Inspection on 14/05/07 for Firgrove Nursing Home

This inspection was carried out on 14th May 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

Firgrove Nursing Home 06/04/06

Firgrove Nursing Home 29/11/05

Firgrove Nursing Home 19/07/05

Firgrove Nursing Home 14/09/04

Firgrove Nursing Home 26/04/04

Similar services:

Springfield House

The Shelley

Thorndene

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Firgrove Nursing Home Keymer Road Burgess Hill West Sussex RH15 0AL Lead Inspector Mrs D Peel Unannounced Inspection 10:20 14th May 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 Firgrove Nursing Home DS0000048351.V336094.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. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Firgrove Nursing Home Address Keymer Road Burgess Hill West Sussex RH15 0AL 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) 01444 233843 Firgrove Care Home Limited Mrs Sareeta Kumaree Lollchand Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (6), Physical disability of places over 65 years of age (6) Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A maximim of 6 service users in the PD, PD (E) category maybe admitted Only service users over the age of 50 years in the category of Physical Disability (PD) maybe admitted A maximum of 35 service users may be accommodated at any one time 6th April 2006 Date of last inspection Brief Description of the Service: The home is a two storey converted detached house in a residential area of Burgess Hill, West Sussex. Accommodation is provided in twenty-three single and six double rooms, which are located on the ground and first floors. Two vertical lifts provides access to each of these floors. Communal facilities, which are located on the ground floor, include a sun lounge, a lounge/dining area, which is roofed in glass and has tables with umbrellas to provide shade when needed and a small reception/sitting area. There is a large garden to the rear of the property, which is accessible to residents from a patio area outside the garden lounge. There is private parking to the front of the house. The current fees being charged by the home are from £550 to £900 per week. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by Mrs Diane Peel on the 14th May 2007. During this visit the intended outcomes for 29 standards were assessed; these included the key standards for care homes providing a service to older people. Prior to the visit to the home the inspector reviewed information gathered about the home and comments made in satisfaction questionnaires returned from three relatives, one person living at the home and one Health Care professional. A further three satisfaction questionnaires were received during the inspection process, two from a relatives and one from a person living at the home. The Annual Quality Assurance Assessment was returned to The Commission for Social Care Inspection (CSCI) and this was used to address areas of improvement which the manager and provider had carried out and also identified areas for further improvement. During the visit a tour of the home took place with all communal areas and private accommodation visited. A case tracking exercise for four residents was undertaken to look at how the assessed needs of this group of residents with diverse needs were being met. Residents were spoken with to gain some information about what it is like to live at the home either in the privacy of their rooms or in the lounge. Staff were observed assisting and interacting with residents in the lounge/dining area. The atmosphere at Firgrove was relaxed and staff were observed to speak to residents meaningfully taking time to explain things when they seemed confused. During this visit the records of three staff were inspected and staff were spoken with informally to find out what it is like to work at the home and to discuss aspects of residents care plans and assessed needs. What the service does well: Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 6 The home is clean, well maintained and provides people with a homely friendly environment to live in. Residents have comfortable rooms which they have been encouraged to make their own. There are a number of areas, in which people living at the home can meet with their visitors, these includes extensive well kept gardens and a sun lounge. People visiting the home and people living at the home say that visiting is flexible and that visitors are made to feel welcome. What has improved since the last inspection? What they could do better: The Annual Quality Audit Assessment returned to CSCI identified that some improvements could be made to ensure that there is documented evidence of the discussion regarding feedback of reviews with relative and people using the service by signing the entries. This had been identified as an action point for improvement within the next twelve months. An area of improvement which been identified on the Annual Quality Assurance Assessment returned to CSCI is that the home intends to introduce weekly menus which will be circulated to all residents in advance. Improvement identified by the registered person on the homes Annual Quality Assurance Assessment provided to CSCI is that a training matrix is to be put in place and further staff are to undertake an NVQ qualification. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 7 A clearer system for recording complaints should be used so that complaints could be clearly audited. 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. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5,6 People who use the service experience good outcomes in this area. People, who come to live at Firgrove Nursing Home and their families, have the information they need to make an informed choice about where they want to live and people’s needs are assessed before they move to the home, so that they know that the home can meet those needs. EVIDENCE: Firgrove Nursing Home has a Statement of Purpose and Service User Guide, which provide comprehensive information about the service, who it can offer a service to and how it will deliver the service. Information provided in the Annual Quality Assurance Assessment returned to CSCI reports that further information can be viewed on the website along with a brochure which can be down loaded. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 10 The Service User Guide details the homes policy for admissions which includes a “pre- admission assessment to establish to establish the suitability of all potential service users” and “all service users will be given an opportunity to visit the home prior to admission and to have a minimum trial period of four weeks.” People living at the home who returned questionnaires to the inspector reported that they felt that they had received enough information about the home before they moved in. The records of four people living at the home were viewed on this visit. All four included an assessment of need, which had been used to develop a plan of care. The manager now writes to prospective service users once the assessment has been carried out to tell them if the home can meet their assessed needs. This was observed to be in place for one person who had recently moved into the home. Firgrove Nursing Home does not provide intermediate care. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People who use the service experience good outcomes in this area. Care planning systems are regularly updated and they give clear information to assist with all aspects of health, personal and social care needs so that the changing needs of people living at the home can be monitored. EVIDENCE: Four care plans were examined at this visit to the home. All four care plans had signatures of agreement to the plan signed by either the person whose plan it was or their next of kin or advocate. The plans were observed to be informative and took an holistic approach to care which covered nursing needs as well social, and emotional and physical needs. Risk assessments were observed to be in place for moving and handling, the use of bedside rails and risk of falls. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 12 The records showed the monthly review, and review of risk of pressure areas, which also included monitoring of peoples weight each month. Daily records were observed to be being completed, hand over notes were observed which showed that care staff leaving the home were discussing each residents progress or problems with staff coming on duty. The Annual Quality Audit Assessment returned to CSCI identified that some improvements could be made to ensure that there is documented evidence of the discussion regarding feedback of reviews with relative and people using the service by signing the entries. This had been identified as an action point for improvement within the next twelve months. Two relative returning a questionnaire to CSCI reported that the home always meets the needs of their relative living at the home and two others reported that they usually meet their relative living at the home. One person commented, “Firgrove is a lovely place, and everyone cares. The care is very good.” The two residents returning questionnaires felt that the home always met their needs. A Health Professional returning a questionnaire reported favourably about the service and in a section asking what could be improved they had commented that they should “retain their current standards”. The home has a policy for control, storage, disposal recording and administration of medication. The Annual Quality Assurance Assessment returned to CSCI reported that this policy had been reviewed in February 2007. Medication is stored in a locked metal cabinet when being taken around the home by a registered nurse for administration to the people who live in the home. This was observed to be in use on the day of the visit. When not in use it is stored in a locked room with other medication prescribed for people who live at the home. A medication fridge is also in use in this room with temperatures being recorded. Disposal of medication was discussed with the manager and the storage of medication waiting for collection by a specialist disposal company was observed. Medication records sheets are kept and completed by registered nurses. The manager has introduced a quality audit system for regular checking of the medication procedures and medication administration records of five people Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 13 living at the home at a time. This system was observed to be in use at this visit to the home. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 14 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): 12,12,14,15 People who use the service experience good outcomes in this area. Activities are offered and residents are encouraged to maintain contact with their family and friends so that they so that they can satisfy their social and emotional needs. EVIDENCE: Comments viewed on the homes own quality assurance questionnaires returned to Firgrove were: “A flexible service, sensitive to needs” “ Respect for individual preferences”. People using the service on the day of this unannounced visit looked relaxed and staff were observed to offer choices about what people wanted to do and where they wanted to be. Photographs of events and activities, which had taken place in the home are displayed on the wall in the main lounge/dining area and on a notice board in the hallway of events. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 15 The religious practices of people living at the home were recorded in their care records. The manager told the inspector that people had the opportunity to take part in a group service to practice their believes but some people chose to have these needs met on an individual basis. Future entertainment from outside entertainers was observed to be advertised on the notice board in the hallway. Discussion with staff confirmed that a variety of activities are offered such as scrabble, ball games and bingo. It was observed that there was an extensive library of books available and some people had newspapers. One relative returning a satisfaction questionnaire to CSCI said, “ I did anticipate more activities”. “ There are occasional concerts and visits by church groups which are popular”. Out of the two people living at the home who returned questionnaires to CSCI one reported that there were always activities which they could take part in whilst the other person said that there were usually activities which they could take part in. On the afternoon of the visit a group ball activity was taking place in the lounge/dining area it was noted that care staff were encouraging those people present to take part. Information about arrangements for visiting are is provided in the Statement of Purpose and the visitors book viewed showed that there are plenty of visitors to the home. Comments observed in the homes own quality assurance questionnaires about visiting the home were: “ Visiting times are very flexible and I have been able to call any time, day, evenings and suppertime”. Comments made in satisfaction questionnaires returned to CSCI included: “ Visitors are always welcome and offered a cup of tea. If I have been unable to visit during the day I have been able to visit in the evenings”. People living at the home who spoke with the inspector about visitors were satisfied with the arrangements for visitors commenting that people were welcome at any time. The menu for the day was observed to be on display in the main dining area. The main meal of the day was listed as liver and bacon or sliced beef with Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 16 mixed vegetables and runner beans followed by a mincemeat sponge with custard. At suppertime the choices were listed as soup, welsh rabbit and salad or sandwiches. At lunch time the inspector joined the people eating their meal in the dining room for the main meal of the day. The meal was of a good standard. There were staff helping people who needed assistance to eat their meals and the mealtime was not rushed. Staff were also observed to discreetly ask people who were struggling “would you like me help cut up the meat”. Alternative deserts were observed to be offered by the cook during the mealtime and food provided to people who had softened diets was observed to nicely presented with pureed meat separated out from the vegetables. The manager told the inspector that a record of what people have chosen to eat is kept in the kitchen and the cook confirmed that people are asked what they want to eat each day. An area of improvement which been identified on the Annual Quality Assurance Assessment returned to CSCI is that the home intends to introduce weekly menus which will be circulated to all residents in advance. People who live at the home who spoke to the inspector about the standard of food were in the main satisfied with the choices and quality although one person reported that the standard was “variable”. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People who use the service experience good outcomes in this area. The complaints procedure enables those using the service so that they have the confidence that any complaints will be taken seriously and responded to. Arrangements are in place to protect people using the service from being place of harm or abuse. EVIDENCE: Firgrove has complaints procedure, which is included in the Statement of Purpose and Service User Guide and on display in the entrance hall. A record of complaints and letters and cards of appreciation were observed and the inspector advised that these should be separated out so that complaints could be clearly audited. It was observed that on the Annual Quality Assurance Assessment returned to CSCI that the complaints record is to be amended for audit purpose and more detail is to be recorded about the nature of the complaint and the outcome. One person returning a surveys to CSCI reported that they did not know how to make a complaint whilst others said that they did know to make a complaint. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 18 People living at the home whom the inspector spoke with about their satisfaction with the service all commented that they would speak to Matron if they had a complaint. The West Sussex Multi Agency Adult protection Policy was observed to be available in the office. Information in the returned Annual Quality Assurance Assessment reported that the homes own safe guarding adults and prevention of abuse policy was reviewed in February 2007. There have been two safe guarding adults investigations brought to the attention of CSCI. Both matters have been investigated through the West Sussex Adult Protection procedures. Observation of staff records and discussion with the manager confirmed that Criminal Record Bureau (CRB) and Protection of Venerable Adult (POVA) are carried out before employing new staff and that the majority of staff have had protection of vulnerable adult training, with other staff awaiting dates for their training. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 19 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): 19,20,21,22,23,24,25,26 People who use the service experience good outcomes in this area. The home is clean, well maintained and so people have a comfortable pleasant, environment to live in. EVIDENCE: The home was observed to be clean and the décor of a good standard on the day of this unannounced visit to the home. Accommodation is provided in twenty-three single bedrooms and six double rooms, located on the ground and first floor. There are two lifts, which provide access to the first floor. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 20 Communal areas consist of a lounge/dining area, which has a glass roof, a sun lounge looking out onto the well kept, rear gardens and a small sitting area in the entrance hall. Shared bedrooms had screens for use to provide some privacy and one person spoken with about sharing a room assured the inspector that they liked sharing a room for the company that they had. All bedroom doors now have locks on them so that people can choose to lock their door if they wish and the manager told the inspector that all bedroom doors (except for three which had been missed and the contractors were coming back to) now have smoke seals in place. It was also observed that self-closing devices have been fitted to all bedroom doors so that people who like to have their bedroom door open can do so without it being a fire hazard. At the last visit to the home there had been concern raised about the freestanding heaters. These have been removed and all radiators have radiator guards. Bathrooms and toilets were clean and it was observed that toilet aids brought to the attention of the registered person at the last visit in April 2006 had been replaced. Comments made in the homes own returned quality assurance questionnaires about the environment were: “living space pleasant and welcoming”, “accommodation is generally clean and well maintained “ and “there is a sense of homefullness”. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People who use the service experience good outcomes in this area. People living at Firgrove are protected by improved recruitment procedures and staff receive appropriate training in line with the residents assessed needs. EVIDENCE: A staff rota is available at the home and at busy times of the day such as lunch time the number of staff on duty allowed for staff to assist people who needed help to eat their meal without them being rushed. The recruitment records of three staff were examined at this visit to the home, which included the most recent person employed. They were observed to include evidence of Criminal Record Bureau (CRB) and Protection of Adults (POVA) checks. A job application was on file, notes taken in response to questioning at interview, two written references, photograph, proof of the persons identity and completed equal opportunity monitoring forms and health declaration forms. Each had record of the training that had been attended and any formal qualifications such as NVQ or evidence that a nurse was registered with the NMC. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 22 Induction booklets were observed for two staff whilst the other person had only been in post for a few weeks and was still undertaking the induction process. This person confirmed that they were still taking part in their induction. Improvement identified by the registered person on the homes Annual Quality Assurance Assessment provided to CSCI is that a training matrix is to be put in place and further staff are to undertake an NVQ qualification. There are currently 6 staff with an NVQ level2 or above and 5 staff working towards an NVQ level 2 or above. Comments made about staff in the satisfaction questionnaires returned to CSCI included: “The staff are always kind and caring but not always available on demand” “The staff are kind to residents and demonstrate skill in dealing with old people in a sensitive manner”. “ Firgrove is a lovely place and everyone cares. The care is good.” One resident returning a questionnaire to CSCI said, “ The staff are friendly and helpful. Every effort is made for my wellbeing and comfort”. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 23 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): 31,33,35,39 People who use the service experience good outcomes in this area. Systems are now in place to monitor the effective running of the home and quality of care so that people living at the home benefit from living in a home, which is well, managed. EVIDENCE: The manager is a registered nurse and has undertaken the process of registration with CSCI. One comment observed in the homes own quality assurance questionnaires was “ Excellent matron, supportive and skilled. Staff are very responsive”. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 24 Staff and people living at the home had positive comments to make about the management of the home. A quality assurance system is being used in the home. Audit systems have been introduced to monitor areas of practice and this is still being developed. to cover all aspects of record keeping. The satisfaction questionnaires of ten people who had returned questionnaires to the manager were observed with the majority of feedback being positive. The medication audit system was observed to be in use. The manager told the inspector that the responsible Individual acting on behalf of the company visits the home regularly as part of maintaining the quality of the service. The manager told the inspector that the home does not look after any service users monies. The home pays for any additional service such as hairdressing and then people’s advocates are invoiced for these additional services. It was observed in the records of one person that their finances were looked after under the court of protection. Staff induction records showed that staff have induction to safe working practices and staff records showed that further training is then provide. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 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 Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 26 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 OP16 Good Practice Recommendations The record of complaints should be separated out from compliments so that complaints can be clearly audited. Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 27 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 Firgrove Nursing Home DS0000048351.V336094.R01.S.doc Version 5.2 Page 28 - 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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