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Inspection on 29/09/06 for Ford Place Nursing Home

Also see our care home review for Ford Place Nursing Home for more information

This inspection was carried out on 29th September 2006.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Barchester Company has comprehensive records, policies and procedures in place that ensure the care offered to residents is suitable and safe. These documents from the care required to the maintenance checks within the building are thorough and counter checked by Senior Management. The ongoing improvement of the environment makes the Home a pleasant and comfortable place to live in. The Manager will keep her knowledge up dated and cascade the information to the staff team, which is very needy especially with the changing views of how people should be cared for at the end of their life. The Home works towards promoting independence and has an understanding of treating residents as individuals.

What has improved since the last inspection?

The Home has just introduced a new care plan format that staff are being trained to use with implementation being imminent. These documents should be clearer in detail and be focussed on the individual and give the whole picture of the persons needs to enable staff to carry out the appropriate support required to each resident. The Home has improved the environment by replacing old carpets in all the corridors, which gives a much cleaner, fresher look to the place. A large conservatory has made a nice sitting area for residents and a completed nurses area has improved the respect to confidentiality that was lacking previously. A new menu has just been introduced to improve the meals provided which has a four-week cycle with choice and is very varied to accommodate all tastes. The Manager has moved her office to be near the front door making her more accessible to families and residents.

What the care home could do better:

The Home needs to have procedures in place that will ensure the rota of staff is covered at all times and that a contingency plan is in place if and when the staff level drops for whatever reason. The personnel records need to be in place to ensure full details are obtained and stored for each staff member.

CARE HOMES FOR OLDER PEOPLE Ford Place Nursing Home Ford Street Thetford Norfolk IP24 2EP Lead Inspector Ruth Hannent Key Unannounced 29th September 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ford Place Nursing Home DS0000067712.V314438.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. Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ford Place Nursing Home Address Ford Street Thetford Norfolk IP24 2EP 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) 01842 755002 01842 750964 www.barchester.com/oulton Barchester Healthcare Homes Limited Mrs Denise Hubbard Care Home 49 Category(ies) of Old age, not falling within any other category registration, with number (49), Physical disability (49) of places Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Ages 55 and over Date of last inspection 15th December 2005 Brief Description of the Service: Ford Place is a 49 bedded nursing home caring for older people. The home, originally a family mansion, was refurbished in 1997 and an extension was added in 1999 with a further extension in 2005 It is situated in the market town of Thetford and is a short walk from shops and other local amenities. The gardens are a positive feature of this home, with landscaped views over the lawns and river, (which runs along the rear boundary of the property). There is a car park at the front of the home with easy access from the road. The older part of the building is on two floors and is accessed by a small shaft lift. The home was purchased in 2004 by Barchester Healthcare Ltd. Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is the completion of a Key Inspection that includes information received over a period of time since the last inspection and has been concluded with a visit to the Home. Contact made and reports sent by the Home since the last inspection is recorded with the Commission and will form some part of the information in this Inspection report. The Commission had received a pre inspection questionnaire and some comments from relatives, residents and one GP. A complaint had been received and investigated very quickly by the Company. Due to the complex needs and the varied use of beds within Ford Place the needs and the skill of staff is very important and formed a large part of this inspection with discussions and information shared by the Manager. Records were looked at, staff and residents were spoken to, a tour of the building took place and comments received along with the pre inspection questionnaire were discussed with the Manager in detail. What the service does well: What has improved since the last inspection? Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 6 The Home has just introduced a new care plan format that staff are being trained to use with implementation being imminent. These documents should be clearer in detail and be focussed on the individual and give the whole picture of the persons needs to enable staff to carry out the appropriate support required to each resident. The Home has improved the environment by replacing old carpets in all the corridors, which gives a much cleaner, fresher look to the place. A large conservatory has made a nice sitting area for residents and a completed nurses area has improved the respect to confidentiality that was lacking previously. A new menu has just been introduced to improve the meals provided which has a four-week cycle with choice and is very varied to accommodate all tastes. The Manager has moved her office to be near the front door making her more accessible to families and residents. 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. Ford Place Nursing Home DS0000067712.V314438.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 Ford Place Nursing Home DS0000067712.V314438.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 The quality outcome for this group of standards is good. This judgement has been made using available evidence including a visit to this service. Ford Place will not take a person into the Home unless they have had a full assessment and their needs can be met. Residents who are admitted for intermediate care are helped to improve and to maximise the independence with the aim of returning home. EVIDENCE: The Home has a thorough assessment process that assist with the task of ensuring the Home can meet the needs of potential residents. The format was seen at the last inspection and was discussed with the Manager on this occasion. Due to the complex needs of many of the residents this format is completed in detail. A recently admitted resident has had her needs met so well that she has improved and the needs have changed. Due to the registration of the Home and the type of needs this lady now needs a new assessment of need to ensure she can be cared for appropriately. Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 9 The Home has a few beds that are used for intermediate care with the team of staff at Ford Place working closely with the community team to promote independence and aim to improve the health of the individuals and get them back home. The beds are in constant use by the local authorities and the Home works proactively to get the residents as well as possible. Specialist advice is sought and equipment is provided for specific needs. Ford Place Nursing Home DS0000067712.V314438.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The quality outcome for this group of standards is good. This judgement has been made using available evidence including a visit to this service. The new care plans about to be introduced will be clearer and easily read to ensure the correct care is offered. Resident’s health care needs are met well. Residents are protected by a robust procedure for medication. Residents are treated with respect and their privacy is upheld. At the time of death all residents and their families are treated with sensitivity and respect. EVIDENCE: The Home has, in the past used some care plans that were not easy to read and would have recordings that were often repeated. In place is a new care plan format (seen) that is just about to be implemented and on the day of the Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 11 site visit a training officer arrived to start this implementation with the care and nursing staff. Although the process will take a period of time in ensuring all staff are familiar with the new care plans and can introduce them to the resident they key work this will be a much better document to work with and be much more person centre focussed. The Home is supported by the local GP practice, hospital and intermediate team. The Manager and Deputies are qualified nurses and can liaise with health professionals at a clinical level to ensure the care the resident requires has all the systems in place to meet the need. The Home works hard to ensure that all medication procedures are followed with various ways and record keeping that monitors and audits the process. Seen were the tidy trolley and checklists that are in place to ensure all tasks had been completed. The Home has risk assessment (seen) in place for oxygen cylinders, forms for people to sign if they take any medication out (seen) and are leaving the premises and an accountability book for any errors or concerns that need addressing. MAR charts that were looked at had been signed correctly and the majority of each had a photograph of the resident in place. (One or two photo’s were outstanding and were to be in place shortly for the very new residents). The way the staff interacted with residents was appropriate and all doors were knocked on before entering. (It was noticed that doors to bedrooms are left open and some residents had their curtains drawn). On talking to the residents and staff this is entirely down to choice and on talking to people who were in bed or in a recliner preferred the door open to see people coming and going. The Home has the correct training and care and nursing staff have the understanding of how a person should be treated in the last few days of their life. Documentation to follow each person’s care and nursing need and clear recording is in place. The respect and handling of situations was observed throughout the day and the time given to relatives and friends in the Home was evident, especially to a family who had lost their family member the day of inspection visit. Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The quality outcome for this group of standards is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by the Home matching their lifestyles and interests. Contact is maintained with families and friends. Resident’s can exercise their choice and have control over their lives. The meals are served in pleasant surroundings and are wholesome and well balanced. EVIDENCE: On walking the building it was evident that the Home offers stimulation and activities. At present the Home has 40 hrs per week for an Activities Organiser. Quite a few of these hours are used for one to one sessions for those people who are spending most of their time in bed. The pre inspection questionnaire talked of many planned events. The day before the site visit a harvest festival had taken place with the produce still on display in the main lounge. A few people were sat watching the television and were enjoying the programme with everyone able to see and hear the set. The activities organiser was going Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 13 around with drinks to encourage hydration. (The Home had had staff call in sick that morning and the Activities Staff member was linking the job of taking drinks around to also giving stimulating conversations to residents). Relatives were coming and going throughout the morning and were all greeted appropriately. One relative was able to say how supportive the staff had been during the illness of their loved one. One comment card received at the Commission from a relative stated that more time by staff for the family and relatives would have helped through the admission process when the trauma of moving had been difficult for all the family. No other comment cards had been received. The Home does not handle resident’s affairs or finances. The families and residents are responsible with just a small amount of personal allowance held for sundry items in the office. All receipts are kept for any purchases and money balances are checked and signed for with any transaction. The books were not looked at on this occasion but had been checked in the past inspections with no concerns. Residents have access to a good balance choice of meals. The manager has just completed a new set of four week menu’s to take the place of the recently left chef’s menu’s. Included on each one is a well-balanced high calorie meal. All the food provided is full of goodness with full fat drinks and supplement foods provided. Residents who are noted to have a poor or unstable appetite have charts on the care plan that monitor how much and when the food and drink have been eaten. Time will be taken to encourage residents to take in the food they like. (A recent person who was not eating had a special milk shake made from banana, milk, cream and ice cream, which was thoroughly enjoyed). All soup is home made with extra cream added. (Many of the residents say how much they like the soups so a good quantity of wholesome produce goes into the preparation and is often more popular than the main meal). The Chef on the day of the inspection had phoned in sick and the Manager was able to find a quick replacement and offer a meal and pudding that was slightly different to the menu but was still well balanced. Plenty of drinks were available with the trolley going around the Home throughout the site visit. Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality outcome for this group of standards is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are listened to and complaints are acted upon. Residents are protected from abuse. EVIDENCE: The complaint received by the commission had been around numbers of staff on one weekend. This had been due to sickness and the Manager not been made aware. A spot check at a following weekend to see staffing levels was carried out by a Senior Manager within the Barchester company and a full report was submitted to the Commission. Since this complaint the Home has given the senior staff members clear directions to make sure the levels of staff do not drop below the numbers stated on the rota. (see staffing standards). On talking to three residents they all felt that any concerns they may have would be dealt with by the staff and Manager. No one had any complaints at the present time. And comment cards received had no complaints mentioned. The Home has a record of all the training that has taken place on the Protection Of Vulnerable Adults. Staff spoken to understand what to look for and how to report any concerns regarding potential abuse. The Home has a whistle blowing policy, which was seen on the last inspection and has not altered since. Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 15 Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23 and 26 The quality outcome for this group of standards is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-maintained Home. Residents own rooms are suitable and individual. The Home is clean and free of unpleasant odours. EVIDENCE: The Barchester Group have very good procedures in place to monitor, maintain and update the Home with any areas of concern for repairing and redecoration. Records are held within the office and are checked by the Company Managers regularly. Some of the health and safety records were looked at and were current and accurate. Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 17 All areas are clean and tidy. The Home has purchased new carpets in the corridors, which has made a vast improvement on the appearance making the areas seem lighter and wider. A new conservatory has been completed with plenty of room to enjoy the view of the garden and the corridor housing the nursing station has now been enclosed to allow privacy and confidentiality to take place. The gardens are kept in good order and are easily accessible to residents. Plans are in place to improve the garden by the conservatory and install areas that are more accessible for wheelchairs. The bedrooms are clean, well decorated and noted was how personalised each room was. Many beds have been replaced with nice wooden, homely looking hospital beds (with another twelve on order). Residents, although quite poorly were looking comfortable and had their personal bits and pieces surrounding them. The Home has a laundry in the cellar, which is neat and tidy. The staff member spoken to has all the records in place of all systems used and the machines are all serviced and maintained correctly which can adequately cope with the large washing demand. The Home also keeps a record of any clothing that may have been damaged by accident and will replace the garment or if an item has been misplaced will search for the clothing or replace. The Home has a plentiful supply of disposable gloves and aprons. There is an infection control policy and all staff have a training programme as part of their induction on infection control. (This was seen in the training folder). Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The quality outcome for this group of standards is adequate. This judgement has been made using available evidence including a visit to this service. Residents care is met by the numbers and skill mix as long as the staffing levels are as stated on the rota’s Alternative ways to gain the NVQ qualification for staff will eventually ensure residents are cared for by trained qualified staff. There needs to be an improvement in the recruitment procedures. Staff are trained and able to do their jobs competently. EVIDENCE: Comments that have been received over the past few months have mentioned concerns regarding staffing levels on certain days. Looking at the rota’s there appears to be adequate staff to the ratio of residents, however, the complex needs and frailty of some residents (especially as some of those residents are receiving end of life support or intermediate care) may not allow the close attention that may be required by the individual. When one or two members of staff call in sick this causes problems and on the day of this visit the activities staff member was carrying out care tasks so was unable to carry out the planned activity. If this happened at the weekend when there is no activities staff member, the Home falls short if they cannot call a staff member in. A Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 19 lengthy discussion around the rota was held with the Manager who has now instructed the Senior Staff members on duty to contact the Manager if all avenues to cover the rota fail. Comments regarding staffing levels are also noted on the residents/relatives survey that was carried out in August by the Home. Many remarks are recorded as positive with many long term staff able to offer the quality care required. Also noted was the ongoing review of staffing levels to ensure the care of residents is not compromised. (Recommendation). The Home is constantly aiming to meet the 50 of care staff who should have gained the NVQ qualification. Quite a few staff have been struggling with the poor support from the college and have yet to gain the certificate. (This has been discussed by many staff members within their supervision). The Home has recognised this problem and is trying other routes to assist the staff in achieving the qualification and therefore have yet to reach the 50 . (Recommendation) Personnel files were looked at and discussed. Noted were one set of records with no references in place and also one person who had been employed since December 2005 and had no POVA or CRB check. The problem with another staff mamber had arisen due to the difficulty in gathering certificates or proof of identity and POVA have been written to by the Home to gain advice on how to proceed. The information that should be held on file as stated in Schedule 2 of the National Minimum Standards is not in place. (Requirement). The Home has a good induction programme and all staff are assisted to complete this programme at a pace that is suitable for them. All statutory training is planned and the Home now has a computer that is used solely for training purposes. The Company also hold staff training records and will highlight a staff members name when the training is due to ensure all staff are updated. (A training officer had arrived to cover care plan training on the day of this site visit). Staff spoken to feel well supported with training that enables them to carry out their job. Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38 The quality outcome for this group of standards is good. This judgement has been made using available evidence including a visit to this service. Residents do live in a Home that is run by a person who is fit to be in charge. The Home does check the quality of the service and is improving in the methods used to gain the information. Staff are appropriately supervised. The health, safety and welfare of residents and staff is promoted. EVIDENCE: The Registered Manager has been the Matron of the Home for many years. She is a qualified nurse with a management qualification. She regularly attends Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 21 courses to update her own knowledge and can then cascade that training to staff. The Home has been proactive in seeking opinions from the residents and relatives by sending out surveys and holding meetings. A copy of the meeting held in July and the action plan and survey results of August were seen with a copy attached to the pre inspection questionnaire. The Barchester Company also carry out regular quality assurance checks although the Commission receives the required Regulation 26 forms adhoc and often only when prompted by the Inspector, yet records within the Home show that Senior Managers within the Company are regular visitors and do internal checks on all areas within the establishment. (Recommendation) As written in the last report the Home now ensures that the staff, have regular supervision. The two Deputy Managers take an active role in this with one supervising care staff and the other the nursing staff with the manager covering the housekeeping, kitchen, administrator and maintenance staff. Throughout the tour of the building it was noted that all areas were free from hazards and were very clean. The Environmental Health Officer was also in the building on the day of the site visit and was not concerned when spoken to regarding the kitchen although some records still needed to be seen and a later visit was planned. Staff records are up to date with who has attended the health and safety training, with prompts sent from Barchester to ensure all staff are trained and competent. All equipment for the safe transfers of residents are in place and serviced (Date stickers noted) Fire training is recorded as taking place and on talking to one staff member it was clear she knew how to react if the fire alarm went off. All chemicals were locked away and all COSHH regulations and safety data sheets were held in a file (seen) in the store cupboard for easy access if required by staff members. Accidents are recorded appropriately and an understanding of the RIDDOR reporting was clarified by the Manager. The Commission has received a high number of Regulation 37 notices (49 in the last 12 months). This is due to the use of the ‘end of life’ bed and some people being admitted within days of dying. On discussion with the Manager this bed is used all the time and accounts for the high number of forms sent to the Commission. Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 4 x x x 4 x x 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x x 3 x 3 Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19.1(c) 19.4 (b) (c) Requirement The registered person must ensure all documentation for staff employed in the Home as listed in Schedule 2 of the National Minimum Standards is held on file. Timescale for action 01/12/06 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 2 Refer to Standard OP27 OP28 Good Practice Recommendations It is recommended that a clear procedure be in place to ensure the staffing levels do not drop below the numbers stated on the rota. It is recommended that staff are encourage to try a different route to achieve the NVQ qualification and helping the home achieve the 50 of staff qualified as stated in this standard. Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Ford Place Nursing Home DS0000067712.V314438.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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