Inspection on 29/06/07 for Emsworth House

This inspection was carried out on 29th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Emsworth House 24/06/08

Emsworth House 15/11/06

Emsworth House 27/09/05

Emsworth House 24/05/05

Emsworth House 15/02/05

Emsworth House 26/10/04

Emsworth House 09/03/04

Emsworth House 18/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Emsworth House Emsworth House Close Havant Road Emsworth Hampshire PO10 7JR Lead Inspector Pat Griffiths Unannounced Inspection 10:00 29th June 2007 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 Emsworth House DS0000037245.V338776.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. Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Emsworth House Address Emsworth House Close Havant Road Emsworth Hampshire PO10 7JR 01243 373016 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) Hampshire County Council Mrs Melanie Jane Brodison Care Home 79 Category(ies) of Dementia (79), Dementia - over 65 years of age registration, with number (79), Old age, not falling within any other of places category (79) Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users must be over 60 years of age on admission. Date of last inspection 15th November 2006 Brief Description of the Service: Emsworth House is a local authority care home, under the management of Hampshire County Council. The home is registered to accommodate up to seventy-nine older people, providing long stay residential or nursing care for older people as well as those with a diagnosis of dementia. The home is situated in a residential area of Emsworth, within easy access of local community and health care facilities and was renovated and refurbished in January 2007. The home is separated into two wings and the accommodation is on two floors, which are accessible by passenger lift. There are lounge/diners on each floor as well as small sitting areas in different parts of the home and there is a courtyard garden in the centre of the home. All bedrooms are single, the rooms in the nursing wing have en-suite facilities, but not those in the residential wing, there are sufficient bathrooms and lavatories on each floor. The residential wing is connected to the nursing wing on both floors. The fees charged range from £392-434 per week, with extra charges for hairdressing and personal toiletries. Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This fieldwork visit was unannounced and took place on 29th June 2007. All key standards were examined and during the course of the day the inspector saw different parts of the home, looking at the communal areas, kitchen, laundry, bathrooms and some of the bedrooms. Documents and records were examined and staff working practices were observed where this was possible without being intrusive. Residents, visitors and staff were spoken to in order to obtain their views of the service that the home provides. Visitors that spoke to the inspector were positive about the care their friends and relatives received. The registered manager had completed and returned an Annual Quality Assurance Assessment [previously a Pre-Inspection Questionnaire] and three comment cards were received from residents in the home. All records referred to in the report were seen on the day and those in the home included care plans, staff files, policies and procedures and staff training records. Other information was used, such as notices received about incidents that have occurred in the home that the commission has received since the last visit made to the home in November 2006. The manager was present throughout the day and was available to provide assistance and information when required. What the service does well: What has improved since the last inspection? The labelling of medications with the residents’ names has improved and the pharmacy have also agreed to individually label the ‘dial-up’ insulin injectors, which will protect the residents and ensure that they receive the correct medication. Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 6 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. Emsworth House DS0000037245.V338776.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 Emsworth House DS0000037245.V338776.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 outcome in this area is good. The judgement has been made using available evidence including a visit to the service. People wishing to use this service benefit from having a comprehensive preadmission assessment of their needs before moving into the home. EVIDENCE: The care plans and pre-admission assessments for three new residents where looked at, which confirmed that potential residents are assessed by a senior member of staff, usually the manager, prior to admission. The assessments were detailed and there was evidence that residents’ and their relatives were encouraged to be involved in the assessment process to ensure that all information is gained. The manager said that the assessment documentation was being updated and the ‘terms and conditions’ of the care contracts is now included in the information packs given to potential residents. Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 9 Care management assessments are also sought and staff reported that both of these pre-admission assessments formed part of the care planning for each resident. The manager said that all potential residents are offered visits to the home prior to admission, but many asked a friend or relative to attend on their behalf as they were not well enough. The home does not provide intermediate care. Emsworth House DS0000037245.V338776.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 adequate. This judgement has been made using available evidence including a visit to this service. Care plans do not always provide sufficient information to ensure that the people in the home, especially those with complex health care issues, have all their needs met. Staff medication administration practices do not always protect the residents. EVIDENCE: As part of the inspection process the care plans of three residents were examined to assess the information provided about how the staff in the home planned to meet the needs of the people who live there. All of the people living in the home had care plans in place, which included daytime and separate nighttime plans. The care plans were seen to contain information about the personal histories, strengths and abilities of each resident, social needs and healthcare needs. There were assessments and notes covering aspects of their care, such as nutrition, mobility, risk of falls, moving and handling Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 11 assessments and information in the daily records indicated when baths or showers were taken. Visits from healthcare professionals such as the GP or chiropodist are recorded on the ‘contact’ sheets that are each care plan. Whilst reading the care plans it was apparent that the reviewing and updating of some of the plans continues to be erratic and inconsistent. The plans for people living in the nursing wing of the home contained lots of detailed information, with information added daily and evidence that they were regularly reviewed and amended when the residents health or personal circumstances changed. A wound care plan was seen, with diagrams and details of the dressings that were needed. There was also evidence that the community ‘tissue viability’ nurse had advised the staff in the home about the care of the wound. On the ‘residential’ wing of the home the night care plans were seen to be up to date. The day time plans contained a lot of information, but some was dated 2005 and not relevant to the current care needs of the residents, and many of the plans had not been regularly reviewed or updated. Incidents had been reported, such as a fall, but the on-going observations or follow up were either not done or not recorded. The manager said that she would have been observed and had soon felt better, so nothing further was written. The home has medication policies and procedures in place, which the manager said were currently being reviewed by Hampshire County Council. One member of staff in each wing is responsible for the stock levels and ordering of medication in the home. The storage and management of medication is effective and records demonstrated that all medication coming into and going out of the home is monitored. Medication on the residential wing is received in ‘blister’ packs, which are disposable when empty. One of the local GP’s commented that it was an expensive method of providing medication, the manager said that that was how the pharmacy provided it. Action points were raised at the last visit regarding medication, to ensure that all medication is labelled with the residents name, that a record of all medication administered in the home is maintained and that all dosages must be given as prescribed. All medication received from the pharmacy is labelled, but a sealed box containing five ‘pen-type’ devices for administering insulin had not been opened so each device had not been individually labelled with the residents name. Following discussions with the pharmacy it has been arranged that in future all devices will be individually labelled, so this action point is met. Dosages of medication given and signed for were seen to be given as prescribed, so this action point is met. Each person in the home who is receiving medication has a Medication Administration Record [MAR] sheet, which is a chart indicating what medication is to be given and when, it also has a photograph of the resident, to ensure that the right medicine is given to the right person. Staff administering medication usually sign in the allotted boxes on the chart to Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 12 indicate that the medication has been given. It was noted that in the nursing wing of the home a lot of the MAR sheets had gaps, with no signatures, suggesting that medication has not been given or nursing staff had forgotten to sign the charts. Some of the medications not signed for included insulin and tamoxifen. The manager questioned the staff, who said that they had forgotten to sign the sheets, but had given the medication. The care staff on the residential wing had signed the MAR sheets correctly and there were no gaps seen on the day of the visit. The manager said that this matter had been addressed following the last inspection visit with discussion in staff meetings and in one-to-one supervisions sessions, but acknowledged that the staff practices had not been closely supervised. Residents that spoke to the inspector felt that staff supported them well, were respectful and made sure they were able to maintain their privacy and dignity as much as possible within the home. Staff were observed speaking quietly and appropriately to the residents during the course of the day. Emsworth House DS0000037245.V338776.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have good quality food and their diverse needs are generally well supported. EVIDENCE: The people who live in the home are encouraged to maintain contact with their friends and families and care plans emphasised the need for staff to support residents in this. Residents spoken with felt they were able to receive visitors at any time and that their visitors were welcomed into the home. The visitors’ policy was clear about the rights of residents to receive visitors and to meet with them in private. There are several sitting rooms and sitting areas available around the home where people could go and meet their visitors in relative privacy if they did not want to chat in their bedrooms or the communal lounges. There was a residents meeting on the day of the visit and relatives also attended. A member of staff attended the meeting and items such as the menu and activities were discussed. The manager said that ‘Magilocks’ are to be fitted to the doors between floors to ensure that residents do not wander Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 14 beyond their own floor or areas. People living in the home have said that they feel uncomfortable about other residents wandering into their rooms during the day and at night. The manager has offered them the opportunity to move to rooms in other parts of the home, but they have declined as they like the rooms they are in. Residents are able to lock their doors, but choose not to, many keep them open during the day as they like to see what is happening within the home. The food in the home is provided centrally by HC3S staff, which is Hampshire County Councils catering staff, and staff involved in the preparation and serving of food in the home were separate from and additional to the care staff. The cook said there was a four-week seasonal menu, which is written inhouse and the food ordered by the kitchen staff. The manager said that menu planning and special diets information was available to assist with menu planning. Meals were well-presented and individually served in adequate portions and included fresh vegetables. The lunch meal that was observed was a sociable occasion, the dining room is large, light and airy, with residents sitting in small groups at separate tables around the room. Staff support was available throughout the mealtime for people who needed it and this support was provided in a discreet, respectful and sensitive manner. Residents spoken with said the food in the home was good and that there was always enough of it, but some commented that they only liked the food ‘sometimes’. The food is cooked in a central kitchen and taken in a hot food trolley to the two wings of the home, the meals seen were hot and looked appetising. Glasses of squash or water were also available at each table. Activities are available in the home for the residents, but the home does not currently employ an activities organiser. The manager said that more care staff are going to be recruited and then the current staff will organise the activities as they enjoy it and three have already completed ‘Vitalize’ armchair exercises training. Activities that are currently provided include the vitalize armchair exercises, bingo, hairdressing and board games. The manager said that none of the residents currently go to church, but ministers from the local churches visit the home. Emsworth House DS0000037245.V338776.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff training in adult protection, and the knowledge that all complaints are dealt with appropriately usually safeguard the people who use this service. EVIDENCE: The home has a complaints procedure in place and encourages residents or their friends and relatives to make complaints whenever they are not happy about the service they have received. There had been some problems earlier in the year when a relative had asked how to make a complaint and had been told that the home was waiting for the new complaint forms. She says she did not make a complaint because no one asked her what was wrong or what they could do about it. It was discussed with the manager, who said that the relative had spoken to her and the matter had been discussed. The manager said that five complaints had been received in last twelve months, and they had all been resolved within 28 days, with only two complaints being upheld. A resident said that they did not know who to speak to if unhappy, and did not know how to make a complaint, and the manager said that this would be addressed and all people living in the home would be made aware of the complaints procedure and copies of it would be made available. The care manager of one of the residents commented that the staff in the home respond appropriately if a person raises a concern. Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 16 The procedures in the home for responding to instances of suspected abuse were clear and staff spoken with were clear about their role within the procedures and about the nature of abuse. Training records demonstrated that all staff received training on abuse issues as part of their induction as well as further, ongoing training throughout their employment Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 17 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. People who use this service live in a safe, well maintained, clean, and hygienic home EVIDENCE: The extension and refurbishment of the home, which affected all areas and departments, was completed in January 2007. The decoration of the home and the furniture provided in the home are of good quality and contributed to the comfortable, homely feel in the building. During the visit the inspector saw different parts of the home, which included the communal areas, the kitchen, the laundry and some of the bedrooms. On the day of the visit the home was seen to be clean and tidy, with no malodours. The care staff in the home are supported by cleaners, laundry, housekeeping and kitchen staff. Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 18 All bedrooms in the home provide single accommodation, the forty-eight rooms on the nursing wing have en-suite facilities and the thirty-one rooms on the residential wing have sinks, with lavatories and bathrooms in each corridor. The manager said that twenty of the bedrooms had overhead hoists in place, which makes moving those residents much easier and is more comfortable for them. The accommodation is over two floors and there is a lift to enable staff and residents to move easily between the two floors. The lift is maintained regularly and was spacious enough for staff to push wheelchairs in and out of it comfortably. Bedrooms seen by the inspector had been personalised with pictures and ornaments and the manager said that if there was room, potential residents were able to bring small items of furniture with them when they moved in to the home. The central kitchen was rebuilt as part of the refurbishment programme and food is taken to all parts of the home in electric ‘hot trolleys’, the kitchen was clean and busy at the time of the visit and the chef showed the inspector round the kitchen explaining that they were using the new documentation for recording the fridge, freezer and cooked food temperatures as well the kitchen cleaning routines. An environmental health officer visited the home following the refurbishment and gave the home a ‘satisfactory’ report. The home has seven dining areas, some of which are lounge diners, and the residents can choose where they would like to have their meals. There are also ten lounge areas in the home, some of which are quiet rooms and do not have a television. There are also two visitors rooms, which the manager said did not get used very often. The laundry was also refurbished, with new washing machines and dryers fitted. It is well managed, with staff on duty from 8am – 8pm, and hygiene standards are maintained in order to decrease the spread of infection. There is a separate washbasin for staff to wash their hands and plastic gloves and aprons, which are also available throughout the home. There are labelled plastic baskets for residents clothing, to reduce the risk of the wrong items being given back to residents. The garden has several different areas for the residents and the manager said that there are still areas that have not been finished which are waiting for lawns to be laid. There is a central courtyard garden that is enclosed and secure for the people who live in the home and like to wander around, it contains seating areas, flowers, shrubs and bird feeders and is visited by lots of the local wildlife. Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 19 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. Robust recruitment practices and staff training protect people who use this service. EVIDENCE: The manager said that the home currently had forty residents because of the staffing levels and she expects to admit more residents once more staff have been recruited. During the week of the visit, twenty shifts had been covered by agency staff, who are usually the same people to ensure some continuity of care for the residents. The manager and inspector discussed methods of ensuring acceptable staffing levels and agreed that staffing levels should be determined by assessing the needs of the residents and calculating the hours of care needed and staffing numbers that are required to meet those needs, not just by the number of residents in the home. On the day of the visit there were eleven care staff on duty in the morning and eight in the afternoon/evening for the three areas of the home. There was also a trained nurse on each floor in the nursing wing and the operations manager in the residential wing. Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 20 The files of three recently recruited staff members were looked at which demonstrated that the home has a robust recruitment procedure and all necessary checks, such as obtaining references from previous employers and Criminal Records Bureau disclosures, are completed before staff start work in the home. Staff receive regular supervision and training needs are identified through this process. Training records showed that staff are able to access a wide range of training and those staff spoken with said the training was of a good quality. The records indicated that all staff had attended mandatory training such as manual handling and fire safety. Further training is planned and will include palliative care, medication administration, first aid, fire safety and adult protection. Staff were seen to interact well with the residents and spent a lot of time talking to them and ensuring they were comfortable. The approach of the staff in the home was very positive and contributed to a calm, happy and supportive atmosphere. Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 21 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. People using the service are usually safeguarded by good management and their privacy, independence and dignity is promoted. EVIDENCE: The registered manager of the home is a very experienced registered nurse and has the necessary skills and qualifications to manage the home. She continues to undertake further training to develop her professional and clinical practice and is able to support and encourage staff to provide good care. Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 22 A relative commented on one of the cards returned to the commission that they were concerned that the manager did not always seem to be available, and whilst there is a senior nurse on duty they are not sure where her office is, having only seen her a few times. This was discussed with the manager, who said that she was usually in and around the home, but also goes out to assess potential residents before they are admitted to the home. The nurses’ office had recently been moved into a different room, which is no longer in the middle of the nursing wing but in one of the corridors and the original room is now available as a sitting room with access to the garden. The manager said that this matter would be discussed with friends and relatives of the residents and stressed that there were always senior care and nursing staff on duty in the home, and any member of staff could be approached initially if there were concerns or complaints. Friends and relatives, who had come in for a residents meeting, spoke to the inspector and were very positive about the staff and the management of the home, saying ‘staff act and listen to what you say’ other comments included ‘I have no criticisms, it’s a wonderful place, always clean, lovely staff’ ‘I went to eleven other homes before letting my mother come to this home!’ The manager said that quality assurance surveys were being done ‘in-house’ and the results had not been collated. It is expected that the surveys will be done annually and the results made available to any interested parties. Health and safety issues are well managed within the home and staff receive regular health and safety related training. Workplace risk assessments were in place and kept up-to-date. No outstanding health and safety issues were observed during the inspection visit. Records showed that all equipment was regularly serviced. The fire records were seen and demonstrated that all equipment is regularly tested and emergency plans were in place Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 Requirement All care plans must reflect the current needs of service users and be kept under regular review The registered person must ensure that a record of all medication administered is maintained. The previous timescale of 30/12/06 was not met Timescale for action 30/09/07 2. OP9 13(2) 17(1) (a) Schedule 3 (k) 30/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Emsworth House DS0000037245.V338776.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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