Inspection on 08/11/06 for Cliff Court

This inspection was carried out on 8th November 2006.

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

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

Other inspections for this house

Cliff Court 31/01/06

Similar services:

Deepdene Care Centre

Ferndale Residential Care Home

David Gresham House

Elizabeth House

Elvy Court Nursing Home

Fontenay Nursing Home

Clairmont Residential Home

Cornford House

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

CARE HOMES FOR OLDER PEOPLE Cliff Court 70 The Promenade Peacehaven East Sussex BN10 8ND Lead Inspector Jennie Williams Unannounced Inspection 8th November 2006 11:00 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 Cliff Court DS0000064914.V309698.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. Cliff Court DS0000064914.V309698.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cliff Court Address 70 The Promenade Peacehaven East Sussex BN10 8ND 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) 01273 583764 01273 585562 Mrs S Awotar Mr R Awotar Miss Sue Burke Care Home 18 Category(ies) of Dementia - over 65 years of age (18) registration, with number of places Cliff Court DS0000064914.V309698.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is eighteen(18). Service users must be older people aged sixty-five (65) years or over on admission. Service users with a dementia type illness only to be accommodated. Date of last inspection 31st January 2006 Brief Description of the Service: Cliff Court is a care home registered for eighteen (18) places and is for people over sixty-five (65) years of age with a dementia type illness. No nursing care is provided at this home. District nurses will provide nursing input for those residents requiring this. Cliff Court is located on the cliffs at Peacehaven, offering sea views from many of the rooms. Residents’ bedrooms are located over two floors. There is a stair lift available for residents requiring assistance to access the first floor. Once on this floor, there are three to four steps in either direction that residents need to be physically able to climb stairs to access individual rooms. The location of the room and an individuals mobility is taken into account when assessing prospective residents. There are twelve (12) rooms for single occupancy, of which one has en suite facilities. There are three (3) double rooms that are not provided with en suite facilities. There are three assisted baths and five toilets located throughout the home. There is a good-sized dining room and lounge room. There is a garden area off the dining room that is accessible for residents. The home is located within an easy walking distance to local amenities. Bus services are available at the end of the road. There is limited parking at the home, but free parking is available in adjacent streets. Weekly fees range from £380 to £500 per week. There are additional fees; hairdressing (£8.50 to £25), chiropody (£10), newspapers/magazines and personal toiletries. This information was provided to the CSCI on the 30 November 2006. Cliff Court DS0000064914.V309698.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Cliff Court will be referred to as ‘residents’. This unannounced key inspection took place over eight and a half hours on the 8 November 2006. Fourteen (14) residents, of both genders, were spoken with during the inspection. One relative assisted a resident to complete a resident survey. Two other residents were provided with surveys, however these were not returned. One care plan was looked at in detail with the resident involved and with their permission. Specific areas of care were looked at in one other care plan. The Registered Manager, Registered Providers and one staff member was spoken with during the inspection. Ten staff surveys were left at the home of which two were returned. Three staff files were inspected. A visiting relative was spoken with and ten relative/visitors comment cards were sent to the home prior to inspection. Six of these were returned. A pre-inspection questionnaire was received prior to the inspection. A tour of the environment was provided and some individual rooms were viewed. Fire records, accident records and medication procedures were inspected. The quality assurance system was discussed and complaint records were inspected. Previous requirements and recommendations at the home were assessed to ensure compliance. The staff rota and menus were viewed. The Inspector ate lunch with the residents. Apart from fire records, no other health and safety records were viewed as this information has been provided in the preinspection questionnaire. Some policies and procedures were viewed. There were 17 residents residing at the home on the day of the inspection. What the service does well: Residents were complimentary about the staff working at the home and felt that their personal care needs were being met. Prospective residents are provided with opportunities to visit the home prior to moving in to ensure the home will meet their needs. Residents felt that their privacy and dignity are respected. One relative comment card reflects “.. is cared for by all the staff in a very caring and sensitive manner…very friendly and family like atmosphere”. Visitors are welcomed at the home and residents may receive visitors in private. Residents were complimentary about the provision of food at the Cliff Court DS0000064914.V309698.R01.S.doc Version 5.2 Page 6 home. Residents are provided with regular fulfilling activities. Residents feel comfortable and know how to make a complaint and feel that they will be listened to. Residents are happy with their individual rooms and are able to personalise them. Staff receive training appropriate to their roles to ensure their safety and that residents needs continue to be met. Residents and staff benefit from supportive and approachable management within the home. Procedures in place for the handling of personal allowances ensure residents’ finances are safeguarded. What has improved since the last inspection? What they could do better: A more structured quality assurance and quality monitoring system would enable management to monitor the success of the home in meeting its aims and objectives and ensure the home is run in the best interest of residents. Policies and procedures around quality assurance and quality monitoring should reflect actual practices within the home. Cliff Court DS0000064914.V309698.R01.S.doc Version 5.2 Page 7 It has been recommended that the policies and procedures are updated and relevant to the current practices within the home. 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. Cliff Court DS0000064914.V309698.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 Cliff Court DS0000064914.V309698.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): 1, 3, 4, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home. The pre-admission assessment process ensures that only residents whose needs can be met are admitted. Intermediate care is not provided at the home. EVIDENCE: The Registered Manager confirmed that the Statement of Purpose and Service User Guide had been amended to reflect the changes in ownership, as required at the last inspection. The content of these documents were not read. A copy of the Statement of Purpose and Service User Guide are available at the home upon request. Cliff Court DS0000064914.V309698.R01.S.doc Version 5.2 Page 10 The pre admission assessment has improved since the last inspection. The Registered Manager generally undertakes the assessments of all prospective residents. Relatives are involved in this process wherever possible and information is obtained from social services and health professionals wherever applicable. The Registered Manager will discuss all prospective residents needs with the staff prior to admitting a resident. Residents of both genders and different religions and culture are all residing at the home. The Registered Manager was able to provide evidence that any specialist religious/cultural needs are able to met at the home. Residents/relatives are provided with an opportunity to visit the home prior to admission. It was confirmed that the first month of admission is a trial period. A visiting relative spoken to confirmed that other relatives within their family were provided with an opportunity to visit the home prior to a resident being admitted. The home does not have dedicated accommodation to provide intermediate care. Respite care is provided if there is a spare place available. The home does not take emergency admissions. Cliff Court DS0000064914.V309698.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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the information provided in the care plans on the assessed needs of residents. Residents are safeguarded by the medication procedures in place and are treated with respect. EVIDENCE: The home has implemented person centred care plans for residents. Care plans provide clear information to staff on the assessed needs of the individuals. With the permission of a resident, the Inspector went through their care plan with them and this individual confirmed that the information within the care plan was accurate. Person centred care plans assist staff and residents in identifying individual strengths and weaknesses and action to take to improve in these areas. Cliff Court DS0000064914.V309698.R01.S.doc Version 5.2 Page 12 The home has risk assessments in place for all residents, with particular attention to falls. For areas that have been identified as a greater risk, a risk reduction plan is implemented. These are kept under regular review. Care plans are not currently being devised or reviewed with residents/relatives. The Registered Manager confirmed that all care plans are currently being transferred to the new person centred format. Due to these care plans being very extensive, key workers are being educated on the new format. The Registered Manager confirmed that once staff are familiar with the new care plan format, residents and relatives will be involved in the reviewing process. This process is proposed to be implemented by February 2007. A visiting relative spoken with confirmed that they were not familiar with the care plan, however staff do discuss the individuals’ care with them. All comment cards received from relatives/visitors demonstrated that they are kept informed of important matter affecting their friend/relative and are consulted about the care if their relative/friend is not able to make decisions. One comment card stated ‘I could not wish for better care for my mother’. There are records kept of visiting health professional visits. A chiropodist visited the home on the morning of the inspection. A resident observed to be wearing glasses confirmed that eye checks are undertaken when needed. Wound care plans were noted to be in place and specialist advice is sought when the need arises. It was confirmed that there are policies and procedures in place for all aspects of dealing with medication. The content of these were not read. There is no one capable of self-administering their own medication. On inspection of the Medication Administration Record (MAR) charts, it was noted that medication on the whole is being signed for at the time of administration. There was one medication noted to be signed for but not given. A requirement has not been made in respect of this, as the Registered Manager will address this error with the individual staff member involved. There was a homely remedy medicine that had expired. This was dealt with immediately by the Registered Manager. Residents spoken with felt that their privacy and dignity are respected. Staff were observed to have a good professional rapport with residents and were observed to offer assistance whilst demonstrating patience and understanding. A visiting relative confirmed that they are able to visit their relative in private if they wish. Screening was observed to be provided in double rooms. Cliff Court DS0000064914.V309698.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): 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’ lifestyle within the home is their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. Residents choice and preferences are catered for at meal times. EVIDENCE: There is an activities person employed at the home Monday to Friday for three hours in the afternoon. Residents and staff spoken to felt there was a good activities programme in place. The activities person has been proactive and has made some games herself that benenfit people with a dementia type illness. A relative/visitors comment card stated ‘the food is excellent and afternoon activities very good’. On obtaining a life history of residents, it was noted that some residents used to enjoy swimming. The Registered Manager arranged for family members to bring swimming costumes in. Residents were provided with an opportunity to go swimming, however this was unable to be continued due to the constraints of the public pools. Cliff Court DS0000064914.V309698.R01.S.doc Version 5.2 Page 14 The activities co-ordinator develops a monthly newsletter with the assistance of the residents. With agreement from individuals/relatives, each newsletter contains a profile of a resident. Residents contribute puzzles and other articles to go into the newsletter and information is provided about various things that have happened at the home. These newsletters are also sent to relatives that reside overseas. The newsletter has recently started adding a feature aspect on dementia. Residents are encouraged to continue with activities they may be involved in within the community prior to admission. There are no restrictions imposed on relatives/friends, however people are encouraged to visit the home at times when it is less disruptive for residents. Members of a church visit the home every month and one resident is supported to attend church services within the community. Some residents spoken with confirmed that their lifestyle within the home is their choice. They choose what to wear and when to get up and go to bed etc. Residents are encouraged to bring in personal possessions with them to personalise their own rooms. The Registered Manager confirmed that one resident receives visits from an advocacy service. Residents were observed to move freely within the home. Residents spoken with were complimentary about the food provided. The Inspector enjoyed chicken supreme and vegetables with the residents for lunch. Residents were observed to be enjoying the meal, although some complained about the hard carrots. Comments were fed back to the cook, who took all comments on board. The usual cook was not on duty on this day. Staff were observed to be nearby to offer discreet assistance to those needing help. One staff member was observed standing over a resident assisting them to eat; this was addressed on the day. The Registered Manager informed the Inspector that family members of a resident who is from another country will on occasions bring in cultural food for this individual. The home supports this. The home is aware of foods that cannot be eaten by an individual due to religious beliefs. Cliff Court DS0000064914.V309698.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): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are dealt with appropriately, reassuring those involved that they are being listened to and that action will be taken, if necessary. Protection of Vulnerable Adults procedures ensure residents are safeguarded. EVIDENCE: The home has a complaints procedure in place and five comment cards from relatives/visitors demonstrated that they are aware of the home’s complaints procedure. There has been one complaint made to the home since the last inspection. This was regarding a bed head being damaged. This was substantiated and the headboard was replaced. There have been no complaints made directly to the CSCI since the last inspection. Of the residents that were asked and able to answer, all confirmed that they feel comfortable to make a complaint. The Registered Manager has undertaken a train the trainer course on the Protection of Vulnerable Adults (POVA) and provides training for the staff at the home. There have been no Safeguarding adult investigations undertaken since the last inspection. There is suitable information available to staff on procedures to take in the event of an allegation of abuse arising. Cliff Court DS0000064914.V309698.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and homely environment and are provided with comfortable indoor and outdoor communal facilities. EVIDENCE: The home is located on the cliff tops in Peacehaven and sea views are accessible from communal areas and some individual bedrooms. It is a short walk to local amenities and there is a bus stop near the end of the road. There is a no smoking policy at the home. There is a chair lift available to assist residents accessing the first floor. There are still three or fours steps in either direction for residents to negotiate to all first floor bedrooms. Residents being admitted to these rooms must physically be able to climb stairs. Cliff Court DS0000064914.V309698.R01.S.doc Version 5.2 Page 17 Rooms viewed demonstrated that they have been personalised to reflect the individual’s choice and personality. The Registered Manager confirmed that problems with the hot water have now been resolved. The Inspector was pleased to see hot and cold taps clearly labelled to avoid any confusion for residents. There are notices throughout the home to assist the residents with their orientation within the home. The home was clean and free from odours on the day of the inspection. Some areas have been redecorated, new equipment purchased and the preinspection questionnaire has highlighted additional work that is proposed to be undertaken in the near future. There remain hand towels in communal areas. The home has risk assessed this for infection control and the Registered Manager confirmed that the towels are changed four times a days. Cliff Court DS0000064914.V309698.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. Residents’ needs are currently being met with the number and skill mix of staff on duty and residents are safeguarded by the recruitment procedures in place. Staff are trained and competent to do their jobs. EVIDENCE: There is usually three carers plus management/senior carer working in the mornings, two carers plus management in the afternoon and two carers work a waking night. Four staff have left employment since the last inspection. There are currently two full time staff vacancies at the home. The Registered Manager confirmed that agency staff requires to be used occasionally at the home. The Registered Manager confirmed that a weekend cleaner/laundry person who worked four hours on each morning and made suppers in the evening has left employment. This position has not been refilled and staff are having to undertake these duties. The Registered Providers also work at the home to assist when staffing levels may be low. No additional staff are employed on the weekend to assist in the extra duties to be undertaken. Staffing levels must be regularly reviewed, ensuring the numbers and dependency levels of residents are taken into account. Cliff Court DS0000064914.V309698.R01.S.doc Version 5.2 Page 19 All relative/visitor comment cards received demonstrated that in their opinion there are always sufficient numbers of staff on duty. The home is working towards ensuring that 50 of care staff achieve National Vocation Qualification (NVQ) level 2 or above. Some of the staff who has left employment had achieved these qualifications. There are three staff with NVQ level 2, two staff nearly completed these studies and a further three are enrolled to commence studies in December 2006. There are 12 care staff employed at the home. There is a suitable recruitment procedure in place. The Registered Manager confirmed that all new staff shadow another carer for two days. It was confirmed that if a staff member has had to commence employment with just a POVA First check, they are supervised until a full Criminal Record Bureau (CRB) check is returned. Any minor shortfalls noted in the recruitment procedure was discussed with the Registered Manager on the day of the inspection. It was discussed with the Registered Manager that clearer interview notes be recorded for the home to evidence why the applicant is suitable to work at the home. Staff comment cards received demonstrated that they are provided with sufficient time to receive relevant training. It was confirmed that staff are kept up to date with mandatory training and are provided additional training relevant to their roles. Some staff have undertaken a long distance course on dementia over three months. There is a training programme in place for all staff. The Registered Manager is aware on the recent changes in induction training, but had not obtained any information on these. Information on the new Common Induction Standards was forwarded on the Registered Manager following the inspection. Cliff Court DS0000064914.V309698.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): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally run in the best interest of residents, however a more structured quality monitoring system would enable management to monitor the success of the home in meeting its aims and objectives. The health, safety and welfare of residents and staff are promoted and protected so far as is reasonably practicable. EVIDENCE: The registered manager is registered with CSCI and has the relevant skills and experience to manage the home. She is a registered nurse (mental health) with current registration with the Nursing and Midwifery Council (NMC). She Cliff Court DS0000064914.V309698.R01.S.doc Version 5.2 Page 21 has completed that Registered Manager Award course and is currently awaiting her certificate. The Registered Manager is aware of the importance of having a structured quality assurance and quality monitoring system in place. Quality assurance was covered in the RMA course. There have been no further quality assurance checks undertaken since the last inspection. The Registered Manager sent out surveys to GPs’ as part of the RMA course and found this a very positive process. The policy and procedure in place for the quality assurance system is not being implemented. It was noted that the policies and procedures folder was disorganised and obtained a lot of outdated and repetitive information. Some of the policies and procedures had been implemented from the previous owners that were not relevant to the home any more. It was discussed with the Registered Providers at the inspection that they review all the policies and procedures and ensure that they comply with current guidelines and reflect their ethos of running the home. The home is not an appointee for any resident. The home will hold personal allowances for residents. Receipts are kept of any financial transactions and there are clear records maintained of incoming and outgoing monies. Monies checked demonstrated that accurate records are being maintained. The pre-inspection questionnaire demonstrates that fire alarms are tested weekly and that the most recent fire drill was in August 2006. A fire risk assessment was undertaken in November 2005 and the Registered Manager confirmed that any areas identified as shortfalls are being addressed. There was work being undertaken on the day of the inspection to connect some magnetic fire doors to the alarm system. The Registered Manager recently attended a health and safety course that provided information on all recent fire safety changes and on how to undertake risk assessments and provided other information on health and safety issues within a care home setting. No other health and safety records were inspected on this occasion as this information has been provided in the pre-inspection questionnaire. Records demonstrate that equipment used within the home are regularly serviced and suitable health and safety checks are undertaken. Cliff Court DS0000064914.V309698.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 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Cliff Court DS0000064914.V309698.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 OP33 Regulation 24 Requirement That a structured quality assurance and quality monitoring system be developed and implemented. Timescale for action 15/01/07 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 OP33 Good Practice Recommendations That the policies and procedures be updated and relevant to the current practices within the home. Cliff Court DS0000064914.V309698.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Cliff Court DS0000064914.V309698.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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