Inspection on 01/03/07 for Meera House Nursing Home

This inspection was carried out on 1st March 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Meera House Nursing Home 20/01/06

Meera House Nursing Home 29/09/05

Meera House Nursing Home 04/01/05

Meera House Nursing Home 12/10/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Meera House Nursing Home 146-150 Stag Lane Kingsbury London NW9 0QR Lead Inspector Julie Schofield Key Unannounced Inspection 10:50 1 6 and 20th March 2007 st, th 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 DS0000022933.V306391.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000022933.V306391.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Meera House Nursing Home Address 146-150 Stag Lane Kingsbury London NW9 0QR 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) 020 8204 9140 020 8206 2205 directors@meeranursing.com Meera Nursing Home Limited Anil Kumar Sohun Care Home 52 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (17), Mental disorder, excluding learning of places disability or dementia (1), Old age, not falling within any other category (33) DS0000022933.V306391.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. Up to 50 persons over the age of 65 in need of nursing care. Up to 2 persons over the age of 65 who require personal care. Within the nursing care places up to 17 persons over the age of 65 years who require dementia care. Temporary variation agreed for one named individual aged 63 years for the duration of her stay. Temporary variation agreed for one named individual aged 56 years for the duration of her stay. Temporary variation agreed for one named individual aged 60 years PD,DE for the duration of her stay. As agreed on the 25th September 2006, one (1) named service user under the age of 65 years can be accommodated. The CSCI must be informed if when this service user no longer resides at the home. 20th January 2006 Date of last inspection Brief Description of the Service: Meera House provides personal and nursing care for up to 52 residents who are elderly. The home predominantly provides a service for Asian elders, who are vegetarian. The home is located within a short drive from shops and amenities in Kingsbury and Edgware. It is also close to local transport facilities. There is parking on site and it is possible to park in the street close to the home. The home has stood on the site since 1989 and has been extended over the years. The last extension in 2003 increased the maximum numbers of service users from 34 to 51 places. An application for registration of another bedroom was approved in 2005. The home now has 42 single bedrooms (25 of which have en-suite facilities) and 5 rooms occupied on a shared basis (4 of which have en-suite facilities). Bedrooms are situated on ground, first and second floors and there are passenger lifts to assist movement. Bathing and toilet facilities are situated on each floor. There are 2 large open plan lounge and dining areas. The home has a well-maintained enclosed and accessible garden, which includes a paved patio area. Information regarding the fees charged is available, on request, from the manager of the home. DS0000022933.V306391.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over 3 days in March. The visit on the 1st March started at 10.50 am and finished at 4.50 pm. The visit on the 6th March started at 11.50 am and finished at 4.05 pm. On the third visit Ms Kalyani, an interpreter, accompanied the Inspector. This visit started at 10.30 and finished at 12 noon. The Inspector would like to thank the manager, members of staff and residents that took part in the inspection. During the visits a site visit took place, the preparation of a meal was observed, records were examined and discussions took place. What the service does well: What has improved since the last inspection? Nine statutory requirements were identified during the previous key inspection and seven are now met. The care plan and placement is reviewed on a six monthly basis and the resident, key worker, family and representative from the placing authority are invited to the review meeting. The manager confirmed that the home has complied with the requirements identified by the pharmacy Inspector during her visit on the 14th February 2006. A discussion took place with residents about their wishes to go out of the home either for a walk or for an outing. DS0000022933.V306391.R01.S.doc Version 5.2 Page 6 Staff have access to external training courses on adult protection procedures in addition to their in house training. Clinical waste containers in bathrooms are emptied on a regular basis to prevent overflowing. Fifty per cent of carers have achieved an NVQ level 2 qualification in care, or equivalent. The manager has successfully completed his RMA qualification. 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. DS0000022933.V306391.R01.S.doc Version 5.2 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 DS0000022933.V306391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Carrying out an assessment of the resident, prior to admission, ensures that the needs of the resident are identified and that the home is able to determine whether these can be met. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Standard 6 was not inspected, as the home does not offer an intermediate care service. EVIDENCE: The case files of 2 residents recently admitted to the home were examined. Each contained an overview assessment, drawn up by the funding authority. DS0000022933.V306391.R01.S.doc Version 5.2 Page 9 The overview assessments included reports by health care professionals e.g. physiotherapist, speech and language therapist or occupational therapist. The files also contained a nursing transfer/discharge report. The manager also meets the resident prior to their admission and completes an assessment on which the home’s care plan is based. DS0000022933.V306391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Assessing the needs of a resident and identifying these in a care plan enables the resident to receive a service tailored to meet their needs. The health and well being of residents is promoted through regular health care checks and appointments. Residents are supported in taking their medication, as prescribed by their GP, in order to maintain their general health. Discreet and caring support is given to residents by staff so that the privacy and dignity of the resident is respected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four files were examined as part of the case tracking process. It was noted that each contained a care plan, tailored to the individual needs of the resident, and which identified and addressed the resident’s personal, health DS0000022933.V306391.R01.S.doc Version 5.2 Page 11 and social care needs. Each component of the care plan was evaluated on a monthly basis and the evaluations were up to date. There was evidence that care plans and the placements were reviewed on a six monthly basis, either during meetings convened by the home or by the funding authority. Relatives were invited to attend the meetings. Each of the individual residents’ records contained a risk assessment for pressure sores and this was reviewed on a regular basis. The nurse confirmed that pressure relieving mattresses and cushions were provided, as necessary, and that a number of strategies were in place e.g. turning during the night to reduce the risk of developing pressure sores. She said that exercise was encouraged although hoists were available for residents who needed assistance with transfers. Each file contained a manual handling risk assessment and this was reviewed on a regular basis. The physiotherapist was on duty during the inspection. She visits the home twice a week and assesses all residents. She is currently actively working with 10 residents although she regularly reviews the others. Residents said that she had given them exercises to maintain or to increase their mobility. Residents’ records included a nutritional risk assessment, which is reviewed on a regular basis. There was a record of access to the services of a dentist, optician, chiropodist etc. Residents also had a flu jab last autumn, if they wished. Residents confirmed that they had appointments with the GP when they were necessary. The storage of medication was safe and secure. Records were examined and were up to date and complete. The home uses a weekly dosette system and medication had been appropriately administered prior to the inspection, according to the day and time that medication was examined. The nurse on duty is responsible for the administration of medication. The manager, GP and pharmacist have signed the policy in respect of homely remedies. It was noted during the inspection that assistance with personal care was offered discreetly. Residents confirmed that staff were respectful. Screening was provided in bedrooms occupied on a shared basis. Private visits by healthcare professionals are carried out in the privacy of the resident’s bedroom. Visits by relatives can also take place in the resident’s bedroom. Staff knock on bedroom doors before entering. DS0000022933.V306391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 A comprehensive programme of activities, including activities inside and outside the home, provide residents with opportunities for stimulation and enjoyment. Residents said that they enjoyed the company of their visitors, who were made welcome by the staff when they visited the home. Residents appreciated the atmosphere in Meera House and said that they were able to exercise choice in their daily lives. Residents’ nutritional needs are met through the provision of a diet that is wholesome and varied and which meets their religious and cultural needs. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Handicraft sessions are held in the home and some items made by residents were available. Residents enjoy knitting, puzzles, reading or colouring. Residents said that outings have taken place to cultural events or to the temple. Prayers and religious observances take place in the home on a regular DS0000022933.V306391.R01.S.doc Version 5.2 Page 13 basis. In August 2006 the Swami Ramdevji visited the home and spent time with residents. Photographs of the visit were on display. Residents confirmed that activities took place and that staff take them out for a walk. Contact with families is encouraged by the home and the manager also keeps in touch with families, via email when they live abroad, to give them an update on the health and wellbeing of their relative. Residents confirmed that when their relatives visited them the staff on duty made their relatives feel welcome. They said that visits could take place in the lounge area or in the privacy of the resident’s bedroom. Residents said that their wish to carry out their religious observances was respected. They said that they were able to choose whether to take part in activities or whether to spend time quietly on their own. It was noted that many residents liked to sit together in small groups and enjoyed chatting together. Residents confirmed that they were able to spend time in their rooms during the day, if they wished. The minutes of the relatives’ meeting in September 2006 recorded that a menu for Jain residents was discussed. At the time of the inspection 10 Jain residents were being accommodated in the home. The preparation of a meal was observed. It consisted of chapattis, salad, savoury crackers, rice, vegetables (separate vegetables for Jain residents), dahl, pickles and buttermilk or yoghurt. It looked and smelt appetising and residents said that the meals served in the home were good. They said that the menu was varied and that their religious and cultural needs were met. The cook said that pureed meals are prepared for some residents and that diabetic meals are also prepared. Generally the home has reduced the fat used in cooking food as part of healthy eating. Food handling training is undertaken by the catering staff and by carers serving food in the dining room. DS0000022933.V306391.R01.S.doc Version 5.2 Page 14 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 A complaints procedure was in place and residents said that they were able to bring any concerns to the attention of the manager or owners. Protection of vulnerable adults training for staff and familiarity with the home’s procedure and the interagency guidelines contribute towards the safety of residents. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure was on display in the home and a copy is contained in the service user guide. It is written in both English and Gujarati. The procedure informs the complainant of their right to contact the CSCI, local councillor and the Ombudsman. It includes timescales for the acknowledgement of a complaint and for notifying the complainant of the outcome of the investigation. The complaints book was examined. There is a cover sheet at the front and it was noted that records included details of the investigation carried out, when feedback is given to the complainant and the action plan devised, if one was necessary. Residents said that if there was a problem or if they had any concerns they could speak to someone in the home i.e. the manager or the owners. A resident said that if a complaint was made DS0000022933.V306391.R01.S.doc Version 5.2 Page 15 “it is immediately sorted out, no arguments”. There is a suggestion box in the entrance hall for the use of residents, staff and visitors to the home. A statutory requirement was identified during the previous key inspection that staff have access to external training courses on adult protection procedures. This has been incorporated into the home’s training programme and a number of staff have attended a training session organised by the local authority. The home has an adult protection policy, a whistle blowing policy, a countering bullying procedure, a harassment policy and an aggression towards staff policy. Amendments have been made to the adult protection policy. The manager said that no allegations or incidents of abuse have been recorded since the last inspection and confirmed that staff have received in house training in adult protection procedures and this is recorded in their files. The home has a training video for use with adult protection training. The home does not practice restraint. DS0000022933.V306391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Residents live in a home, which is decorated and maintained to a good standard. One carpet needs attention. Residents live in a home where standards of cleanliness are high. Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection a site visit took place. The ground floor and garden areas are accessible to all residents and there are passenger lifts in the home to enable the residents to move around the home. A resident said that the home was “comfortable and warm”. It was noted that the maintenance of the home was good and that furnishings and fittings were of a good quality. The DS0000022933.V306391.R01.S.doc Version 5.2 Page 17 décor of the home reflects the culture and religion of the residents. Residents confirmed that they were satisfied with their rooms. Room 43/44 is a shared room and the carpet was stained by one of the beds. It was noted during the inspection that all corridors, communal areas and bedrooms where the doors had been left open were clean and tidy and free from offensive odours. Residents confirmed that the home was always kept clean. The laundry room is situated on the ground floor and is entirely separate to any areas where food is prepared or consumed. The facilities consist of commercial appliances and are appropriate for the size of the home. Washing machines have sluicing cycles and there are hand-washing facilities in the laundry room. A statutory requirement had been identified during the previous key inspection that clinical waste containers in bathrooms are emptied on a regular basis to prevent overflowing. This was now met. The manager said that the home has arranged an external trainer to lead infection control sessions for members of staff. This is in addition to the in-house training sessions given to staff in respect of MRSA and correct hand washing. DS0000022933.V306391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Staffing levels were sufficient to meet the needs of residents. The home continues to support staff undertaking NVQ training, as residents benefit from staff that have developed their understanding and awareness of the needs of the residents. The target of 50 of carers trained to NVQ standards or equivalent has been reached. Recruitment procedures that include obtaining all the necessary documents promote the safety and welfare of residents and the home needs to ensure that 2 references are obtained for each new member of staff. A comprehensive programme of training for staff encourages good working practices. However all staff need dementia care training. Overall quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are separate rotas for each of the 2 units in the home. Each rota has a separate section for nurses and for carers and day staff and night staff are shown separately. There are sections for support staff e.g. domestic and catering staff. The manager said that 4 carers are allocated to each unit, on each shift during the day. There is an extra carer on duty between 9 am and 11 am in each unit to help with the breakfast and this carer serves the food DS0000022933.V306391.R01.S.doc Version 5.2 Page 19 and assists residents with feeding. At night 2 carers are allocated to each unit. A nurse is in charge of each unit on each shift during the day and the night. There are male staff working in the home (1 carer and 2 RGN,s) and these will assist male residents with personal care, if the resident wishes. The home also employs finance and administrative staff, laundry staff, a handy person and a gardener. The hours of the manager are supernumerary and although mainly Monday to Friday, 9 am til 5 pm, the manager and the owners call to the home unannounced during the evenings and weekends to monitor the quality of the service. They also provide an on call management rota for when the manager is off duty. Of the 31 carers on the rota 12 have completed their NVQ level 2 training in care. One carer is still studying and 3 other carers are due to enrol in April. Three people working as carers are qualified nurses. Therefore the home has reached the target of 50 of carers achieving an NVQ level 2 in care qualification, or equivalent. Three staff files, of staff recently employed to work in the home, were examined. It was noted that each file contained evidence of a satisfactory CRB disclosure, evidence of right to work and proof of identity. One file contained only 1 reference. A statutory requirement was identified during the previous key inspection that all staff working in the home undertake dementia care training. The manager said that over half the staff team had undertaken this training and that the programme would be complete by the end of March 2007. The requirement has been amended and will apply to the dementia care unit only. Training records and the training programme for 2006-7 were available. Training in respect of health and safety, manual handling, food hygiene, principals of care, the role of the care worker, nutrition and the older person, needs of the service user, fire safety, palliative care etc had been provided. Induction training was based on the Common Induction Standards developed by the Sector Skills Council. DS0000022933.V306391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 By continuing his personal development, through further training, the manager is promoting the efficient and effective running of the home. There are quality assurance systems in place to enable the future development of the service to reflect the views and needs of the residents (or persons acting on their behalf). Support is given to residents who need assistance in managing their finances so that residents’ financial interests are protected. Training for staff in safe working practice topics promotes the health and safety of residents, staff and visitors to the home. The testing/servicing of equipment in the home demonstrates that it continues to be safe to use. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. DS0000022933.V306391.R01.S.doc Version 5.2 Page 21 EVIDENCE: A letter confirming the manager’s successful completion of the RMA was available. He already holds a DMS, has a masters’ degree in social policy and administration and is a qualified RGN. Since the last inspection he has attended training courses in “end of life stage”, continence management, protection of vulnerable adults and mental health. A discussion took place with the manger in respect of quality assurance systems and monitoring in the home. He said that residents have the opportunity to give feedback on a day to day basis and residents confirmed that they spoke with him. Residents also said that when the owners visited the home they always spoke with residents. The home distributes an annual satisfaction questionnaire to relatives and to funding authorities. The topics identified on the questionnaire included the accommodation, feeling safe, communication, food and drink, laundry, contact with the managers, activities, respect for the resident’s religion, confidentiality and celebration of religious festivals. In 2006 almost half the relatives returned a completed questionnaire but only 1 funding authority returned a completed questionnaire. The results of the questionnaire were displayed on the residents’ notice boards in the home and there was a comparison with the results from previous years. Most areas recorded a satisfaction score of 75 or higher with the best scores being obtained in respect of contacting the manager, nurses and carers being available when needed and respect for religious and cultural festivals. A relatives meeting is held annually and approximately 40 of residents are represented by a member of their family. The results of the annual survey were discussed at the relatives meeting in September 2006. Arising from comments made at last meeting it was noted that the manager drew up an action plan. Concerns had been expressed regarding items of laundry getting “mixed up” and so the home had ordered name labels, which carers were sewing to items of clothing. The manager expressed an interest in starting an open afternoon, on a monthly basis when he would specifically make himself available for relatives to call in to see him, if they wished. The home assists 2 residents with their financial affairs. A member of the company is the appointee for one of these 2 residents. Records were available and it was noted that these were up to date and complete. Details of expenditure, money passed on to the resident and balances were included in the records. The savings book for the resident where a member of the company was the appointee was available for inspection. It was noted that fire action and fire procedure notices on display throughout the home are in English and in Gujarati. Two fire safety training sessions took place in January 2007 for new staff and as a refresher for established members of staff. The fire risk assessment for the building had been updated in November 2006. Records demonstrated that fire precautionary equipment and DS0000022933.V306391.R01.S.doc Version 5.2 Page 22 systems were checked on a weekly basis and the manager said that key findings were relayed to members of staff. Fire drills were carried out on a monthly basis. There were valid certificates for the Landlords Gas Safety Record, portable electric appliance testing and water chlorination. There were satisfactory servicing records in respect of the lifts, hoists and wheelchairs. There is a good system in place for checking when servicing is due and keeping certificates received and the home is to be commended. Product information was available for items kept in the COSHH cupboard. An OT assessment report dated December 2006 was on file and no major issues had been identified. Training in safe working practice topics is given to staff and includes the annual provision of training in manual handling. In addition to the qualified nurses on duty 2 of the carers have undertaken first aid training. DS0000022933.V306391.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 4 DS0000022933.V306391.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP19 OP29 Regulation 23.2 19.1 Requirement That the carpet in Room 43/44 is cleaned or replaced. That each staff file contains 2 written references. (Previous timescale of the 1st May 2006 not met). That all staff working in the dementia care unit receive training in dementia care. Timescale for action 01/06/07 01/05/07 3 OP30 18.1 01/07/07 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 OP33 Good Practice Recommendations That relatives’ meetings are held on a quarterly basis. 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