Inspection on 06/03/07 for Courtlands

This inspection was carried out on 6th March 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

Courtlands 13/10/05

Courtlands 26/04/05

Courtlands 21/02/05

Courtlands 20/08/04

Courtlands 09/07/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE Courtlands Rosudgeon Penzance Cornwall TR20 9PN Lead Inspector Richard Coates Unannounced Inspection 6th March 2007 09:30 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 Courtlands DS0000009010.V331964.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. Courtlands DS0000009010.V331964.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Courtlands Address Rosudgeon Penzance Cornwall TR20 9PN 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) 01736 710476 01736 711141 Mr Mark Fairhurst Mrs Gillian Fairhurst Mrs Julie Hocking Care Home 37 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (12), Old age, not falling within any other category (37) Courtlands DS0000009010.V331964.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents to include one named person only under the age of 65 Date of last inspection 13th October 2005 Brief Description of the Service: Courtlands is a care home providing accommodation and personal care for up to 37 older people, including up to 12 residents with dementia and a further 12 with mental illness. The registered providers are Mr Mark Fairhurst and Mrs Gillian Fairhurst. Mr and Mrs Fairhurst are closely involved in the day-to-day management and administration of the home. The home is situated in the village of Rosudgeon, between the towns of Penzance and Helston. It is a large detached property standing in its own grounds. Most of the bedrooms are single and several have en suite facilities. There are three double bedrooms, all with en suite facilities. The home has two floors; the upper floor is accessed by a shaft lift. The entrance provides suitable access for people with disabilities. There are two lounges and a dining room on the ground floor and a further lounge on the upper floor. The grounds are spacious and well maintained. The home has suitable office space and facilities for staff to store their personal belongings. At the time of this inspection, major building work and improvement to the premises were nearing completion. This will change the facilities of the home from the description given above. Some of the facilities described above have not been accessible during the building work. The fees as given at March 2007 were from £293.25 to £469.00. Courtlands DS0000009010.V331964.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a planned unannounced inspection to review compliance with the recommendations set in the last inspection report dated 13 October 2005 and to inspect against the national minimum standards identified as key standards by the commission. The provider submitted a pre-inspection questionnaire before the inspection visit. The inspector visited the home over two days. The methods used were the inspection of records and documents, a tour of the premises, observation and discussions with the registered manager, staff and residents. What the service does well: Courtlands provides a safe and comfortable home for older people. Service users and their representatives reported that Courtlands provides good quality care and accommodation. Residents commented, “We are very well looked after”. Residents had not felt the need to make any complaints. They felt that the providers and registered manager were approachable and would resolve any issues that they raised. The providers obtain detailed assessment information from commissioning authorities before each resident’s admission and carry out a needs assessment so that they are sure that they can meet these needs. All residents have written care plans which direct and inform staff about their care needs. Residents and their representatives felt that that their health needs were well monitored and appropriate assistance sought promptly when required. Residents felt that they were supported to follow their preferred daily routine. They reported that there were sufficient activities and enough to do. They felt that visiting arrangements were satisfactory and their visitors were welcomed to the home. Residents expressed satisfaction with the quality and quantities of the meals provided. The home is well maintained, tidily decorated and clean and hygienic. The management and staff have worked well together to limit the disruption to the lives of residents caused by the current building work. Residents made positive comments about the staff’s kindness, skills and attitudes. They felt safe when being assisted with care. The providers have a well-developed training programme for staff. They support staff in their training so that residents and their representatives can have confidence in a well trained and supervised staff team. Staff stated that the informal and formal supervision supported them to do their jobs well. Staff were satisfied with the support from the management team. Courtlands DS0000009010.V331964.R01.S.doc Version 5.2 Page 6 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. Courtlands DS0000009010.V331964.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 Courtlands DS0000009010.V331964.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents are assessed so that they can be assured that the home can provide adequate care. EVIDENCE: The statement of purpose was not inspected in detail. However, the provider will amend the home’s statement of purpose and service user guide to reflect the changes in the facilities and accommodation resulting from the major building works during late 2006 and early 2007. The statement of purpose provides clear information on the admission procedure and on the assessment of each prospective resident’s needs, to ensure that these can be met. The Courtlands DS0000009010.V331964.R01.S.doc Version 5.2 Page 9 records for two recently admitted residents included comprehensive assessment and admission information from the commissioning authorities. This included information from specialists, hospital and health care workers. Prospective residents and/or their representatives are invited to contribute to the assessment process through completing a questionnaire. This covers their personal history and preferences. The home’s assessment format includes all the areas of a prospective resident’s health and social care needs, and is completed with them, wherever possible. However, it is essentially a tick-box format. Where prospective residents have more complex needs, a flexible format, which supports staff in recording informative expansions of the tick boxes, may be required. The home does not have dedicated facilities for providing intermediate care. The service can provide rehabilitative care for residents who intend to return to their own homes. A rehabilitation care package would require individual care planning and an assessment and information provided by health care professionals working with the person. The home’s manager and some care staff have undertaken training in rehabilitative care. Courtlands DS0000009010.V331964.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Written care plans direct and inform staff about the residents’ health and personal care needs so that these can be met. The healthcare needs of residents are monitored and addressed so that their needs are met. The arrangements for the management of medicines protect residents. EVIDENCE: All the residents’ records tracked had written care plans, which addressed their personal, social and health care needs, including their religious and cultural needs and personal preferences. There were records of regular reviews. These care plans were not consistently signed by residents or their representatives as evidence of their participation and agreement. The care Courtlands DS0000009010.V331964.R01.S.doc Version 5.2 Page 11 planning process includes consideration of the specific aims of a resident’s placement in the home. The staff are currently engaged in writing life stories with residents. This provides information which assists care staff in meeting the residents’ needs and understanding their preferences. Each resident has an identified key worker. The care plans for residents with more complex needs were not consistent in the level of direction and information provided to staff. Staff write informative daily notes, but these are not recorded consistently daily. The home has established good links with local NHS healthcare professionals and residents’ care plans include their healthcare needs. Community nurses visit the home at least twice weekly to provide treatment to residents requiring nursing interventions. All residents are registered with local GPs. Residents are assisted to access a range of healthcare professionals according to their individual needs and wishes. Staff record health care contacts and appointments for each resident. A private chiropodist visits monthly and a dentist and optician make regular visits. Residents reported that staff request guidance or a visit from the GP or nurse promptly when this is necessary. They felt that their health was well monitored. There are detailed written procedures for staff on the management of medicines. Senior carers, who have undergone training in the safe handling of medicines, deal with residents’ medication. Residents are asked to provide their written consent to administration. Medicines are stored in a locked cupboard in the office and administered around the home from a standard medicines trolley. The home used the Boots monitored dosage system. There are clear records of medicines received into the home, administered to residents and of unused medicines returned to the pharmacist. The storage facilities and the medication administration records were in very good order. A sample of a controlled drug was checked against the register and found to be accurate. Two residents currently retain and manage their medicine for themselves. They have suitable locked facilities in their room for this. Residents reported that staff were skilled and sensitive. They felt that staff respected their privacy and dignity, and they had confidence in them when they provided assistance and care. They said that they were “very well looked after” and had no complaints or concerns. The registered manager stated that staff receive training in the values underpinning care work during their induction. Courtlands DS0000009010.V331964.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, and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported in a lifestyle which accords as far as possible with their own expectations and preferences. A range of activities takes place which meets residents’ social, religious and recreational interests. The diet provided is varied and nutritious, with attention to individual preferences. EVIDENCE: The home’s statement of purpose provides information on the activities provided. The home has three separate lounges and a dining room to ensure that residents can choose whether or not to participate in activities. Residents’ hobbies and interests are considered during the assessment and care planning processes. The home employs two activities organisers; information on forthcoming activities is displayed on the home’s notice board. The residents stated that they are satisfied with the activities provided to them in the home Courtlands DS0000009010.V331964.R01.S.doc Version 5.2 Page 13 and there was enough to do. Residents were engaged, for example, in reading newspapers and books, knitting, conversation and receiving visitors. There is a varied programme of planned activities including keep fit, reminiscence and arts and crafts. There was an art session using a specific technique during the inspection where and residents were very satisfied with the attractive work they produced. There is a multi-denominational Christian service fortnightly. Residents reported that they were supported to live their preferred daily routine in relation, for example, to times of getting up, having breakfast and going to bed. This was confirmed by the range of times over which people were starting their day. Residents said that the visiting arrangements were flexible and satisfactory, and their visitors were made welcome. The home’s kitchen is included in the area of the building work. The provider has used a properly fitted out kitchen in a portable building at the rear of the home during this time. Each resident’s needs and preferences in regard to food are included in the assessment and admission process. The menu records detail a varied and wholesome diet. Residents made positive comments on the quality and quantity of the food. Residents were satisfied with the choices at breakfast, which include a cooked option. There is a four weekly rotating menu for lunch. Two main choices are available at lunch, with further individual preferences available. The menu is displayed on the notice board and is discussed daily with residents. We took lunch with the residents on the first day of the inspection. The main choices on were beef stew and dumplings cooked with Guinness, and a fish pie. This was an unhurried and pleasant social occasion with well-presented and appetising food. Residents reported that the choices at tea were soup, bread and butter, savouries, cake and fruit. Residents were enjoying a choice of home made cakes with their mid afternoon drink. Wine and sherry is generally available at Sunday lunch and special occasions. One resident is being assisted with eating at present. A number of residents require diets suitable for diabetes, and one resident is a vegetarian. Courtlands DS0000009010.V331964.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure that would ensure that complaints are listened to and acted upon. The provider has established arrangements to protect residents from abuse. EVIDENCE: The home has a written complaints procedure that is readily available to residents and their representatives and complies with the standard and regulation. The registered manager retains records of complaints and compliments. There have been no complaints recorded since the last inspection. Residents’ individual views are sought through the assessment and care planning process; there are regular residents’ meetings. Residents said that they had not felt the need to make any complaints, but they were confident that the registered providers and registered manager were approachable and would address any issues that they raised. Courtlands has an adult protection policy and procedure which complies with the Cornwall Multi-Agency Adult Protection Code of Practice. Staff receive Courtlands DS0000009010.V331964.R01.S.doc Version 5.2 Page 15 training in adult protection following their induction and as part of their NVQ level 2. The provider is introducing refresher training for staff in safeguarding vulnerable adults and the registered manager has completed specific training as a trainer in this area. The home had a copy of the Cornwall Multi-Agency Adult Protection Guidance and the Alerters’ Guidance. Courtlands DS0000009010.V331964.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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is accessible, well maintained and safe. The current building work will result in a significant improvement to the premises and facilities. The premises are clean and hygienic providing a pleasant environment and reducing risks to residents. EVIDENCE: The home is located on the edge of the village of Rosudgeon on the main road between Penzance and Helston. Building work to provide seven bedrooms with en suite facilities, a new dining area, an improved kitchen and a two new Courtlands DS0000009010.V331964.R01.S.doc Version 5.2 Page 17 staircase towers is due to be completed in April 2007. This work will improve the accommodation and facilities, but will not increase the number of residents that the home is registered to accommodate. The occupancy of the home has been reduced, as there has been no access to parts of the building. Management and staff have worked together effectively to reduce the impact on the residents. The main entrance to the home will be in the new area; there is currently a temporary main entrance at the foot of the completed staircase tower. This entrance has a short ramp and a small threshold. The home has a shaft lift. This has not been in use during the building work as it is situated in the section of the premises being improved. There is also a stair lift between the ground and first floor. The grounds are spacious, with a secure area accessible to residents from the ground floor. The area around the front of the home has been a building site for some months. However, this work should be complete by the spring of 2007. The home was warm, well furnished and in generally good decorative order. The registered provider employs a maintenance manager, who ensures that necessary repairs and safety checks are carried out. One small area of the home adjoining the office area was showing signs of needing redecorating; the registered provider said that this area would be redecorated and recarpeted when the major building work is completed. Some chairs in the ground floor lounge were showing signs of wear and tear; the registered provider has replacements on order. The provider has installed a new assisted bath, and the tiling around this was just being completed. There are three shared rooms, which have suitable screening curtains. Residents reported that they found their rooms comfortable, and many rooms have been pleasantly personalised. The provider continues the programme of fitting suitable locks to residents’ bedrooms. During the building work there have been two rooms on the ground floor, and one on the first floor, providing sitting and dining areas. There is a new conservatory at the rear. Residents reported that the home was kept clean and fresh, and they were satisfied with the cleanliness of their bedrooms. The bathrooms and toilets were clean and hygienic. The vinyl flooring in one ground floor toilet is rather worn. There is extensive information and written procedures to guide staff on the control of infection. They are provided with suitable equipment for infection control. Staff reported that there was always a plentiful supply of gloves and aprons. There are hand washing facilities and disposable towels situated around the home. The provider has installed a modern sterilising sluice, which will deal effectively with commode bowls and bedpans. This was an outstanding recommendation from the last inspection report. The laundry has two washing machines and two tumbler dryers all of industrial standard. Courtlands DS0000009010.V331964.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, and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing and training arrangements ensure that the needs of residents are met. There is a good level of qualified staff. Recruitment procedures support and safeguard the residents. EVIDENCE: The roster shows that five or six care staff, in addition to managers, are on duty at busy times of the day and four care staff during the evenings. At night there are two waking staff and a further worker sleeping in on call. This is in addition to satisfactory levels of domestic and catering staff to ensure that staff providing direct care can spend time with the residents. Residents felt that there were sufficient staff and reported that call bells were responded to promptly. The provider has appointed two care managers who report to the registered manager. They provide support, supervision and training for staff and also deliver personal care. Staffing has not been significantly changed during the period of reduced occupancy caused by the current building work. The provider has a written recruitment policy and a comprehensive equal Courtlands DS0000009010.V331964.R01.S.doc Version 5.2 Page 19 opportunities policy. The records of two recent recruitments provided evidence that staff have undergone the required checks to determine their fitness to work with vulnerable older people. The registered manager retains records of recruitment interviews. Staff receive written statements of their terms of employment. There is a training plan for the home. Records of staff attendance at training courses are maintained on their files. Training is provided in house and through local colleges and independent training providers. All new staff receive induction training based on the Skills for Care common induction specification, with records maintained on file. One worker said that her induction had been very effective in preparing her for the work and she had received very good support. Staff were positive about the training they receive and said that it enabled them to do their jobs well. Staff records showed the regular delivery of required training, for example in moving and handling, food hygiene, and the safe handling of medicines. The provider has introduced training in dementia care through Truro College and in partnership with Cornwall Care Ltd. A number of staff will complete training in palliative care. Senior staff are training to deliver in-house training. The registered provider, Mrs Gillian Fairhurst, has completed an Institute of Leadership and Management qualification at level 5. The home has won the ‘Investors in People’ award. Just over half the care staff are qualified to National Vocational Qualification level 2 or 3, with six more staff in training for their qualification. Courtlands DS0000009010.V331964.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, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an experienced and qualified registered manager who has a sound understanding of her responsibilities. The provider uses a range of methods to obtain the views of residents and their representatives. The provider operates a clear system for safeguarding residents’ spending money. The health and safety of residents and staff are promoted and protected. EVIDENCE: Courtlands DS0000009010.V331964.R01.S.doc Version 5.2 Page 21 The registered manager, Mrs Julie Hocking, is an experienced manager in the care of older persons. She has completed her registered manager award, and recently completed a qualification in training, dementia care training to level 3, and training to be a trainer for adult protection. There are clear lines of accountability in the management of the home. Staff stated that Mrs Hocking was approachable and they had confidence in her. They felt that they received effective formal and informal supervision to support them to do their jobs well. The provider seeks residents’ views and the views of external stakeholders through the home’s formal quality assurance programme. The provider produced a summary of the outcomes of the last quality assurance exercise in October 2006. There is a clear and accessible complaints procedure. Residents reported that there are meetings on a regular basis, with records kept, and they are encouraged to express their views. Staff felt that they worked well together as a team to provide a high standard of care, staff meetings were very good and new ideas were welcomed. Most residents manage their financial affairs with the assistance of their relatives. The home’s financial manager acts as an agent to collect benefits for two residents, and retains records of the disbursement of their personal allowances. The home provides an arrangement for the safe keeping of residents’ spending money. The records detail payments in from the residents’ financial representatives, payments of cash to, or on behalf of, the resident, and a running balance. All transactions are receipted. The residents or their representatives provide their written authority for the home to make payments for them. It was recommended that the financial manager carry out a regular check on a sample of the records of spending money. The registered manager and maintenance manager lead on health and safety. There are records of regular fire system tests and equipment checks and fire drills. The manager has completed the home’s fire safety risk assessment. The records show staff training in all aspects of health and safety, including fire safety. Staff stated that the provider paid appropriate attention to health and safety. The registered manager provided in the pre-inspection information a detailed list of required maintenance and safety checks. We checked a sample of these against the original documents and found them to be accurate. The environmental health officer last visited in respect of food hygiene on 13 February 2007 and had made three legal requirements. The provider reported that these had all been addressed. There is a detailed general environmental health and safety assessment, covering every aspect of work and life in the home. Following a recommendation in the last inspection report, the registered manager has refined the risk assessment for the use of cot sides on beds. There is one example of this at present and a satisfactory risk assessment had been completed. Courtlands DS0000009010.V331964.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 X X 3 X X 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Courtlands DS0000009010.V331964.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The care plans for residents with more complex needs should provide consistently detailed directions and information to staff so that they can meet the residents’ diverse needs. Care staff should record a daily entry in each resident’s care plan notes. Residents or their representatives should sign their care plan to evidence their participation and agreement. 2. 3 OP7 OP7 Courtlands DS0000009010.V331964.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Courtlands DS0000009010.V331964.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. 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