Inspection on 29/09/05 for Maynell House

This inspection was carried out on 29th September 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Maynell House 18/09/09

Maynell House 30/05/07

Maynell House 01/03/06

Maynell House 30/03/05

Maynell House 30/09/04

Maynell House 17/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Maynell House High Road East Felixstowe Suffolk IP11 9PU Lead Inspector Deborah Seddon Unannounced Inspection 29th September 2005 09.30 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 Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 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. Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Maynell House Address High Road East Felixstowe Suffolk IP11 9PU 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) 01394 272731 01394 272731 Pri-Med Group Ltd. Ms Wendy Jacqueline Patient Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th March 2005 Brief Description of the Service: Maynell House is a care home registered to provide accommodation and personal care for up to 25 older people. The home is part of the Pri-Med Group Ltd and is one of the organisations’ three care homes for older people in Felixstowe. It stands back from the main road in it’s own extensive grounds. The house was once part of the independent boarding school for girls and it retains many of it’s original features, but has been extended to provide additional accommodation, including a pleasant veranda where residents can sit in warm weather. The home is on three floors and access to all but one room is either by staircase or a passenger lift. All rooms are tastefully decorated and furnished. There are two lounge areas and a dinning room. Interesting gardens surround the house, which includes a water feature complete with mature fish. Bedrooms are equipped with a single bed, wardrobe, chest of drawers, bedside cabinet and an easy armchair. With the exception of two rooms all have en suite facilities providing either a bath or a shower. Many of the bedrooms have views over the gardens. Residents are encouraged to bring their own personal possessions into the home, including small items of furniture. There is an emergency call bell system in operation situated in each bedroom and bathroom. The home is staffed 24 hours a day, with two waking night staff. The company has achieved Investors in People Award, initially in 1995 and has subsequently been re-accredited three times. Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 9.30am. Debbie – front of the report states it started at 10a.m. It took place over seven and halfhours during a weekday. Time was spent with the organisations’ training director, the registered manager of the home and two staff. A tour of the premises was made and a number of records were examined including those relating to the care of residents, staff and a selection of policies and procedures. The inspector spent time talking with the residents collectively and four residents individually and with the relatives of one resident who were visiting at the time of the inspection. The inspector was able to join the residents and relatives meeting that had been scheduled for the afternoon of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Radiators seen during the inspection are mostly original and are in keeping with the home, however there is a potential risk of burns to residents if they Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 6 fall against an unguarded radiator. The inspector was informed that a programme of installing radiator covers was in place through all Pri-med homes, however in the mean time to ensure the safety of the residents risk assessments must be undertaken with respect to radiators which are not guarded or of a guaranteed low surface temperature variety. Medication administration record (MAR) charts were seen which showed creams prescribed by the general practitioner (GP). However these are not being signed for on the MAR charts. The inspector was informed that the creams are held in the resident’s rooms and staff apply these when attending to the service users personal care needs. Although most of the creams could be bought as over the counter medicines, they were listed as prescribed on the MAR chart and these should be signed for when administered. One of the creams was Fucidin, which is a prescribed medicine. In line with good practice a chart should be held in residents rooms and staff should sign to say they had administered all creams. 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. Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 7 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 Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 8 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): 1, 2, 3, 4, 5, 6, Residents and their families can expect to have detailed information about the home and have an opportunity to visit before making a decision about where they live. Residents can expect to have their health and personal needs fully assessed before moving into the home to ensure that their specific needs will be met. EVIDENCE: The manager provided the inspector with a copy of the most recent statement of purpose and the service users guide. These are both well presented and contain a lot of very detailed information for prospective users of the service, and focuses on Pri-med’s philosophy making the home “your home, not ours” The personal files and individual care plans of three residents were inspected; each resident was provided with the homes terms and conditions of admission and terms of business, which detailed the homes and the resident’s obligations, and details of fees and payment agreement. Each resident and the manager had signed to say they had read and agreed the first two pages of the agreement. Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 9 The care plans seen had comprehensive detailed pre admission assessments completed by the manager. These consisted of 11 sections, which contained key information about the service users background, general health and physical well-being and current care needs and their social interests and hobbies. All the information from the pre admission assessment formed the basis of the individual service users care plan. Evidence that residents were able to visit the home on a trial basis was seen in two of the three care plans. One resident had stayed at the home on two separate occasions prior to moving into the home and another resident had stayed for a holiday with their spouse, and had moved into the home when their partner was admitted to hospital. The statement of purpose seen includes the home’s policy for dealing with emergency admissions and that key aspects of the admission process would be undertaken within 48 hours of the admission. The home does not provide intermediate care. Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 10 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, 11, Residents can expect to have their health and personal needs identified, and reviewed on a regular basis to ensure that their needs are met at all times. EVIDENCE: Three care plans were inspected. At the front of each plan was a care assessment sheet with the details of the resident’s next of kin and general practitioner (GP) and previous medical history and known medical conditions. The assessment sheets were made up of 13 sections, which included issues around the resident’s health and personal care needs. Each of these headings was further explored in detail to form the care plan focusing on the resident’s assessed needs and evaluation of the support required. Evidence was seen that the residents care plans were being reviewed on a regular monthly basis to reflect their changing needs. Residents had signed a consent form to say that they had discussed and agreed their care plans, which included their wishes in the event of death, dying or serious illness. One resident had recorded they did not want to be resuscitated and wished to be cremated. The other two care plans seen had instructions that the residents wished to be cremated and had the details of the funeral arrangements. Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 11 Detailed progress notes were kept by staff, tracking the heath and welfare of residents, one resident’s night plan stipulated that the night staff were to check on them twice during the night due to a medical condition. Evidence was seen in the residents’ daily recording that night staff had recorded checking the resident at 2am and 6am. The daily recording notes had also highlighted that the resident had an area on their left leg that was not healing and an entry was made that there had been a visit from the GP who had made a referral to a dermatologist. Two residents benefit from the input of a freelance fitness therapist, who is a qualified physiotherapist and was working with one resident to increase their fitness levels, strength, flexibility, and monitoring their weight. The therapist was seen with the residents on the day of the inspection, they were about to go for a power walk. The other resident had had a stroke and the therapist was working with them towards regaining strength, flexibility and mobility. Evidence was seen on each of the care plans of detailed moving and handling assessments identifying the support required and equipment to be used. Falls assessments were in place with a scoring system to identify the risk of the resident falls and preventative action required, however one resident diagnosed as diabetic with a related condition of neuropathy causing limited feeling in their lower limbs was not referred to in the risk assessment. Evidence was seen that these risk assessments were being reviewed on a regular monthly basis. Risk assessments were in place for two residents who were self-medicating; they had a key to their own lockable storage in their rooms. One of the residents told the inspector that they are able to order their own repeat prescriptions and arranges with Walton pharmacy to deliver their medication to Maynell House, this was being reviewed monthly to ensure that the resident is still able to manage control of their medication independently. A senior staff member was observed administering the lunchtime medication. Moss pharmacy provides the home’s prescribed medication using the monitored dosage system (MDS). Medication administration records (MAR) charts were seen and had been completed satisfactorily, with the exception of creams, which had been prescribed by the general practitioner (GP). These were not being signed for on the MAR charts. The training director and manager informed the inspector that creams were held in the residents rooms and staff applies these when attending to the service users personal care needs and that the creams although on the MAR charts were over the counter medications. However the inspector pointed out that one of these creams was Fucidin, which is a prescribed cream, and that this should be signed for when administered. The training director and manager agreed that in line with good practice a chart would be held in residents rooms and staff would sign to say they had administered all creams. Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 12 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, Residents can expect to live in a home that supports a life style that matches their expectations. Residents can expect to receive a good standard of fresh and appealing food with a wide variety of choice as part of their daily diet. EVIDENCE: A notice board in the dining room displayed a range of activities on offer to the residents; regular bus outings were scheduled to Dedham, Flatford, Harwich, and Orford. An entertainer, Brian Roy Entertains, had been booked to celebrate a resident’s birthday and a trip had been arranged for residents to go to the Spa Pavilion theatre to see a play ‘The Final Celebration’. A priest from a local village visits the home to hold a service for residents wishing to attend. In house entertainments included pottery and reminiscence meetings. Residents are supported to maintain contact with their relatives on a regular basis. A residents and relatives meeting had been scheduled for 1.45pm on the day of the inspection and several of the relatives attended. One resident’s relative stayed on after the meeting and was spoken with by the inspector. They felt that “staff are very attentive and supportive to their relatives needs, although they were quite independent and could manage most tasks on their own” they also commented that it “was a nice friendly home”. Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 13 The residents meeting was held after lunch in the dining room. The inspector was able to join the meeting where evidence was seen that the residents views were sought in events occurring within the home. Plans were being made to celebrate the battle of Trafalgar which has it’s 200 years celebration in October, residents took a vote on having fireworks, entertainment and stalls to raise money for the Royal National Lifeboat Institute (RNLI). The manager informed the residents that following a visit from the British Broadcasting Corporation (BBC) and their discussions with two of the residents about the involvement and interest in the Second World War, they had received forms for other residents to complete if they have further information for the BBC archives. Residents were asked what other entertainment they would like. Suggestions ranged from a Glen Miller afternoon with music, an outing to the ferry golf club which has an over 60’s brass band, other residents wanted a small orchestra to visit the home. All residents agreed that they would like to have regular beetle drives; one of the relatives visiting agreed to coordinate a beetle drive once a week. The manager also informed residents of alterations being made in the building to accommodate a new bathroom and wheelchair accessible shower room. The inspector was able to speak with residents following the meeting about their experiences living in the home; comments ranged from “wouldn’t go anywhere else, very happy indeed” and “good home, dinner was very good, can’t grumble about the food” and “staff are very good and the food is excellent” Food seen was nicely presented and residents had a choice of meal. The menu for the day of the inspection was cottage pie or bacon and cheese and tomato quiche, garlic and herb potatoes, ratatouille and cauliflower. Dessert was a choice of bread and butter pudding and custard or a selection of cold sweets. One resident spoken to who was used to cooking for themselves had reservations about the food. They appreciated that cooking for a large number of people was difficult to meet everyone’s individual tastes, however, they felt that the food was often bland and had little salt and herbs added. The inspector observed food being prepared and noticed that the cook had used garlic and herbs in the roast potatoes. The cook informed the inspector that they brought in ready-made curry and pasta sauces by Lloyd Grossman for the resident to cater for their acquired tastes. A discussion took place at the residents meeting about choices of food and the addition of salt, many of the residents did not like to much salt and some were on a salt free diet. The manager spoke to all residents about the affects of too much salt on the kidneys and high blood pressure, and it was generally agreed that those whom wanted more salt could add this at the time there food was served. Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 14 Every month the home produces an activities list. Evidence of this was seen when speaking with residents in their rooms. They showed the inspector the list, which had the date and time of the residents meeting and details of all other activities scheduled for September including a visiting library and a pottery class. One resident told the inspector they receive a list of books from the library at the beginning of the month to choose from and another resident showed the inspector a pot they had made and painted in the pottery group. Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18, The home has clear policies and procedures in place for the protection of vulnerable adults and dealing with allegations or suspicions of abuse. Residents can expect to have their complaints dealt with promptly and effectively. EVIDENCE: The home has a ‘management of complaints policy’, which is included in the statement of purpose and residents handbook, referred to as ‘How to tell us about your views’. The policy informs residents that they will be supported to make complaints and that these will be dealt with within 28 days. The policy also gives the details of the commission for social care inspection (CSCI) and Suffolk county council customer services officer to refer the complaint if the resident is not satisfied with the response to their complaint. The complaints book was seen and 2 complaints had been made from a relative of a resident since the last inspection. The complaints were investigated by the manager on both occasions and fed back to the resident and the relative of the action taken and outcomes within the timescale of 28 days. They appeared to have been resolved. The home has a clear management of abuse policy in place, which states that the home will work with all legal and caring agencies to ensure that residents will be protected from harm. This included a copy of the Suffolk vulnerable adult protection inter agency policy operational procedures and staff guidance pack. This policy is also linked in with the prevention of abuse policy including whistle-blowing procedure. All staff receive training on the protection of vulnerable adults and a welcome pack when joining the company, which directs them on their responsibilities to report bad practice. Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 16 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, 20, 21, 23, 24, 25, 26, Residents can expect to live in a well-maintained and welcoming environment, which provides a good range of communal and personal accommodation, however the safety of the residents cannot be assured with regards to the risk of burns from unprotected radiators. EVIDENCE: Maynell House has a nice homely feel and is nicely presented both inside and out; all areas of the home were nicely decorated and clean and tidy. The home is on three floors and has access to all but one room either by staircase or a passenger lift. All bedrooms seen were tastefully decorated and furnished with resident’s own belongings. One resident informed the inspector that “they had brought their own furniture and belongings so that they still had things around them that reminded them of home” and another resident introduced the inspector to a pet cat that they were looking after which kept them company in their room. All bedrooms were fitted with locks and residents who were able held their own key. Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 17 Communally there was a range of facilities available. There is a separate dining room and two lounges, one that has a bar. One lounge leads out into the garden veranda where residents were observed sitting in the sun reading after lunch. The manager showed the inspector a hairdressing salon that had recently been redecorated. This had 1940’s and 1950’s black and white pictures on the wall of film stars such as Marilyn Munroe and Audrey Hepburn and hairstyles of that period and that fairy lights had been purchased to put around the mirror. A passageway connecting the main house to the building that used to be the schoolrooms called ‘the link’ provides a nice bright seating area for residents to sit and has views across the garden to the summer house. All bedrooms had adjustable beds provided and with the exception of two bedrooms all have en suite facilities providing either a bath or a shower. There are two communal bathrooms, which have a bath seat and hoist fitted. Each of the bathrooms was decorated in a theme, one has a nautical theme and the other was decorated with the pears soap adverts. The manager informed the inspector that further decoration work was being carried out to two rooms, one to increase the size of the existing bathroom to install a parker bath and another to create a shower room that would have disabled access. During the tour of the building it was noticed that the radiators in residents bedrooms and bathrooms and communal areas did not have radiator guards. Although it was summer time and radiators were not in use there is a risk that residents could sustain burns from falling against hot radiator surfaces when being used in the winter months. The training operations manager informed the inspector that all Pri-med homes were scheduled to have the radiator covers fitted, however in the mean time the inspector suggested that the manager undertake a risk assessment to high light where residents would be most at risk. Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 18 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, Residents can expect to be supported and protected by a staff team, who have received training and have the skills and knowledge to care for them. Residents can expect to be cared for by a team of staff who are supervised, supported and available in sufficient numbers to meet their needs. EVIDENCE: Staff rotas seen indicate that there are sufficient staff on duty to meet the needs of the residents. The manager informed the inspector that the staffing ratio was for 4 staff to work on the early shift between 8-2 and 3 staff to work the late shift, with 2 waking night staff between the hours of 10pm and 8am. Evidence of this was seen on the rota for the 29th September 2005 and observed throughout the inspection. On a Tuesday and Friday an extra member of staff is included on the shift to help as an escort on the minibus trips. The training director and their team are responsible for staff training and development. There was a positive attitude and commitment to staff training from all staff and residents spoken with. All new members of staff are issued with a welcome pack and a training and development programme setting out timescales and details of their training, which includes the induction and foundation training in line with the sector skills council for social care (TOPPS) guidance. Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 19 The home benefits from being part of a large organisation, which has developed it’s own excellent training package for all staff which is similar to national vocational qualification (NVQ) incorporating 4 levels. The training is based on a hands on learning approach and all care and ancillary staff are encouraged to take part in their own learning and development for which they receive certificates and badges of achievement. Three staff files were inspected, each had certificates of their induction and foundation, which consisted of core training including the required topics required in the TOPPS training and moving and handling, first aid and food hygiene and adult protection. All 3 staff had an NVQ level 2. The staff files seen demonstrated that the home had the necessary checks in place for the safe recruitment of staff. All three files looked at had records of the staffs criminal records bureau check (CRB) and in the case of a new employee a protection of vulnerable adults (POVA) check was made prior to them commencing employment at the home as well as an application for their CRB. Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 20 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, 32, 36, 38, Residents can expect to live in a home that is effectively managed and is run in their best interests by an experienced management and supported staff team. EVIDENCE: The manager of the home is a registered nurse and has been the matron of Maynell House for 4 years and has previously managed a home in Gloucestershire. They also have a diploma in the management of care services; level 4 qualification. On the day of the inspection the manager was observed holding a residents and relatives meeting where they shared information about developments in the home and asked for residents suggestions on forthcoming events occurring in the home. Evidence was seen on three staff files that a regular process of supervision and annual performance and development appraisals of staff were taking place. Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 21 The manager, as part of the staff’s ongoing training programme, also undertook training reviews. Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 X 2 Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13,2 Sch 3(3)(i) Timescale for action All lotions and creams 29/11/05 administered must be recorded on a medication sheet or chart. Fucidin, is a prescribed cream, and this must be signed for when administered. In line with good practice a chart should be held in residents rooms and staff should sign to say they had administered all creams. Risk assessment must be undertaken with respect to radiators, which are not guarded, or of a guaranteed low surface temperature variety. 29/11/05 Requirement 2 OP38 13 (4) (a) (c) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Maynell House DS0000024444.V256825.R01.S.doc Version 5.0 Page 25 - 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. 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