Inspection on 18/05/06 for Gateford Hill Care Home

This inspection was carried out on 18th May 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.

Other inspections for this house

Gateford Hill Care Home 21/11/07

Gateford Hill Care Home 15/11/05

Gateford Hill Care Home 30/06/05

Gateford Hill Care Home 10/12/04

Gateford Hill Care Home 06/05/04

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Gateford Hill Care Home Worksop Nottinghamshire S81 8AF Lead Inspector Karmon Hawley Key Unannounced Inspection 18th May 2006 10:00 X10029.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 Gateford Hill Care Home DS0000024640.V296563.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 and Care Homes for Adults 18 – 65*. 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. Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gateford Hill Care Home Address Worksop Nottinghamshire S81 8AF 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) 01909 475402 01909 500179 Ashbourne Homes Ltd Mrs Catheryn Burgum Care Home 66 Category(ies) of Old age, not falling within any other category registration, with number (36), Physical disability (30) of places Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 Brief Description of the Service: Gateford Hill provides older people nursing, residential care for older people, younger disabled nursing unit and a residential unit for younger people. The care home is now owned by Southern Cross. The care home is divided into separate units: 9 older people nursing, (Milner Suite) 18 younger physically disabled nursing, (Cavendish) 27 residential older people, (Machin) and 12 younger people residential (Lindrick), 66 placements in total. The home has 64 single and one double room, 62 rooms are fitted with en-suite facilities. Each of the units has a lounge, dining room, assisted bathing facilities and kitchen facilities. The home, which has thirty-three acres of land, is located in a quiet area at the edge of a residential estate in Gateford, Worksop. Access is mainly by car, a regular bus service is available to the perimeter of the housing estate. The current weekly fees are as follows: residential very dependent £310; elderly nursing £343 plus contribution. Younger person short breaks £473, long term £432.50; younger person nursing £432.50 plus contribution. 1-1 care agreed individually based upon service users needs. Private residential £362.50; nursing £434. This information is made available on the initial point of enquiry. Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the site visit an analysis of the performance of the home over the previous year took place in line with the key national minimum standards. The evidence gained was assessed and thus the site visit planned in accordance with further evidence required to demonstrate compliance with the national minimum standards. One inspector undertook the site visit over course of four and a half hours. The main method of gaining evidence during the site visit was case tracking, this is a method of sampling the records of six randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Six service users were spoken with so as to give the inspector an insight into the conditions and standards within the home. Those spoken with were happy with the staff, care received and the standards within the home. The manager assisted in the inspection process and three members of staff were spoken with. Staff were able to demonstrate an understanding of service users needs and the core values and principles in relation to their job role. What the service does well: A kind and caring ethos was prevalent throughout the home and a comfortable rapport was evident between service users and staff. Service users spoken with were very happy with life within the home and care received. They stated that staff were kind, caring and respectful. Staff spoken with were extremely compassionate with regards to service users needs and ensuring a quality of life is maintained and service users are given the utmost respect. Care plans were of a holistic nature encompassing whole person needs and respecting equality and diversity. The lifestyle within the home offers the opportunity for service users to live a life of their choice and expectations ensuring a quality life is experienced. Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 6 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. Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) 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 The quality rating for this outcome area is good this judgement has been made using evidence available including a visit to the service. Service users may be assured their needs will be assessed and met prior to admission. EVIDENCE: Prior to admission service users undergo a pre admission assessment, which covers the requirement of this standard. Service users are visited in the community or they may visit the home and spend time there so they may make an informed choice. All care is agreed and negotiated at this point in time according to individual needs. Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users health, personal and social care needs are set out in an individual plan of care ensuring service users needs are fully met. Service users health care needs are met. Service users are protected by the homes medication policies and procedures. Service users may be assured that they are treated with respect and their right to privacy is upheld. Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 10 EVIDENCE: Service users undergo various assessments with regards to mental health, incontinence, nutrition, manual handling and the daily activities of living, which underpin the plan of care. Care plans in place were extremely personalised, in depth and reflected complex needs. The manager stated that a holistic approach is taken to ensure care plans encompass whole person needs; there was evidence to substantiate this. There was evidence to demonstrate that service users and their family had been involved in the care planning process and reviews. Risk assessments were in place for identified risks and adequate management plans. Daily records were maintained and significant events were recorded. Staff are in the process of implementing new paper work introduced by Southern Cross. At present a sample of care plans are being transferred on to this paperwork in line with the new methodology. The manager is auditing these to ensure there are at the correct standard prior to all care plans being transferred. The completion of this process will be within the next two months. Service users spoken with stated that their needs were met. There was evidence available to demonstrate that service users have access to the multidisciplinary team, specialist services and equipment. One service user spoken with was able to substantiate this. Appropriate medicine policies and procedures are in place. Staff undergo relevant training to ensure the safe administration of medicines. Medicines checked with the prescription sheet corresponded. Service users undergo an assessment with regards to self-administration and are facilitated to do so if appropriate. All staff continue to undertake the training in residents welfare and staff are instructed on maintaining service users privacy and dignity during the induction process. The manager stated that this philosophy is also continually revisited during a staff member’s employment. There are now doorknockers on all service users rooms to ensure staff continue to respect privacy and knock before entering. Staff spoken with were able to discuss the core values and principles and how privacy and dignity is maintained. All service users spoken with stated that staff were respectful and privacy is maintained. All consultations are carried out in service users own rooms and there is a private lounge available on the Lindrick unit if required. There is a public telephone and Internet connection service users may use and some service user have their own telephones. Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The quality rating for this outcome area is excellent this judgement was made using evidence available including a visit to the service. Service users are enabled to find a lifestyle that matches their expectations and preferences and satisfies their needs. Service users are enabled to maintain contact with relevant others. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing diet in pleasing surroundings. Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 12 EVIDENCE: Life within the home is stated to be flexible and staff stated that service users are facilitated to make their own choices and live an independent life; this was noted within plans of care observed. Service users are able to choose what time they get up and go to bed and how they spend the day, depending upon risk assessments, which are drawn up with compromise and balance. The manager discussed the issues of rights, compromise and negotiation that takes place to ensure service users needs are met whilst safety issues are discuss and maintained. Service users are free to leave the home and return as they wish. There is a mini bus available to facilitate visits out and service users also use dial a ride if required. One service user discussed a recent trip to the market. There was evidence available to demonstrate that service users attend events and access services in the local community. There are church services facilitated in house and several service users attend church in the local community. There is a full time activities coordinator who plans activities with service users. Activities on offer are wide ranging and themes are followed throughout the year to aid orientation. Service users spoken with stated that there are no restrictions placed upon their lives and they may make choices on how they spend the day. One service user case tracked was in fact out to lunch on the day of the site visit whereas another was attending college, as there is a link with the local college educational facility. Three service users have their own computer and there is also one available within the home for service users to use. All the service users spoken with stated that there are activities on offer should they wish to partake. There are no restrictions imposed upon visitors and they are welcomed in to the home. One service user spoken with substantiated this. Visitors may be received in private should this be required and there are many seating areas around the home and also in the garden. Service users if able handle their personal finances, however if unable to do so assistance is available to ensure the safekeeping of this. Service users are able to bring in their own possessions should they wish. There was evidence to demonstrate advocates are in use as required. The manager and staff spoken with were able to discuss the issues of equality and diversity and how it is maintained within the home. An ethos of general openness is promoted and staff are available for both private and group discussions if required. Independence and opportunity is facilitated acknowledging what service users want to do and for staff to try and find a way to facilitate this so they may achieve their potential. Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 13 The catering services are shortly to be taken over by Southern Cross; therefore staff are working towards implementing new systems and structures. Appropriate records were observed and maintained accordingly. A four weekly menu is followed, which offers a wholesome and appealing diet. There are choices at each meal and also an option to uplift the portion for the younger disabled person to ensure adequate portions are offered. Service users may also make their own drinks in the kitchen area within each unit; some service users if able make their own breakfast. Within one case file observed a service user had their own kettle and fridge and had made their room as a selfcontained apartment. Specialist diets are catered for and liaised with the catering manager. Service users spoken with substantiated that meals are of a good standard and that choice is offered. Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. Service users and relevant others may be assured that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: New policies and procedures in line with Southern Cross methodology have been implemented in the home. Fundamentally there are no major differences from the previous policies and procedures and complaints are acted upon appropriately. The policy is on display and made available to service users and relatives. There has been one complaint received since the previous inspection regarding fees and general minor concerns related to this. The manager has investigated these concerns and responded appropriately to the complainant. To date she has not received a response to this. Staff when spoken with were able to discuss how they would deal with a complaint effectively. All service Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 15 users spoken with were happy with care received and life within the home and express no complaints. Appropriate policies and procedures are in place with regards to adult protection. In line with Southern Cross methodology all senior staff are to be issued with the complete set of clinical polices and procedures to ensure they are fully aware of and implement these. 96 of staff have undertaken training in resident welfare. All staff in post have current criminal record bureau checks in place. Staff when spoken with were able to discuss issues with regards to the protection of vulnerable adults to a good standard. Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The quality rating for this outcome area is good this judgement has been made using evidence available including a visit to the service. Service users live in a well-maintained, clean, pleasant and hygienic environment. Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 17 EVIDENCE: A maintenance man is employed and there was evidence available to demonstrate that ongoing maintenance takes place. New documentation has been introduced and there was evidence that implementation of this has begun. The environment was observed to be well maintained and the home is decorated to a good standard. The corridor on the younger disabled residential unit has been measured for a new carpet as this is in need of replacement. On the day of the site visit there was a potential trip hazard identified here, this was rectified and repaired immediately. The gardens and ground are well cared for and present an attractive view and facility for service users and visitors. On the older persons residential unit the staff office has been relocated to the room that was previously the hairdressing room so staff are more available for service users and visitors. Service users spoken with stated that the home and the surroundings were beautiful. There are sufficient domestic staff employed to ensure the cleanliness of the home. The home was clean, pleasant and hygienic on the day of the site visit. Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to this service. The number and skill mix of staff meets service users needs. Service users are in safe hands at all times. Service users are supported and protected by the homes recruitment policies and procedures. Staff are trained and competent to do their jobs. Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 19 EVIDENCE: The staffing rotas were observed and demonstrated that sufficient staff are employed to meet service users needs. Staff spoken with substantiated this and service users spoken with stated that staff are available when needed. The unit managers draw up the duty rota and take skill mix into consideration when doing so; the nurse manager and general manager then oversee this. The induction programme remains in depth and there was evidence available to demonstrate that new staff have undertaken this procedure. Two members of staff have attained the National Vocational Qualification level 2 and 14 staff are in the process of working towards this qualification. One member of staff has attained the National Vocational Qualification level 4 and another is in the process of working towards this qualification. Four staff files were observed and contained the required documentation. All staff have individual training files. Mandatory training continues to be at a good standard and additional training is in the process of being arranged in line with the training standards employed by Southern Cross. Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The quality rating for this outcome area is good this judgement was made using evidence available including a visit to the service. The home is run and managed by a person fit to be in charge. The home is run in the best interests of service users. Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 21 Service users personal finances are safeguarded. The health, safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager is now registered with the Commission for Social Care Inspection. She has completed the National Vocational Qualification level four and is in the process of undertaking a palliative care course. On speaking with staff they spoke very highly of the manager and stated that the home was well run. Service users spoken with also were happy with the way in which the home was run and managed. On speaking with the manager she remains very dedicated to her job role and demonstrated that the priority of the home was to ensure a quality service is maintained at all times and that service users welfare is paramount. The manager carries out in depth audits on a monthly basis, these cover a wide range of areas and is validated by the operations manager once completed. Following completion an action plan is devised to ensure any negative issues are resolved. The regional manager visits the home monthly and completes the required regulation 26 feedback forms. These were evidenced and were satisfactory. Service users have completed questionnaires the manger is yet to collate these; once this is done an action plan will be devised and service users notified of the outcomes. Appropriate policies and procedures are in place to protect service users finances. Four service users personal finances were checked and these corresponded with the accounting record. Individual accounts are maintained and receipts are available for all transaction. For those service users who are able to handle their own finances a lockable facility is available. All maintenance and servicing checks and related health and safety documentation, such as fire system testing and accidents records were observed and were satisfactory . Gateford Hill Care Home DS0000024640.V296563.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 X 2 X 3 3 4 X 5 X 6 X 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 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 X 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 4 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Gateford Hill Care Home DS0000024640.V296563.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. Gateford Hill Care Home DS0000024640.V296563.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!