Inspection on 12/01/06 for Hampton Court Care Home

This inspection was carried out on 12th January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hampton Court Care Home 12/12/07

Hampton Court Care Home 05/04/07

Hampton Court Care Home 10/06/06

Hampton Court Care Home 11/05/05

Hampton Court Care Home 20/12/04

Hampton Court Care Home 22/06/04

Hampton Court Care Home 09/03/04

Hampton Court Care Home 06/10/03

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

CARE HOMES FOR OLDER PEOPLE Hampton Court Care Home Wrottesley Park Road Perton Nr Wolverhampton West Midlands WV8 2HE Lead Inspector Mr Keith Jones Unannounced Inspection 12th January 2006 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 Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 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. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hampton Court Care Home Address Wrottesley Park Road Perton Nr Wolverhampton West Midlands WV8 2HE 01902 840317 01902 844200 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) Mrs Gurdip Kaur Sahota Mr Resham Singh Sahota, Mrs Kamaldip Gill Mrs Joanne Christine Moore Care Home 52 Category(ies) of Physical disability (22), Physical disability over registration, with number 65 years of age (32) of places Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. PD 30 Nursing Minimum Age 60 on admission OP - 22 (PC only) minimum age 60yrs on admission Date of last inspection 11th May 2005 Brief Description of the Service: Hampton Court is a care home located in Perton near to Wolverhampton. The home was purpose built, with service users accommodated on one level. Amenities can be reached easily by transport, but are not within walking distance. The proprietors outlined at the beginning of the report privately own the home. The home is registered to accommodate up to 52 service users in total, including elderly service users requiring personal and nursing care, and elderly service users with physical disabilities, and are a minimum age of 60 years. The home is directly accessed from the main road and there is ample car parking facilities at the front. The home was built in open countryside backing onto farmland and there are grounds all around the home which are accessible to service users including wheelchair users. There are 42 single rooms with en suite facilities, and 5 double rooms also with en suite facilities. The corridor areas are wide and allow easy access for mobility and moving/handling aids. There are two large communal day rooms, each with a dining area off. There is also a reception lounge/sitting room where visitors can be received in private. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over one day, by one inspector; the registered provider and senior care staff, in a professional, frank and open manner. The last inspection report was discussed, and it was noted that outstanding requirements and recommendations had been dealt with, or were being addressed satisfactorily. On the day of inspection there were 36 service users in residence. A tour of the Home allowed free and open access to all areas for inspection. The opportunity was taken to speak with a number of service users, relatives and members of staff. Service users and staff took an active role in the inspection process and contributed to the subsequent report. A full case tracking of five service users with the senior duty nurse yielded a valuable insight of policies in action. An inspection of administrative procedures and documentation preceded a detailed follow-up report. The provider, senior nurse and staff were thanked for their cooperation and open willingness to contribute to the inspection process. A full verbal report was offered at the end of the inspection. The inspector thanked all concerned for their contribution to a pleasing and constructive inspection. What the service does well: What has improved since the last inspection? There have been a resolution to internal difficulties in staff moral and discipline, resulting in a more confident and diligent application of procedures and services throughout. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 6 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. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 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 Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,and 5 Hampton Court ensures that prospective residents have the necessary information to enable an informed choice to be made. Aims and objectives, terms and conditions are clearly presented in a way to facilitate easy understanding of services and standards of care. Relatives of prospective residents were spoken with, who expressed their appreciation for the standard of attention offered to them on their assessment visit. The Home ensures that the admission process is a reflection of a joint understanding that residents are aware, and that staff are able to meet expectations, to realise a comfortable transition. The Statement of Purpose has been reviewed and will be made available for examination before the next inspection. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 9 EVIDENCE: The revised draft Statement of Purpose and service user’s guide represent a much-improved description of the home’s aims and objectives, philosophy of care and terms and conditions. It offers service users and their relatives the opportunity to make an informed choice about where to live. Requirements prescribed in Schedule 1 have been addressed. The document will need to be kept under review to reflect changing circumstances. It is clearly stated in the Statement of Purpose that independence, privacy and dignity are encouraged, with the full involvement of family in all matters concerning the well being of service users. The Statement of Purpose also indicates the terms and conditions, which are discussed with service users and relatives prior to admission. A pre-admission assessment, always carried out by a senior member of staff appreciated any special needs of the individual including cultural, social or personal needs, which are fully discussed and documented. This assessment initiates the process of care, each individual having a plan of care based on a daily living process. The Home demonstrated through case tracking, that the assessor explained this information in respect of each individual to ensure a clear understanding is established. The registered person also makes a judgement as to the suitability of each prospective service user using the same criteria. Emergency admissions are taken in, as seen in case tracking, and were found to be competently assessed and a routine of care swiftly established. At all times the family is kept fully informed of the situation, offering service users and their relatives the opportunity to make an informed choice about where to live. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 There is a well-designed care assessment and planning system tailored to each individual, based on daily living activities. Care records offered a comprehensive package of awareness and planning. There is however, a need to maintain the review of the package. Health care needs are well met with local services and referral to other agencies. There exists a simple, yet effective medicines administration system, accurately monitored and actioned. The storage site is presently being transferred to a central treatment room. The Inspector was impressed with the much improved confidence and closeness within the Home of staff, residents and visitors, and the mutual respect that prevailed. EVIDENCE: There was evidence to show that a detailed review of the process has produced excellent generation of care plans. The pre-admission assessment represents the foundation for a comprehensive care planning process. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 11 Six residents’ care files were tracked and demonstrated a system of detailed information on the individual, their life style and needs, events and contacts, procedures and reactions measured on a daily basis and reviewed monthly. There had been a two-month gap in recording the review of plans, although the daily record showed thoroughness in applied care planning. The policy of the home is to maintain service users own GP support wherever practical, otherwise residents are registered with the local surgery. District nursing services are also received and the home has an established and positive professional rapport. Discussions with service users confirmed their acceptance and confidence in the overall standard of care and service given. Several residents on bed rest were found to have been diligently cared for. Routine turns were recorded, oral and ocular hygiene was evident, fluid balances were well maintained. There was evidence that suitable equipment was deployed effectively. Carers were seen to interact with residents with purpose and compassion. The facilities and bedrooms were presented to facilitate privacy for the individual, which included medical examinations and personal care procedures, being performed in private. The medication systems were found to be well organised, secure and efficient. The transfer of stock was presently being completed with the transference of the CDA cupboard. There were no residents self-medicating at the time of inspection. The procedure for handling accidents and incidents was inspected and found to hold a policy of referral for medical/paramedical opinion if in doubt. Reports were informative, detailed and meaningful. However the recording and archiving of reports needs a review, due to the disorganised system. Service users spoken to were particularly pleased in the way their privacy and dignity was respected, not only by the care staff, but everyone connected to the running of the home. Social contacts are respected, and much freedom is given on an open policy of visiting, without detracting from a respect for privacy, if so wished. Relatives who had travelled a fair distance, were complimentary in the way they were received and accommodated, and were impressed with the standards of care offered to their (retired nurse) aunt. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 The home aims to provide a life style for service users, which enriches their social, cultural, religious and recreational interests and needs. The Home has benefited from the services of a social co-ordinator over the past six months. The home operating an established open visiting policy. The standards of catering at Hampton Court have maintained the momentum of improvement with a stable catering staff, Meals and variety are parts of an good service, to which all service users spoken to were complimentary EVIDENCE: There was evidence to show an improved atmosphere of social interaction in the south wing lounge area with staff actively engaged in offering attentive exchanges with residents. There had been a social/activity co-ordinator working part-time during the past six months. Although this person is leaving Hampton Court, there is an acceptance in appreciation of the valued contribution to the holistic needs of residents. Discussions with service users and staff clearly identified a relaxed and informal atmosphere in which the service user’s needs were recognised and accommodated. A routine exists to establish a framework for managing the home, not as a yardstick for service users to comply with. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 13 Several residents expressed their appreciation for the freedom they enjoyed, with the security that there are familiar events to the day they could relate to. Those service users’ rooms inspected showed a strong influence of personalisation in the inclusion of belongings, some furniture and general décor. The home does not act as appointee for any service user beyond helping with pocket monies. Relatives are usually the preferred option for control of money. Some service users preferred to keep small amounts themselves, and a locked facility was available in each bedroom. The improving standards of catering at Hampton Court offered a highly acceptable service, to which service users spoken to were complimentary of all aspects of quality. A menu on a four weekly cycle offered a wholesome, varied and excellent choice. Individual preferences were recorded in assessment and conveyed to cook, who met with, and discussed their requirements. It was confirmed that the cook knew each resident, and some of the relatives. An appetising lunch was served during inspection, with two choices available, served in well furnished, clean dining rooms offering social interaction. Staff were seen to offer discreet assistance to those who required it. The choice of dining room, lounge or bedroom was at the discretion of service users. The kitchen was inspected with the cook and found to present a well equipped and organised area. All fridges and freezers were well maintained and checked daily by the kitchen staff. A cleaning schedule was in place and seen to be up to date and accurate. COSHH signs and notices were in evidence with cleaning chemicals secure, appropriate and under control. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 17 The home had a meaningful complaints policy, clearly identifying the CSCI as a resource to approach with a complaint or grievance. Service users’ legal rights are protected by the systems in place. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. EVIDENCE: A complaints book is maintained which shows a responsible approach in handling complaints appropriately. Experience has proven the depth of sensitivity of senior staff to addressing complaints in an effective manner. Minor complaints were received in-house and found to be resolved to complainant’s satisfaction. It was recognised that there had been a number of complaints with a common thread, that has been addressed and dealt with effectively. Staff moral has improved since action taken by the management. It is recognised that at the time of inspection there were no outstanding issues of complaint. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. There is an in-house code of conduct presented to staff on induction, which has been complemented with the provision of the General Social Care Council’s recognised code of conduct booklet, allocated to all staff. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 through to 26 There is tangible evidence that routine maintenance has been improved with a provider able to exercise her mandate of direction. Most resident’s bedrooms, however were comfortable with personal surroundings, safe and pleasantly furnished, although there are some areas and rooms that do not yet meet satisfactory standards. EVIDENCE: Hampton Court has improved the resources needed to facilitate a clean, wellmaintained accommodation for service users throughout from the last inspection. There were several rooms showing signs of wear and tear and one in particular heavily damaged by the resident which must be addressed. The general, overall standard of accommodation is comfortable, personalised and provided a number of homely features. Residents approached were seen to be comfortable and confident in their environment, demonstrated through amiable banter and frequent complements, especially on the residential north wing. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 16 The external gardens and pathways were safe, although showing little attention to development of a garden landscape. The external state of the building was seen to be in good state of repair. It was acknowledged that the process of risk assessment throughout the building is near completion. It was reinforced that this work was essential in the creation and maintenance of a development programme. The provider was required to produce an update for this year’s final maintenance plan, and to submit a development plan for 2006/07. Internal access was facilitated with adequate, well-lit and airy corridors. The refurbishment and re-decoration programme is a constant feature, recent upgrades to the treatment room was inspected and found to be of a satisfactory standard. Plans are developing to offer bedroom flat facility for staff recruited from overseas in the converted loft space of the north wing. This is planned to accommodate an extensive training area. Remedial work on improving laundry facilities, including staffing has greatly improved the standards of hygiene and organisation. There was a communal clothing basket, which is to be discontinued immediately. Hampton Court provides a range of communal areas for service users to sit. Service users have virtual free access to safe and comfortable surroundings throughout the home. There is a comfortable, well provided for dining rooms. The rooms were suitably light and bright to allow service users to take part in activities such as reading. Social, cultural and religious activities tend to take place in the lounges and service users are able to access any lounge. The standard and presentation of all the toilets and bathrooms were of a good quality, clean, uncluttered and odour-free. Adequate attention has been given to ensure maximum privacy within risk-assessed boundaries. Toilets are accessible to all and within close proximity to all communal areas. All bedrooms are en-suite. One bathroom on the south wing had been damaged recently and presented a health hazard, with broken tiles still on the floor. The room had been off-limits that morning. Fire equipment were seen to be well maintained although one extinguisher was found free standing on the main corridor. Two sluice doors were found unsecured. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Staffing levels were seen to be satisfactory, the daily care staffing rota showed adequate balance between skills, qualifications and numbers to provide a good standard of care. The improvements made in staff selection/appointment has had a significant effect upon the provision of cares to ensure protection of service users. Records show staff training had a broad spectrum of clinical and allied subjects covered, ensuring that staff fulfil the aims of the home and meet the changing needs of service users. EVIDENCE: There were 36 service users in the home on the day of the inspection. Off-duties for week commencing 9/01/06 – 22/01/06 were provided and examined; staffing levels were seen to be satisfactory. The daily care staffing rota showed adequate balance between skills, experience and numbers to provide a satisfactory standard of care. The staffing establishments were examined and found to be satisfactory in meeting the staffing notice. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 18 An average coverage was seen to be: Early shift – 0700 – 1400 - 1 trained nurse and 5 care staff. Late shift – 1400 – 2000 - 1 trained nurse and 4 care staff Night shift – 2000 – 0700 - 1 trained nurse and 3 care staff. Agency staff were used to cover shortfalls in coverage, with a significant core of bank nurses supplemented with flexible rostering and overtime. The care manager has returned from maternity leave although part-time. The impact on improving staff performance and moral was recognised. There have been improvements in domestic and laundry staff since the last inspection which is reflected in the improved, observed standards. It is recognized that a full time chef, and a stable team have improved catering throughout the range of catering services. It was noted that these staff have not as yet received a contract of employment, a point that must be addressed forthwith. The maintenance/handyman facility continues to be performed by contract staff, which has seen an improvement of service in maintaining the fabric of the Home with the registered provider personally directing work. Consideration should be given in an appointment of a committed and contracted individual. As previously mentioned the need for a socialization/activity coordinator has been established. It is recommended that a replacement, and continuation of this work be addressed. The Home has extensively reviewed and established a satisfactory procedure for interview, selection and appointment of staff. This involves a standard application form to assess and profile, 2 references taken and CRB (enhanced) checks gathered before a contract is offered to successful candidates. The thoroughness of staff selection has a significant effect upon the provision of cares to ensure protection of service users. Three staff files were tracked and confirmed the policies in action. All staff have been offered the GSCC code of conduct to supplement internal policies. A checklist approach to the appointment of staff is established and secured a satisfactory process of staff administration. All new staff goes through an induction process that will ensure that they are going to be the right person for the Home. It is recommended that all staff have a statement of terms and conditions of service through a comprehensive contract. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 19 Staff induction programmes are well established, forming the base upon which in-service supervision and training are planned and achieved. Some continuing work is needed to maintain the achievements secured through regular staff supervision. Records show a broad spectrum of clinical and allied subjects covered, ensuring that staff fulfil the aims of the home and meet the changing needs of service users. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38 The authority of the registered provider has been significantly enhanced following the last inspection. This accountability has resulted in a much improved level of performance through a broad avenue of issues, especially in the supporting infrastructure of services. The return from maternity leave of the care manager has again enhanced the quality of care. It is recognised that the care manager has requested a job-share arrangement in the near future which is being addressed by the provider. EVIDENCE: There is a more relaxed and informal atmosphere apparent in the interaction of staff and residents that demonstrated a positive relationship, which was mentioned by several service users, relatives and staff, providing a basis for mutual respect, so essential to the provision of care. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 21 Positive moves have been made to establish service users and family forums, on a monthly basis, actively seeking consumer feedback through dialogue and through surveys. Staff meetings are re-established and are beginning to make an impact upon quality assurance issues. Service users and relatives are regularly involved in many aspects of the caring process, and Social Workers’ review meetings are often a vehicle for assessing quality. It was agreed that the provider would initiate a full risk assessment on the environment including the setting of objectives, effective budgeting of plans and target dates to aim for. These plans are to be submitted for scrutiny. A sample examination of administrative, monitoring, planning and care records showed an organised and professional attitude to effective record keeping. In general they were found to be well maintained, accurate and up to date. The procedures for maintenance and evaluation of risk were seen to be in need of re-evaluation to ensure the safety and welfare of service users and staff. Staff training programmes included relevant aspects of Health and Safety, first aid, moving and handling and fire training were recorded. Servicing records of essential equipment were examined including hoists, and electrical maintenance, including personal electrical PAT testing. All accidents and incidents were recorded for staff and service users, including provisions for Riddor should the need arise. The administration and management of the home have responded well to the last inspection with purpose, and sensitive to the needs of service users. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 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 3 3 3 3 3 2 2 Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? yes 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 Regulation 15(2) Requirement It is a requirement that all care plans are evaluated monthly. Timescale for action 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 Refer to Standard OP19 OP22 OP1 OP10 OP24 OP29 OP19 Good Practice Recommendations The management provide the NCSC a refurbishment/development plan for the Hampton Court site for period 2006/07. That consideration be given to the replacement of the activity co-ordinator. The Registered Provider provide a Statement of Purpose for submission and approval That the practice of providing communal clothing for service users to cease. A re-furbishment plan be drawn up to address the state of routine maintenance and damage to rooms identified. That all staff are issued with a signed contract of employment. That sluice doors be locked when not in use. Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Hampton Court Care Home DS0000022329.V271385.R01.S.doc Version 5.0 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. 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