Inspection on 03/05/05 for Deerhurst

This inspection was carried out on 3rd May 2005.

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

Deerhurst 09/02/07

Deerhurst 19/12/05

Deerhurst 16/12/04

Deerhurst 24/06/04

Deerhurst 03/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Deerhurst 10 Deerhurst Soundwell South Glos BS15 1XH Lead Inspector Grace Agu Unannounced 3 May 2005 09:30 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 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. Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Deerhurst Address 10 Deerhurst Soundwell South Glos BS15 1XH 0117 9041170 0117 9041171 deerhurst@brunelcare.org.uk Brunelcare Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Carol Burt Residential Care Home with Nursing 66 Category(ies) of OP Old age x40 over 50 years registration, with number DE Dementia x26 over 50 years of places Up to 5 placements of day care per day Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Manager must be a RN on part 1 or 12 of the NMC register Staffing notice dated 21/2/1997 and Amendment dated 29/4/05 applies May accommodate up to 26 persons aged 50 years and over with Dementia May accommodate up to 40 OP Old age persons aged 50 years and over. May accommodate up to 5 placements of day care per day Date of last inspection 16 December 2004 announced Brief Description of the Service: Deerhurst is a purpose built home, registered in March 1997 and operated by Brunelcare. Mrs Carol Burt registered manager with the Commission for Social Care Inspection.The home is situated in a residential location, within a quiet cul-de-sac and is accessible to local shops, amenities and bus routes. The property provides bedroom and communal accommodation over two floors for sixty service users. Bedroom accommodation is provided in good-sized rooms with ensuite facilities (a toilet, sink and walk in shower). All areas of the home are accessible via two lifts.The home is divided into three units. The two units on the first floor provide general nursing care for service users and the third unit on the ground floor is specifically designated for people with dementia. Access to this area is by the use of an electronic keypad that offers protection to this group. Each unit has a lounge and dining room. There are a suitable number of bathrooms and toilets with adaptations to meet the care needs of service users. Appropriate equipment is provided for individual use, based on the personal and nursing care needs. The home has currently redeveloped the facilities, providing an additional six beds for service users with dementia. This was completed in April 2005. As a part of the redevelopment, a link corridor was built from one end to the building to the other, forming an enclosed garden area. The home is set in its own grounds with attractively maintained gardens.Car parking is available for several cars. Visitors are welcome in the home at any time. a Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven hours and was a follow up inspection of the new completed extra six beds on the Burden Trust unit. Two inspectors visited the unit on 25/4/05 before it was opened on 27/4/05 following the recommendation. The unit was found to meet the entire requirement to include the installation of a keypad to the entrance of the unit. Generally the home was found to be clean, warm homely and well lit. The residents were found relaxed and looked well cared for, those spoken with made positive comments about the home and were satisfied with the care they received at the home. Staff were seen interacting with residents and dealing with residents with challenging behaviour in a sensitive and professional manner. What the service does well: A Comprehensive service users guide is given to the prospective service user to enable them to make an informed choice about living at Deerhurst Nursing Home. The prospective service user is informed on admission of a one month trial to enable them to make an informed decision whether to stay. High quality care planning system, which is holistic, is in use and this specifies how identified needs are to be met. Care plans are regularly reviewed. Meaningful activities are provide for service users and ensures that individual interaction is provided as necessary. Good meals are provided for the residents and staff ensure that meals are not hurried and residents who are unable to feed themselves are fed in a respectful, sensitive and dignified manner. A robust complaint procedure is in place and all complaints are investigated properly and action taken where required. There are ongoing training courses to enable staff to meet individual residents needs and ensure residents are protected from harm and abuse. A stringent recruitment procedure is followed to ensure that appropriate staff are employed at the home. The home is adequately staffed to include care and domestic staff. Aids and equipment are provided in sufficient quantity to assist care staff in meeting the needs of residents. Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 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. Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 123456 The process of admission of prospective service users is comprehensive, detailed and well planned to enable the service users make a choice of moving to the home with the assurance that their needs will be met. EVIDENCE: The home’s statement of purpose has detailed information about services and facilities provided at the home. The manager stated that the service user’s guide ‘About Deerhurst’ is given or sent to the prospective service user or their representative when they visit to look round. Two service users’ files contained ‘License to Occupy’ which is Brunelcare’s Terms and Conditions. This document contained fees to be paid and other extra charges (Hair dressing and chiropody). This document is issued to both self-funded and local authority funded residents. Two care files of recently admitted residents contained preadmission assessments and care plans completed on how the assessed needs were to be met. One resident’s family member stated that she is satisfied with the care of her/his relative; she stated ‘Manager came to see my relative and told me the home can look after him/her’. Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 Page 9 Staff spoken with stated that they have received training on dementia care to enable them meet the needs of service users admitted on the Burden Trust. Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7891011 The home offers care and support to service users throughout their life and towards the end, it also protect service users by reviewing their health needs and there is appropriate drug administration. EVIDENCE: Nine care plans were reviewed. There was evidence of pre assessment before admission to the home. Assessment on admission and individualised care plans detailing how these needs are to be met. This is followed up by monthly reviews and intervention if needs change. There is a comprehensive care plan of one service user recently admitted to the home. The detailed specific drug regime from the hospital is followed religiously and professionally; the details of all health professionals to contact in an emergency were in place. All equipment and aids needed for meeting his/her needs are in place. The service user’s relative stated that she/he is satisfied with the care given to his/her loved one at the home. She/he praised the manager and the care staff and stated’ I didn’t know that such a place existed. It is like being at home. They said I could make myself a cup of tea in the servery. We are grateful’ The Registered Nurses met on the unit spoke confidently about how the service users need was being met and viewed continuing care as a challenge and a learning experience for nurses working outside the hospital environment. The Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 Page 11 manager echoed what the nurses said and hoped that this would not be the last experience. Other care files looked at had care plans, which were person centred. One service user spoken with said ‘staff let me get up when I want to. There is no hurry’. There was evidence of likes and dislikes in the care files. One care plan stated that the service user likes to have a sleep in the afternoon. There were entries in the daily report to evidences this. The care files had evidence of visits by health professionals to include General Practitioner (GP) chiropodists opticians and Dentists. There was evidence of pressure sore audits and risk assessment for pressure sores and appropriate intervention. Wound care plans were in place along with treatment required for managing wounds. One care plan viewed had a care plan agreement, which was not signed by either the service user or the representative. Medication administration was checked on one unit and was found to be satisfactory. There was medicine policy in place. Evidence of receipt and disposal of medication was seen. The controlled drugs were properly recorded and signed by two registered nurses and balances were correct. The controlled drug of a deceased service user was noted and the registered nurse stated that it would be disposed of after seven days. Care staff were noted knocking on doors before going into service users rooms. One service user stated, ‘staff treat me with respect but sometimes they don’t wait before coming in, it may be because I am a bit deaf so may not have heard them’. Another service user stated ‘staff make sure the door is closed when I am bathing or using the toilet’ Staff were noted interacting with service users in a respectful manner. Evidence of service users wishes upon death was seen on the care files. One service user’s care file contained contact details of the vicar to visit if he/she became very ill. Staff have attended bereavement and loss training to gain understanding of how to meet service users’ needs when terminally ill and at time of death. Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 Page 12 Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12131415 The home provides meaningful activities to service users, enables them to maintain contact with families and friends end ensure that choice is provided in respect of meals and meal times. EVIDENCE: Care files examined contained activities plan, which is completed by the service user or representative on admission to enable the home to plan a suitable activity based on the details given. Record of activities was noted in each service care file. Session recorded included bingo, music entertainment and one to one sessions such as chatting and reading. A service user who declined to join in activity was recorded and reason for decline. Four service users were seen participating in religious activity (Holy Communion) in private. Other service users were noted having their hair done in a designated hairdressing room on the ground floor. Two relatives spoken with confirmed they are able to visit the home at any time. One service user stated that her her/his family regularly visits every week. Service users spoken with stated that they have a choice of when to get up and retire, choice of having meals in their room and choice of having a rest on the bed in the afternoon after lunch and a choice of participating in any leisure activities at the home. Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 Page 14 The two-week menu seen contained varied nutritional meals. There was a choice of two meals at lunchtime on the day of inspection namely Cottage Pie or Breaded Plaice with potatoes and fresh vegetables. Rhubarb and custard, ice cream of fruits for pudding. There was freshly made cakes for afternoon tea. Staff were noted assisting service users with meals and those who were unable to feed themselves were fed in a sensitive and dignified manner while interacting with them. Service users spoken with said they enjoyed the meal. One service user said ‘they always give us good food here’. Another one said the ‘food is very nice’. Part of the lunch time meal (puddings) was noted dished out individually on the trolley and left uncovered outside the servery while the service users were still having their main meal. This was discussed with the manager who said she would ensure that this practice is not repeated. The kitchen was found clean and tidy. Fridge and freezer temperatures were recorded regularly. The chef is a qualified cook with Advanced diploma in food safety. All kitchen assistants had achieved NVQ 2 in catering, however had not attended specific training on Control of Substances Hazardous to Health (COSHH). The manager explained that all staff had attended Health and Safety training and that COSHH is a part of the health and training. It was recommended that kitchen and laundry staff attend specific COSHH training to enable them to have a better understanding of the chemicals used at the home. The food processor in the kitchen was found with food particles some grime and flaking paint which exposed the metal work on the food processor. The chef stated that the food processor was serviced twice a year but could be hard to operate sometimes, vegetable oil is applied to make it easier to operate and this tends to build up. The chef also stated that the processor is cleaned after each use. This was brought to the attention of the manager. It is required that the food processor be refurbished and cleaned to rid it of the grime and food particles or purchase a new one to ensure food safety and protect service users. Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 161718 Service users are able to complain and are confident that the home is able to protect them from abuse. EVIDENCE: The home has complaint policy and procedure, which is displayed, in the main reception and at the nurse’s station in the three units. The complaint procedure is also included in the service user’s guide; there was information about the Commission for Social Care Inspection (CSCI) to enable service users and their relatives to contact the Commission if they were not satisfied with the outcome of their complaint. The complaint logbook contained one complaint from a relative about the new building work. This complaint was satisfactorily investigated and action taken was recorded. There was also a policy on Protection of Vulnerable Adults from abuse. There was a copy of South Gloucestershire Joint Policy on Protection of Vulnerable Adults. There was also a Whistle blowing policy and procedure to enable staff to report any bad practices without fear of reprisal. Staff spoken with stated that they had attended training on abuse. One staff stated ‘I will report any abuse to the manager’. New staff file viewed contained Criminal Record Bureau checks and two suitable references before commencing employment. Manager stated that all registered nurses working at the home had Personal Identification Number verified by the Nursing and Midwifery Council (NMC) before commencement and periodically. Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1920212223242526 The home has a safe, clean well maintained environment, comfortable bedrooms and specialist equipment suitable for service users needs. EVIDENCE: The home was found clean, tidy and free from offensive odours. Air freshener units were installed on the corridors and the visitor’s toilet on the ground floor. A link corridor is built as a part of the new six bedroom development on the dementia unit. This corridor connects two ends of the unit to form an enclosed garden area for service users on Burden Trust unit. The unit has a key padded entrance to ensure protection. All bedrooms have en-suite facilities consisting of a toilet, wash hand basin and a walk in shower. The six new completed bedrooms on the dementia unit have similar facilities. All bedrooms viewed were personalised, colour coordinated, clean and pleasantly furnished. One service user met in her/his room stated that she/he felt comfortable in her room. All the corridors have handrails fitted on both sides. The toilets and bathrooms had grab rails and various manual handling equipment and aids to assist the Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 Page 17 staff with meeting service users needs. Staff were seen using this equipment in a professional manner. One service user was noted being assisted by staff to walk with a Zimmer frame. Some service users were noted using specialist cutlery and plate guards on a non slip tablemat to maximise their independence. Staff were seen attending to service users wearing gloves and aprons, indicating awareness of infection control. The laundry includes washing machines with sluicing facilities. The laundry was noted with large quantity of unwashed clothing, the laundry assistant stated that one of the machines had broken down, it had been reported to the manager and the home was expecting an engineer to arrive to repair it. Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27282930 The home’s recruitment process demonstrates safeguards are in place, and also ensures staff competency, adequate numbers and skill mix along with training to protect service users. EVIDENCE: There is a robust recruitment policy and procedure in place to ensure that only appropriate staff are recruited at the home. A record of one recently appointed staff member contained required information to include CRB disclosures, two references, proof of identity and medical questionnaire to ensure fitness for employment. Manager stated that registered nurses working at the home has satisfactory checks from the NMC for proof of registration. A care staff that recently completed a course on ‘New Roles for nursing’ with South Gloucestershire Council was met inducting a new staff member. She explained that the course involves undertaking simple tasks such as dressings observations, blood taking, to relieve registered nurses to perform more demanding clinical duties. This care staff is also an equal opportunities and manual handling trainer as well as NVQ Assessor. These roles enable her to spend time with new staff to ensure that they are competent before being allowed to work independently with service users. All staff spoken with at this inspection stated that they have achieved NVQ level 2 in care and have attended various training to include NAPPI (Non Aversive Physical and Psychological Intervention), Manual Handling, First Aid, Health and Safety, Food hygiene and Infection Control. One staff stated that’ training here is brilliant’. Another staff stated that she/he came here because ‘they train you properly to do your job’. This demonstrates that Brunel Care is committed to Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 Page 19 providing good service by ensuring that it’s staff are adequately trained and are competent to meet the needs of service users. Although the home has care staff vacancies, there was adequate numbers of staff to meet the needs of present category of service users. On the rota, there were three registered nurses; eleven care assistants (excluding one on induction) on morning shift, three registered nurses, seven care assistants on afternoon shift, and three registered nurses and three care assistants on night duty. The manager stated that there is also a care staff from 4pm –10pm to assist with the high demand of service users needs at that time. This was evidenced on the rota. As a condition of registration for the six new beds in the dementia unit an additional staff is expected to be on duty when the unit has full occupancy to ensure that service users needs are met and they are adequately protected. One service user stated ‘staff are always there when I needed them’. Separate staff work in the kitchen and laundry and for domestic duties. There is also an activities organiser and an administrator. Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3132333435363738 The home benefits from good leadership and management; its practices have offered protection to health and safety of service users. EVIDENCE: Carol Burt remains the manager at Deerhurst. Service users, staff and relatives spoken with on the day of inspection commented positively and highly on the Manager’s ability to manage the home. One service user stated ‘she is good’ another stated ‘Manager is excellent’, one relative said ‘manager is hard working. Two staff members stated ‘ manager is approachable and would listen when you go to see her’. On the day of inspection, although supernumerary, she was met in nurses uniform and on several occasions seen on the units interacting with staff and service users. The manager stated that she was interviewing for the post of deputy manager who will be responsible for dealing with clinical issues at the home. Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 Page 21 Staff were supervised regularly, staff members spoken with stated that they have had supervision. This was evidenced in the staff files viewed. One registered nurse stated that she had attended supervision and appraisal courses to enable her to supervise the care staff on the unit. The home has different ways of monitoring the quality of its services. These include Regulation 26 visits by the provider, care planning reviewing processes, residents meetings, staff meetings, policies and procedure reviews, pressure sore, wound and falls audits. The home has a structured induction programme. One care staff met on the day teaching manual handling to a new care assistant said that ‘ it takes as long as it takes for induction’. This to ensure that the new staff member is competent and confident to work with service user to meet their needs. Care records were seen locked in cabinets in each unit and keys held by the Nurse in charge. The manager stated that one service user on self medication has a lockable cupboard for his/her medication and had been risk assessed before commencing self-administration. All staff and other records are kept locked in the manager’s office. The fire logbook is well maintained as well as the home maintenance book. The manager stated that arrangements are being made to install a fire alarm panel in the new unit for easy detection if the alarm goes off. The manager also stated that the head office is dealing the problem with emergency lightings, which is currently not working and would also update the call point in the new unit. Staff have attended fire lectures and fire drills. There is a service record of the lifts, hoists, Nurse Call system, fire alarm service and portable appliance tests (PAT) of all electrical appliances. The administrator manages the personal spending allowance of service users and this will be viewed at the next inspection. It scored 3 at the last inspection. Accidents were recorded and followed up. Policies and procedure viewed include whistle blowing, Infection Control, Medication, Manual Handling, confidentiality, Complaint, Training, Death and Dying and Challenging Behaviour. Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x x 3 3 3 Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 Page 23 NO Are there any outstanding requirements from the last inspection? 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. 2. 3. Standard 7 38 15 Regulation 15 12 12 Requirement Timescale for action 5/6/05 Ensure that service user care plan agreements are duly signed Ensure that a kitchen equipment 5/7/05 is refurbished or a new one purchased. Ensure pudding served to service 11/5/05 users are covered between transportation from the kitchen and serving. 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 38 Good Practice Recommendations Domestic staff should have specific training on COSHH. Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 Page 24 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 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 Deerhurst D56 D05 OP UV S20237 Deerhurst V208958 030505 Stage 4.2.doc Version 1.30 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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