Inspection on 06/08/07 for Hanford Manor

This inspection was carried out on 6th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hanford Manor 24/07/09

Hanford Manor 30/08/06

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 6th August 2007 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 Hanford Manor DS0000064913.V342065.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.V342065.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 hanfordmanor@hotmail.com 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.V342065.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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 25 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. Over the past 5 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.V342065.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector over one day from 8.45 a.m. – 5.00 pm. The National Minimum Standards for the care of Older People provided the basis for the inspection. The service returned a completed Annual Quality Assurance Assessment as required prior to the inspection and this forms the basis of some information in this report. There was an inspection of the environment including a sample of bedrooms. Documentation relevant to the inspection process was inspected. There were 18 people in residence at the time of this inspection, including one in hospital. Most residents were seen and 10 spoken with directly, some in their bedrooms, others in the lounge areas. Additionally 5 written feedback forms were returned by relatives to CSCI prior to the inspection. There were very positive responses and accounts of life in the home from both residents and relatives. New residents were seen and commented that they had settled well into the home and assisted greatly by staff. Written comments from relatives included “Within the home there is a relaxed atmosphere and staff have a good rapport with clients. They are attentive to my fathers health needs and contact the appropriate specialists as require e.g. diabetic nurse. He enjoys his meals and the menu appears to be varied, healthy and balanced”. What the service does well: A small home with flexibility of routines geared to residents needs and able to adapt to chosen lifestyles. There is a good staff training programme and all staff have or are involved in NVQ training. All statutory training and additional specific training to improve professional standards is provided. There are extensive grounds where residents can sit or wander, alone, with staff or visitors. Complaints are dealt with swiftly and details and outcomes discussed with complainants. The home seeks to improve standards from any complaints or suggestions made. Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 7 There must be 3 staff on duty on the evening shift to ensure the safety and welfare of residents. This is a well-discussed issue with the home and has been a view expressed by residents and visitors to CSCI. References for new staff must always be obtained from the last employer and any gaps in employment investigated. Following falls residents must be monitored closely to ensure their health, safety and welfare and records should detail the condition of the person. The information in daily notes for all residents must be improved to allow progress to be monitored. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hanford Manor DS0000064913.V342065.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.V342065.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Pre-admission procedures are good – people are encouraged to visit and spend time in the home and pre-admission assessments are always carried out in current environments. All residents have written contracts. Some updating of the Statement of Purpose/Service Users Guide is needed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a Statement of Purpose/Service Users Guide and copy provided as needed to prospective residents. There is a copy of this information in all bedrooms. Some updating is needed to the statement of purpose to include all areas of need which can be met by the home. The AQAA from the home indicates a Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 10 wish to establish future regular review/updating of these documents and are considering the need to provide alternative formats to more easily inform those unable to use the standard format. A recommendation of the last report to provide self-funding residents with a review of placement after 6 weeks to ensure an equal service with funded residents has been acted upon. The review is carried out with the resident/relative/manager. All self-funding residents are given private contracts almost immediately following admission. Prospective residents are encouraged to visit wherever possible and if they wish, to spend time at Hanford Manor eg for lunch, overnight or a short stay. Two recently admitted residents said that they and their family had visited the home prior to placement, one had chosen the bedroom to suit her needs. Pre-admission assessments are carried out by the home prior to a decision to admit and Care Management Assessments obtained. These were seen in two records inspected. Assessments were detailed and provided adequate information to inform care planning. Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Health, personal and social care needs are clearly set out in care plans. The daily recording (daily notes) of care should be improved, more concise and informative. There is a safe system of medication in use in the home that has a good record in this area. Privacy & dignity is respected by staff and visiting healthcare professionals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two requirements from the last inspection have both been actioned. – Food and fluid intake charts are established for a bedfast ill resident recording all Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 12 inputs to ensure hydration and progress. Visiting Chiropodists now see all residents in their bedrooms to ensure privacy and dignity. The care planning system implemented a couple of years ago provides good, detailed but concise information concerning all aspects of need and care and working well for the home. A sample of care plans were seen for new and established residents. All were based upon assessed need and reviewed monthly and updated as needed. Although the care planning format is a nursing based one it includes completed waterlow and nutritional assessments used as a positive guide to risk and need. Information seen in newly established plans showed details of the health and social care needs of people with clear instructions on how to meet needs and sustain good health and care. A bedfast resident reviewed at the time of the last inspection 12 months ago continues to receive a good standard of care to ensure his high dependency needs are met. His relative spoke highly of the care provided for him when seen at the last inspection and has provided written feedback prior to this inspection expressing similar satisfaction with his care to date. He is turned regularly in bed and free from pressure ulcers. His continued progress is a testament to the care he has continued to receive at Hanford Manor. The area of weakness in recording is in the daily notes recorded for each resident. These were brief and cliché ridden containing comments like “no health concerns” -It is important to record concisely but provide nformation about the care provided for the person with any concerns clearly stated. There were some discrepancies between daily notes and hand-over notes between staff – some were in fact missing but comments made must be synonymous. A care of a resident who had a fall with no apparent injury but later found to have an injury was reviewed. Documentation was poor following the incident and it was clear that the person had not been monitored closely following the fall. A requirement is made that following falls residents must be monitored and reviewed closely to ensure their safety and welfare. Staff report that the GP practice and District Nurses provide a good service to the home. District nurses visit twice daily to administer insulin and at other times as required for specific examination, blood tests etc. Staff said that they felt able to approach the nursing service if they had any concerns about a resident. There are no tissue viability needs in the home at this time. Residents are weighed regularly, weight charts showing close monitoring. The medication system was inspected and comprise a Monitored Dose System (blister packs) provided by local pharmacy. The home has a good record in the receipt, storage, administration and disposal of medication. Inspection on this visit further confirmed this. There was also evidence of regular reviews of medication, recorded in care plans, with the GP practice. A resident who had Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 13 fallen as a result of what staff considered to be medication related reasons was reviewed and new medication prescribed reducing the risks. In one bedroom there were 4 creams in use and had not been prescribed. The family prefer to purchase the creams in use but the home should re-consider prescription and recording of their administration as they have an overall duty of care if these items are used inappropriately. Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Flexible routines accommodate chosen lifestyles. The social and recreational interests of residents are met. Visitors are welcomed and there is contact with community groups. Food provision is good with greater choice and independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Hanford Manor is a small home able to adapt and be flexible to fit in with residents routines and preferences. If possible particular interests are promoted and efforts made to provide resources to fulfil the interest, be it gardening, betting on the horses, visiting friends, local places of interest or the pub. There was evidence during the inspection of chosen lifestyles being known and accommodated. Two recently admitted residents prefer to spend their time in their bedrooms, one having all meals there the other having breakfast and Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 15 visiting the dining room for other meals. A person admitted 2 weeks previously from another home which is closing said that she had “settled very well”, she came to view the home, was impressed, chose her bedroom and said that staff were helpful, attentive and “helped her a lot”. She was impressed with an an-suite facility she had not before and was also offered tea during the night when she is up to toilet etc. Chosen routines were recorded in care plans such as rising/retiring times etc, although these are flexible in one plan the preferred retiring time was 9.30 pm but notes showed she regularly stays up until midnight and beyond, watching TV etc. as she chooses. The home has a good record of providing activities. There are 2 levels: Planned activities include monthly entertainers and music/movement providers, an art/painting session provided by friend of the home, 6th Form Students from local College visit regularly during term time, pastoral care is provided monthly in house by local clergy and trips arranged monthly either by hire mini-bus for 7 or 2-3 people in car. Internal activities are provided with the usual indoor activities and there are also visits from library staff providing a reminiscence service. Residents spoken to and also in written feedback said that they were satisfied with the activities provided. One member of staff has completed a course on providing activities and the home are looking to extend that training further. Food provision is reported to be good by residents. Mealtimes are flexible and there is a varied and balanced diet with choices at all mealtimes. In order to further extend this a breakfast buffet has been introduced (with resident consultation) to allow greater choice and independence. A toaster is available if residents prefer to use it. A cooked breakfast is provided on 3 days each week, on other days there is a varied choice with hot options. Drinks and snacks are available throughout the 24 hour period, jugs of juice etc. evidenced in bedrooms. New resident is provided with a drink at 4a.m. and 7 a.m. as he wishes. There is filtered coffee available in the lounge area throughout the day for visitors or resident use. Hanford Manor DS0000064913.V342065.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The complaints procedure is readily available to all. The home acts swiftly to investigate complaints and involve complainants. There has been staff training about awareness of aspects of abuse and procedures for reporting it. At this time one investigation continues relating to an allegation of abuse. Another investigation completed showed there was no basis for the allegations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a straightforward and accessible complaints procedure which is displayed in the home and also part of the Service Users Guide. Residents and their representatives are encouraged and supported to make a complaint on any area of service provision. Suggestions on how the improve the service are sought and encouraged in meetings, surveys or informal daily discussion. Investigation of complaints have high priority and complainants informed and involved in the resolution of the complaint. Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 17 The homes complaints record shows there have been 2 complaints since January 2007. One concerned a residents transported to hospital without an escort – the family were to meet the person at the hospital but not withstanding that the person should always be escorted. The procedures have been changed to incorporate that. Another complaint related to a resident who had a fall and injury not evident for 3 days – the procedures have been changed to call paramedics when people fall to ensure there are no injuries and families must always be informed. It is recommended that outcomes of complaints although discussed with family, should also be recorded in letters sent to complainants. There have been 2 referrals for Safeguarding (Vulnerable Adults Procedures) since the last inspection. One concerned alleged physical abuse by staff but upon psychiatric investigation was found to be totally unfounded. The other referral is currently being investigated under those procedures, the outcomes not yet known. All staff receive training in the protection of vulnerable adults from external courses and as part of NVQ training. The home has recently purchased a DVD on the topic watched by all staff but now also part of staff induction. Hanford Manor DS0000064913.V342065.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The environment is safe and well-maintained with an ongoing improvement plan. There are comfortable facilities both internally and externally. Bathing facilities have been improved with the creation of new shower facility. Bedrooms are comfortable and well-personalised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A continual programme of maintenance and improvements to the environment (buildings & grounds) has been in place over recent years and continues on an ongoing basis. The home is clean, pleasant and hygienic reflected in feedback from residents and visitors in quality assurance assessments by the home. Residents can arrange their bedrooms and furnishings as they wish. There are Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 19 2 lounges and several more informal seating areas offering choice of quiet or busier areas, small or larger group choices and places where residents can sit alone or with visitors with added privacy. Externally there are a number of seating areas in the extensive, pleasant garden area and it is possible to sit at the rear, front and sides of the building. Some residents enjoy a short walk around the building on a regular basis. There is a 5 year planned programme of improvement and refurbishment. Since the last inspection the kitchen area has been upgraded – former domestic type units and fittings have been replaced with commercial and more robust fittings including stailess steel fittings throughout including sinks, cupboards, working areas and storage. This has vastly improved the kitchen and food preparation areas upgrading to higher commercial standards. The dining room has been redecorated with new soft furnishings and replacement storage facilities improving the presentation of this area. The seating was replaced 2 years ago and new tables and re-carpeting are planned to complete the upgrading. As part of the ongoing replacements/improvements some bedrooms have been redecorated and upgraded with new furniture and carpets – this is ongoing. Bedrooms seen were well-personalised and this included bedrooms of recently admitted residents who had chosen the layout of furniture in their rooms. A new shower facility has been provided to replace an unassisted bathing area. This provides a bright, spacious and attractive facility and a greater choice of personal care for residents. An inspection of all communal areas and a sample of bedrooms generally indicated a good level of hygiene. The exception was a room identified with a mal-odour relating to continence management. The Continence Advisor has carried out a re-assessment and further tests being processed by the GP. Hanford Manor DS0000064913.V342065.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Staffing deficiencies in the evening must be addressed urgently. There is a good training programme constantly improving staff skills. NVQ training is an expectation of all staff. Recruitment procedures could be further improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care staffing hours are planned at 476 hours per week, basically providing 3 care staff during the day and 2 at night. Unfortunately the planned hours do not match the actual hours and the reason for this is the evening shift when only 2 staff are often provided rather than 3. The Manager states this is due to recruitment difficulties. At the time of the last inspection 3 residents had stated in written feedback to CSCI that staffing hours were not adequate in the evenings. Since that time further complaints and comments from visitors have also commented that 2 staff are not adequate for the needs of residents during the evening period. Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 21 This is a peak time of resident need (bathing, bedtimes, personal care etc) and there also are many visitors arriving/departing at that time. Two staff on the evening shift is not adequate or safe. It is a requirement of this report that 3 staff must be provided to ensure residents needs are met at this time and safety is not compromised. In addition to the care staffing hours there are adequate domestic and catering hours. There are 24 hours per week for administration, a maintenance worker and recently a contractor to maintain the grounds. Care staff provide the laundry service also. All staff have achieved NVQ2 or above or are working towards it. There is an extensive training programme in place for all staff and an ethos that training is a positive aspect of work and achievement. Induction, statutory and specific professional training courses are provided for all staff, this is a positive feature of the home. Recruitment procedures have improved in the home. However a sample of staff files seen on this visit revealed that a new member of staff had sought 2 references from a previous employed from whom there had been an instant resignation. But there was no reference from a later (last) employer. This must always be pursued and obtained for all new staff. Hanford Manor DS0000064913.V342065.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. There is good, positive management of the home with an ethos of constant improvements. The home is run in the best interests of residents. Record keeping could be improved in the quality of daily notes complied for each resident. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 23 There were 2 requirements of the last report relating to Management. One was to complete the final requirements of the Fire Officers report – The Manager states that that has been done and the Fire Officer due to make a final visit on 24/08/07 to approve the work. A requirement to notify all accidents requiring medical attention, to CSCI has been carried out. There have been several accidents in the home during the past year and it was not possible to review these during the inspection. The Manager is requested to provide CSCI with a detailed report containing the details of all accidents including time, location, cause and outcomes and also to indicate that a risk assessment has been established/reviewed in relation to each accident. A 5 year business plan is presently being compiled and will be given to CSCI – all the objectives of the 5 year plan just completed have been achieved. The Registered Manager takes a positive lead in the home and there is an open atmosphere where residents, staff and visitors can approach the manager daily in the home. Continuous improvement has been a key part of the approach of the Manager with investment in staff training, the building and environment and quality of care. The Manager is also a Director of the home. Regular questionnaires are circulated to residents and visitors the results published in the Newsletter the home publishes quarterly. Outcomes indicated satisfaction with food, staff, activities and care. The Manager has commissioned a new Quality Assurance package which she will implement during the next year. There were no Health & Safety issues arising from this inspection. Records relating to Fire safety were inspected and regular checks of equipment and servicing had been carried out. There were indications that the home is run in the best interests of residents with flexible routines, consultation with residents on a daily and personal level with residents meetings a focus for feedback. Issues highlighted in feedback have resulted in additional choices and facilities for residents, initiated by them. It was clear that residents views were sought, listened to and acted upon. Records seen were generally satisfactory and to a good professional standard. The exception was the daily records completed by staff for each person. Recording was brief, inadequate, repetitive and not informative. This must be improved. There was also a disparity between daily records and staff handover records in an example seen. This must be addressed. Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 24 Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 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 2 STAFFING Standard No Score 27 1 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X 2 3 Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 26 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 OP27 Regulation 18(1)(a) Requirement Adequate numbers of staff must be deployed at all times to ensure the safety and well-being of residents. References must always be obtained from the last employer and any gaps in employment investigated. Records required to ensure the safety and well-being of residents must be completed accurately and adequately. Residents must be monitored closely following falls to ensure their health, welfare and safety. Timescale for action 17/08/07 2 OP29 19(1) 31/08/07 3 OP37 17(1) (3) 17/08/07 4 OP8 12(1) 17/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 27 Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Local Office 1st Floor, Ladywood House 45-56 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hanford Manor DS0000064913.V342065.R01.S.doc Version 5.2 Page 29 - 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!