Inspection on 17/07/07 for Melford Court Nursing Home

This inspection was carried out on 17th July 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.

Other inspections for this house

Melford Court Nursing Home 19/07/06

Melford Court Nursing Home 27/10/05

Melford Court Nursing Home 12/05/05

Melford Court Nursing Home 17/01/05

Melford Court Nursing Home 16/06/04

Similar services:

Henrietta House

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Melford Court Nursing Home Hall Street Long Melford Sudbury Suffolk CO10 9JA Lead Inspector Jane Offord Unannounced Inspection 17th July 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Melford Court Nursing Home DS0000024445.V345940.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. Melford Court Nursing Home DS0000024445.V345940.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Melford Court Nursing Home Address Hall Street Long Melford Sudbury Suffolk CO10 9JA 01787 880545 01787 881845 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) www.bupa.com BUPA Care Homes (BNH) Limited Mrs Susan H Whitney Care Home 52 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (52), of places Physical disability (2) Melford Court Nursing Home DS0000024445.V345940.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 1 The Home is registered to provide care for two (2) service users with physical disability (PD) aged from 45-64. 2 The home may accommodate five named sevice users with dementia (DE,E) as detailed in correspondence dated 24/11/04. 19th July 2006 Date of last inspection Brief Description of the Service: Melford Court is situated in the town of Long Melford. The frontage of the Grade II listed building forms part of the main street giving residents easy access to the local shops, library, church, restaurants and public houses. There is limited parking to both the front and side of the home. The enclosed courtyard and garden run along the side and back of the home. Melford Court was purchased by BUPA from the Community Hospitals Limited in 1997, and has undergone extensive refurbishment. The accommodation is situated on two floors and consists of 45 en-suite bedrooms, 38 of which are singles and 7 doubles. Four of the double rooms are at present being used as large single rooms with ensuite bath or shower. They are known as premium ‘Village Rooms’. The home provides assisted bath and shower facilities, extra communal toilets, a dining room, three lounge/activity rooms and a hairdressing room. Access to the first floor is via stairs or passenger lift. The fees for the home range between £457.00 and £875.00 per week but do not cover the cost of hairdressing, chiropody, toiletries and newspapers. Melford Court Nursing Home DS0000024445.V345940.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection looking at the core standards for care of older people took place between 9.00 and 16.30 on a weekday. The registered manager was present throughout the day and assisted with the inspection process providing documents and information. This report is compiled using information available prior to the inspection and evidence found on the day. A tour of the building was undertaken and all areas were revisited later in the day. A number of residents, staff and visitors were spoken with and a selection of documents and files were inspected including the care plans of four newly admitted residents, staff training records, medication administration records (MAR sheets), the duty rotas and some service and maintenance records. Care practice was observed and part of a medication administration round was followed. Residents looked relaxed and comfortable using all areas of the home and gardens. It was a hot day but staff were taking care to open windows to take advantage of any breeze and the air conditioning unit in the top corridor was working as well. Communication between staff and residents was polite and friendly. Breakfast and the lunchtime meal were carefully served and looked appetising. Residents spoken with said they had enjoyed their meals. What the service does well: What has improved since the last inspection? Melford Court Nursing Home DS0000024445.V345940.R01.S.doc Version 5.2 Page 6 Fire doors that need to be open during the daytime have been fitted with Dorgards. Redecoration of the upstairs corridor was taking place at the time of the inspection. The manager has succeeded in obtaining a grant to put in a wet room on both floors and change one bath that residents cannot use because there is no form of assistance and none of the present residents is able to bathe independently. 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. Melford Court Nursing Home DS0000024445.V345940.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 Melford Court Nursing Home DS0000024445.V345940.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): 1, 2, 3, 5, 6. Quality in this outcome area is excellent. People who use this service can expect to have an assessment of need and sufficient information to make an informed choice about moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a statement of purpose and service users guide containing all the information required by the care home standards including a copy of the terms and conditions of residence and the complaints policy. A copy of both documents and a BUPA brochure are left in each resident’s room for them or their representative to look at when they wish. Four newly admitted residents’ files were seen and each contained a contract with the terms and conditions of residency that had been signed by the resident or their representative. Melford Court Nursing Home DS0000024445.V345940.R01.S.doc Version 5.2 Page 9 Each file had a pre-admission assessment form completed before the resident was admitted by a senior member of staff. It covered areas of need such as skin integrity, mobility (including transfers/standing/sitting/bed movement), eating and drinking, elimination, breathing, personal hygiene, sleeping and pain. Other things assessed were communication, comprehension, orientation, mood and anxiety. The resident’s lifestyle and final wishes were also recorded. One resident spoken with remembered the manager visiting them in hospital prior to moving into the home. They did not visit the home before moving in but one of their children had done so and brought information about the service in to them. The home does not offer intermediate care but they have one room at the front of the building for respite care. This is noted in the statement of purpose. Melford Court Nursing Home DS0000024445.V345940.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. Quality in this outcome area is good. People who use this service can expect to be treated with respect and have their health care needs met but they cannot be assured that all medication practice is safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans for four newly admitted residents were seen and showed that they had been written based on the assessment of need for each resident. There were interventions for personal hygiene, continence, mobility, pressure area care, night needs and oral care. Individual interventions reflecting a resident’s particular needs included breathing (due to dysphagia at high risk of chest infection from aspiration), dysphagia requiring a PEG feed, how to manage verbal aggression and wound care. One resident had had a skin graft and the area had been photographed and the care plan detailed size and the dressings needed. Another plan had details of the correct hoist and sling to use for transferring the resident. Melford Court Nursing Home DS0000024445.V345940.R01.S.doc Version 5.2 Page 11 The files contained a number of risk assessments for moving and handling, falls, nutrition, skin integrity and the use of bedsides. If the assessment showed the resident was at risk a care plan was generated to manage the risk. There was evidence that the care plans were reviewed with the resident and/or their representative and this was confirmed in discussion with a visiting relative. One review had recorded the relative as saying, ‘staff know what they are doing. My parent is in good, capable hands’. The files had contact details of any health professional involved with the resident including GP, chiropodist, optician, dentist and specialist nurses. Visits to or by these professionals were recorded and any treatment prescribed or changes were noted. There were details of past and present medical conditions and any known allergies. During the day staff were observed knocking on doors of rooms before entering and offering residents a choice about where they wanted to be or sit. Shared rooms had screens to maintain privacy during personal care. Staff spoken with were clear about the importance of maintaining the residents’ dignity and were able to give examples of how they worked to ensure dignity was maintained. The home has comprehensive guidance on medication management and training records showed staff who deal with medicines receive up date training. This was confirmed by the nurse who did the medication administration round that was followed on the ground floor at lunchtime. The medicine trolley is kept securely in the clinic room and the nurse washed their hands prior to commencing the round. No signature gaps were noted on the MAR sheets and codes were used appropriately if medication was not administered. ‘As required’ (PRN) medication that gave a choice of dose i.e. one tablet or two, 5mls or 10mls did not always have the amount given recorded making an audit trail impossible. A number of the instructions just read, ‘give as directed’. The manager said they had had a problem getting some GPs to write full instructions but they would persist in trying. When the nurse left the trolley to administer medication to a resident in their room they did not secure the trolley. It was left out of their sight in a busy corridor with medication available to anyone passing. The records of the temperature in the drugs refrigerator showed that for a number of days it was functioning at below the lowest recommended level for the safe storage of medicines of 2 degrees centigrade. It had not been reported to the manager or the maintenance person. The controlled drugs (CDs) register was seen and a random check on some of the CDs held tallied with the records. There was evidence that the home audits the CDs on a weekly basis. Melford Court Nursing Home DS0000024445.V345940.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. Quality in this outcome area is good. People who use this service can expect to be offered meaningful pastimes and a well-balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All the residents’ files seen contained some life history work and had details of the residents’ interests and hobbies. Their religion was recorded if they followed one. Contact details of the next of kin and others important to the resident were noted together with the relationship to the resident. During the day it was noted that a number of visitors came and went. They visited residents in their own rooms or one of the lounges as they chose. The home has several large lounges but also some smaller quiet areas where residents can entertain visitors in private but not their own bedrooms. Visitors are welcome to join residents at mealtimes and if notice is given they can have a choice of meal from the menu. One visitor was seen on the day sitting with their relative at lunch and although they did not have a full meal had been given a drink and a snack. Melford Court Nursing Home DS0000024445.V345940.R01.S.doc Version 5.2 Page 13 The home employs an activities co-ordinator who spoke of some of the pastimes and outings they organise for the residents. They try to have one event a week and the previous week had had a garden fete. This week they planned to take a number of residents to the public house next door to the home for supper. Each summer Long Melford has a street fair and Melford Court is well placed on the main street to participate. They were planning a tombola stall to increase the amenity funds for the home. Apart from the planned events daily activities such as movement to music, art and craft, the trolley shop, an in-house coffee morning and various board and card games are organised. Residents have the choice of taking part or not and the activities co-ordinator makes a point of visiting residents who remain in their rooms by choice or through illness. They will often give them a manicure or hand massage while they have a chat. One resident showed their nicely painted nails and said they had enjoyed the attention. One resident’s records noted that they had attended an evening concert and had a glass of wine. The resident said they had enjoyed it very much. In another record the relatives’ expectations included the comment, ‘we feel assured that the staff will continue to provide XXXX with company and introduce them to social events’. The home celebrates Holy Communion in one of the lounges regularly. A number of residents also attend the Sunday service in the Free Church across the road from the home. Some relatives attend too and usually they all return to the home for lunch via the local public house, only to enjoy the garden and have a coffee, one resident said. The home has recently commenced a scheme called, ‘Resident of the Week’ whereby all the residents’ names go in a hat and one name is pulled out. That resident has their picture on the notice board and is allowed to choose any meal they wish. Their chosen menu is added to the set menus on the Thursday of the week so any resident can choose it too. The extra choice on the week of the inspection was rump steak with chips, peas and mushrooms followed by lemon meringue pie. The ‘Resident of the Week’ also has the choice of any particular treat or outing they fancy such as a visit to the seaside, a special video or a trip to the pub or theatre. The kitchen was visited and the menus were seen. They showed a four-week rotation with a choice of main meals at lunch and hot and cold snacks at supper. For example a lunch choice was chicken supreme with noodles or a choice of jacket potato with filling both served with spicy beans and fresh vegetables, followed by jam sponge and custard or ice cream. The supper menu offered soup, fish fingers and chips, salad or a cheese and pickle roll followed by fruit fool or ice cream. At breakfast there is a choice of cereals, fruit and a cooked breakfast and at teatime there are home made cakes. Melford Court Nursing Home DS0000024445.V345940.R01.S.doc Version 5.2 Page 14 The stores of fresh frozen and dry ingredients were seen and showed a wide range of good quality ingredients. The cook said they had daily deliveries of fresh fruit and vegetables from a local supplier and that the meat was locally sourced. Temperatures of refrigerators and freezers were recorded and showed they were functioning within safe limits for food storage. The cook has access to a BUPA book of recipes for special diets including cultural and religious needs. The serving of the lunchtime meal was observed and meals were plated in the dining rooms from hot trolleys and served either to residents at the tables or covered and taken to people who chose to eat in their rooms. One resident in the dining room was seen to put an inappropriate amount of salt on their meal so a carer removed the plate and replaced the meal offering to put some salt on for the resident. People spoken with said they had enjoyed their meal and the clear plates were evidence of that. Melford Court Nursing Home DS0000024445.V345940.R01.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. People who use this service can expect to have complaints taken seriously and be protected from abuse by staff training and knowledge. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a robust complaints policy that is found in the pack of information left in each bedroom and supported by the BUPA brochure that accompanies the pack. CSCI have not received a concern or complaint about the service since before the last inspection. The complaints log had noted two complaints since the last inspection, one about a carer’s attitude and the other about the length of time taken to answer a nurse call bell. Both were investigated and the complainant received an apology in both cases and signed to say they were satisfied with the outcome. The home has a copy of the guidelines issued by the Adult Protection Committee of Suffolk and their own policy that is in line with the Department of Health ‘No Secrets’ guidance. Induction and training records of staff show Protection of Vulnerable Adults issues are covered initially and updated. Staff spoken with were clear about their duty of care and able to provide examples of situations that could be of concern and how they would manage them. Melford Court Nursing Home DS0000024445.V345940.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. Quality in this outcome area is good. People who use this service can expect to live in a clean, well-maintained home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Melford Court is an attractive grade II listed building with secluded mature gardens to the side and rear of the house. There is a large purpose built modern extension mainly built in 1989 that is not listed. The accommodation is on two floors with stairways in different parts of the building and passenger lift for those with reduced mobility. There is a lounge on both floors but several other small seating areas throughout. The dining room is on the ground floor and there are assisted bathrooms and toilets on both floors. Melford Court Nursing Home DS0000024445.V345940.R01.S.doc Version 5.2 Page 17 The décor and furnishings are attractive and in keeping with the style of the house and appropriate for the client group. There is an ongoing redecoration programme and the upstairs corridor was in the process of being redecorated. The home was clean and tidy on the day of inspection with no unpleasant odours noted. It was a very warm, humid day and staff had opened a number of windows to let in any breeze to keep residents comfortable. The upstairs corridor gets stuffy so two air conditioning units have been installed to help maintain an ambient temperature. The manager explained the plans for changing one wing of the home to make a unit for people with a diagnosis of dementia. The unit will have eight single en suite bedrooms, a lounge and dining room and access to a secure garden. They said there was a consultant coming to advise on the plans to ensure they have not overlooked any details. Some staff have already undertaken the Otley College dementia course and a further three day training was planned for that week. The laundry was visited found clean and tidy with the exception of some clothing soaking in the butler sink. The washing machines had sluice programmes and automatic product feed to reduce contact with hazardous products. There was evidence that red alginate bags were used for managing soiled linen and this was confirmed in discussion with a member of staff. The laundry had a separate hand washing basin supplied with liquid soap and paper towels. Melford Court Nursing Home DS0000024445.V345940.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. Quality in this outcome area is good. People who use this service can expect to be supported by adequate numbers of correctly recruited and trained staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rotas were seen and showed that on an early shift there were three or four trained nurses rostered with enough carers to make the overall number of staff up to twelve. The afternoon shift also had three to four trained nurses with numbers made up to eight and the night shift had two or three nurses and carers to make four staff overall. The registered manager was supernumerary. An ancillary team that included kitchen, domestic and laundry staff, a maintenance hostess and activities staff, also an administrator and receptionist supported the care team. Staff and residents spoken with felt that under normal circumstances there were enough staff to meet the needs of the residents. On the day of inspection it was noted that call bells did not ring for long and that used cups and plates were cleared away efficiently. The files for four newly recruited staff were seen and contained documentary evidence that identification and criminal records checks (CRB) had been carried out prior to the person starting work. Each file had two references, a full work history and the terms and conditions of employment. Melford Court Nursing Home DS0000024445.V345940.R01.S.doc Version 5.2 Page 19 The files also contained evidence of an induction programme that was covered over the first few weeks and then built on with further training. The induction covered moving and handling, food hygiene, health and safety, fire awareness, infection control and activities. Ongoing training included control of substances hazardous to health (COSHH) regulations, team working, care practice and dignity, first aid and dementia. More advanced subjects were managing challenging behaviour, bereavement, medication training and risk assessment. A number of staff were spoken with during the inspection and they confirmed that these courses had been offered and they had attended at least some of them personally. As the home offers nursing care a proportion of the care staff are trained nurses. The home employs twenty-eight carers of whom fourteen hold an NVQ in care of level 2 or above. This gives 50 of carers with the qualification and meets the National Minimum Standards recommended level. Melford Court Nursing Home DS0000024445.V345940.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. Quality in this outcome area is good. People who use this service can expect to have their finances and welfare protected and their opinions sought. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is a registered nurse with a Batchelor of Science degree in nursing. They have worked in the National Health Service and the private sector. They have been registered manager at Melford Court since 1997 after joining the team in 1991. They hold an NVQ assessors award and continue to update their knowledge having recently undertaken the Otley College dementia awareness training in preparation for the planned new unit. Melford Court Nursing Home DS0000024445.V345940.R01.S.doc Version 5.2 Page 21 Meetings are held three monthly for residents and relatives, minutes are taken and made available by putting copies on notice boards or giving out on request. The most recent meeting held in May 2007 covered a range of issues from the planned changes in care plan documentation to the anticipated CSCI inspection, redecoration programme, proposed ‘Resident of the Week’ scheme and a forthcoming change to the front door entry code. There was also a discussion about forthcoming social events and some suggestions for other outings. BUPA has an ongoing system of Quality Assurance and Development monitoring in place. They audit all aspects of the service from health and safety compliance to food hygiene and the standard of maintenance. An action plan is devised after an audit and progress is checked monthly when the area manager does their visits. Previous inspections have looked at the system for managing residents’ personal monies and the administrator said the system remains the same. All monies are managed through a cheque account held by BUPA head office and accessed by computer. Individual balances are available and individual interest is accrued. Monthly statements are available to the residents or their representatives and receipts of expenditure are kept to allow an audit trail. Two signatures are required for any transaction. The fire log and a number of service certificates were inspected and showed that fire panels and emergency lighting is checked daily and there was evidence that action was taken if a fault was found. Fire alarms and fire doors are checked weekly and the lift serviced six monthly. A fault had been identified on the last lift service and the manager was able to provide evidence that it had been rectified swiftly by replacing a faulty roller. The kitchen had been deep cleaned in November 2006 and a Gas Safety certificate had been issued in October 2006. External consultants had been to complete a fire health check in February 2007. Hoists are checked monthly and they had all had a loler test in June 2007. Melford Court Nursing Home DS0000024445.V345940.R01.S.doc Version 5.2 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 4 4 4 X 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X 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 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Melford Court Nursing Home DS0000024445.V345940.R01.S.doc Version 5.2 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) Requirement Timescale for action 17/07/07 2. OP9 13 (2) Medication administration practice and recording must be improved to ensure medicines are secure at all times and there is an audit trail. This is to make sure residents and their property are safe. Medication must be stored at the 17/07/07 correct temperature to prevent it deteriorating and any refrigerators used must operate between the recommended temperatures of 2-8degrees centigrade. This is to ensure residents receive medication that is effective. 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 Melford Court Nursing Home DS0000024445.V345940.R01.S.doc Version 5.2 Page 24 Melford Court Nursing Home DS0000024445.V345940.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Melford Court Nursing Home DS0000024445.V345940.R01.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. 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