Inspection on 13/06/08 for Frenchay Park Nursing Home

This inspection was carried out on 13th June 2008.

CSCI found this care home to be providing an Good service.

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

Frenchay Park Nursing Home 24/02/09

Frenchay Park Nursing Home 14/08/07

Frenchay Park Nursing Home 27/02/07

Frenchay Park Nursing Home 13/07/06

Frenchay Park Nursing Home 10/02/06

Frenchay Park Nursing Home 10/06/05

Frenchay Park Nursing Home 03/11/04

Frenchay Park Nursing Home 11/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Frenchay Park Nursing Home 140 Frenchay Park Road Frenchay Bristol BS16 1HB Lead Inspector Vanessa Carter Unannounced Inspection 13th June 2008 09:00 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 Frenchay Park Nursing Home DS0000034485.V366019.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. Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Frenchay Park Nursing Home Address 140 Frenchay Park Road Frenchay Bristol BS16 1HB 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) 0117 9659957 0117 9653936 frenchay@westburycare.co.uk Ms June Marilyn Phillips Mr Gordon Norman Brooking, Mr Derek Marsh ***Post Vacant*** Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 30 14th August 2007 Date of last inspection Brief Description of the Service: Frenchay Park is registered as a Care Home to take up to 30 residents requiring nursing care. The Home is on the edge of Bristol near to the ring road and motorway junction. It is a short journey away from the high street in the Fishponds district, which is the main shopping area. The home is 4 miles away from the centre of Bristol and can be accessed by car or bus as it is on a main bus route. The home is a converted older property with single and shared bedrooms on two floors. There are two lounges and a separate dining room. There is a passenger lift providing access to all service user areas. All parts of the home are accessible to wheelchair users. The cost per week to live at Frenchay Park Nursing Home will cost from £498 to £525. This weekly fee does not include provision for things such as hairdressing, chiropody, dental, ophthalmic, or audiology services. Prospective residents can get information about the home by looking at the Service Users Guide kept in the main entrance, which gives details of the services and facilities available at the home. The entrance table also has a copy of the most recent inspection report. Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key inspection was unannounced and took place over one day. A total of seven hours were spent in the home. Evidence to form the report has also been gathered from a number of other sources:• Information provided by the Home Manager • Talking with some of the staff team - registered nurses, care staff and ancillary staff • Observations of staff practices and their interaction with people who live in the home • A tour of the home • Case Tracking the care of a number of people who live in the home • Talking with a number of people • Talking with visitors to the home • Looking at some of the homes records • Information supplied by some people who live in the home and their relatives, in CSCI survey forms What the service does well: The information available about the home and the pre-admission assessment processes ensure that placement is only offered to those people whose needs can be met. The people who live in this home will receive the care and support that they need and they will be treated with respect and with dignity. Those who live here are able to participate in a range of activities and can have visitors at any time. There is a choice of what to eat and they are provided with a varied and well balanced diet. People that live in this home and relatives can be assured that any concerns or complaints they have, will be listened to and acted upon. They will be safeguarded from harm. Frenchay Park Nursing Home is comfortable, homely and well maintained. It is fully equipped to meet the needs of the people who live there. The people who live in this home will be cared for by staff who are well trained and will be able to meet their specific care needs. Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 6 Frenchay Park is currently a well run home with strong leadership, where the views of the people who live there are important and included in decisionmaking processes. This means that the home is run in their best interests. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Frenchay Park Nursing Home DS0000034485.V366019.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 Frenchay Park Nursing Home DS0000034485.V366019.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): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information available about the home and the pre-admission assessment processes ensure that placement is only offered to those people whose needs can be met. EVIDENCE: The home’s Statement of Purpose provides a true reflection of the current service provision, and contains all the necessary information to enable any prospective person, or their relatives, to make an informed choice about moving in to the home. There is currently no brochure for the home and the manager was unsure as to whether there are plans for one to be produced. The service users guide has recently been updated and is made available to each person – a copy is kept in the main hallway. Completed survey forms were received back from 18 people and their relatives, and all stated that they had received enough information. “I really liked the home and the staff when I visited to decide if it was the right place for me” and “my son visited the home to have a look around”. Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 9 Each person is provided with a statement of terms and conditions regarding their stay. Contracts are issued to those people who are responsible for meeting their own fees. For those who are assisted by the local authority or PCT, a contract is set up with the relevant authority. A pre-admission assessment is always undertaken prior to a placement being offered. These measures ensure that the home is able to meet the person’s specific care needs and that they will have any necessary equipment in place. Where appropriate, assessments and care plans from adult community care and health needs assessments are obtained, as part of the information gathering process. The documentation for two recently admitted persons was examined. The information obtained is used to form the basis of the person’s plan of care. The home offers placement to older people aged 65 years and over who have personal and general nursing care needs. The home is not registered to look after people whose primary care need is dementia, however will look after people who develop the condition for as long as it is appropriate for them to do so. Three of the home’s beds are classed as ‘interim block-booked beds’. These may be used for rehabilitation work, after a hospital stay and before someone is ready to return to their home. In these instances the home staff will work closely with Occupational Therapy services and other outreach services, to achieve the goal of helping the person to return to their own home. Someone could also be placed in these beds whilst they are waiting for a vacancy in “the home of their choice”. Frenchay Park Nursing Home DS0000034485.V366019.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, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in this home will receive the care and support that they need and they will be treated with respect and with dignity. EVIDENCE: Care planning documentation for three people was looked at to determine the processes involved in preparing individual personal plans of care for each person. The plans were each based upon a comprehensive assessment of needs, and each person’s individual needs were set out in a clear and organised manner, stating how the needs were to be met. There is evidence of a person-centred approach to care planning and this is a marked improvement on the last inspection. It is evident that the person is involved in having a say how their care needs are to be met and it is recorded whether they prefer to be cared for by a male or female carer, and what time they would like to get up in the morning and retire at night. One plan needed some very minor updating in order to reflect a change in need and this was discussed with the manager. Reviews of care plans are generally carried out on a monthly basis, more often if necessary. Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 11 “I am being very well looked after”, “the staff are always very kind, friendly and helpful” and “ I am very happy at the home” were just a few of the positive comments made about the service. The people who live in this home are encouraged to retain the services of their family GP if this is appropriate. There are currently five different GP practices visiting the home. GP’s will be asked to visit their patients as and when necessary. Examples of other healthcare professionals that visit the home include the tissue viability nurse, dentists and opticians. Social Workers will visit to review the placements of the people who they have arranged funding for. Wound care documentation was seen for one person. There were clear records that evidenced how often the dressings were being attended to, what products were to be used, how the home were monitoring the wounds and what progress is being made. Medication systems were not assessed on this inspection visit however no concerns have been raised with us and there were no concerns at the last inspection. It was noted that official hazard warning signs were displayed where oxygen was being stored or was in use. People who completed CSCI survey forms said that they were well looked after and that staff were kind and helpful. Observations of staff interaction with a group of people in the lounge area evidenced plenty of respectful familiarity. Those people spoken to during the course of the inspection had the following comments to make – “I am fine”, “I am quite happy thank you” and “it is very important that I always have my hearing aid. The girls remember this now”. The home regularly looks after people who have end of life care needs and will offer placement to people who have attracted continuing health care funding. The staff team will ensure that the right care and support is delivered because they will have discussed with the person, and their families about any specific wishes, at the appropriate time. Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those who live here are able to participate in a range of activities and can have visitors at any time. There is a choice of what to eat and they are provided with a varied and well balanced diet. EVIDENCE: A social activities person is employed and works six hours each weekday. A wide range of different activities is arranged each day, and week and there is always a review after new activities have been introduced so that “customer feedback” can determine whether it worked well or not. The activities person will spend time with any new person to find out what they would like to do. A timetable of things that are going to happen that day are recorded on a large white board displayed in the dining room. People who live in the home made the following comments, either in person or via CSCI survey forms – “I like taking part in the activities when I am well enough. It is something to look forward to and breaks the day up”, “I enjoy all the activities that are done at the home”, “I enjoy trying new games and things” and “I prefer spending my time on my own in my room, but I do enjoy the music and the entertainment”. Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 13 Visits by the local church, and holy communion are arranged on a monthly basis. The manager explained that services for other denominations would be arranged as and when needed. There is plenty of evidence to show that the people who live in this home are in control of their lives and able to make their own decisions. People are encouraged to make choices about where they take their meals, where they spend their time and how they want to be cared for. The previous inspector had felt that staff working practices over-influenced people’s lives, but this was not evident during this inspection. There is a choice available at all meal times. Breakfast choices are usually determined the day before. The midday meal is served from a bain-marie and on the day of inspection there was a choice of either a ploughmans or sausage and mashed potato. “The food is really good and there is plenty to choose from”, “I enjoy some meals more than others” and “I did choose to have the sausage but have changed my mind and am having the ploughmans. It is something different”. Two cooks are employed, and when required agency cover is needed, the same person is requested and generally supplied. The manager talked about a recent example whereby the home has purchased in prepared food to meet a person’s cultural dietary needs – this had been agreed prior to the person’s admission. Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People that live in this home and relatives can be assured that any concerns or complaints they have, will be listened to and acted upon. They will be safeguarded from harm. EVIDENCE: The complaints procedure is included in the home’s statement of purpose and information given to people. Everyone who completed a CSCI survey form said that they were aware of the complaints procedure. One person said “the manager or the deputy would sort out any concerns but I am generally very happy with everything”, whilst another said “on the whole everything is okay. You can’t expect things to be all the time”. CSCI have only received one complaint regarding this home and this was referred on to the temporary manager. The manager reported that the complainant had been satisfied as an outcome of investigations into the issues raised. The home maintains a record of complaints received, the outcome and any action taken as a result. These measures demonstrate that the people who live in the home can be assured that they will be listened to and complaints would be dealt with appropriately. The manager and staff team demonstrated that the best interests of the people who live there, are paramount at all times, and that the appropriate actions would be taken if any adult protection issues were observed or alleged. Those staff spoken with during the course of the inspection demonstrated their knowledge of protection issues and knew of their responsibilities to report any bad practice (whistle-blowing). Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 15 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Frenchay Park Nursing Home is comfortable, homely and well maintained. It is fully equipped to meet the needs of the people who live there. EVIDENCE: Frenchay Park Nursing Home is a converted older property, with a newer extension, that provides accommodation for up to 30 people. There is car parking to the right of the home and gardens to the rear and the left side. The building appears to be well maintained. There is level access into the home. The accommodation is arranged over two floors and there is a passenger lift to the first floor. Communal areas consist of one dining room, a lounge and a smaller quiet room. Each room is well decorated and there is access out into the courtyards, where patio seating is arranged. Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 16 There are a sufficient numbers of toilets and bathrooms located throughout the home. Commodes are also available for each person in their bedrooms. The bathrooms are fitted with hoists. There are two ‘stand-aids’ and two sling hoists, plus manual handling belts and turntables – the amount of equipment available has been significantly increased since the last inspection to take into account the increasing dependency of the people who live in the home. There is a range of different types of seating in the lounges to meet different peoples needs and specialist, ‘profiling beds’ are provided for all but four people. There is plentiful supply of pressure-relieving air mattresses. There are five shared bedrooms and 20 single bedrooms. Most of the bedrooms were seen during the course of the inspection. None of the bedrooms have en-suite facilities, but do have a wash hand-basin. They each contained all the necessary furniture and had matching curtains and bed linen. Some rooms had been personalised, people are encouraged to bring in items to make them feel at home. All bedrooms have a guarded radiator installed and have a window with restricted opening. Appropriate checks are made on a regular basis to prevent risks from water-borne infections and from hot water being delivered too hot. The home was clean and tidy on the day of inspection. The 18 people who completed the CSCI survey form said that the home was always clean. One person described the home as “spotless”, whilst another said “the home is always clean and tidy”. The laundry facilities are located in a room off the main reception area and although this is already recognised as not being ideal, there is no alternative. The washing machine is able to wash foul laundry at appropriate temperatures to clean linen and control cross infection. This equipment broke down during the course of the inspection and arrangements were promptly made for the laundry to be attended to at a nearby sister home. Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in this home will be cared for by staff who are well trained and will be able to meet their specific care needs. EVIDENCE: There is currently a full compliment of staff consisting of registered nurses, care and ancillary staff. Numbers of staff per shift are based upon the care needs and dependency levels of the people who live in the home. The care staff follow a two week duty rota and will work every other weekend. All registered nurses are part time and the manager is aware that this is not ideal and could potentially lead to a lack of consistency – good communication methods are essential to ensure that information is passed from one shift to another. The staff receive a full handover report at the beginning of each shift. Within the staff team, some have already achieved an NVQ award whilst others are currently enrolled on the course. Some are doing NVQ level 2 and others level 3. There is a 70 ratio of staff who have either got or are working towards an NVQ and this evidences good commitment by the home to provide well trained staff. In order to determine that the home follows safe recruitment procedures, the files of new staff who have started since the last inspection were examined. For each person there was written application, two written references (one from a previous employer), a declaration of medical fitness and POVA1st and Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 18 CRB (criminal Records Bureau) checks. The files were in order evidencing that the home follows safe procedures and ensures that only suitable staff are employed. The training matrix shows that staff receive regular training. Courses are arranged internally and from external trainers. Included is mandatory training in moving and handling, fire safety, protection of vulnerable adults and health and safety. For the registered nurse this will also include various clinical updates, such as wound care, hospice training, infection control and dementia awareness. Staff who were spoken with during the course of the inspection confirmed that they have had regular training. New staff are expected to complete an induction training programme when they start working at the home, however the programmes for the last two workers to be employed, had not been fully completed despite them both working at the home for about six months. The home must be able to demonstrate that all new staff have received induction training, that meets Skills for Care guidelines, within 12 weeks of appointment to their post. These measures will ensure that new staff are aware of the home’s policies and work according to the home’s statement of purpose and expected standards. Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 19 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, 32, 33, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Frenchay Park is currently a well run home with strong leadership, where the views of the people who live there are important and included in decisionmaking processes. This means that the home is run in their best interests. EVIDENCE: The current temporary home manager has been managing the home since October 2007 but is not registered with the Commission for Social Care Inspection, and leaves the post at the end of June 2008. Marked improvements have been made in the management of the home during this time and the overall analysis is that people who live in the home can expect a good quality service. One comment received from a relative who completed a CSCI survey form was “Since the new Matron has taken over, the place is 100 better all round”. It is essential that the registered provider makes provision for further strong management and leadership, to ensure that the Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 20 improvements continue and the standards of care remain good. There has been no registered manager for this service for a two-year period and this situation cannot be allowed to continue. Staff and people who live in the home are encouraged to have a say about some aspects of the home’s management. For example the menu’s have been changed according to suggestions made by people who live in the home, activities are arranged that they would like to take part in, and a spirit of “team working” has been introduced. The views and opinions of the people who live at the home, and their relatives is important, and meetings are held regularly. Staff meetings are also held regularly. There are plans to undertake a survey – “making life better for you”, now that the inspection is over and CSCI surveys have been completed. The policy and procedures for holding peoples’ personal money was examined and three individual accounts were looked at. There are good accounting methods that detail transactions in and out of the accounts. The three accounts tallied with the records held. Staff receive regular supervision from senior members of staff. Practical supervision sessions have been introduced by the temporary manager and have been effective in improving working practices. Records were seen of such sessions and staff confirmed that they have regular supervision. The home’s records were well kept and made readily available for inspection. The temporary manager has introduced order to the manner in which records are stored. All maintenance records and utility servicing is up to date. The maintenance person, who works three days a week, completes regular health and safety checks. All the necessary fire checks were up to date as was staff training and fire drills. The environmental health officer last visited the home in January 2008. One requirement was made about the kitchen needing a repaint although it is recognised that the whole kitchen area needs to be revamped. This features as part of the home’s development plan. One area of the home’s improvement that the temporary manager has been unable to see through is the introduction of better risk assessment processes. This has been delayed because of problems arranging relevant training. One specific area where this must be introduced is risk assessments prior to the use of bed rails to ensure that this is the most appropriate method of maintaining a person’s safety, and does not present additional hazards. The home is currently only obtaining consent for their use from relatives. Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 21 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 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 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 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 3 X 3 3 3 2 Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 22 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 OP30 Regulation 18(1)c Requirement The registered person must ensure that all staff complete an induction training programme appropriate to the work they are to perform, and that the relevant records are maintained of such. Timescale for action 13/07/08 2 OP31 9 The registered person must 13/09/08 employ a suitably qualified and experienced manager, who makes application to us to be the registered manager. The registered person must introduce a system of risk assessment prior to the use of bed rails, to ensure they do not present further hazards. 13/07/08 3 OP38 13(7) Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 23 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 Frenchay Park Nursing Home DS0000034485.V366019.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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