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Inspection on 12/02/07 for Meadowside & St Francis

Also see our care home review for Meadowside & St Francis for more information

This inspection was carried out on 12th February 2007.

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.

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

Meadowside & St Francis is homely, comfortable and welcoming. The staff are trained and competent in their jobs and there was a nice atmosphere during the inspection with staff interacting well with the Service Users and a number of visitors in the home. The nursing side (St Francis) still maintains a homely feel despite the need for medical and clinical equipment. The information about the home given to prospective Service Users and or their representatives has sufficient detail to allow an informed decision to be made about moving into the home. When possible, prior to admission, the manager or her deputy visit the person in their current setting to perform a full needs assessment in addition to receiving care plans from other social and health care professionals. Once admitted to the home Service Users needs are set out in a care plan, the plans provide sufficient information for care staff to be able to meet the individuals` health, social and psychological needs. The processes in place protect the health and welfare of the Service Users such as the complaints procedure, health and safety procedures. Regular training for the staff help to assure the people living in the home that they are well looked after. Service Users are able to maintain contact with family and friends and exercise choice and control over their lives. Service Users receive a wholesome appealing diet. Service Users are asked on the day of the meal what they would like to eat, with alternatives to the menu always being available. The home is tastefully decorated and furnished and presented as clean, bright and hygienic.

What has improved since the last inspection?

Redecoration is ongoing and has improved the environment within the home. The manager has introduced internal rotation of staff to ensure that all staff can care for a Service Users needs 24 hours a day. The consent form used for bed rails is more comprehensive and the manager is to ask the relevant GP to sign the form also.

What the care home could do better:

The `personal account record` sheets used to manage Service Users personal allowances should be stored more securely. The administrator who manages the sheets showed the inspector where they would now be kept.

CARE HOMES FOR OLDER PEOPLE Meadowside/St Francis Meadowside/St Francis 5 Plymbridge Road Plympton Plymouth Devon PL7 4LE Lead Inspector Mandy Norton Unannounced Inspection 25th January 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 Meadowside/St Francis DS0000056816.V318742.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. Meadowside/St Francis DS0000056816.V318742.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Meadowside/St Francis Address Meadowside/St Francis 5 Plymbridge Road Plympton Plymouth Devon PL7 4LE 01752 337938 01752 346682 meadowsidestfrances@btopenworld.com 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) A J & Co (Devon) Limited Mrs Gina Marie Paterson Care Home 69 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability (10), Physical disability of places over 65 years of age (69) Meadowside/St Francis DS0000056816.V318742.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Service Users aged 65 years and over PD(E) Maximum registered 69 service users (both) TI(E) Maximum registered 9 service users (both) OP Maximum registered 25 service users (both) Physical Disability under 65 years of age (10) Date of last inspection Brief Description of the Service: Meadowside and St Francis Care Centre is situated in a residential area in Plympton, Plymouth, Devon. The Care Centre is divided into 2 units; one provides nursing care for a maximum of 44 service users (St Francis) the other provides personal care for up to 25 service users (Meadowside). The home caters for persons over the age of 65 years, male and female, with physical frailty, illness or disability (the home is able to take up to 10 people under 65 at any one time). The accommodation is provided on three floors, all but 5 rooms are accessed by a passenger lift; more able service users can access the other 5 rooms by stairs or stair lift. Each unit has dedicated communal areas including lounges and dining rooms, service users from either unit can socialise in either area. Some bedrooms fall below 10 square metres, a formal assessment of individual needs and consideration to choice is given when these rooms are utilised. The home benefits from spacious grounds, which are well maintained and accessible to wheelchair users. Service users who have an interest in gardening are encouraged and facilitated to continue to help around the gardens. The home is owned by A.J. & Co (Devon) Ltd, who own another care home in Cornwall. There is access to the local shops and amenities. There is a bus stop very near to the home. The fees charged range from £351 to £546 (February 2007). People requiring ‘continuing care’ and ‘individual persons packages(IPP) have their fees negotiated by the placing authority on an individual basis. ’The latest inspection report is available in the foyer and the manager was Meadowside/St Francis DS0000056816.V318742.R02.S.doc Version 5.2 Page 5 advised that the Statement of Purpose should be updated to include information about where people can access the latest report if they do not have access to the internet. The contracts issued include name and date of admission and who pays the fee, how the fee is broken down and the total fee, plus the homes terms and conditions of residency. Meadowside/St Francis DS0000056816.V318742.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place from 10.50 am until 4 pm and was conducted with the manager. A tour of the home was carried out. The report contains views from the completed staff surveys returned (14) reflected throughout, information taken from the completed pre inspection questionnaire and views of Service Users spoken on the day of the inspection. What the service does well: Meadowside & St Francis is homely, comfortable and welcoming. The staff are trained and competent in their jobs and there was a nice atmosphere during the inspection with staff interacting well with the Service Users and a number of visitors in the home. The nursing side (St Francis) still maintains a homely feel despite the need for medical and clinical equipment. The information about the home given to prospective Service Users and or their representatives has sufficient detail to allow an informed decision to be made about moving into the home. When possible, prior to admission, the manager or her deputy visit the person in their current setting to perform a full needs assessment in addition to receiving care plans from other social and health care professionals. Once admitted to the home Service Users needs are set out in a care plan, the plans provide sufficient information for care staff to be able to meet the individuals’ health, social and psychological needs. The processes in place protect the health and welfare of the Service Users such as the complaints procedure, health and safety procedures. Regular training for the staff help to assure the people living in the home that they are well looked after. Service Users are able to maintain contact with family and friends and exercise choice and control over their lives. Service Users receive a wholesome appealing diet. Service Users are asked on the day of the meal what they would like to eat, with alternatives to the menu always being available. The home is tastefully decorated and furnished and presented as clean, bright and hygienic. Meadowside/St Francis DS0000056816.V318742.R02.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: 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. Meadowside/St Francis DS0000056816.V318742.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 Meadowside/St Francis DS0000056816.V318742.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): 1, 2 & 3 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use this service or are prospective Service Users have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. This home does not provide intermediate care. EVIDENCE: Meadowside/St Francis DS0000056816.V318742.R02.S.doc Version 5.2 Page 10 The manager said that prospective Service Users are assessed by herself or the deputy matron, who go to visit the person in their current setting to make an assessment. The pre admission form seen included information about potential Service Users current abilities, medication, next of kin and equipment required. The matron is going to add a question about whether the Service User wants the staff to administer medicines or not. The manager was welcoming a new Service User to the home on the day of the inspection. A relative came to look around the home, unannounced during the inspection and although the staff were very busy, the provider was able to show him around. The manager said that the potential Service User had already been to look at the vacant room himself. The home has its own website - www.mdsf.uk.com which has information about the home and the services it offers. The site is linked to the CSCI website where the previous reports can be accessed and is also linked to Plymouth City Council who have up to date information about vacancies within the home. Meadowside/St Francis DS0000056816.V318742.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 good. This judgement has been made using available evidence including a visit to this service. The manager promotes and maintains Service Users health and ensures access to health care services to meet assessed needs. The homes medication systems protect the welfare of residents. Service Users are treated with respect and their right to privacy is upheld. EVIDENCE: Six (6) care plans were examined; in all of those seen there were assessments which provided information about skin integrity, moving and handling, safety including risk of falls, use of bed rails risk assessments and nutritional screening. The information generates the plans of care, which provide the Meadowside/St Francis DS0000056816.V318742.R02.S.doc Version 5.2 Page 12 basis for the care to be delivered. Any ‘wounds’ have a wound care chart which is kept in the treatment room, for completion/ review once the wound has been dressed. Records are maintained in the care plans for all visits to the home by social or health care professionals. All Service Users are registered with a GP. The nursing side of the home (St Francis) looks after a number of highly dependant Service Users and people who require palliative care. The staff use the ‘Liverpool Care pathway’ accessed by all of the health professionals involved with Service Users with palliative care needs – this is noted as good practice. Despite the amount of equipment in use especially on the ‘nursing side’ the environment remains homely and not clinical. The medication system is well managed; The pharmacist supplies medicines in blister packs that are kept in the drugs trolleys. A second drugs trolley is in use to allow medicines to be given out by trained staff on different floors at the same time. The manager was advised to ensure the homes medicines policies include procedures for transcribing medicines/information from GP’s. The matron is going to add a question to the pre admission sheet about whether Service Users would like the staff to administer their medicines or not (following assessment). Disposal of unused/ out of date medication is safe, well recorded and removed by a licensed contractor. There were pots of cream with no opening date written on them. It was recommended date of opening is clearly marked on creams and lotions kept in Service Users rooms. During a tour of the home staff were overheard interacting with Service User ’s appropriately, joining them into conversations and talking with them individually. Doors were closed when personal care was being delivered. Staff were seen & heard knocking on doors before entering Service User ’s rooms. The home works well with local services and professionals in providing palliative care. The staff involved have relevant training and experience in this area. The staffing levels allow staff to carry out the care required by these Service Users in a sensitive and caring way. Meadowside/St Francis DS0000056816.V318742.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. Effort is made by the home to provide an activities programme and social interaction/stimulation for Service Users. Service Users are able to maintain contact with family and friends and exercise choice and control over their lives. Service Users receive a wholesome appealing diet and are not rushed encouraging the mealtime to be a social event. EVIDENCE: Meadowside/St Francis DS0000056816.V318742.R02.S.doc Version 5.2 Page 14 The full time activity co-ordinator is involved in a variety of activities with Service User’s. The February 2007 activities are displayed in the entrance foyer. Completed staff surveys say daily activities are ongoing. The inspector sat in the lounge and noted the activity co-ordinator spending time with a Service User making cards. She brings her dog in (has done for 7 years) and this is popular. There are also budgies and a cockatiel. There were visitors in the lounge with their relatives and the atmosphere was homely and friendly. Relatives spoken to said that the staff try to engage Service Users and include them in activities. The gardens are accessible and well maintained. Some Service Users were sitting outside smoking. Clients can have their own TV, radio and telephone (they are responsible for the individual bill). A tour of the home showed some Service Users in their rooms watching appropriate TV programmes, reading newspapers and magazines and chatting with visitors. Others were in one of the 3 lounges with their visitors or chatting to other Service Users. The menus (provided with the pre inspection questionnaire) are on a rolling 4 week system. Alternatives are always available. Service Users spoken to said the meals were good and well presented. The matron said that tea, coffee and other hot drinks are served and available 24 hours a day, visitors are also catered for. Relatives can have a meal from the menu at a cost of £3. The manager said that several people take this opportunity. Service Users can eat in their rooms or in the dining room. People were seen dong both during the inspection. Staff spoken to said that it is nice to have the number of staff they do so Service User’s needs both physical and social can be met. Meadowside/St Francis DS0000056816.V318742.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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users and their relatives/friends know how to make a formal complaint. People are safe living in this home. EVIDENCE: The complaints procedure was seen displayed within the home and is in the Statement of Purpose, given to all Service Users and /or their representatives on admission. The manager and deputy’s role includes discussing concerns and/complaints with Service User’s and /or their relatives. The manager is involved with any investigations. An incident had been reported to the matron on the day of the inspection and she described the actions she was going to take to investigate the issues. The matron was clear about how to investigate and possible outcomes following the investigation. Meadowside/St Francis DS0000056816.V318742.R02.S.doc Version 5.2 Page 16 Thirteen (13) of the fourteen (14) completed staff surveys indicated they were aware of adult protection procedures Meadowside/St Francis DS0000056816.V318742.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, 20, 22, 23, 24, 25 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is safe and well maintained and clean and hygienic ensuring the Service Users live in a satisfactory environment. EVIDENCE: A tour of the home showed that Service Users rooms contain personal items including furniture, ornaments and pictures. There has been a programme of redecoration and procurement of equipment ongoing since the home was purchased by the current owners. Meadowside/St Francis DS0000056816.V318742.R02.S.doc Version 5.2 Page 18 The home is well equipped to meet the needs of Service Users identified with moving and handling risks and disabilities that affect their capability to bathe (hoists, stand aids, showers and assisted baths and toilets). Specialist mattresses and seating and adjustable beds were seen in place for those Service Users requiring them. There is call bell system throughout the home, Service Users seen in their rooms had a bell placed within their reach. There were a variety of toilet facilities for use by Service Users throughout the home. There is a shaft lift to all floors. The rooms that are not accessible via the shaft lift are used by people who are able to use a stair lift. There is accessible, landscaped outdoor space for the Service User’s to use. Several Service Users take advantage of the gardens to relax in and to smoke if they wish. A number were seen doing so on the day of the inspection. There are 3 lounges on the ground floor and a dining room in the residential side of the home (Meadowside). All lounges were tastefully decorated and furnished and looked comfortable. Visitors were seen with their relatives in the lounge and in the privacy of their own rooms. Hand washing facilities were seen throughout the home as were protective gloves and aprons. The maintenance staff carry out the ongoing decoration, portable electrical testing (PAT) and any other maintenance jobs that need attention on a day to day basis. All faults/ jobs are written in a maintenance book for the attention of the handymen. The home looked well maintained on the day of the inspection. Two rooms on the ‘nursing side’ were having their en-suite facilities removed to allow more space for Service Users who need extra equipment in their rooms but do not use the en-suite facilities. Despite the need for a variety medical and clinical equipment to meet the needs of the highly dependant Service Users the nursing side (St Francis) still maintains a homely feel. Meadowside/St Francis DS0000056816.V318742.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. There are sufficient numbers of staff with appropriate skills and knowledge to meet the needs of Service Users in this home. The homes recruitment procedures protect Service Users from being placed at risk of harm or abuse EVIDENCE: Duty rotas examined during the inspection indicates that the manager works full time. She is supported by trained nurses and carers on the ‘nursing side’ (St Francis) and carers on the ‘residential side’ (Meadowside). Each ‘side’ has its own duty rota. The catering, domestic, administrative and maintenance staff work across both sides of the home. The matron and deputy described the internal rotation shift pattern that is being introduced on the ‘nursing side’ in order to ensure all of the nurses and care staff are aware of all of the ongoing needs of the Service User’s over a 24 Meadowside/St Francis DS0000056816.V318742.R02.S.doc Version 5.2 Page 20 hour period. More trained nurses have just been recruited to ensure that all Service Users needs are met including those with complex requirements. Twelve (12) of the fourteen (14) completed surveys confirmed that the care plan allows enough time for the care to be completed. Thirteen (13) of the fourteen (14) completed surveys confirmed that funding and time are provided to receive relevant training. Seven (7) of the fourteen (14) completed surveys stated that staff meetings are held and that they were observed carrying out their work and given the opportunity for one to one supervision. Four (4) of the remaining seven (7) stated that they meet with their manager regularly. The inspector looked at five (5) staff files, they had all of the required documents in them including; 2 written references, a CRB check, application form, contract of employment and job description. The staff files are stored securely. Copies of certificates of training are kept in the staff files. Certificates examined showed that a range of study days and courses have been attended by staff and are relevant to the categories of care that the home has. The matron said that they are happy with the current internal training provider they use, who can tailor study days to meet the needs of the staff. The matron said that the relevant staff have been able to access specialist training to manage some of the more complex tasks they are asked to undertake. This has been noted as good practice. Some training has also been provided by the local multiple sclerosis (MS) nurse. The manager said that some of the trained staff have link nurse responsibilities such as infection control, tissue viability, continence and diabetes. They attend meetings and relevant study days and feedback up to date information to other staff. Meadowside/St Francis DS0000056816.V318742.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 home is managed by an experienced Registered Nurse. There is a formal quality assurance system in place. Personal money held in the home on behalf of Service Users is managed appropriately. The registered provider shows a responsible attitude toward promoting and protecting the health, safety and welfare of Service Users and staff. Meadowside/St Francis DS0000056816.V318742.R02.S.doc Version 5.2 Page 22 EVIDENCE: The current manager has several years experience of managing the home and has achieved a registered managers award (RMA). The manager is regarded highly by other professionals. Many staff have had training in health and safety and any issues are reported to the manager and/or the maintenance team who deal with the issues in a timely fashion. A tour of the home confirmed that there were no urgent health and safety issues outstanding. The administrator manages Service Users money. Income and outgoings are written on a personal account record sheet. It was advised that these records should be stored more securely. The home has secure storage for money and valuables. The manager said that bed rails are only fitted following an assessment and then only by maintenance personnel or a trained nurse. The consent for use of bed rails is signed by the Service User or their next of kin or legal representative. The accident book examined was completed appropriately. The manager checks all entries as part of the internal audit process. The manager ensures in house satisfaction surveys are circulated at regular intervals. The administrator sends out the questionnaires after a person has been at the home for a little while and periodically after that. The outcomes are documented and actions taken written on the completed surveys. The manager said she is able to speak to people on an individual basis to discuss any concerns or worries they may have. The manager holds staff meetings periodically. Five (5) of the fourteen (14) completed staff surveys indicated that meetings are held regularly. Others indicated that individual supervision and meetings are held to sort out particular practice issues and /or concerns. The fire log book and accident books examined and were up to date and completed as required. Meadowside/St Francis DS0000056816.V318742.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 4 3 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 X 3 X 4 3 4 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Meadowside/St Francis DS0000056816.V318742.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 OP9 Good Practice Recommendations All creams and lotions stored and used in Service User’s rooms should have the date of opening written on them. Meadowside/St Francis DS0000056816.V318742.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Meadowside/St Francis DS0000056816.V318742.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. 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