Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 27/04/07 for Little Sisters Of The Poor

Also see our care home review for Little Sisters Of The Poor for more information

This inspection was carried out on 27th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a very good admissions policy, which sets out the admission criteria. The policy asks for people to be involved in their own assessment and there is evidence that this policy is working in practice. The service users are supported by well-trained, highly motivated and experienced staff team. The staff offer consistent care and attention to the service users. The staff are very respectful and treat the service users with dignity. There is a good programme of social activities in place and there is pictorial evidence in the home of recent activities including the St George`s Day social event. The service users spiritual needs are fully met and the service users and visitors confirmed the excellent support they get to enable them to maintain their religious observance. The home is clean and maintained in very good condition. It is safe and comfortable environment and enhances the self-esteem of the service users. The provider provides good training for the staff, which equip them to carry out their duties effectively and efficiently. Relatives and service users spoke of the respect staff show them and the professional way in which they carry out their duties. The home has a good induction programme for new staff, which are well documented and put into operation. The home has a health and safety committee, which meets every three months to review health and safety issues in the home.

What has improved since the last inspection?

In the last inspection report, a requirement was made on the manager to develop the care plans. Since then appropriate action has been taken to address this and the home now has care plans that are well put together which identifies individual`s need and provide guidance to staff on how best to meet those needs.

What the care home could do better:

The service user guide and the complaints procedure should be reviewed to reflect the new address and telephone number of the local office of the Commission for Social care Inspection. Pre-admission assessments carried out by the home do not always indicate where the assessment took place. This should state the setting within which the assessment was carried out, as assessment in a person`s own home may have a different result to that carried out in a hospital setting or in the care home.

CARE HOMES FOR OLDER PEOPLE Little Sisters Of The Poor Holy Cross Home Ettrick Grove High Barnes Sunderland SR4 8QA Lead Inspector Sam Doku Key Unannounced Inspection 27th April and 8th May 2007 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 Little Sisters Of The Poor DS0000015715.V334704.R02.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. Little Sisters Of The Poor DS0000015715.V334704.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Little Sisters Of The Poor Address Holy Cross Home Ettrick Grove High Barnes Sunderland SR4 8QA 0191 567 0862 0191 564 2026 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) Little Sisters of the Poor Religious Foundation Sister Kathleen Kiernan Care Home 46 Category(ies) of Dementia (14), Old age, not falling within any registration, with number other category (46), Physical disability (4) of places Little Sisters Of The Poor DS0000015715.V334704.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th November 2005 Brief Description of the Service: The Holy Cross home provides care to older people over the age of 65 years and some of who may have dementia or mental health needs or a physical disability. The home provides personal care only and any health needs are dealt with by the Community Nursing Services. It is a large detached brick built house, which offers accommodation over 3 floors, as well having its own chapel and living accommodation for the Sisters. It stands within its own grounds, which are extensive and also feature a religious grotto with a range of seating being available that service users and their families can use. The physical standards of this home are in excess of the National Minimum Standards. There are strong community links with the services that they provide, which includes a day service and luncheon club. The Mother Superior who is the registered manager of the home. The registered manager is assisted by a team of Sisters all of who belong to the Order of the Little Sisters of The Poor and who are referred to as Sisters throughout this report. The home is situated at High Barnes, leading off from the Chester Road. A small thriving shopping centre is a short walking distance from the home. The shopping centre has a post office, chemist, local grocery shop, newsagent and public house. There is easy access to a bus service, which offers access into the City Centre where a range of services and shops can be accessed. A regular bus service operates from the front of the home. The scale of charges is £369.00 per week. Little Sisters Of The Poor DS0000015715.V334704.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced key inspection involving one inspector and was carried out at 10:15 on the 27 April and 8 May 2007 involving two separate visits. The purpose of the inspection was to assess the care practices and the general management of the home. Prior to the date of inspection, a pre-inspection questionnaire was sent to the manager for completion. The returned questionnaire provided useful information about home, which helped to prepare for the inspection and provided the opportunity to identify specific areas to be explored during the inspection. Questionnaires were also sent to the service users and relatives, seeking their views on the quality of the service. Eight responses were received from the service users and fifteen responses from relatives. Both relatives and service users were very positive about the home and quality of the service provided. Some of the comments include, “my mother is not only looked after excellently but loved”, “ I wouldn’t be here if I haven’t had the care I need”. The inspection process involved talking to the service users to find out what they think of the service. The process also included observations of staff practices and procedures, examination of documents and records and also discussions with staff and management. The atmosphere and environment within the home was friendly, relaxed and comfortable throughout the time of the inspection. A number of service users and visiting relatives were spoken with. All were very complimentary about the home, the staff and the care provided. Service users appeared cared for and comfortable with the staff. Staff were professional in their manner and in the care practices they were involved in. The service users were able to express their views candidly to the inspector. What the service does well: The home has a very good admissions policy, which sets out the admission criteria. The policy asks for people to be involved in their own assessment and there is evidence that this policy is working in practice. The service users are supported by well-trained, highly motivated and experienced staff team. The staff offer consistent care and attention to the service users. The staff are very respectful and treat the service users with dignity. Little Sisters Of The Poor DS0000015715.V334704.R02.S.doc Version 5.2 Page 6 There is a good programme of social activities in place and there is pictorial evidence in the home of recent activities including the St George’s Day social event. The service users spiritual needs are fully met and the service users and visitors confirmed the excellent support they get to enable them to maintain their religious observance. The home is clean and maintained in very good condition. It is safe and comfortable environment and enhances the self-esteem of the service users. The provider provides good training for the staff, which equip them to carry out their duties effectively and efficiently. Relatives and service users spoke of the respect staff show them and the professional way in which they carry out their duties. The home has a good induction programme for new staff, which are well documented and put into operation. The home has a health and safety committee, which meets every three months to review health and safety issues in the home. What has improved since the last inspection? What they could do better: The service user guide and the complaints procedure should be reviewed to reflect the new address and telephone number of the local office of the Commission for Social care Inspection. Pre-admission assessments carried out by the home do not always indicate where the assessment took place. This should state the setting within which the assessment was carried out, as assessment in a person’s own home may have a different result to that carried out in a hospital setting or in the care home. Little Sisters Of The Poor DS0000015715.V334704.R02.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. Little Sisters Of The Poor DS0000015715.V334704.R02.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 Little Sisters Of The Poor DS0000015715.V334704.R02.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): 3, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Full and comprehensive needs assessments are carried out by a social worker and also by the home before service users move into the home. This process ensures that the care needs of the individual can be met by the home. It also provides confidence in the service users and their relatives that the home is capable of meeting their needs. Service users and their relatives are invited to visit the home and to meet staff and other service users before deciding on coming to live in the home. This arrangement gives prospective service users and their relatives the opportunity to view the facilities and make personal assessment of the place. Little Sisters Of The Poor DS0000015715.V334704.R02.S.doc Version 5.2 Page 10 EVIDENCE: The registered manager confirmed that it is the policy of the home to obtain full assessments from a social worker before admissions are arranged. The home also carries out their own assessment of the individual in their own setting to make sure that they can meet the prospective service user’s needs. This give confidence to all those involved, including the prospective service user and their relatives that the home is able to support and care for the person before they move in. However, the assessments carried out by the home did not always indicate when the assessment was carried. The service users commented positively on the assessment arrangements. Relatives also commented positively and said they found the assessment process reassuring as it provided them with the opportunity to discuss any issues that they may have about the home. The service user guide provides good information for prospective service users. Service users confirmed that they were offered the opportunity to visit the home and they did so with their relatives before making up their minds. This provided a positive adjustment into residential care for some of the service users. Two service users described the support they received from the home to enable them to visit the home and see it for themselves. They stated that this gave them the opportunity to meet with other service users and to speak with the staff and get to know a little bit about staff and the care provided. Little Sisters Of The Poor DS0000015715.V334704.R02.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, 10, 11. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Detailed care plans are available for care staff to work to. These reflect the care needs of the individuals and how these are being met, and therefore ensuring that each person receives the care that they are entitled to. Medication administration procedures ensure that the service user’s health care needs are addressed. Staff have a friendly and respectful approach towards service users, which empowers them and gives them control over their lives. The home has good care practices in place to promote the spiritual, physical and psychological wellbeing of service users at the time of their death. Little Sisters Of The Poor DS0000015715.V334704.R02.S.doc Version 5.2 Page 12 EVIDENCE: Since the last key inspection the home has reviewed the care plans and staff have had suitable training in the implementation of care plans and how to record the outcomes for the service users. The new care plans provide good information about the care needs of the individuals and action plans are formulated to address them. The care plans are regularly reviewed and the details are amended to take account of the changing needs of the individuals. Risk assessments have also been carried out for those service users for whom it is thought necessary. The risk assessments are supported by risk management plans to ensure that all staff are aware of how best to manage a specific risk. The home makes suitable arrangements for meeting the healthcare needs of the service users. There is a house doctor who visits the home on weekly basis and makes himself available for service users to see him if they wish. There are individual record of contacts with healthcare professionals, including GPs, psychiatrist, chiropody service, dentist, optician and other healthcare services. The manager confirmed that the district nursing service is utilised when needed for advice and treatment of pressure area care, tissue viability, and other medical support. This promotes the service users rights to proper healthcare. The service users confirmed that their healthcare needs are met through the arrangements for them to have access to healthcare facilities. The senior staff who are responsible for the administration of medicines have had safe handling of medication training. One of the Sisters has the responsibility for the medication system and for coordinating and managing the medication system in the home. The home has proper arrangements for the storage and administration of medicines in the home. The drugs administration system was examined and there were no discrepancies. There was clear audit trail of prescriptions and medicine received. The effective drugs administrative system promotes the health and welfare of the service users. Staff commented on the arrangements for caring for people who are dying. All staff had good understanding of the care required at such times. There is evidence that service users who are approaching death have their physical, emotional and spiritual needs met. Service users confirmed that the staff treat them with respect and promote their right to privacy. Comments from the service users include “staff always ask your views about things they want to do for you”, “they treat you with respect here”, “this is not just a job for the staff, it is a vocation”. Visiting relatives also stated that the staff treat them with respect and dignity. Visitors stated that the staff always keep them informed about the progress of their relatives. Little Sisters Of The Poor DS0000015715.V334704.R02.S.doc Version 5.2 Page 13 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, 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service users are encouraged and supported to lead active lifestyles based on their preferences and choices. Such support has enabled the service users to continue to maintain close relationship with their loved ones and the community from which they come from, thus promoting their continued sense of belonging. Organised social and recreational activities are purposeful and in line with the lifestyle and culture of the service users. This promotes their sense of wellbeing and satisfaction. The service users receive nutritious diet, which contributes to their health and wellbeing. Little Sisters Of The Poor DS0000015715.V334704.R02.S.doc Version 5.2 Page 14 EVIDENCE: Care plans set out the service users social, recreational and religious needs, and there is evidence of these needs being fully met. Service users confirmed that they enjoy the activities organised for them, including the daily mass conducted in the Chapel. Suitable arrangements have been made for those who are not able to attend, to watch the service live on their TV in the privacy of their room. Service users confirmed that they are free to join in other social activities if they wish and that they are not made to join in activities if they do not want to. The most recent social activity was a colourful party held on St George’s Day which the service users commented on positively. Photographs were taken of the occasion and displayed in the home, prompting topics of conversation amongst the staff and the service users. Relatives stated that they are able to visit at anytime convenient to them. They said the flexible visiting times make it easier for them to visit more often. Service users confirmed that the daily routines are organised flexibly to allow them to express their preferences. The service users cited, daily mass, meal times and bed times as examples of such flexibility. The service users stated that although there are set times for meals, they can have their meals at separate times or in their room if they wish. This allows individuals to make positive choices about some aspects of their routines. There is a four-week rotational menu in operation in the home. Past menus indicate that the home provides wholesome and nutritious meals for the service users thus promoting good health. Service users were very complimentary of the food. They confirmed that they are provided with good choice and that there is always plenty of food for them. Meals were served in a pleasant environment with minimum noise levels and relaxing atmosphere. Service users were able to help themselves to how much they wish to eat and people who were less able to manage this were offered discreet assistance by the staff. Service users commented that meals times are always pleasant and enjoyable experience. Little Sisters Of The Poor DS0000015715.V334704.R02.S.doc Version 5.2 Page 15 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, 17, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policies and practices in the home protect the service users from abuse. The home has a complaints procedure that is understood and available to all the service users and their relatives. The procedure and the associated training of staff in protection of vulnerable adult protect the service users from all forms of abuse. However, the contact details of the local CSCI office should be updated. EVIDENCE: The home has a written complaint procedure, which is regularly reviewed by the Order. Summary of the complaint procedure is included in the Service User Guide and the terms and conditions of residence. There is also a “Whistle Blowing” policy in place and copies of these procedures are also are also readily available for service users and visitors to see. Some of the service users and relatives indicated that they are aware of the procedure and would know how to complain if they had a need to do so. Little Sisters Of The Poor DS0000015715.V334704.R02.S.doc Version 5.2 Page 16 Staff have had training in protection of vulnerable adult and also on the home’s whistle blowing policy. The provider’s adult protection policy is in line with the City of Sunderland adult protection policy. Staff had good knowledge of the policy and also described what action they would take if they suspect any form of abuse. The home has a system for the recording of complaints they receive. A concern received from a relative was logged in the complaints book. No complaints have been received since the last inspection. Little Sisters Of The Poor DS0000015715.V334704.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 25, 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Holy Cross provides a good standard of personal and communal accommodation. The home is clean and maintained to good standard, including attention to safety of the environment thus promoting the welfare of the service users. The home provides accommodation and equipment that meet the needs of the service users. This promotes independence and also the self-esteem of the service users. Little Sisters Of The Poor DS0000015715.V334704.R02.S.doc Version 5.2 Page 18 EVIDENCE: The home provides good standard of accommodation. This meets the needs of the service users. Bedrooms are individually decorated and reflect individual taste. Service users are encouraged to furnish their rooms with personal items, making it pleasant and familiar environment for the occupants. The bedrooms are large and spacious and allow service users to accommodate their personal belongings without the rooms looking cluttered. All areas of the home are clean and maintained to good standard. There are areas of the home currently being decorated but adequate precautions have been taken to ensure safe environment for the staff, service users and visitors. The home provides a number of communal areas for service users to choose from. These include a range of lounges, dining rooms, library, activities room and other communal sitting areas. The garden is well-maintained and tendered. Service users spoke about going for walks in the grounds and enjoy the quiet and peaceful surroundings. Little Sisters Of The Poor DS0000015715.V334704.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home continues to maintain sufficient staffing levels that meet the needs of the service users. The good recruitment procedures in the home are robust and effective in safeguarding the safety and welfare of the service users. Care is provided by well trained and competent staff team that ensure a good service for the service users. EVIDENCE: Adequate staffing is provided to meet the needs of the service users. Past rotas showed that the home provides good staffing ratios that meet the needs of the service users. Service users and relatives, all commented that there is always sufficient staff on duty to meet their needs. Little Sisters Of The Poor DS0000015715.V334704.R02.S.doc Version 5.2 Page 20 The majority of the staff have been working in the home for a long time and the staff turnover rate is very low. The majority of the staff have attained NVQ Level 2 or above. Staff spoke of the good training they have received and the benefits to them and the service users. The home has a comprehensive induction training programme, which is carried out over a twelve weeks period. A senior staff member has specific responsibility for the induction of staff into the work place. Staff stated that they have had training in moving and handling, first aid, fire safety training, food hygiene, health and safety and protection of vulnerable adults awareness training. The registered manager and the other Sisters who are senior staff confirmed that individual supervision arrangements are taking place more consistently. The records of the most recently appointed staff were examined. These contained evidence of good recruitment procedures being followed. This ensured that the service users are protected from possible abuse from people who would be deemed as not suitable to work with vulnerable people. Little Sisters Of The Poor DS0000015715.V334704.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager leads a team of competent, dedicated and committed staff who provide good quality service for the people they look after. There are good care practices in place that protected the safety and welfare of the service users and the staff. The manager offers clear leadership and direction to the staff so that they can consistently meet the needs of service users. The home has good arrangements in place for managing the service users’ personal savings. This protects their financial interests and also prevents any financial abuse. Little Sisters Of The Poor DS0000015715.V334704.R02.S.doc Version 5.2 Page 22 The health and safety of the service users are promoted by a well managed staff team and proper administrative and safety procedures. EVIDENCE: The manager has long experience of working in care setting for older people and is a registered nurse. She has previously managed other homes in other parts of the country. The registered manager runs the home for the benefit of the service users in line with the Christian ethos of the Order. The home has a good system in place for managing the personal allowances for the service users. Details of purchases and receipts are available for those whose monies are held by the home. The Order’s Health and Safety policies remain in place. These cover policy areas such as fire prevention and Care of Substances Hazardous to Health (COSHH). There is evidence that staff adhere to the policies as set by the Order. Servicing records confirm that all portable appliances have been tested. A record is maintained of regular water temperature tests in the home. Regular servicing of fire equipment, gas and electrical appliances have been carried out by the contracted companies. All the servicing records that were examined were up to date. These included servicing of hoists, water treatment, electrical installation and gas servicing. Up to date servicing and maintenance of these services and equipments ensure a safe environment for the service users and the staff who work there. Records examined indicate that fire precautions relating to weekly fire alarm testing and record of inspection takes place. There are records in the home indicating fire drills and fire instructions with staff. Little Sisters Of The Poor DS0000015715.V334704.R02.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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 4 X 3 X X 4 4 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 4 X 3 X 3 X X 4 Little Sisters Of The Poor DS0000015715.V334704.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 OP3 Good Practice Recommendations Pre-admission assessments carried out by the home do not always indicate where the assessment took place. This should state the setting within which the assessment was carried out, as assessment in a person’s own home may have a different result to that carried out in a hospital setting or in the care home. The service user guide and the complaints procedure should be reviewed to reflect the new address and telephone number of the local office of the Commission for Social care Inspection. 2 OP16 Little Sisters Of The Poor DS0000015715.V334704.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Little Sisters Of The Poor DS0000015715.V334704.R02.S.doc Version 5.2 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!