CARE HOMES FOR OLDER PEOPLE
Hoar Cross Nursing Home St Michaels House Abbots Bromley Road Hoar Cross Near Burton on Trent Staffs DE13 8RA Lead Inspector
Mr David Cowser Announced Inspection 14th February 2006 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 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. Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Hoar Cross Nursing Home Address St Michaels House Abbots Bromley Road Hoar Cross Near Burton on Trent Staffs DE13 8RA 01283 575210 01283 575310 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) Hoar Cross Care LTD Rosemary Joy Saint Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (20), Physical disability (51), Physical disability of places over 65 years of age (51), Terminally ill (5) Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 9th August 2005 Brief Description of the Service: Hoar Cross nursing home is a privately owned and managed property situated in the rural Staffordshire hamlet of Hoar Cross. The establishment is set in its own grounds with garden areas, and has extensive views over open countryside. The home is registered for a total of fifty-one service users in the following categories; Physical Disabilities 51, Physical Disabilities Elderly 51, Terminal Illness four, Old Age (not falling within any other category) 20, Day care 10.The home has twenty-five single occupancy bedrooms and thirteen double bedrooms, and all are adequate in dimensions. Fifteen single bedrooms and six double bedrooms have an en-suite facility. Adequate lounge, dining and recreational spaces were provided on the ground floor of the home. Two shaft-lifts service the first floor of the home. The approach to care in the home is based on integration of service users within the full range of communal spaces. Teams of care assistants reporting to trained nurses provide care, and a care manager (RGN) is in charge. A GP practice from the next village service the home and also provide medicines. NHS professionals and facilities are accessed when required and the home provides transport for surgery/hospital attendances. Activities and outings are facilitated and there is strong links with the local rural community. Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This routine announced inspection was made on the 14 February 2006 at 09:00hrs. 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 seven hours. The registered care manager (RGN) was in charge of the home; accompanied by a first level nurse and six care assistants. The ancillary staff on duty included; housekeeper and laundry worker, two cooks and an assistant, a maintenance man, two gardeners and an activities organiser. The business administrator was also on duty. These staffing levels were adequate to meet the needs of the current 36 residents in the home. The homeowner was also present for the inspection. There were a total of 36 elderly service users in the home, of which 32 patients were receiving nursing care, and four were receiving personal care for needs associated with old age. The age range of service users was 56 to 102 years. The inspection included the following elements; a tour of the building, observation and inspection of records relating to provision of care, discussions with several residents and visitors, discussions with the 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 9 August 2005; there had been no changes to the management of the home, no complaints had been received, and no additional visit had been necessitated. 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 three residents and four 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. Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 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. Nutritional/food 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 sampled the main meal of the day, which met all requirements and was well presented. Assistance was seen being given to people with care needs to help them to make a choice, by staff with 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. No complaint had been recorded since the last inspection, and a complaints system was in place. 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 (RGN) and teams of nurses and care staff provided care. A good working relationship was evident with the local GP practice, who also provide medicines (dispensing practice). 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. Staffing levels and skill mix had been
Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 Page 7 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 a good percentage (68 ) of care assistants were qualified to NVQ level 2 or above. In house training in relevant subjects had been on going. These aspects had contributed to the high standards of care being provided by the home. The registered care manager is sufficiently experienced, and competent. The general management aspects were good. The 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. 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 ledger (previously checked) had reconciled with the money held. 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. Many thank you cards and complimentary letters were seen from appreciative relatives. What has improved since the last inspection? What they could do better:
The upgrading and improvement work, currently in progress, must be completed and commission as agreed. The worn carpet, at the top of the slope on the first floor corridor, must be replaced ( As part of the renovation program). The redecoration throughout the home, in the areas identified, has commenced and must be completed as agreed. The main kitchen must be kept
Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 Page 8 clean, and workmen must reinstate all ducting covers after each session, as agreed. The registered manager should complete her studies and achieve the NVQ level 4 management qualifications, as agreed. 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. Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 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 Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 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): 3,6 Residents had been correctly placed in a home of their choice, which had the ability to meet their needs, following an assessment of their needs. 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 residents 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.
Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 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. Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 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): 7,8,9,10 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. EVIDENCE: The service user plans and associated documentation seen were complete, reflected the current condition of residents, and had been regularly reviewed. Care aspects had been well recorded and were seen cross referenced to associated documentation such as accident book and incident sheets. Entries seen within the care plans were meaningful. Where appropriate assessment documentation should include cognitive and behavioural aspects, as discussed. Discussions with both residents and staff members evidenced that health and personal care needs were being well met. Several service users commented positively about the care being provided. A total of five care plans were examined in greater depth, with a check on all aspects of care starting at the pre admission/assessment stage.
Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 Page 13 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. 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 one resident had a pressure area (acquired elsewhere), which was being correctly dealt with by the nursing staff. Community Psychiatric Nurses were also accessed to meet the mental health needs of service users. The above attendances were seen well documented. Death and dying aspects had been dealt with correctly in a sympathetic manner. Cards and letters were seen from thankful relatives. Staff when asked where knowledgeable on this subject, which was covered in their training. The number of deaths recorded during the past 12-month period had been eight, which is relatively low. The medicines within the home, medication administration records, controlled drugs book and drugs disposal book, 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 nursing 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. Two residents told the inspector that they were treated with respect, and that the staff were very kind. 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. Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 Page 14 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 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: Several 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, where possible, with relatives and friends and this was seen documented. Residents spoke of their visitors and their involvement with the home. One visitor attending the home during this inspection, told the inspector of the good links and communication with her. A dedicated member of staff coordinates and records the activities and entertainment provided. Several residents commented that this work had been appreciated. A discussion took place with the residents in one of the lounges regarding the past events and also the coming events. There is a very
Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 Page 15 active ‘Friends of Hoar Cross’ group, who raise money and organise activities for the residents. Several 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, including residents’ needs with diabetes, and special diets. The menus had been changed with input from the residents and staff knowledgeable of their likes and dislikes. The cook when asked said that fresh good quality food from local suppliers was delivered on a weekly basis, the records seen confirmed this. Adequate supplies of fresh vegetables and fruit were also seen. The care staff spoke with each resident on a daily basis to establish his or her choice of food for the day, and this was seen documented. The inspector sampled the mid day meal and it was well cooked and presented, meeting all requirements. Two residents said that an alternative to these would be provided if requested. Several residents were unable to make a decision regarding choice of meal, due to their current condition, and the inspector saw them being assisted by staff who were knowledgeable of their likes and dislikes. Residents were seen being discretely assisted to eat in an unhurried manner. All the above had contributed to the daily life and social aspects meeting service users needs and expectations. Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 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 complaint had been received since the last inspection. One observation had been made on the CSCI reply cards, but on checking the matter had already been dealt with. No additional visit to the home had been necessitated. Many ‘thank you’ and complimentary cards were seen 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 all the above issues had been discussed at length during staff induction, training and on-going supervision. All of the above had contributed to the protection of service users. Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 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): 19,26 The home was clean, pleasant and hygienic, and a suitable and safe environment for the provision of care was provided in the areas currently in use. The upgrading and improvement work, currently in progress, must be completed as agreed. EVIDENCE: A tour of the buildings, and a check on the maintenance documentation, evidenced that the parts of the premises being used were fit for purpose, clean warm and tidy. However the following items must now be satisfactorily addressed: The main kitchen must be deep cleaned, and workmen must reinstate all ducting covers after each session, as agreed. The upgrading and improvement work in the home, currently in progress, must be completed and commissioned as agreed. The worn carpet, at the top of the slope on the first floor corridor, must be replaced. The redecoration work throughout the home, in the areas identified, must commence as agreed.
Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 Page 18 The duty rosters evidenced that adequate ancillary staff were employed. Staff when asked had knowledge on infection control, and referred to the relevant documentation. Adequate hand washing facilities, including hand gel, were available throughout the home. The records evidence that maintenance of the premises was being addressed. The redecoration of the home has continued. The grounds and gardens were seen to be adequately maintained and were appreciated by residents spoken to. Hot water temperature checks, and emergency lighting/fire alarm tests were seen up to date and correct. Risk assessments were seen in place. When asked residents and relatives were happy with the environment and were appreciating the improvements slowly taking place. There are no outstanding issues known from the Fire Prevention officer and the recent report from the Environmental Health department is being addressed. Commissioning certificates and letters of satisfaction will be required on completion of the current work in progress. Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 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): 27,28,29,30 Adequate numbers of suitably trained and experienced staff are correctly employed to meet the assessed needs of residents. EVIDENCE: The registered care manager (RGN) was in charge of the home; accompanied by a first level nurse and six care assistants. The ancillary staff on duty included; housekeeper and laundry worker, two cooks and an assistant, a maintenance man, two gardeners and an activities organiser. The business administrator was also on duty. These staffing levels were adequate to meet the needs of the current 36 residents in the home. The homeowner was also present for the inspection. The duty rosters seen, and a discussion with the manager and the staff, evidenced that adequate numbers of nursing and care staff had been on duty to meet the needs of the existing service users. Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 Page 20 Staffing rosters were checked and were in order. An examination of the rosters evidenced that in addition to the registered care manager the following care staff had been maintained or exceeded for the 36 residents: a.m. 2RGN 6 Care assistants p.m. 1RGN 5 Care assistants nights 1RGN 2 Care assistants The care manager and her deputy also provide an on-call system. In addition to the above adequate ancillary staff had been rostered on duty throughout the week. Four residents asked stated that staff were available when requested, and that the staff were capable. In addition to qualified nurses the records seen evidenced that 19 care assistants were employed, of which 13 (68 ) were trained to NVQ level 2 or above. NVQ training is continuing. 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. The records seen and a discussion with the staff evidenced that, individually and collectively, they had the necessary experience and skills to meet the assessed needs of the current service users. All of the above had contributed the homes ability to meet the needs of residents and afford protection to them. Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 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): 31,33,35,38 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. EVIDENCE: The registered care manager is well experienced and should complete level 4 NVQ qualifications, as agreed. An open, positive and inclusive atmosphere was observed during the visit and confirmed to the inspector by service users, staff 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
Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 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 representatives 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 not checked, but previously had been found correct. 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, water testing, fire alarms and equipment, Lift maintenance and examination, and maintenance/testing of lifting equipment. As the home is all electrically powered there is no requirement for gas installation and boiler testing. The homeowner gave assurances that the home was 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. Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 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 4 8 4 9 4 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 3 3 x x 3 Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 Page 24 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. 2. 3. Standard OP19 OP19 OP19 Regulation 23(2(b) 23(2(d) 23(2)(b) Requirement Timescale for action 31/03/06 The worn carpet, at the top of the slope on the first floor corridor, must be replaced. The redecoration throughout the 09/10/05 home, in the areas identified, must commence as agreed. The upgrading and improvement 14/09/06 work, currently in progress, must be completed and commissioned as agreed. The main kitchen must be kept clean and all ducting covers must be reinstated after each session by workmen, as agreed. 21/02/06 4. OP19 23(2)(b) 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 OP31 Good Practice Recommendations The registered manager should complete her studies and achieve NVQ level 4 management qualifications, as agreed.
DS0000061268.V279031.R01.S.doc Version 5.1 Page 25 Hoar Cross Nursing Home Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hoar Cross Nursing Home DS0000061268.V279031.R01.S.doc Version 5.1 Page 26 - 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!
