Inspection on 08/08/07 for Freshford Cottage Nursing Home

This inspection was carried out on 8th August 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

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

CARE HOMES FOR OLDER PEOPLE Freshford Cottage Nursing Home Dane Road Seaford East Sussex BN25 1DU Lead Inspector Elizabeth Dudley Key Unannounced Inspection 10:30 8th August 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 Freshford Cottage Nursing Home DS0000068936.V345342.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. Freshford Cottage Nursing Home DS0000068936.V345342.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Freshford Cottage Nursing Home Address Dane Road Seaford East Sussex BN25 1DU 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) 01323 897845 Zeenat Nanji Tasneem Osman Post Vacant Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Freshford Cottage Nursing Home DS0000068936.V345342.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home may from time to time accommodate service users under the age of sixty-five years on admissions. Date of last inspection Brief Description of the Service: Freshford Cottage is a care home providing nursing care to twenty older people. It is situated in Seaford within easy walking distance of both the seafront and the town centre and has car parking facilities for approximately 12 cars. There are rail and bus links to Brighton and Eastbourne within walking distance. The home provides accommodation for residents over two floors in six single and seven double bedrooms, seven of which have ensuite facilities. Communal accommodation is provided by a lounge, dining room and conservatory, a small patio at the front of the property is also available for residents use. Three assisted bathrooms are provided. The home has recently undergone a change of ownership and the present owners whilst presently redecorating and refurbishing the existing property, intend to build an extension, which will substantially increase the number of rooms in the home. A new manager is in post. The CSCI was informed on the 8th August 2007 that the current fees range from £500 -£600 per week. Other services provided such as hairdressing and chiropody are charged separately and the management can provide details of this. Freshford Cottage Nursing Home DS0000068936.V345342.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on the 8th August 2007 over a period of seven and a half hours and was facilitated by the manager Mrs J Ramnath and the owners, Mrs Z Nanji and Dr T Osman. This was the first inspection under the new management and ownership. Over the course of the day a tour of the home was undertaken, in depth discussions were held with four residents, six members of staff and three visitors to the home and all residents were spoken with on a general basis. Documentation in the home was examined and this included care plans, medication charts, staff training and personnel files, catering documentation and health and safety records. Prior to the inspection ten residents questionnaires and ten visitor questionnaires, including two to health care professionals, were sent out by the CSCI. At the time of writing one health care professional, one resident and one visitor had returned questionnaires. Comments relating to the care given and the staff were favourable: “ staff are kind and look after us well”. “ Food is good and there is a variety of menu” with a health care professional saying “Good caring nursing home very respectful of patients needs”. Several comments were made about the shortage of staff at times, noticeably weekends, but the manager and owners are taking measures to address this. What the service does well: The home provides nursing care to twenty older people and residents and visitor said that this was of a good standard. Care plans are currently being reviewed and those completed addressed the needs of the residents in a thorough manner and gave clear instructions to the care staff. The home has 80 of its care staff qualified to National Vocational Qualification level 2 or 3 in care The home is in the process of being refurbished and this is being addressed to a satisfactory standard. Freshford Cottage Nursing Home DS0000068936.V345342.R01.S.doc Version 5.2 Page 6 Management seeks the views of the residents about the service offered and recently sent out questionnaires about the standard of catering. Adjustments were made to the menus following responses from residents. What has improved since the last inspection? What they could do better: Staffing must be kept at the levels identified in the duty rota with sufficient staff on duty to meet the needs of the residents living at the home, and adjusted as their needs increase. Residents said that they were not always aware of the choices available to them at meal times or of what activities were available. Comments were received that at times there was no cooked option at suppertime, and that suppers in general, did not always meet expectations. Some rooms above ground level did not have window restrictors and the manager has said that this will be addressed. The management must not employ staff prior to a Protection of Vulnerable Adults First check and Criminal Records Bureau check being in place and wherever possible should obtain references from the person’s previous employment. Freshford Cottage Nursing Home DS0000068936.V345342.R01.S.doc Version 5.2 Page 7 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. Freshford Cottage Nursing Home DS0000068936.V345342.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 Freshford Cottage Nursing Home DS0000068936.V345342.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): 1,2,3,4,5,6. People who use the service experience good quality outcomes in this area. Sufficient information is provided to prospective and existing residents to inform them about the facilities offered by the home, and to allow them to make a decision on whether the home is able to meet their needs and expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service User Guide comply with the regulations and accurately reflect the services offered by the home. Discussions were held with the manager regarding additional information that could be included in the service user guide to familiarise new residents with the routines of the home. Freshford Cottage Nursing Home DS0000068936.V345342.R01.S.doc Version 5.2 Page 10 Not all residents are in receipt of a service user guide as the review of this has only recently been completed, but the manager envisages that within the next week all residents will have one. The home has produced a brochure, which is given to all prospective residents. The Terms and Conditions of residence complies with the National Minimum Standards and regulations and all new residents have received a copy of this, existing residents will have the previous owners terms and conditions replaced with the new document in due course. The manager assesses all prospective residents using an assessment method that assesses physical social and psychological needs. Assessments of two recently admitted residents were examined and these contained sufficient information on which to base the initial plan of care. Following the assessment the manager informs the prospective resident, in writing, of whether the home can meet their needs. Residents are admitted for a months trial period prior to making the decision over whether they wish to remain at the home, both the prospective resident and their representatives can visit the home to look around and meet the staff and other residents. Staff working at the home have experience in the nursing care of the older person, with 83 of the care staff having the National Vocational Qualification level 2 or 3 in care The home admits residents for respite care but not for intermediate care. Freshford Cottage Nursing Home DS0000068936.V345342.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 quality outcomes in this area Progress made with a new care planning system identifies the actions to be taken to ensure that the care given to the residents is in line with their current needs and expectations. The standard of medication administration safeguards the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Six care plans (33 ) were examined during the inspection, the staff are in the process of implementing a new care planning system and four of the care plans seen were in the new format. All care plans examined had risk assessments relevant to any specific risks relating to the individual resident. Care plans had been reviewed on a monthly Freshford Cottage Nursing Home DS0000068936.V345342.R01.S.doc Version 5.2 Page 12 basis and there was evidence of patient centred care planning, but only two of the care plans showed evidence of them being formed in consultation with the resident, and most of the care plans required completion of the residents life history and social needs. The four care plans using the new care planning system generally addressed individual residents needs in depth and included clear instructions on how to meet these needs, although in some areas more clinical information about residents was required. Daily records were generally informative but contained some information that would have warranted being care planned. Separate care plans were included for the night routine of the resident. Residents are able to keep their own General Practitioner if in the area, and contacts with the tissue viability nurse and other health care professionals are maintained. Residents and relatives spoken with praised the standard of care given in the home and the speed with which other health care professionals were contacted when required. Visitors said that they were kept informed of any concerns relating to their relatives resident in the home. Residents nursed in bed appeared comfortable and there was evidence that electric pressure-relieving mattresses were monitored for the correct pressure. Staff were treating residents with respect and dignity when administering personal care, but staff must ensure that when waiting for hairdressing etc that residents do not spend too much time in the corridor, and it would be good practice to move some residents from their wheelchairs during the day in order to change position and prevent pressure damage. The standard of medication administration safeguards the residents, with staff now using the monitored dose system. The medication administration practice was safe. A medication that is not covered by the controlled drugs act is currently in use in the home, good practice guidance from the CSCI pharmacy inspector is it should be stored and recorded as if it was covered by this legislation. The provider is hoping to commence the Liverpool care pathway (a care system to ensure terminally ill residents are kept pain free) within the home, as presently staff do not have any ongoing training in the care of the dying resident. This standard could not be assessed in full at this inspection Freshford Cottage Nursing Home DS0000068936.V345342.R01.S.doc Version 5.2 Page 13 Freshford Cottage Nursing Home DS0000068936.V345342.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): 12,13,14,15. People who use the service experience adequate quality outcomes in this area Residents are able to make choices of how they wish to spend their day, but some are not aware of the choices of food available to them, and arrangements at meal times are not conducive to it being a social occasion. Opportunities for leisure activities provided by the home meet the expectations of the residents but residents were not always informed of what activities are offered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents spoken with said that they were able to make choices about their daily lives in the home and that these choices were listened to and respected by the staff. Staff helped residents to get ready to go out with relatives “ at any time of day- never too much trouble for them” and staff sometimes take residents out to the local shops or sea front. Freshford Cottage Nursing Home DS0000068936.V345342.R01.S.doc Version 5.2 Page 15 Residents said that there were some activities provided and these have included visiting entertainers, card and board games and aromatherapy although there is an activity programme in place, not all residents were aware of, or had seen this. A social care plan is in place for residents but regular updating of this to reflect varying interests and activities offered within the scope of the individuals’ abilities would ensure that staff recognise the necessity for leisure activities and mental stimulation to be part of the holistic care of the resident. Visitors were in the home all through the day and said that they were always made welcome at the home and that staff were always willing to help their relatives get ready for outings with them. Three visitors were spoken with during the inspection and made positive comments about the home. Ministers of religion visit the home and residents are able to attend religious services at the local churches. The home can access advocates for any residents requiring this service. The menu has recently being reviewed and this showed a varied diet available. Many residents have meals in their chairs rather than at dining tables. One visitor said “this is a shame as it would be nicer if they all sat at a table”. Two relatives also stated that the meals were not always attractively presented One resident and two relatives of residents expressed concerns over the supper menu, particularly at weekends, and that a cooked option was not always available on these days, this was also a subject of a previous complaint by a visitor. Staff were assisting residents with meals in an empathetic manner. There is only one choice per meal identified on the menu and although the manager said that alternatives were available, residents in general were not aware of this. ‘ If you don’t like what they give you, you can send it back and they will get something else’. It would be benefit the residents to know what choices were available prior to the meals being served. The manager gave a questionnaire concerning catering to the residents and menus have been changed as a result of the responses gained from this. The kitchen was clean, and although there was evidence of fridge and freezer temperatures being checked daily, records required by the Environmental health agency had not been kept up to date. The manager is addressing this issue. Freshford Cottage Nursing Home DS0000068936.V345342.R01.S.doc Version 5.2 Page 16 Due to few catering staff being employed care staff have to help out with preparing suppers at weekends, care staff have their food hygiene certificate, as does the manager. Freshford Cottage Nursing Home DS0000068936.V345342.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): 16,17,18. People who use the service experience good quality outcomes in this area. Residents and their representatives can be confident that the management of the home addresses complaints in an open and professional manner. Whilst some staff have not received current training in the safeguarding of those in their care, staff spoken with were aware of their responsibilities towards the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints policy in place, which is made available to residents in the Service User guide. It is recommended that a copy of this be displayed in the home to be readily available for reference for visitors. The home has received two complaints since March 2007 and although one of these was concerned the provision of medical care to a resident it reflected the time immediately prior to the present owners taking over the home. The present management addressed this to the complainant’s satisfaction. The second complaint identified an inadequate evening meal at a weekend. The manager addressed both of these. Freshford Cottage Nursing Home DS0000068936.V345342.R01.S.doc Version 5.2 Page 18 The home can bring in advocates for residents if required. The manager said that residents can vote by postal voting or if able can go to the polling station with a member of staff. All registered nurses have received training in the safeguarding of adults and training is ongoing in this for the care staff. The provider is a registered trainer in safeguarding adults and will be delivering this to the care assistants as a matter of priority. It is recommended that the home keep a copy of the multiagency guidelines in the home for reference when dealing with any safeguarding issues that may occur. All grades of staff spoken with were aware of their responsibilities regarding the safeguarding of the residents in their care although care staff were not specifically aware of the protocols involved other than inform the senior staff member or the manager. All knew they could contact social services or the CSCI if necessary. Freshford Cottage Nursing Home DS0000068936.V345342.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): 20,21,22,23,24,25,26. People who use the service experience adequate quality outcomes in this area Ongoing redecoration and provision of new furniture and fittings will provide a pleasant home for the people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The provider is currently in the process of refurbishing the home, but some of this refurbishment will be completed when the planned new extension to the home is commenced. Redecoration and re carpeting has taken place in the ground floor corridor, lounge and some bedrooms, and an improvement plan has been produced Freshford Cottage Nursing Home DS0000068936.V345342.R01.S.doc Version 5.2 Page 20 which identified the timescales for various work to be completed. Visitors and residents spoke highly of the improvements in place so far. There is a small patio at the front of the building, which residents can sit in, although some said that due to the position of the home, it gets very windy, and they prefer to sit inside. Individual rooms are comfortable with a lockable drawer and in most cases a lockable door with residents being given keys if wished. Water temperatures to residents’ outlets are monitored and records showed that these were in line with recommended parameters. There are three assisted bathrooms in the home and there are plans to include a walk in shower room. Seven of the residents’ rooms have ensuite bathrooms consisting of a washbasin and toilet. Window restrictors are not in place in some rooms on the first floor and the provider gave assurances that this will be addressed in the week following the inspection. On the day of the inspection the standard of cleanliness in the home was satisfactory and no odours were apparent. One comment card received prior to the inspection said that the general cleanliness was “ usually good but could be variable at weekends’, a similar comment was made by another visitor to the home during the inspection. Freshford Cottage Nursing Home DS0000068936.V345342.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 adequate quality outcomes in this area Levels of staffing of both care staff and supporting ancillary staff are not always sufficient to allow residents’ needs to be met in a timely manner. Staff receive sufficient and suitable training to enable them to care for the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions with staff and the duty rota showed that at some times there had been insufficient staff to meet the needs of the residents. This was also identified in questionnaires and on talking to visitors at the home. The home has had a policy of not using agency staff to cover staff sickness and holidays but rather using the existing staff to cover, this has resulted in staff working excess hours and at times being unable to cover shifts resulting in shortage of available staff. This was discussed with the manager. There have been instances when there have been insufficient catering and domestic staff to support the care staff and resulted in care staff having to prepare suppers for the residents, with staff saying this has had implications on the residents’ care. Freshford Cottage Nursing Home DS0000068936.V345342.R01.S.doc Version 5.2 Page 22 Registered nurses are on duty throughout the twenty-four hours. Visitors to the home stated that at weekends there are insufficient staff at times and that the cleanliness of the home was not as good as during the rest of the week. The provider and manager gave assurances that this would be addressed The staff training programme showed that staff are in the process of updating their mandatory training with a fire lecture taking place on the day of the inspection. There are five members of staff, which require updating with moving and handling training, but this is arranged to take place in the next month. Staff said that training opportunities within the home were good, 83 of the staff have the National Vocational Qualification level 2 or 3 in care and two further members of staff are studying for this. New staff have been undertaking an induction course specific for the home over a period of one day, the home has not yet commenced the recognised induction programme although has the programme to implement when new staff are employed. Four (20 ) of the staff personnel files were examined, one member of new staff had commenced work with a transported Criminal Records Bureau check, but is not working at present. Assurances were given by the provider that the member of staff would not work until all checks as required by regulation were in place. References should include at least one from a previous place of employment and should not be from family members. Photographs of staff members are required in staff files. Freshford Cottage Nursing Home DS0000068936.V345342.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): 31,32,33,34,35,26,37,28. People who use the service experience good quality outcomes in this area A quality monitoring system is in place and by means of on-going audit; ensuring standards in the home meet resident’s expectations. Risk assessments and maintenance within the home protects the residents, staff and visitors. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home commenced employment at the home in March 2007 when the home was purchased. She has previous experience at management level in a care home, is a registered general nurse (level1) and is commencing Freshford Cottage Nursing Home DS0000068936.V345342.R01.S.doc Version 5.2 Page 24 study for the Registered Managers Award. She has not yet applied for registration with the Commission for Social Care Inspection. The home has commenced a quality monitoring system, with a catering audit being done and questionnaires sent out to residents. Changes were implemented in the menu following the responses to the audit. Staff and residents meetings have taken place on a two monthly basis. The Annual Quality Assurance Assessment provided to and required by the CSCI was detailed, and addressed issues to be monitored and improved whilst giving an anticipated time scale for these to take place. Policies and procedures have recently been reviewed. Staff supervision is taking place on a two monthly basis and consists mainly of clinical supervision at the present time. The provider is doing monthly provider visits (Regulation 26 visits) and these are kept at the home. Insurances as required by the regulations were in place and in date, a business plan was available and the financial records of the company were seen during the registration of the present owner. The home is not an appointee for any residents and has no dealings with or keeps any monies for residents. The Annual Quality Assurance Assessment identified that all servicing of equipment and utilities has taken place and that a fire risk and other risk assessments were in place. A more detailed warning notice should be put on the two kitchen doors, which lead to steep flights of steps, for the safety of new staff. These are bolted when the cook is not in the kitchen. Records showed that one incident affecting a resident had not been notified to the CSCI under regulation 37 although in general these have been received. Freshford Cottage Nursing Home DS0000068936.V345342.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 3 3 3 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 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 2 2 2 3 3 3 3 STAFFING Standard No Score 27 2 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 3 3 3 3 3 Freshford Cottage Nursing Home DS0000068936.V345342.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. 1 Standard OP27 Regulation Reg 18(1)(a) Reg 19 Schedule 2 Requirement That the numbers of staff working at the home on each shift are appropriate to meet the assessed needs of the residents That staff do not commence work at the home until all documentation as required by the regulations has been received. Timescale for action 01/09/07 2 OP29 01/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations That the medication as discussed in the main body of the report is stored and recorded as a controlled drug. Freshford Cottage Nursing Home DS0000068936.V345342.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Freshford Cottage Nursing Home DS0000068936.V345342.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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