Inspection on 30/08/06 for Hanford Manor

This inspection was carried out on 30th August 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

Hanford Manor 24/07/09

Hanford Manor 06/08/07

Hanford Manor 18/01/06

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

CARE HOMES FOR OLDER PEOPLE Hanford Manor 85 Church Lane Hanford Stoke on Trent Staffordshire ST4 4QD Lead Inspector Peter Dawson Key Unannounced Inspection 30 August 2006 08:45 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 Hanford Manor DS0000064913.V306080.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. Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hanford Manor Address 85 Church Lane Hanford Stoke on Trent Staffordshire ST4 4QD 01782 642144 01782 262956 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) Hanford Care Homes Ltd Mrs Claire Lovatt Care Home 25 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (24) of places Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2006 Brief Description of the Service: Hanford Manor is a large detached Georgian property set in its own grounds in the village of Hanford. The home is on a ‘bus route with easy access to Stoke and Newcastle. There are good parking facilities. The building has been extended and provides accommodation for up to 24 people. Accommodation is on 3 floors and there is a shaft lift providing access to all floors. All bedrooms are for single use and 7 have en-suite facilities. There are 2 lounges overlooking the garden at the front of the building and other recessed areas also providing seating suitable to receive visitors. One room is the nominated smoking area. There is a large separate dining area and 13 bedrooms also on the ground floor, the remaining bedrooms are on the first floor and 3 on the second floor. There are adequate numbers of bathroom/toilet areas throughout the building. During the past 3 years most areas have been redecorated and refurbished, this includes communal areas and bedrooms. This process is ongoing. The grounds are large, pleasant, peaceful and private. There are patio areas surrounding the building used extensively in the summer months. Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. At the time of this unannounced key inspection there were 19 people in residence, including 2 in hospital. Most were seen and spoken to separately and together. It was helpful to have a group discussion with each of the small groups of residents in the two lounges. All were positive about the care and service provided at Hanford Manor. They spoke well of staff who they said “treated them well” and supported them. Discussions included food, routines, care, activities and environment – all produces spontaneous positive responses from the residents. These comments supported the views expressed in writing by residents in confidential feedback to the Commission prior to the inspection which included comments such as “Overall I am very happy here and have no complaints about anything”. One visitor was spoken to she visits her husband virtually daily. He is quite ill and virtually bedfast at this time. She said that he received excellent care from the staff and had made a surprising recovery recently from pneumonia which she attributed to staff care. The Manager and 3 care staff on duty were spoken to during the inspection and the impression gained was of a relaxed and committed staff team. The environment was inspected including a sample of bedrooms. The redecoration and upgrading of some areas continues to improve the presentation of the home. Records relating to the inspection process were inspected including the new care planning format introduced just prior to the last inspection. This was working well - staff were pleased with the format and felt it assisted them in identifying and meeting the needs of residents. The system is clear, concise and user-friendly. A pre-inspection questionnaire was received prior to the inspection, the information forms part of that contained in this report. Complaints have been received and investigated by the home positively and objectively with outcomes shared with complainants. The Commission have received a letter from a Care Manager on behalf of the family of a former resident now deceased. The letter expresses satisfaction with the high level of care and support provided to both the resident and family prior to the death. Weekly fees for this home recorded in the pre-inspection questionnaire are – Social Services rates plus £20 top-up. The same fees apply to self-funding residents. Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The new care planning format is operating successfully. It is a the Standex system based upon a nursing model of care but provides a clear and concise account of the actions required to identify and meet needs. Reviews, risk assessment and daily notes are part of the system. New non-slip vinyl flooring has been fitted in all bathroom and toilet areas (including en-suites). This has improved presentation of those areas. New dining room chairs have replaced the former “captains chairs” and are more comfortable and improve presentation. There has been re-decoration of several areas which is part of the ongoing programme. Some windows have been replaced in bedrooms and the patio area relayed. An additional telephone has been provided for residents/relatives in the corridor area leading to the dining room. The previous point was located in the smoking area. CRB/POVA checks have been obtained for newly appointed staff and documents required under Schedule 2 previously required have been obtained. Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 7 Moving & Handling training has been provided for all staff. There are regularly 6 monthly sessions to update all staff and new staff given individual collegebased training. A new fire-door has been installed in the area near the smoking area as required by the Fire Officer. There is therefore now only one remaining requirement which is in hand. The improvements have been made on a phased basis agreed with the Fire Officer. 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. Hanford Manor DS0000064913.V306080.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 Hanford Manor DS0000064913.V306080.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 Information is readily available to make an informed choice about admission and trial visits to the home encouraged. Assessments are carried out as required. It is recommended that self-funding residents are afforded the same option as funded residents to have a review of placement after 6 weeks. The quality of this outcome is good. This judgement was made using the available information and a visit to the home. EVIDENCE: The Statement of Purpose/Service Users Guide was updated in 2005 and copies given to all residents. Further copies were seen to be available in the home. There is a copy in a folder in each bedroom. Copy also given to prospective residents. Information is presented in an easily-readable format. Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 10 Funded residents have copies of Local Authority contracts. Self-funding residents are given a contract by the home. Pre-admission assessments are carried out by the Manager or Senior Carer prior to admission in the prospective residents current situation. These were seen in relation to 2 recently admitted residents, were on the format of the new care planning documentation system and were quite adequate. Care Management assessment had also been obtained (Single assessment documents) in relation to those people. Prospective residents are always invited to visit the home prior to admission. This was confirmed in relation to a prospective resident who spent a day visiting the home on the day prior to the inspection. Relatives are always involved in pre-admission procedures and visit the home. Funded resident have a review of placement after 6 weeks. It is recommended that the home carry out a review of a self-funding resident who has been at the home now for over 6 weeks. This will ensure an equal service to both funded and self-funding residents. Hanford Manor DS0000064913.V306080.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 10 Care plans contain concise and comprehensive information. Health care needs are met. Some improvements in recording of nutritional information could be made. The medication system is accurate and safe. Privacy/dignity could be improved by visiting Chiropodists. The quality of this outcome is good. This judgement is made using the available information and a visit to the service. EVIDENCE: A new care planning system (Standex) was introduced late in 2005 and continues to operate very successfully. All information is now in one place, concise and easily accessed and understood. This improves access to required care planning information for all staff. The system incorporates a regular review process which is carried out on a monthly basis. There are facilities for residents/relatives to read/sign care plans. Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 12 The system for referral to health care professionals was strengthened some time ago and this now operates successfully. This is supported by precise information in the new care planning information relating to diagnoses, treatment plans and record all interventions by health professionals. This was seen to be satisfactorily completed in the 3 care planning records inspected in detail. There has been only one incidence of pressure area management required. That resident is currently in hospital. The pressure area has been treated and monitored by the District Nursing service. District nurses visit twice daily for administer insulin injections to a new resident and blood sugar levels monitored closely with staff. There are assessments for all as required for continence management by the District Nursing Service. Annual checks are arranged for optical and dental care. Chiropody is provided by the NHS service and supplemented by a private service where needed. It was clear from written feedback from a resident that the NHS Chiropodist sees residents in the communal areas. This practice contravenes privacy and dignity and must cease. Assessments on the new care planning system were seen in relation to waterlow and nutritional assessments. These had been completed for the new residents reviewed during the inspection. There was evidence of regular monthly weighing of residents. Following discussions during previous inspections the weekly weighing of those with significant weight loss has taken place. The care of a resident who spends the majority of time in bed due to illness was reviewed. Waterlow/nutritional assessments had been carried out, special overlay mattress provided and the person was free of pressure area sores. He is turned on a 2 hourly basis and this is recorded. Fluid and flood intake has been an area of concern and record kept of these, although this could be further improved. Records should be dated and the amount of fluid intake quantified, calculated and reviewed on a daily basis. Similarly a separate record of the amount of food given should be quantified and reviewed. This will improve the recording and allow swift assessment of progress/deterioration. The wife of this residents was spoken to whilst visiting and she was entirely satisfied with the care provided for her husband at this difficult stage of his illness. She said he had made a marvellous recovery recently following an episode of pneumonia. The principles of privacy and dignity were observed to be preserved although as stated above chiropody care contravened these principles. The medication system was inspected. There was accurate recording on MAR sheets. Medication is the specific responsibility of a Senior Carer and she had Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 13 clearly by reviews with GP’s reduced the amount of anti-psychotic medication given in the home. Returns to the pharmacy are accurately recorded and countersigned by the Pharmacy. There are regular reviews of the medication system in the home by the Pharmacist. Hanford Manor DS0000064913.V306080.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 Evidence of chosen lifestyle were observed and confirmed by several residents. Residents were satisfied with the activities programme and contacts with the community. There have been consistently good reports from residents/visitors relating to food provision. The quality of this outcome is good. This judgement is made using the available information and a visit to the service. EVIDENCE: Residents are treated as individuals. This is a stated part of the homes philosophy and also their claim to diversity. There was evidence of chosen lifestyles being accommodated derived from observations and discussions with residents individually and in the lounge areas. Routines are flexible to accommodate chosen lifestyles evidenced in people rising late, having meals served in bedrooms and accessing bedrooms throughout the day. Some Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 15 residents choose to spend a large part of the day in their rooms enjoying the privacy and peace to spend their time. A telephone for residents/visitors has been provided following a requirement of the last report, to allow an alternative to the telephone in the smoking area. This is now in the area of the approach to the dining area that the Manager feels is adequate, although privacy is not ensured. In written feedback residents stated that they were happy with the activities provided. The Manager leads positively in this area with visiting social contacts from local schools, trips by car to town and country, visiting theatre and other local venues. Staff engage in activities as time allows. Some months ago a member of staff was allocated daily with responsibility for leading activities, this has been successful and other arrangements are now in place. Staff engage in reminiscence with items from the library service which were seen around the home. More simple but positive approaches are provision of newspapers and periodicals e.g. National Geographical Society publications to promote interest and discussions. There are 2 main lounge areas, one has TV the other does not, allowing resident choice and the opportunity for natural communication. Craft, entertainers and movement/music sessions allow choice of activity interest. There is a monthly service provided by local clergy for those interested. Roman Catholic pastoral care is provided also upon demand. Some relatives attend church with relatives. Residents without exception confirmed that they were satisfied with the variety, quality and choice of food in the home. The EHO visited recently and it was stated that there were no requirements relating to food or health & safety issues. The garden area is very attractive, secluded and provides good access and seating for residents. Those spoken to confirmed that they had made positive use of this area in the recent hot spell. This is a small home and therefore daily interactions between staff and residents are personal and relaxed. There have not been any residents meetings this year, although one is scheduled for September. Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 16 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 – 18 The complaints procedure was found to be adequately tested and the handling of them very positive. Staff have had training in and aware of the Vulnerable Adults procedures. The quality of this outcome is good. This judgement is made using the available evidence and a visit to the service. EVIDENCE: There is a complaint procedure in place and on display for residents and visitors. There is a copy in the service users guide – all residents have a copy. The fact that the procedure is known and available is reflected in the fact that the home have received five complaints over the past year relating to care, practice and health care issues. All have been thoroughly investigated. Some have been partly substantiated. The results have all been reported to the complainants. Some aspects of complaints related to dehydration of residents and this is reviewed further in Standard 8 above. A meeting with relatives was arranged by the home to discuss particular aspects of one complaint. The home does make a positive response to all complaints. Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 17 An area of concern (not complaint) raised with the Commission by the relative of a former resident was discussed. This in part related to aspects of the behaviour of a particular resident and possible bullying tactics. It was clear that the matter was well known to staff and the dynamics and behaviour of two residents had presented some difficulties which were addressed. All staff are aware of the procedures for reporting suspected or actual abuse. All have completed a course in Elder Abuse training. A written compliment was received by the Commission recently from a Care Manager on behalf of the family, outlining the excellent and sensitive care provided by all staff prior to the death of the resident. Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 18 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 – 26 The environment is safe and has been improved internally. This continues. Good access to a well maintained and attractive garden area. A shower facility is being considered. Facilities support residents independence. The quality of this outcome is good. This judgement was made using the information available and a visit to the service. EVIDENCE: There has been a necessary ongoing redecoration and refurbishment programme over the past 4 years and most areas have been improved. All rooms have been redecorated in the past 3 years both communal and bedroom. Older bedroom furniture has been discarded and replaced. The improvements continue. Since the last inspection all bathroom and toilet areas have been fitted with non-slip vinyl flooring improving their presentation. Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 19 There is an assisted bathroom on the ground and first floors. There is an unassisted bathroom (not used) on the second floor. There are plans to provide a walk-in shower as bathing alternative. There are hand/grab rails in relevant areas. There is no registration for wheelchair users in this home. Some residents are transported by staff in wheelchairs for distances. There is a shaft lift to all 3 floors and hoist with stand-aid/lifting slings. A large proportion of the bedrooms (13) are located on the ground floor. All bedrooms are for single use. An alternative telephone has been provided as reported above following a request from relatives. There is an excellent, attractive and safely accessible large garden area to the front and side of the building, with additional patio area at the rear. The grounds extend to two thirds of an acre and are well maintained. There are secluded vantage points in the garden area revealing many local landmarks. Some attention is required to improve the presentation of porch area at the front of the building and this is in hand. All parts of the home were clean and hygienic and there were no mal odours. The laundry located in the basement was seen and is adequate for its use. Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 20 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 – 30 Additional staff are required on the evening shift. Staff training has been a high priority for the new Manager and this continues. Staff recruitment practices have been improved since the last inspection. The quality of this outcome is good. This judgement was made using the information available and a visit to the service. EVIDENCE: The current staffing hours are 380 care hours per week. Additionally there are 36 domestic hours plus catering hours (7 days). Laundry work is carried out by care staff. There are 24 hours for administration. There are 3 care staff on duty from 7.30 a.m. – 6.0 pm and two on duty from 6 – 9.30 pm. There are 2 waking night care assistants. Three residents in written feedback to the Commission indicated that staffing levels were not adequate in the evenings. The home previously increased the numbers on duty from 6 – 9.30 pm to 3 staff but due to staff leaving this is presently only 2 staff. The home intend to re-instate those hours and are Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 21 presently in the process of advertising/recruiting staff for this purpose. This is certainly necessary. 66 of care staff are currently trained to NVQ2 level or above which exceeds the recommended minimum 50 . A senior carer is to commence studies for NVQ for in September. The home have a good record of providing staff training and this is ongoing. 6 staff recently attended Falls Awareness Course. 80 of staff have attended a course on Anxiety & Depression. Moving & Handling training is provided twice a year for staff, all have received this training, new staff complete this as they commence duties. All staff have received Food Hygiene and Health & Safety training and all have completed courses in Elder Abuse/Vulnerable Adults procedures. Recruitment procedures in the home have been poor and requirements made in the previous report. On this visit all required POVA/CRB checks had been carried out and appropriate references obtained. Documents require under Schedule 2 had also been provided in relation to those staff. Staff meetings are no longer minuted following request from staff. Meetings are now smaller and informal. A full staff meeting will be held occasionally to include all staff. Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 22 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 – 35 & 37-38 There is evidence of good, positive management and leadership. Staff are regularly supervised. Record keeping is to a high standard. Accidents to residents where appropriate have not been reported to the Commission. Requirements of the Fire Officer have been completed as required. The quality of this outcome is good. The judgement is made using the available evidence and a visit to the service. EVIDENCE: The Registered Manager is also Proprietor and takes a positive lead in the home. She has made vast improvements in the home over the past 4 years including improvements to the environment and considerable input into staff training, the results are plane to see. These remain her main objectives. Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 23 The Manager needs to secure a place in training for the Registered Managers Award and is presently pursuing this. There is a 5 year business plan and the objectives set for this the fifth year have all been met. Evidence of routines confirm the home is run in the best interests of residents. The home does not handle monies on behalf of residents who are supported by relatives in this process. This system seems to work well. Record keeping policies and procedures are to a good standard. The recording of care information was to a good professional standard. Moving & Handling training for all staff was a requirement of the last report and has been provided. Fire records were seen and routine checks and drills carried out at the required intervals. There has been a phased plan of improvements to fire safety in the home and all requirements of the Fire Officer have been completed over the past year with the exception only of fitting incumescent strips to all fire doors. A contractor has been identified for this work and a date is being arranged for the work to be carried out. A fire risk assessment is in place. The majority of staff have completed first aid training sufficient to ensure one trained person on duty at all times. Hazardous substances under COSHH are stored securely in locked cupboard. An alternative to bleach has been identified and being brought into use. It is recommended that a window restrictor is fitted to the bedroom of a resident identified on the first floor. No accidents to residents have been reported to the Commission since the last inspection. It is a requirement of this report that all accidents requiring medical attention and all head injuries are reported to the Commission as required under Regulation 37. Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 24 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 2 11 x 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 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x 3 3 x 3 2 Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 25 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. 1 Standard OP8 Regulation 12(1) Requirement Records relating to food & fluid intake to be quantified, dated and totalled with action taken where minimum inputs not met. Visiting Chiropodists must see residents in bedrooms to protect privacy and dignity. Complete final requirements of the Fire Officer as planned. Accidents to residents requiring medical attention and all head injuries must be reported to the Commission. Timescale for action 30/08/06 2 3 4 OP10 OP38 OP38 12(4)(a) 23(4) 37 (c ) 30/08/06 30/11/06 30/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP1 OP38 Good Practice Recommendations Review placement after 6 weeks for self-funding residents to ensure the same level of service offered to funded residents Fit window restrictor to bedroom window on first floor as DS0000064913.V306080.R01.S.doc Version 5.2 Page 26 Hanford Manor 3 OP27 discussed. Three staff should be provided on the evening shift from 3 – 9.30 pm. Hanford Manor DS0000064913.V306080.R01.S.doc Version 5.2 Page 27 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. 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