or informally over meals when everyone is together. People living there say they see the manager most days and felt happy to raise issues with her. Those who chose to speak with the inspector confirmed that they felt involved in the life of the home, and that staff supported them in maintaining their Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 22 personal interests and recreational activities. One person said it was “like being in a family”. More than one person commented that staff and management were always available and listened to what they had to say. The registered manager has the required qualifications and experience, and is highly competent to run the home and ensure it meets its stated aims and objectives and promotes an open and supportive working environment, which staff and residents confirm. The best interests of the people living in the home are central to the way the home is run and staff and management have a clear vision of the future that is based on the home’s shared values and high standards. Staff in the home have regular staff meetings and have good access to training and said that it was a good working environment. Staff said that the manager and senior staff are approachable, helpful and support staff with family responsibilities in their working practices. Staff working in the home say they feel they had the time and resources to give a high standard of care to the people living there and so had a high level of job satisfaction. Records looked at that are required by regulation are up to date and in good order. Policies and procedures are reviewed and updated to improve practice where a need is identified. Records of maintenance indicated that the home had systems, training and practices to promote resident health and safety. There was evidence that appropriate testing and cleaning was being carried out and that the home did Legionella and water testing. There are working practices in place to minimise the risk of accidents and the home has a comprehensive range of policies and procedures in place to promote and protect residents and staff. All equipment is maintained under annual service agreements. Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 23 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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 8 9 10 11 3 3 3 3 3 3 3 3 3 3 3 4 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 X 3 3 Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 24 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. Refer to Standard Good Practice Recommendations Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 Boarbank Hall Nursing Home DS0000006136.V333563.R01.S.doc Version 5.2 Page 26 - 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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