CARE HOMES FOR OLDER PEOPLE
Hawksyard Priory Care Home Armitage Lane Armitage Rugeley Staffordshire WS15 1PT Lead Inspector
Mr David Cowser Key Unannounced Inspection 5 September 2006 9:30 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 Hawksyard Priory Care Home DS0000022334.V307764.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. Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Hawksyard Priory Care Home Address Armitage Lane Armitage Rugeley Staffordshire WS15 1PT 01543 490012 01543 492546 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) Hawksyard Priory Nursing Home Limited Mrs Susan Haskett Care Home 76 Category(ies) of Dementia - over 65 years of age (27), Learning registration, with number disability (1), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (27), Physical disability (6), Physical disability over 65 years of age (49), Terminally ill (4) Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. PD(E) Minimum age 60 years DE(E) - MD(E) Minimum age 60 years Conditions for Palliative Care 1. That at least one of the Nursing Staff have the recognised Qualification ENB931 or K260 within 9 months. 4th October 2005 Date of last inspection Brief Description of the Service: Hawkesyard Priory is a privately owned care home situated on the outskirts of the Staffordshire village of Armitage. The home is a former Dominican Priory and is set in large grounds. The home is registered to provide both nursing and personal care, including mental health care, for up to a total of 76 elderly service users. Access to the home is via a long driveway. A regular bus service stops at the end of the drive and all shops and community facilities are available in the village. Accommodation is provided on three floors. The ground floor (22 beds) and second floor (26 beds) offer accommodation for service users with general personal care and nursing care needs. The top floor (26 beds) offers accommodation for service users with mental healthcare needs. Separate lounge and dining facilities are provided on each floor. Hairdressing and smoking facilities are also provided. A large church is also part of the buildings. Services and facilities including laundry, catering and hotel services facilities are good. Activities, hobbies and entertainment all take place and transport is provided when required. Families and friends are encouraged to take part in activities and trips out. Qualified nurses and teams of care assistants provide care. Community nurses and NHS facilities are accessed when required. A local GP practice and Pharmacy service the home. Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key unannounced inspection was made on the 5 September 2006 @ 09:30hrs. The inspection was undertaken using the National Minimum Standards for Older People as a reference. The total time spent for the inspection, including pre and fieldwork, amounted to 12hrs. A registered nurse was in charge of the home accompanied by 2 first level registered nurses and fourteen care assistants. The ancillary staff on duty included; housekeeper, six domestic workers, five maintenance personnel, three catering staff, and an activities organiser. A business support person was also on duty. These staffing levels were adequate to meet the needs of current 74 service users in the home. The total of 74 elderly residents included; 26 receiving nursing care for mental health needs, 36 people receiving nursing for physical needs, and 6 receiving personal care for needs associate with old age. The inspection included the following elements; a tour of the building, observation and inspection of records relating to provision of care, discussions with eight residents and four visitors, discussions with staff members on duty, observation and sampling of other services provided such as catering and laundry, and an inspection of the managerial aspects such as staffing issues, quality assurance and health & safety. Since the last inspection on 4 October 2005; there had been no changes to the management of the home, no complaints had been received by CSCI and no additional visits had been necessitated. Residents and visitors made positive comments, including; ‘I am very comfortable and the staff are marvellous’. ‘It is very good here compared to other places and the food is always good’. ‘The matron and staff really care’. Current fees range from; £325 to £465 per week. What the service does well:
Residents and/or their representatives had been able to choose the home, following an assessment and an invitation to visit, prior to admission. Asking four residents and seven visitors, and inspecting the admission documentation, confirmed this. The above aspects had ensured that each resident had been suitably placed, and that the home had the ability to meet their assessed needs. Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 6 It was evident, from discussions with residents and staff, and an inspection of the relevant documentation, that the provision of health and social care had been addressed well. Service user plans seen had been well completed and regularly reviewed. The plans were based on the community care plans completed by social workers, and agreed by residents/representatives. There was a good safe system in place for the receipt, storage, administration and disposal of medicines. No errors were noted concerning medicines, and residents asked said that they had their right medicines on time. Privacy, dignity and choice aspects for residents were seen being upheld during the caring process. When asked several residents and relatives said that they were very happy with the health and personal care being delivered by the home. During the past 12 months the number of accidents and incidents in the home was low. Activities and entertainment had taken place, and were seen documented. Residents told the inspector that they had appreciated and enjoyed the recent events and activities, and that they were able to choose whether or not to take part. Four visitors confirmed that links had been maintained with them and links had also been maintained with the local community. Catering aspects were very good and records seen showed that individual dietary requirements had been met. Residents spoke of choices and said that they were pleased with the food provided. The inspector observed the main meal of the day, which met all requirements and was well presented. Assistance was seen being given to people with mental health or dementia care needs to help them to make a choice, by staff who had knowledge of the residents likes and dislikes. All of the above had assisted the residents in their daily living and social activities. No incidents or reports of abuse of any kind had been evidenced or recorded since the last inspection and policies and procedures seen covered these issues. Two complaints had been recorded internally since the last inspection and both were not upheld. No complaints had been received by CSCI. Residents and relatives understood the complaints procedure. These aspects had contributed to the protection of service users. The home was fit for purpose, and provided a safe environment for the residents, staff and visitors. A homely atmosphere had been created and the premised were clean, warm and tidy. Adequate areas for residents were provided including; communal space, dining/activity space, bathing/toilet facilities, and bedrooms. Services and facilities including catering and laundry were adequately provided, and staffed. All residents asked stated that they were happy with the facilities and that they were comfortable with their surroundings. The registered care manager and teams of nurses and care staff provided care. A good working relationship was evident with the local GP practice and pharmacist. NHS facilities and both community and hospital health professionals had been accessed when required. Community Psychiatric Nurses were also accessed to meet the mental health needs of service users.
Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 7 Staffing levels and skill mix had been adequate to meet the assessed needs of the existing residents. Recruitment of staff aspects was good. Staff training had been given a high priority, with induction training being followed by NVQ training. In addition to the trained nurses 54 of care assistants were qualified to NVQ level 2 or above. NVQ training and in house training in relevant subjects is on going. These aspects had contributed to the good standards of care being provided by the home. The registered care manager is experienced and has attained the registered managers award. The general management and management of health and safety issues had been given a high priority, and no shortfalls were noted. The documentation seen evidenced that the premises were adequately maintained. All records had been correctly filed and stored. Assurances were given regarding the positive financial viability of the home, and that suitable accounting/business procedures were adopted. The current public liability insurance certificate was seen. There was a safe system of accounting for residents day to day monies and the ledgers reconciled with the money held. Quality assurance systems are in place. All the above had contributed to the protection and well being of residents in the home. Throughout the inspection the people who use, or have contact with, the home expressed only positive views. A folder containing many thank you cards and complimentary letters from appreciative relatives was seen. What has improved since the last inspection? What they could do better:
The requirements and recommendation of the previous report were all met and only one recommendation, concerning care planning, was made during this inspection. Future alterations and extensions are planned for the home, which will increase the number of single bedrooms. Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 8 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. Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 9 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 Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 10 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): Standards 3,6 The quality outcome for the above standard, based on available evidence and outcomes of this inspection, is good. Residents had been correctly placed in a home of their choice, which had the ability to meet their assessed needs. Intermediate care is not undertaken in this home. EVIDENCE: The documentation seen, and a discussion with both residents and their representatives, evidenced that residents had been assessed prior to admission and they had been able to make a choice about the home. All had been given the opportunity to visit the home prior to choosing to stay. Two residents spoken to had visited the home, and had a meal prior to deciding to stay, and this was seen documented within the care plans. A full assessment of each resident’s needs had taken place before admission and this was seen documented. The community care plans provided by the social worker, as part of the individual needs assessment process, were seen within the service user plans. Residents asked confirmed that they had been fully involved and were in agreement with the assessments.
Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 11 All of the above had contributed to suitable placements and the residents needs being met. Intermediate care is not undertaken in this home. Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 12 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): Standards 7,8,9,10 The quality outcome for these standards, based on available evidence and outcomes of this inspection, is good. Individual health, personal and social care needs, as documented within care plans, had been adequately addressed with privacy and dignity afforded during the caring process. There was a safe system in operation for the receipt, storage, administration and disposal of medicines. NHS health care facilities and professionals had been accessed when required. Particularly attention had been paid to meeting mental health and dementia related needs. EVIDENCE: The service user plans and associated documentation seen was well written, meaningful and reflected the current condition of residents. A recommendation was made relating to wound care in one of the care plans seen, and the use of a body diagram, all as agreed. The care plans seen and the associated documentation, and a discussion with both residents and staff members, evidenced that health and personal care needs were being well met. A total of 10 care plans were examined in greater depth. The dementia/mental illness related needs of residents had been documented when applicable, and
Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 13 staff training had been provided covering these issues. NHS facilities and professionals including community nurses, medical consultants and clinical nurse specialists had all been accessed when required, and these events were seen recorded. A good working relationship had been established with community nurses and the community mental health team, and the documentation n seen evidenced this. Local GP practices and a pharmacy service the home, and there is a good working relationship with them. Records of their visits and outcomes were seen documented. Currently six residents had a pressure area (4 acquired elsewhere), which were being treated in the correct manner and well documented. The medicines within the home, medication administration records, controlled drugs books and drugs disposal books, were all checked and no errors were noted. It was observed that a safe system was in place, and that the comprehensive medicines policy documentation seen was being complied with. The documentation seen evidenced that only trained nurses and senior care staff administered medicines. No resident was ‘self medicating’, but locked facilities were available. During the inspection it was observed that privacy and dignity were being afforded to residents, and there was very good interaction with staff. Care staff were seen knocking on doors before entering. Several residents told the inspector that they were treated with respect, and that the staff were very kind. Residents, and several relatives, all commented positively about the care being provided. There had been 21 deaths in the home during the previous 12 months, which is acceptable in view of the numbers of poorly nursing patients admitted over this period. All of the above evidence satisfied the inspector that the individual health, personal and social care needs of residents had been addressed in the correct manner. Hawksyard Priory Care Home DS0000022334.V307764.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): Standards 12,13,14,15 The quality outcome for the above standards, based on available evidence and the outcomes of this inspection, is good. Social contact had been maintained and the daily activities, along with autonomy and choice, had contributed to the resident’s lifestyle experiences meeting their expectations. Catering aspects were good and met individual needs and preferences. EVIDENCE: The residents told the inspector that their views had been listened to, and that they had been able to influence some aspects of the running of the home e.g. mealtimes, menus. These comments had been documented along with the feed back from the resident/relatives questionnaires, and they had been acted upon. Contacts had been maintained with relatives and friends and this was seen documented. Residents spoke of their visitors and their involvement with the home. Visitors attending the home during the inspection, told the inspector of the good links and communication with them. Several visitors attending the home during this inspection spoke of the particular good links and involvement of relatives. Trips out to the community had previously been organised and
Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 15 transport provided. The manager had coordinated and recorded the events, and residents commented that these had been appreciated. The residents spoke of their satisfaction with the meals and choices offered. The menus and catering records were examined and evidenced that the dietary requirements of residents were met. A discussion evidenced that individual likes and dislikes had been established and complied with. The cook had established resident’s choice of food for the day. The records evidenced that residents’ needs with diabetes had been met. The cook when asked said that fresh good quality food from local suppliers was purchased on a daily/weekly basis, the records seen confirmed this. Adequate supplies of fresh vegetables and fruit were also seen. The mid day meal seen was well presented and met all nutritional requirements. The meals were seen being served in a caring and unhurried manner. All of the above had contributed to the satisfaction expressed by service users/representatives during the inspection. Hawksyard Priory Care Home DS0000022334.V307764.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): Standards 16,18 The quality outcome for the above standards, based on available evidence and this inspection, is good. An open culture existed where complaints or grumbles are listened to and acted upon. Residents are protected from all forms of abuse. EVIDENCE: An examination of the complaints records, the relevant policy and procedure documentation, and a discussion with staff and residents, evidenced that complaints and grumbles were listened to and dealt with. No complaints had been received by CSCI since the last inspection. Two internal complaints had been recorded and neither had been substantiated. The manager had correctly dealt with these complaints, to the satisfaction of the complainants. No additional visits to the home were necessitated. A folder was seen with many ‘thank you’ and complimentary cards from appreciative relatives. No incidents of abuse of any kind had been evidenced or recorded. The policy documentation seen, and a discussion with staff confirmed that residents are protected from all forms of abuse. Documentation seen also evidenced that these issues had been discussed at length during staff induction, training and on-going supervision. Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 17 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): Standards 19,26 The quality outcome for the above standards, based on available evidence and the outcomes of this inspection, was good. The home, was clean, pleasant and hygienic, and provided a suitable and safe environment for the provision of care. EVIDENCE: A tour of the building, and a check on the maintenance documentation, verified that the premises were fit for purpose, clean warm and tidy. The senior staff when asked told the inspector of their knowledge on infection control, and showed him the relevant documentation. Adequate hand washing facilities were available throughout the home. The laundry and sluicing facilities were seen to be compliant. The records evidenced that the premises were being maintained. On going painting and re-decorating was in progress. Hot water temperature checks,
Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 18 and emergency lighting/fire alarm tests were seen up to date and correct. There are no outstanding issues known from the Fire Prevention or Environmental Health departments. The bedrooms seen were comfortable and residents spoke of their satisfaction. A programme of replenishment of fabrics and bedding was in progress, and had been appreciated by the residents spoken to. All of the above had contributed to the comfort and protection of people using the service. Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 19 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): Standards 27,28,29,30 The quality outcome for the above standards, based on available evidence and this inspection, is good. Adequate numbers of suitably trained and experienced staff are correctly employed to meet the assessed needs of residents. EVIDENCE: A registered nurse was in charge of the home accompanied by 2 first level registered nurses and fourteen care assistants. The ancillary staff on duty included; housekeeper, six domestic workers, five maintenance personnel, three catering staff, and an activities organiser. A business support person was also on duty. These staffing levels were adequate to meet the needs of current 74 service users in the home. The total of 74 elderly residents included; 26 receiving nursing care for mental health needs, 36 people receiving nursing for physical needs, and 6 receiving personal care for needs associate with old age. Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 20 The duty rosters seen, and a discussion with the care manager and the staff, evidenced that adequate numbers of staff had been on duty to meet the needs of the existing service users. The rosters seen evidenced that the following care staff had been on duty or exceeded for the 72 residents; a.m. 2RGN/RMN 14 Care assistants ( Care manager RGN for 5 days), p.m. 2RGN/RMN 11 Care assistants, nights 2RGN/RMN 6 Care assistants. Adequate ancillary staff had been provided each week. Six residents asked stated that staff were available when they wanted them, and that the staff were capable. The records seen evidenced that in addition to the registered nurses the home employed 58 care assistants, of which 31 (54 ) were trained to NVQ level 2 or above. The records showed that training was on going. General training had been given a high priority and the training records of individuals were seen. The records evidenced that care assistants had benefited from ‘in house’ and external training, which had covered the needs of the registered client group. Staff told the inspector that they had been afforded the time off and encouraged to study. The homes recruitment policy, procedures and documentation were examined and recruitment issues had been handled correctly. Staff had been subject to POVA/CRB comprehensive checks, and these were seen recorded. Staff asked stated that they had job descriptions and contracts of employment. All of the above had contributed to the quality of care provided and protection of service users. Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 21 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): Standards 31,33,35,38 The quality outcome for the above standards, based on available evidence and this inspection, is good. An experienced registered care manager is managing the home, in the best interests of service users, and in an open an inclusive atmosphere. The home is on a sound financial footing, and has safeguards for the health and well being of residents’ staff and visitors. Managerial aspects of the home are good. EVIDENCE: The registered care manager is both well experienced, and qualified. An open, positive and inclusive atmosphere was observed during the visit and confirmed to the inspector by service users, and relatives. From observations made, discussions with service users and staff, it was evident that the home was being run in the interests of service users. Quality assurance, including feedback from residents and their representatives, was
Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 22 seen documented. Documentation seen evidenced that the views of visiting professionals had also been established, and included in the review process. Staff supervision sessions, six times per year, had all been completed and documented. A check on the records and a discussion with both residents and relatives evidenced that all service users had the opportunity to handle their own finances and residents and families had chosen to do so. Day to day monies of residents and the associated records were checked and found correct, with all money held reconciling with the ledger. Inventories of valuables and belongings brought into the home were seen recorded. No health and safety issues were noted during this inspection, including a tour of the home. The documentation seen for checks and examination of plant and equipment was correct and up to date, these included; electrical installation and portable equipment tests, gas testing, boiler servicing, water testing, fire alarms and equipment, lift maintenance and examination, and maintenance/testing of lifting equipment. The homeowner has given assurances that the home is financially viable and that suitable accountancy and budgeting procedures were adopted. The current public liability insurance certificate was seen up to date and correct. All of the above aspects had contributed to the safety and well being of service users, staff and visitors. Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 23 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 X X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 4 X X 4 Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Care plans relating to wound care should be completed as soon as possible following admission, and a body diagram should be used where appropriate, all as agreed. Hawksyard Priory Care Home DS0000022334.V307764.R01.S.doc Version 5.2 Page 25 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
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