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Inspection on 11/01/08 for Charlotte House Mental Nursing Home

Also see our care home review for Charlotte House Mental Nursing Home for more information

This inspection was carried out on 11th January 2008.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

What the care home does well

The home is well managed, the staff demonstrated their commitment to the high standard of care provided. Relatives of residents and a visiting professional spoken to, confirmed that the home achieves high standards of nursing care.

What has improved since the last inspection?

The home uses a new IT system and information stored on it is constantly reviewed and is shared within the teams for good communication in the care of the residents.

What the care home could do better:

The Statement of Purpose and Service User Guide needs review to ensure the information they contain is up to date. The home must review the appropriateness of the information stored on their IT system and if it presents the information in the most efficient manner. Residents` clothes must be ironed or pressed Only 5 of the beds in the home can be raised or lowered hydraulically. The remaining 52 beds are at least 10 or 15 years old and cannot be raised or lowered because the manual mechanisms have broken. This means that staff experience more difficulty and risk when nursing people who need care in bed. Standard 24.3 Regulation 23(2)( c).

CARE HOMES FOR OLDER PEOPLE Charlotte House Mental Nursing Home Snowy Fielder Waye Isleworth Middlesex TW7 6AE Lead Inspector Ms Pauline Griffin 11 & 22 th nd Key Unannounced Inspection January & 7th February 2008 12:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Charlotte House Mental Nursing Home DS0000010943.V357255.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. Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charlotte House Mental Nursing Home Address Snowy Fielder Waye Isleworth Middlesex TW7 6AE 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) 020 8758 0080 020 8758 0054 manager.burroughs@careuk.com Care UK Community Partnerships Ltd Tony Anin-Boateng Care Home 60 Category(ies) of Dementia (0), Mental disorder, excluding registration, with number learning disability or dementia (0), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (0) Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users to include a maximum of 10 DE over the age of 50 and up to 60 MD & MD (E) 28th February 2007 Date of last inspection Brief Description of the Service: Charlotte House provides nursing care to 46 elderly mentally ill/physically infirm people over the age of sixty. It is also registered to provide care to 10 people over the age of fifty. The home is set in a modern building that is divided into four units over two floors. All rooms are single occupancy with en suite facilities. Four of the rooms were double size and these are now used to provide for individual residents who have special needs. The home has a passenger lift and features four assisted bathrooms. Each of the four units has as large communal lounge and dining room. The home is decorated and furnished to a high standard throughout. The Registered Manager is supported by a management team of a Deputy and two trained nurses – who are Heads of Units. On each of the two floors there are two trained nurses on duty and five care workers. The home also enjoys the services of an Administrator and 2 Activity Co-Ordinators. The home also benefits from the services of a full time Chef, 3 kitchen assistants, 3 domestic staff, 3 laundry assistants, a maintenance person and a gardener. The home employs 45 permanent staff and used 7 bank staff to cover shortages. The home is located next to West Middlesex University Hospital and close to the amenities of Hounslow High Street. There is a large secure garden to the rear of the building that can be accessed from the ground floor. Current fees range from £650 to £850 per week. Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating of this service is 3 star. This means the people who use this service experience excellent quality outcomes. This was an unannounced inspection taking place over three days for a total of approximately 14 hours. The inspection was assisted by the Registered Manager and interviews carried out with a Senior SRN, an Activities CoOrdinator, a Care Worker, the Chef and a Psychiatrist who was visiting the home. Interviews were also carried out with two relatives of residents. Files of four residents and five members of staff were chosen at random and examined. Policies, procedures, records, logs and maintenance certificates for the building and utilities were studied. The home’s medication procedures were looked at and the quality monitoring system was examined together with other feedback from resident’s meetings, staff meetings and senior manager’s monthly review visit reports (under Regulation 26 of the National Minimum Standards). One member of staff interviewed said ‘this is a good organisation to work for because they have high standards of care’ another said ‘our Registered Manager is very good and you can go to him anytime to discuss anything and know you will feel comfortable’ a third staff member said ‘Care UK is an excellent organisation, especially with training’. The visiting Psychiatrist asked me to quote him as saying ‘ the Management are professional and their assessments and care plans are very good and are implemented’. A resident’s son said ‘my Mother receives good care’ and another resident’s wife said ‘ I have confidence in this nursing home and the staff are good’. A tour of the premises was made accompanied by several different members of staff. The Inspector also spent time with the Chef in the kitchen discussing the menu and watching the food being prepared. One requirement had been made from the previous inspection and this had been complied with. This is a well managed nursing home that excels on all levels in service delivery to the residents. Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 6 What the service does well: 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. Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives are provided with information to enable them to make an informed choice about the home. EVIDENCE: The Registered Manager handed the Inspector the home’s Statement of Purpose and Service User Guide. It was noted that although they were both comprehensive, both of these documents had not been reviewed for two years and some of the information was out of date. Standard 1 – 1.1, 1.2 of the NMS and Schedule 1 of the Regulations apply. The Registered Manager said that copies of the Statement of Purpose and the Service User Guide are made available to residents and/or their representatives. Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 9 The home makes it’s own assessment of prospective residents, using information provided by members of the social services departments, health care professionals or other sources of relevant information. Four residents’ files were chosen at random and two were ‘case tracked’. Most of the information is held on the code secure computer system called ‘Saturn Live’ Database. The information seen was detailed and up to date and included full needs assessments and care plans. Medical information and health related logging for things like skin integrity, continence, nutrition, weight monitoring, mobility and mental state/cognition were included. The home encourages prospective residents and their family(s) to visit the home prior to admission and the Registered Manager said that they were offered a ‘welcome pack’ and the Statement of Purpose. The Registered Manager said that the home was being used more and more for palliative care rather than the rehabilitative service as it had been in the past and the examination of referrals confirmed this. The home is able to provide specialist services from relevant professionals including physiotherapy and occupational therapy. Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that individuals and their representatives are involved in the decisions about the care they receive to make sure their needs and wishes are respected. EVIDENCE: The service user plans seen were comprehensive and up to date and included reference to all aspects of care including health, personal choices and social care needs. Care plans are reviewed each month. There is hygienic hand mousse in a pump applicator inside the door of every room. Medical information and health related requirements in areas like skin integrity, continence, nutrition, oral, sight, hearing, weight monitoring, mobility and mental state/cognition/behaviour are included in the care Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 11 planning process. Residents receive access to chiropody, dentistry and therapeutic services according to need. Medication administration charts were examined and all were found to be satisfactorily completed. The Inspector was shown the medication cabinet in one of the four units as well as the medication kept in the refrigerator and controlled medication cabinet. The Inspector also looked at the ‘returned’ medication system used by the home and these were stored for each person with a colour code for times of the day. Individual containers of liquids, powders or creams were kept separately and were clearly marked with people’s names. The Inspector observed the staff treating people in a sensitive and respectful manner during the course of the inspection. The Registered Manager said the staff skill mix, gender and culture mix, enables the home to offer a choice of who performs the personal care for a resident. Residents are given a specific care worker to act as their key worker. Residents looked well cared for and were well groomed. The Inspector was shown the laundry and was told when that clothes were not usually ironed. The Inspector saw that clothes were hung up after they were washed and dried but trousers and other items of clothing were creased. Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are provided with a range of activities to choose from including trips outside the home. The food and menu choice is excellent and residents can enjoy a variety of dishes to suite their preferences, dietary and cultural needs. EVIDENCE: The Inspector interviewed the Activity Co-Ordinator and discussed the programme of activities arranged for the residents. The programme included, exercises, art, craft, music, videos, reminiscence and pet therapy. There is a programme of different religious services and short trips to places like Syon House (weather permitting). The Activity Co-Ordinator’s room had craft equipment and a selection of box games and she demonstrated her enthusiasm for her work by describing the things she knew people enjoyed the most. The Inspector visited the sensory room in the Kew Unit. This is used to help residents relax with soft lights, novelty mobiles and music. The Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 13 programme of activities were posted on the notice boards throughout the home. Residents can have visitors at any time and visitors are welcome to share a meal with a resident if they give a little notice to the Chef. One visitor confirmed that he often enjoyed a meal with his Mother and said that he always enjoyed the food. The Registered Manager makes every effort to ensure that residents’ wishes are respected. Examination of the Relative’s Meeting and Staff Meeting Minutes and customer survey feedback summary from September 2007 provided evidence that people’s choice and wishes are respected. The Inspector spent time with the Chef discussing the menu and watching the food being prepared. The Chef demonstrated his enthusiasm for his work and the kitchen was clean, hygienic and orderly. Food Hygiene and Health & Safety at Work Regulations were seen to be being adhered to in the kitchen. The kitchen was well equipped. The food was kept in a satisfactory manner and the stocks showed what a good choice of ingredients are provided. The Inspector was shown that refrigerator/freezer temperatures are logged each day to monitor that food is being kept at safe temperatures. The homemade vegetable soup for the evening supper was sampled and found very good. The supper menu on the evening of the inspection was from a choice of homemade soup, sandwiches with various fillings, sausage roll with mashed potatoes and an ice cream for sweet. Menus are well balanced and contain food suited to the needs of the elderly and they are also provided with plenty of choice. The menu of the day is posted on notice boards throughout the home. There is an album of pictures of prepared meals to help residents make a choice. Residents can have hot and cold drinks and snacks on request. . Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their representatives are confident to express their concerns and have access to an effective complaints procedure. The policies, training and supervision of staff ensures that residents are protected from abuse and have their rights respected. 16 & 18 EVIDENCE: The home has a complaints policy and this is included in both the Statement of Purpose in a shortened form. The complaints procedure is set out in the Service User Guide and gives the action that can be taken if people are not satisfied with the outcome of their complaint. The home has not received a complaint in the previous 12 months but the home receives many written compliments. The Registered Manager said that he always listens to relatives and friends and responds immediately. The home has a policy on Safeguarding Vulnerable Adults from Abuse with Best Practice Guidance. The policy describes the different forms abuse can take and details the procedure for dealing with investigation of allegations of abuse. There is also a Whistle Blowing Policy that sets out the responsibilities of the organisation, Registered Manager and staff members. The training Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 15 records show that 43 staff members attended POVA training in the past 2 years. Adult Abuse is covered in the induction training provided to each staff member when they commence work with Care UK. Charlotte House Mental Nursing Home DS0000010943.V357255.R01.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, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers a safe, well maintained and comfortable environment and the atmosphere is open and welcoming. EVIDENCE: Charlotte House is furnished and decorated to a high standard throughout. The reception area is furnished with comfortable seating for several people and there is a coffee making facility, newspapers and information regarding the nursing home. The Registered Manager’s and the Administrators Office are positioned off the reception area. All people visiting the home pass through the reception area and use the visitor’s book to log their arrival and departure. There is a CCTV security system covering the entrance areas of the home. The grounds of the home are well maintained and attractive. Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 17 Each of the four units were visited by the Inspector and it was noted that each bedroom door, had a photograph of the occupant together with their name and a short poem. The dining areas were set out for two or four people in a restaurant style with small tables, table cloths and napkins. Each lounge had comfortable easy chairs with television and audio equipment. Several bedrooms were inspected and found to be well furnished and personalised with items that residents had brought with them. Each bedroom has en suite facilities and there are two assisted bathrooms on each floor. The Inspector discussed with the Registered Manager the fact that the home has only 5 modern hydraulic pump action adjustable beds out of a total of 57. The person responsible for maintenance said that the remainder of the beds in the home are from between 10 and 15 years old and the manual winding adjusters do not work and cannot be repaired. The Registered Manager said that staff work in twos and risk assessments are carried out to ensure safety. However, the Inspector noted from referrals seen that the home is increasingly providing palliatative care services that require nursing in bed. A review must be made of the number of people who need care to be provided in bed, to identify whether the home has a satisfactory number of adjustable for staff to work safely. The Inspector checked the medication storage in a small medical room on the first floor and it was found that the water was far too hot for staff to wash their hands safely. The person responsible for maintenance said that he would adjust the water temperature and make sure that a valve to govern the temperature of the water was fitted as soon as possible. The home had no mal odours and was clean and hygienic throughout. The laundry was orderly and sited away from the bedrooms and communal areas. There are policies and procedures in place for dealing with hygiene and infection control and there are protective gloves placed at points where staff need to use them. There are two industrial sized washing machines that can be programmed to wash at high temperatures to ensure infection control. The water system in home had been checked by an accredited company for Legionella and to ensure it complies with the Water Supply Regulations 1999. Charlotte House Mental Nursing Home DS0000010943.V357255.R01.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. The home uses good recruitment and training practices and this ensures that the staff team are trained, skilled and in sufficient numbers to provide a good standard of care to the residents. EVIDENCE: The Registered Manager said that he occasionally used staff from an agency but they were fully vetted and observed as they worked in the home. He said that he trained the agency staff in moving and handling himself and careful consideration was given before any decision was made to accept them. The Registered Manager is a trained moving and handling instructor. During the course of the inspection, staff were observed working well alone or as a team in their care of the residents. The Registered Manager said that the home did not carry vacancies and had a permanent team who included a mix of staff, many of whom were RGN, RMN, ENMI, NVQ3 or NVQ2 trained. The Registered Manager said that just over 40 of the staff team had achieved an NVQ at level 2 or 3 or were in the process of achieving it. The staff rotas are compiled by the Registered Manager and displayed in the nurse offices on each unit. There are adequate numbers of staff on duty at Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 19 any time of the day. Each of the two floors has a Unit Manager who is a qualified nurse. There are also 2 senior staff members and five care workers on duty in each of the four units. The home also has 3 domestic assistants for cleaning duties and 3 laundry assistants. The home uses good recruitment practices. Five staff files were chosen at random and examined. The files included evidence that all the checks required by the NMS had been obtained. Each file had a check list at the front ticking off the action taken and information obtained. Files contained an Enhanced Criminal Records Bureau clearance, employment histories, qualifications, passport, photograph, work permit details, health and criminal records declarations, training, job description and a contract of employment. The files were well maintained and easy to refer to. A staff training matrix was produced and this gave percentages of attendance against each member of staff. The courses covered in this matrix were COSHH, Food Foundation, Skills for Life, Care UK Induction, Customer Care and Health and Safety. Further information was provided giving the names and dates of staff members who had attended courses during 2006 and 2007. This showed details of other specialist courses attended by some members of staff like dementia care, epilepsy, diabetes, end of life care, equality and diversity, fire safety, fire warden training, first aid, hoist training, infection control, POVA, risk assessment, safe handling of medication and training on the Home’s IT system. The training records did not clearly show an overview of the members of staff who had received training, the subjects covered, when the course had last been attended and a review date for update training. The Registered Manager said that training is given a high priority by the organisation. Charlotte House Mental Nursing Home DS0000010943.V357255.R01.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): 32,33,35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: Both staff and relatives of residents spoken to during the inspection, said that the Registered Manager is approachable and fair. During the course of the inspection, the Registered Manager demonstrated his commitment to providing the highest quality service to the residents. Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 21 The home holds regular residents’ and staff meetings and minutes examined showed that these are used to provide information and improve communication. The home uses an outside agency who carry out surveys on their behalf and produce an annual summary. The Inspector was handed the Customer Satisfaction Survey conducted with relatives and friends by the agency used by Care UK for quality monitoring. The survey was dated September 2007 and the information was based on 16 questionnaires (although 50 were sent out only 16 were returned). The outcome of this postal survey was favourable to the home. The home should investigate other methods of obtaining feedback information from relatives, representatives, professionals, other stakeholders, complaints and compliments to ensure that the quality monitoring process is as broad as possible. The home receives a monthly visit from a senior manager of their organisation who interviews staff, residents, relatives and tours the home, checking the building and recording systems. A copy of the monthly report is forwarded to the CSCI in accordance with Regulation 26 of the NMS. The Registered Manager is proposing to produce a regular newsletter and has asked the representatives of the residents for items to include in it. The home holds sums of money for each resident and these are kept in separate pouches in the office safe. Two residents’ accounts and pouches were checked and found to be in order. Details of the way the home deals with the money floats of residents who have no next of kin were seen and found satisfactory. The home has up to date policies covering the different aspects of the Health and Safety at Work Legislation 1974 and other safety legislation. Risk assessments examined were carried out satisfactorily and where a risk had been identified, the assessment included methods to reduce or eliminate it. Charlotte House Mental Nursing Home DS0000010943.V357255.R01.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 2 x 3 x 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 4 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 x 3 x x 2 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 x 4 4 x 3 x x 3 Charlotte House Mental Nursing Home DS0000010943.V357255.R01.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. 1. Standard OP1 Regulation 4,5 & 6 Schedule 1 Requirement Timescale for action 01/05/08 1. OP24 The Statement of Purpose and Service User Guide must be reviewed and brought up to date in accordance with NMS Standard 1.1 and 1.2 & Schedule 1 of the Regulations 22 (2) ( c) A review of the average number 01/04/08 of people in the home at any one time - who need care or nursing in bed must be made to identify whether the home has adequate adjustable beds for staff to work safely. A copy of the details of the review must be forwarded to the Registered Individual of the home and to the CSCI. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP10 Good Practice Recommendations Residents’ clothes should be ironed and pressed. Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 24 2. 3. OP26 The water in the dispensary is too hot for staff to wash their hands. Training courses attended by staff should be recorded in an easy reference chart can be evidenced and that the range of courses, who attended and when - can be seen in an ‘at a glance’ format. The quality assurance system should be reviewed to include other strands and methods of obtaining information. OP30 4. OP33 Charlotte House Mental Nursing Home DS0000010943.V357255.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Charlotte House Mental Nursing Home DS0000010943.V357255.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!