Inspection on 24/10/06 for Hansa Rest Home

This inspection was carried out on 24th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Hansa Rest Home 18/07/07

Hansa Rest Home 22/11/05

Hansa Rest Home 27/06/05

Hansa Rest Home 04/10/04

Hansa Rest Home 20/04/04

Hansa Rest Home 28/04/03

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

CARE HOMES FOR OLDER PEOPLE Hansa Rest Home 9 Empress Road Lyndhurst Hampshire SO43 7AE Lead Inspector Marilyn Lewis Unannounced Inspection 24th October 2006 10:00 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 Hansa Rest Home DS0000012170.V311819.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. Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hansa Rest Home Address 9 Empress Road Lyndhurst Hampshire SO43 7AE 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) 023 8028 2298 Mr Peter John Louis Colato Mrs Ann Colato Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 2005 Brief Description of the Service: Hansa Rest Home is a detached house set in a quiet residential street a short distance from the centre of Lyndhurst. The home is privately owned and run by Mr and Mrs P Colato. Mrs Ann Colato is the registered manager of the home and their daughter is deputy manager. The care home is registered to provide accommodation and support for up to nine older people. Residents are accommodated in seven single and one double room. Five of the single rooms and the double room have en-suite facilities. Residents have access to the two lounges and dining rooms and the pleasant garden. Accommodation is on two floors and a chair lift is provided for those who do not wish to walk up the stairs. Pre inspection information received by the commission on the 28th September 2006 stated that the fees ranged from £389.50 to £473.50 a week. Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 24th October 2006. The inspector toured the home and had the opportunity to meet with four residents, two carers, the assistant manager, the deputy manager, Mrs Colato, the registered manager and Mr Colato the registered provider. Care plans were sampled for three residents and records were seen included those for medication, complaints, accidents, staff training and staff recruitment. What the service does well: Good interaction was observed between staff and the residents and residents spoken with were satisfied with the care provided. One resident said that staff were very caring and that ‘they look after me well’. Another resident said that she was able to ‘talk with the carers about anything’ and that ‘they are always ready to listen’. No one is admitted to the home without a care needs assessment to ensure the home can meet their care needs and prospective residents can visit the home before making a decision about living there. Residents health is protected by the home only allowing staff who have received training in dealing with medicines to administer the medication. Residents said that staff treated them in a friendly and respectful manner and they felt able to exercise control and choice over their daily lives. Residents were able to participate in social activities as they wished. One resident said that she appreciated spending some time on her own in her room and another said that she enjoyed going for walks in the village with a carer. Visitors are welcome at the home at any time and one resident said that her relatives were always made to feel welcome. Residents spoken with liked their rooms and those seen contained many personal items such as photographs, ornaments and small items of furniture. Residents also said that they found the communal rooms comfortable. The home looked clean and homely. Residents and staff said that they thought the staffing levels were sufficient to provide the care and support required. Staff receive regular supervision and they said that they received good support from the registered manager and the deputy manager. Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 6 The home follows robust procedures when recruiting staff that includes completing Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks before new staff commence work at the home. This protects the safety of the residents. What has improved since the last inspection? What they could do better: Care plans and risk assessments seen had not been completed fully and did not show evidence of resident’s involvement. Although staff appeared to understand the care needs of the residents and the support required to meet those needs, the lack of information could put resident’s health and safety at risk if due to an emergency, staff were required to be employed who did not know the home or its residents. The registered manager said that an issue regarding one area of the kitchen that required attention would be addressed when the kitchen was refurbished. Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hansa Rest Home DS0000012170.V311819.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 Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 and 6 Quality in this outcome area is, good. This judgement has been made using available evidence including a visit to this service. No one is admitted to the home without a full care needs assessment to ensure the home can meet their care needs. Prospective residents are provided with the information they require to make an informed choice and are able to visit the home before making a decision about living there. EVIDENCE: The home has a Statement of Purpose and Service User Guide that provide prospective residents and their relatives with information about life at the home. The documents state that the home occasionally provides respite care but does not admit people for intermediate care. On admission each resident is provided with a written contract giving the terms and conditions for residency. The contract states what services are included in Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 10 the fees and services available at an additional cost, such as hairdressing, newspapers and chiropody. The registered manager said that she visits prospective residents at their home or place of residency such as another care home to undertake a full care needs assessment before offering a place at the home. A care needs assessment was seen for one resident who had been admitted since the last inspection. The resident said that she had been visited at home and that her relatives had also chatted with the registered manager during the visit. The registered manager said that prospective residents and their relatives are able to visit the home before making a decision about living there. A resident confirmed this saying that they had visited with a relative, to see their room, and had met with staff and another residents before taking a place there. The resident also said that she had received the home’s Statement of Purpose, which she and her family had found helpful. Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents health care needs are met, they feel they are treated with respect and they are protected by the home’s clear procedures for dealing with medicines. Although care plans and risk assessments require completion and review, staff are aware of the care needs of the residents and the actions required to support them. EVIDENCE: Care plans were seen for three residents. The plans contained information on the resident’s preferences for participating daily activities including what time they liked to get up and go to bed. Resident’s interests were included in the plans and their likes and dislikes for food items. However the care plans were not complete, with one plan stating that the resident had trouble standing or walking but there was no assessment for moving and handling. Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 12 The care plans did not show evidence of involvement by the resident in the development and review of the plans. One resident said that staff looked after her well but she was not aware of what was in her care plan. Risk assessments had not been completed for some daily living and social activities. There was no risk assessment for one resident who used a walking frame and occasionally used a wheelchair. Another resident did not have a risk assessment for leaving the home to attend church although the plan stated that the person had short- term memory loss at times. The daily record for one resident stated that the person had on one occasion left the home without telling anyone but a risk assessment had not been undertaken since this occurred. A carer said that staff discussed the resident’s needs and the actions needed to support them during handover meetings and daily discussions. The carer appeared to know the care needs of the service users even though they were not clearly documented in the care plans. The deputy manager said that care plans and risk assessments would be reviewed and completed as a priority. The lack of information could put the resident’s safety at risk if due to an emergency staff had to be employed who were new to the home and did not know the care needs of the residents. Records seen indicated that the resident’s health needs were met. GPs visit on request and district nurses also visit as necessary. An optician visits annually and a hearing aid technician attends on request. A chiropodist visits every six to eight weeks. The registered manager said that a dental practice is located very close to the home and residents usually attend at the practice as necessary. A resident said that staff had arranged for her GP to call when she was feeling unwell. The home has procedures in place for dealing with medicines. Medication records seen had been completed appropriately. A system was in place to record medication coming into the home and the disposal of unwanted medicines. The deputy manager said that only staff who had received training in the administration of medicines were able to give the medicines. Information on medicines used at the home was available for staff. One resident who self- administered a medicine had a lockable storage container in her room to store the medicine. A risk assessment for the selfadministration of the medicine had not been completed, although a blank form was available in the records. The deputy manager arranged for the form to be completed during the visit. Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 13 During the visit staff were seen to knock on doors and wait before entering rooms and spoke with residents in a friendly, respectful manner. Two residents said that staff treated them with respect at all times. Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to choose to participate in social activities, are able to receive visitors as they wish and enjoy a choice of meals served in a relaxed atmosphere. EVIDENCE: The home does not provide a regular programme of activities but offers activities on a day- to- day basis. The registered manager said that many different activities had been tried including the use of a computer for residents to email relatives. The registered manager added that residents currently living at the home were not interested in using the computer, but the facility was available should someone wish to use it in the future. During the inspection visit some residents spent time reading newspapers, some watched television and others went with staff for walks around the village. One resident said that she liked being able to do as she wished which sometimes meant spending time alone in her room writing letters. Another resident said that she enjoyed going for walks around the village with a carer. Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 15 Resident’s interests were documented in the care plans seen and the registered manager said that staff spent time chatting to residents and reminiscing. A local church minister visits the home monthly to take services for those who wish to attend and one resident regularly attends services at a nearby church. The visitor record book indicated that residents have frequent visits from relatives and friends. A resident said that she felt her relatives were always made to feel welcome when they came to the home. It was evident during the visit that residents were able to exercise control over their lives. Staff were observed to ask residents where they would like to sit and what they would like to do. Resident’s preferences for participating in daily living activities such as when they would like to get up and go to bed were documented in their care plans. Good interaction was seen between staff and residents and between the residents themselves. All residents spoken with said that the food provided at the home was good. Resident’s likes and dislikes for food items were noted in their care plans and the registered manager said that this information was used when arranging the menus. Residents were offered a choice of meals, with staff chatting to them during the morning to identify which meal they would like for lunch. At lunch residents ate their meals in the dining room with staff supporting them in a friendly and relaxed manner. The registered manager said that there were no special diets at present though diabetic and vegetarian meals had been arranged in the past. When the cook was not on duty a care staff member who had received training in food hygiene prepared the meals. Hansa Rest Home DS0000012170.V311819.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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents know that any complaints will be taken seriously and acted upon and they are protected by staff awareness of the prevention of abuse. EVIDENCE: The deputy manager said that the home had not received any complaints since the last inspection. The process for making a complaint was documented in the home’s Statement of Purpose. A resident said that if she had any complaints or concerns she would speak with the registered manager or the deputy manager. The resident said that she felt they would listen to her concerns and take action if necessary. The resident added that she had never had cause to voice a concern. The home has procedures in place for the Protection of Vulnerable Adults. Two staff members spoken with knew the procedures to follow should abuse be suspected. A staff member said that she had received training in the prevention of abuse during her induction programme. The home has robust recruitment procedures that include completing Criminal Records Bureau (CRB) and Protection of Vulnerable Adult (POVA) checks before Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 17 new staff members start work at the home to protect the safety of the residents. Hansa Rest Home DS0000012170.V311819.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): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Hansa Rest Home provides a clean and homely environment for all who live and visit there. EVIDENCE: Hansa Rest Home is a large detached house situated in a quiet residential road, close to the amenities available in the centre of Lyndhurst and the New Forest. The property stands in pleasant gardens that have seating provided for residents and their visitors. The deputy manager said that the kitchen and laundry room were due to be refurbished and the layout of that area was to be reworked to also provide an improved office and a staff room. Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 19 Accommodation is provided on two floors with a chair lift allowing access to each floor for those unable to use the stairs. Residents are accommodated in seven single rooms and one double. At the time of the visit the double room was being used as a single room. Resident’s rooms looked clean and homely and contained many personal items. One resident said that she liked her room and had appreciated being able to bring items that included small pieces of furniture, pictures and ornaments into the home. The resident said she ‘felt at home’ there. Five of the single rooms and the double room have en-suite facilities. The remaining rooms are fitted with hand basins and have bathrooms and toilets close by. Bathrooms and toilets seen looked to be clean. The handrail in one bathroom needed renewing as it was in a poor state of repair. The deputy manager showed the inspector the replacement rail that was due to be fitted. At the time of the last inspection an area of carpet on the landing was uneven and the registered manager was asked to complete a risk assessment for it. The deputy manager said that since the last inspection carpet fitters have visited the property to address the issue but have been unable to make the area completely even. Only a small ripple was evident in the carpet and a risk assessment has been undertaken for residents and staff using the area. Residents have access to two communal lounges and dining room. A resident said that the chairs in the lounge were comfortable. The deputy manager said that currently no residents required the use of a hoist to assist in moving and handling. Visitors to the home are asked to sign the visitor book on entering and leaving the property so that staff are aware of the people in the home at any one time. A staff member said that this also gave the opportunity to ask residents if they wished to receive their visitors. Residents are able to entertain their visitors in the communal rooms or in the privacy of their own room. During the visit staff were seen to wear protective clothing such as disposable aprons and gloves as necessary. Staff had received training in infection control during induction and some had attended specific courses on the control of infection. Staff involved in food preparation had also received training in food hygiene. Hansa Rest Home DS0000012170.V311819.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): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by the number and skill mix of staff employed at the home and are protected by the home’s robust recruitment procedures. Staff receive mandatory training required to do their job and the management are addressing the issue of staff requiring NVQ level 2 or above in care. EVIDENCE: The home employs the registered manager, the deputy manager, an assistant manager, two full time and two part time carers and a cook. Two carers and the registered manager or deputy are on duty during the day and at night the assistant manager or a carer, sleep on the premises and is contactable by an alarm system. The assistant manager has accommodation on the upper floor of the home. A staff member said that there were sufficient staff on duty at any one time and a resident said that staff were on hand to assist as needed. The registered manager said that staffing levels were flexible to allow for the changing level of needs of the residents and for social activities such as outings to take place. Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 21 The deputy manager holds the Registered Managers Award and the assistant manager is a trained nurse who has recently started the Registered Managers Award course. None of the four care staff currently hold an NVQ or are in the process of obtaining the qualification. However two carers are due to start the course in February. A course has been chosen that provides training in care of the elderly and activities for people in residential care. Additionally one of the part time carers is a third year trainee nurse. The registered manager is an NVQ assessor. Recruitment records were seen for two staff members. The records contained all the information required including two written references and proof of identity. Criminal Records Bureau and Protection of Vulnerable Adult checks had been completed before the staff members had commenced work at the home, protecting the safety of residents. The deputy manager discussed staff training. At the time of the last inspection a requirement was made for staff to receive the training they required to do their jobs including moving and handling and food hygiene. Systems are in place to address this issue. All new staff complete an induction programme that was in line with Skills for Care. A new staff member said that she was undertaking the induction programme that covered all aspects of care provision. All staff except one carer who had recently been employed had attended training in moving and handling. Training had been arranged for the carer requiring it. The deputy manager has completed a trainers course on dealing with medicines and two staff members are in the process of completing a course in the administration and handling of medicines. Two staff members had completed training in infection control and a further two were due to start the training course. The four staff members who are involved in the preparation of meals have attended training in food hygiene. The registered manager, deputy and assistant have attended health and safety training and are cascading the information down to the carers. The assistant manager and a carer said that they received support and encouragement from the registered manager and the deputy manager to attend training courses. Hansa Rest Home DS0000012170.V311819.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): 31, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the residents whose financial interests are protected by the home’s procedures for handling money and who are supported by staff who are supervised and use safe working practices. EVIDENCE: The registered manager, Mrs Ann Colato, holds the Registered Managers Award. Mrs Colato and her husband have owned and run Hansa for eight years. Staff spoken with said that Mrs Colato was supportive and residents said that they were able to speak with her at any time. Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 23 The registered manager said that formal resident meetings were not held but staff were encouraged to sit with residents in the lounge and share coffee time with them. This allowed time for relaxed conversations and opportunities for residents to discuss any concerns they may have regarding life at the home. A resident said that she felt able to chat to staff about ‘anything’ It was evident during the visit that there was a good rapport between the registered manager and deputy manager and the residents and care staff. The deputy manager said that a survey in the form of a questionnaire was arranged annually with residents and their relatives asked to complete the forms. Information obtained was used when developing the annual development plan for the home and this was discussed during one to one meetings with residents and in chats to relatives. Completed forms were not seen but a resident said that they had filled in a questionnaire that asked their views about meals and the cleanliness of the home. Records seen indicated that staff meetings were held monthly. The deputy manager said that an agenda was provided for staff before the meeting and minutes were taken of the meeting. The minutes were made available to all staff including those who had been unable to attend the meeting. A staff member said that she found the meetings very helpful and a good opportunity to discuss working practices. The home does not hold any money for residents. The registered manager said that relatives or representatives are responsible for resident’s financial interests. The deputy manager said that arrangements had been made for the assistant manager to attend training in the supervision of care staff so that supervision of staff can be shared. A staff member said that she received regular supervision that covered all aspects of care provision and personal development. Records seen confirmed that supervision sessions were taking place. The deputy manager said that some policies and procedures were being reviewed and updated including those for complaints, equality and disciplinary. A staff member said that she was asked to read the home’s policies and procedures during her induction period and discussed them during supervision meetings. At the time of the last inspection specialist equipment such as hoists was overdue for servicing. Records seen on this visit indicated that the equipment had been serviced. During the tour of the home hazardous substances such as cleaning fluids were stored safely. Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 24 The kitchen and laundry that are domestic in style were clean. Some food items in the fridge had not been covered and dated. The assistant manager arranged for food to be covered and dated or discarded during the visit. One area of the kitchen needed attention as it looked poorly maintained. The deputy manager said this would be addressed, as the kitchen and laundry were due to be refurbished. Fire records seen indicated that checks of fire safety equipment were carried out regularly but that some staff had not attended a fire drill in the last year. Since the inspection visit the registered manager has contacted the inspector to confirm that all staff had attended a fire drill. Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 x 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 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 3 x 3 Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (2) Requirement The registered manager must ensure that care plans are kept under review to reflect the changing needs of the residents. The registered manager must ensure that residents or if appropriate their relatives/representatives are involved in the review of their care plans. The registered manager must ensure that risk assessments are undertaken for all resident’s daily living and social activities. Timescale for action 31/12/06 2. OP7 15 (2)(c) 31/12/06 3. OP7 13(4) (b) (c) 30/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Hansa Rest Home DS0000012170.V311819.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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