Inspection on 16/05/07 for Carleen Nursing & Residential Care Home

This inspection was carried out on 16th 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

Carleen Nursing & Residential... 28/11/05

Carleen Nursing & Residential... 19/04/05

Carleen Nursing & Residential... 23/09/04

Carleen Nursing & Residential... 21/04/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Carleen Nursing & Residential Care Home 38 Portchester Road Fareham Hampshire PO16 8PT Lead Inspector Kathryn Kirk Unannounced Inspection 16th May 2007 10:30 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 Carleen Nursing & Residential Care Home DS0000011511.V336153.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. Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carleen Nursing & Residential Care Home Address 38 Portchester Road Fareham Hampshire PO16 8PT 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) (01329) 232418 01329 230310 info.carleen@tiscali.co.uk Serincourt Ltd Joyce Ann Dawson Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability (36), Physical disability of places over 65 years of age (36), Terminally ill (36), Terminally ill over 65 years of age (36) Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users in the TI and PD categories must be at least 50 years of age on admission. 28th November 2005 Date of last inspection Brief Description of the Service: Carleen Nursing and Residential Care Home is registered to provide nursing and personal care for 36 people, no more than nine of which may be service users requiring only personal care. Service users must be over the age of 50 years. The Home is also registered to admit people who are terminally ill or who have physical disabilities. Carleen is a large house that is in a residential area of Fareham and is close to local amenities. The home has a ground floor extension and provides accommodation over two floors, which are connected by a passenger lift. There are two sitting rooms and a dining room on the ground floor. The home has large, well-tended, front and rear gardens which are accessible to the residents and there is ample parking space for staff and visitors at the front of the building. Current fees range between £425 and £600 per week. Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Thirty two people were living at Carleen at the time of this inspection. Evidence was gathered for this report by making a visit to the home on 16 May 2007. During the visit, six service users and two visitors spoke about life in the home and commented on the quality of service provided. Other peoples’ needs were such that they were unable to contribute verbally and so time was spent observing how staff interacted with them. Other evidence was obtained through talking to the manger, some staff, by touring the building, and by looking at some paperwork in the home. Further evidence was gathered from written correspondence received by The Commission for Social Care Inspection, this includes a self-assessment of the service and written feedback from one person who lives at the service. The service has recently conducted its own quality audit by polling the views of 18 people who live at Carleen and their relatives and 14 visiting professionals. Reference will also be made to these findings in this report. No requirements or recommendations have been made as a result of this inspection. What the service does well: Asked how do you rate the quality of care nearly all of the replies of residents or their relatives said either “excellent” or “good”. One visitor at the time of the visit said “I’d give it a 10/10” All fourteen professionals surveyed said that they were satisfied with overall care provided. Carleen has a track record of providing good quality care and continues to do so. Record keeping is detailed and accurate and this helps to ensure that staff provide the right amount of support and care to individual service users. Routines and activities reflect service users wishes and interests and ensure that people can continue to make choices in their lives. There is a good atmosphere in the home and staff were observed to have a friendly and respectful relationship with service users. The home is well managed and the manager is supported by a knowledgeable and committed staff team. A particular strength of the home is the high level of quality assurance that is undertaken. This means that staff are continuously reviewing and evaluating the practices and policies that inform the care that is given and it helps to ensure that people’s different and changing needs and wishes are at the heart of the service. Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? The following statements come from the homes own quality assurance assessment. Evidence gathered during this inspection finds them to be accurate. “We have improved our paper work for the admission process and provided an information pack for respite residents.” “Our assessment of residents nutritional status has been reviewed and helped us to ensure that residents nutritional needs are being met.” “We have looked at the management of medicines and introduced six monthly reviews for all residents. Training in the management of medicines has been available to all staff.” “Joint working with the Primary Care Trust has been carried out to try to prevent falls. Training has been available for all staff”. “The Liverpool Pathway has been introduced. Training was provided for staff by a palliative care nurse specialist from the local hospice”. “We have provided more social activities for our residents”. “We have promoted the dignity and privacy of residents by reducing the number of shared rooms and providing a hairdressing room and two shower rooms”. “We are continually reviewing our policies and procedures. Most recently, adult protection, falls assessment and prevention and the prevention and treatment of pressure ulcers.” “We have continued to improve the environment through our decoration and refurbishment programme”. “Induction training was reviewed in line with the new Skills for Care induction training programme. Refresher training has been provided for staff employed for over two years. We have an additional key trainer in moving and handling techniques.” Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Carleen Nursing & Residential Care Home DS0000011511.V336153.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 Carleen Nursing & Residential Care Home DS0000011511.V336153.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): 3, intermediate care is not provided and so standard 6 does not apply Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full assessment of the needs of the person has been completed. This helps to ensure that the service can provide the appropriate level of care and support. EVIDENCE: Previous inspections have concluded that comprehensive assessments of the needs of potential service users are made before they moved into the home. One record checked to establish that this was still the case, included information about personal and health care needs as well as a nursing assessment that was gathered before long term admission to the home was agreed. One person who lived at the home said that a staff member had visited them before they moved in and asked a lot of questions. Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 10 One person who completed a questionnaire said that they received enough information about the home before they moved in so they could decide if it was the right place for them. The service has devised a leaflet for people who have a short stay at the service, which provides general information about the home. This is supplemented in more detail by the homes service user guide, which is updated regularly. The self-assessment of the service shows that of the all the people who have moved in on a permanent or temporary basis in last 12 months, only one placement has broken down. Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Robust quality monitoring systems ensure that peoples’ health and personal care plans are regularly reviewed and updated. This helps staff to respond effectively to each individuals need. Service users rights to privacy and dignity are always observed. EVIDENCE: At previous inspections care plans were found to include comprehensive information. In a recent survey of people living at the home, conducted by the service 16/18 people who responded rated the quality of care in the home as either ‘excellent’ or ‘good’. Care plans are kept in peoples’ bedrooms and so are easily accessible to them. During the visit to the service, time was spent with two people discussing their care plans. The plans covered health and personal care needs and included information about communication methods, through discussion it was evident that they contained accurate information, that has been regularly reviewed, Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 12 although there was a tendency at times to focus on peoples needs rather than their abilities, for example, one plan said the person needed help to wash and dress although the person concerned said that they could wash their own hands and face. Records seen showed that assessment of risk with regard to lifting and handling and the likelihood of falls has been completed and is regularly updated. In the last 12 months there has been some joint work undertaken with the Primary Care Trust to try to prevent falls in the home and staff have received training in this area. People spoken with on the day of the visit felt that health care was promoted and gave a lot of examples of their personal experiences of this. Social and health care professionals all felt that people were referred to them appropriately and said that staff followed instructions given by them. A barthel index is completed every month for each person to help staff to monitor health. The self-assessment questionnaire says that all people are assessed for risk of pressure ulcers by registered nurses and one nurse takes a lead on the promotion of continence and the management of incontinence. In the last 12 months nutritional screening has also been introduced and appropriate action is taken as necessary. The manager said that she and ten nurses have undertaken training in palliative care and in the last twelve months, the service has introduced the Liverpool Care Pathway. The manager has also undertaken a course in the care of the elderly bereaved. No one currently living in the home currently administers their own medication. The homes policies and procedures have been updated to include a six month review of medicines for all residents. A registered nurse who liaises with the GP undertakes these reviews. Staff spoken with confirmed that they have received training in the management of medication; this includes all care staff, not just those responsible for administering medicines. This has been introduced within the last twelve months. Medication procedures were clearly described by a staff member. All medicines were seen to be securely and appropriately stored. This includes controlled drugs and medication that needs storing in a fridge. Recent Medicine administration records were checked for two people and did not contain any unexplained gaps. Records of controlled drugs that were checked were also accurate and two people had witnessed when they had been administered. 16/17 people who responded in a survey to the question how do you rate the way your privacy and dignity is maintained answered either ‘good’ or ‘excellent’. People are asked their preferred form of address during the initial assessment. Staff were observed to knock at bedroom doors before entering. Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 13 The number of shared bedrooms has been reduced and people in shared rooms confirmed that screens are used for privacy. Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are encouraged to pursue their interests and preferences in their daily routines and are able to maintain contact with their families and the local community. Meals are good and how they are received is closely monitored. EVIDENCE: Peoples’ interests are recorded as part of the care planning process. People spoken with on the day of the visit to the home talked about their preferred daily routines and said that they could stay in their rooms or join others in the communal areas as they wished. There is a staff member responsible for coordinating activities She was there on the day of the visit and was preparing to run a craft session. People living at the home talked enthusiastically about the activities provided. These include reminiscence sessions and keep fit classes They said that they enjoyed watching old films and said there was something on every day. Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 15 People are encouraged to continue to attend community groups that they were involved in before moving to the home, for example one person attends a local chapel, another goes to the stroke club. One visitor said it was a shame that people could not be taken out more, for example to go clothes shopping. The service respects different needs, for example one person is in the Salvation Army. They not only receive visits from them but the Salvation Army band also came to play at the home. 17/18 people surveyed rated the visiting arrangements as either ‘good’ or ‘excellent’. People on the day of the visit confirmed that they could receive visitors when they liked, in private if they wished to. All professionals surveyed agreed that staff always made them welcome and said that they could also see people in private. As discussed earlier, people have access to their personal records. There is information in the home about how to contact external advocates should they need to. It was observed that people are able to bring personal possessions with them into the home. People’s choice has increased in terms of washing as two new shower rooms have been installed. People asked were generally satisfied with the quality of the food. A food satisfaction survey has recently been completed at the home. This asks peoples opinions, including their views about size of meals, choice of food, presentation and times of meals. Staff said that as a result of the feedback they are arranging a meeting to review the menus. On the day of the visit a good variety and supply of fresh fruit and vegetables was seen in the kitchen. Staff practices during lunch were observed. They were seen to offer help to those who needed it, and mealtimes were not rushed. They were also seen to offer people a choice of drinks. Residents said that they always did this. Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 16 Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is an effective complaints procedure in place and staff understand how to protect service users from abuse. EVIDENCE: It has been concluded in previous inspections that the home has an appropriate complaints procedure. Information about how to make a complaint is available in the service user guide, a copy of which is in the entrance hall. All residents and visitors spoken with said that they knew how to make a complaint and felt that staff listen to any concerns they may have. The record of complaints was seen and showed that no complaints have been made in the past twelve months. The manager said that any minor concerns, for example over missing laundry, are dealt with quickly and informally. The service has an appropriate adult protection procedure in place. Records show that staff receive training in this area during induction, further training in the first six months of employment and then refresher training annually. Through discussion it was evident that the manager had a good understanding of the procedures to follow to ensure peoples safety and protection. Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Carleen Nursing Home is clean, well maintained, comfortable and homely EVIDENCE: The environment was assessed to be good at previous inspections. The self-assessment questionnaire says, “the environment is audited every six months and an action plan is raised. The company employs a full time maintenance team and a gardener who visits the home once a week” There was evidence at the time of this visit that positive changes are being made to the environment and that the action plan is being followed, for example some bedrooms are being redecorated, additional shower rooms have been installed and additional storage space has been provided. Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 19 People’s views were that the home was well maintained and clean. One visitor described it as “very homely” This was found to be the case during the visit. The number of shared rooms has been reduced since the last inspection and there are now only six doubles. An Environmental Health Officer had inspected the kitchen area in 2006 and the two issues raised have been addressed. The kitchen is in need of some refurbishment but this is already identified in the action plan. Laundry facilities are sited away from areas where food is stored or prepared. There are procedures in place for the control of infection and there was evidence that staff follow infection control procedures, for example, paper towels and liquid soap were available in toilets and kitchen areas and staff wear protective gloves and aprons to carry out care tasks. Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff are well trained and well supported. There is a good skill mix and they are deployed effectively to meet the needs of service users. Recruitment procedures are satisfactory, ensuring the protection of residents. EVIDENCE: Staff said that during the day there is always one trained nurse upstairs and one downstairs. At night there is one trained nurse on duty, who is supported by three carers. Care staff, cooks, kitchen assistants, domestics, and an activities co-ordinator support nursing staff. One nurse said that it can get busy at times but when this happened that she was able to call on staff in other parts of the building to help. People who live at Carleen felt that they received the right amount of support from staff, for example they did not have to wait too long for their call bells to be answered. Records show that no agency staff have been employed at the home in the last three months. Through discussion with staff it was evident that staff turnover is low and a number of staff have worked at Carleen for many years. People spoke positively about the staff who were described as ‘polite’ and ‘ all lovely’ ‘nothing is too much trouble’ One professional said ‘on every visit to Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 21 Carleen I have been very impressed by the professionalism of staff and nursing care, staff helpful and friendly’ Records show that 75 of care staff have or are working towards a National Vocational Qualification in care, level 2 or above. Recruitment procedures were found to be robust at previous inspections. One staff file was checked during the visit to ensure that all the necessary checks continue to be made and that the service has collected the relevant information about staff members. The file, which related to a recently employed staff member, contained all the necessary documentation, including evidence that a Criminal Records Bureau check had been completed, two references, a medical questionnaire, a curriculum vitae and evidence of identification. The manager said that all staff are provided with a GSCC code of conduct during their induction. One fairly new staff member spoken with said that the induction training is good. The manager said that the induction training programme is based on the new ‘skills for care’ programme, and said that all staff receive part of the programme prior to commencing their duties. A group of staff spoken with all agreed that there was lots of training available and said that if they have a gap in their knowledge or skills they can discuss this with the management team who will either provide information or training for them. They also said that they use the Internet to find out information. The company has a training department and employs a training co-ordinator and an NVQ assessor. Records seen showed that all staff receive training in key health and safety areas. Other subjects, for example dementia and communication are also covered. Through discussion with the training officer it was evident that the quality of the training that is arranged for staff is a prime consideration. The service audits the quality of its training programme but the manager said that an external audit is also going to take place by a senior advisor from Skills for Care to ensure best practice. Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 22 . Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33 35 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed and the quality of the service is monitored very effectively to ensure that people’s health safety and wellbeing are protected and promoted. EVIDENCE: The manager has been in post since March 2006 and has successfully completed the registration process. She has been a registered nurse since 1974 and has worked for the company since the year 2000. She was the Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 24 deputy manager at Carleen prior to taking over as manager and has also been the deputy manager in one of the company’s other homes. She is at present studying for a National Vocational Qualification; level 4 in care and will then undertake a Registered Managers Award. Staff described the management team as supportive and said that the owner telephones every day to ensure that all is well. As discussed throughout this report the service has very effective quality assurance processes in place to ensure that it is run in the best interests of people who live there. These include the regular review and update of policies and procedures, questionnaires for residents, relatives, staff and visiting professionals and regular staff supervisions and meetings. There is evidence that the service responds to feedback given, for example the activities co-ordinator has been given an extra three hours a week to provide more social and recreational opportunities for people. There is an annual development plan, which is regularly reviewed to ensure it is meeting the aims and objectives of the home. The management team have a clear vision of how they wish to continue to develop and have made a number of improvements, for example installing additional showers to improve choice and reducing the number of shared rooms to improve privacy. They consult with external agencies where necessary, for example the primary care trust and skills for care, to help them to further develop the service. Secure facilities are provided for the safekeeping of money and valuables. The manager said that staff only manage small amounts of money on behalf of people and that records and receipts are kept. As discussed in previous sections, staff are provided with appropriate health and safety training to ensure safe working practices. Records show that electrical, gas and fire safety equipment have been recently checked and serviced. Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 25 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 X 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 26 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 Carleen Nursing & Residential Care Home DS0000011511.V336153.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Carleen Nursing & Residential Care Home DS0000011511.V336153.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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