Inspection on 18/02/06 for Needwood House Nursing Home

This inspection was carried out on 18th February 2006.

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

Needwood House Nursing Home 08/10/08

Needwood House Nursing Home 16/10/07

Needwood House Nursing Home 27/03/07

Needwood House Nursing Home 15/06/05

Needwood House Nursing Home 17/01/05

Needwood House Nursing Home 01/09/04

Needwood House Nursing Home 01/03/04

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

CARE HOMES FOR OLDER PEOPLE Needwood House Nursing Home 58 - 60 Stafford Street Heath Hayes Staffordshire WS12 2EH Lead Inspector Mr Keith Jones Unannounced Inspection 18 February 2006 06:45 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 Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Needwood House Nursing Home Address 58 - 60 Stafford Street Heath Hayes Staffordshire WS12 2EH 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) 01543 275688 01543 275688 Mr John Richard Mansell Mrs Ann Carol Mansell Care Home 25 Category(ies) of Dementia (25), Mental disorder, excluding registration, with number learning disability or dementia (25) of places Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. DE is Dementia Elderly over 60 years MD is Mental Disorder Elderly over 60 years including one named person aged 59 yrs, male with dementia Date of last inspection 9th June 2005 Brief Description of the Service: Needwood House is situated in a quiet street, a short distance from the High street in the small town of Heath Hayes. Amenities and services are well provided for, and a regular bus service offer good connection to Cannock and Lichfield. The home is a two-storey town house adapted for the care of the elderly who have dementia and mental illness. The home offers a good standard of care under the protection of a wellqualified and experienced management and staff, who promote a sense of individuality and feeling of belonging in a homely environment. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted with two CSCI Inspectors and the senior nursing staff on duty. The timing of the inspection was determined to ascertain whether there was a policy of waking residents up early, to assist the day duty care staff. The Inspectors found that of 25 residents, six had been got up between 0600 and 0700 hours, of which two had been self motivated to rise early. Of two residents who had required nursing attention, one had been woken and was in the day room and one was sat in his room dozing. There were no sound reasons for the remaining two residents to have been awoken that early, both were found dozing in the day room with a meaningless children’s television programme on. The policy of the Home declared that each resident will be allowed a personal lifestyle, suited to their wishes. The Home is required to reinforce that policy, and introduce a fact finding assessment for each individual, to determine a singular sleep and waking pattern. The remaining 19 residents were awoken according to their needs from 0700 hours onwards, with most needing a full bath before dressing. This would take up to the next four hours. None of the residents approached made any adverse comments about their daily routine, although one felt that she had to wait some time from getting out of bed to getting her breakfast. Following the review and evaluation of waking, the second Inspector withdrew, leaving the lead Inspector to complete an unannounced Inspection. The last inspection report was discussed, and it was noted that there had been no outstanding requirements or recommendations. A tour of the unit permitted free access to all areas, service users, relatives and staff, when open discussion took place. A full case tracking of seven service users with the senior nurse yielded a valuable insight of policies in action. An inspection of administrative procedures and documentation preceded a detailed follow-up report. A full report was offered at the end of the inspection with open discussion with the registered nurses from day duty and night duty, who, in the absence of the care manager and provider, performed their duties in a professional manner. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 6 What the service does well: 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. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 The Statement of Purpose represents the foundation upon which the home operates, offering service users and their relatives the opportunity to make an informed choice about where to live. Following an assessment, the senior nurse assessor determines the suitability of the application in view of the facilities available, and at the capacity of the home, to manage the individual and any special needs. EVIDENCE: The Statement of Purpose was recognised as a reflection of the organisational and professional philosophy to meet resident’s needs and enhance their quality of life. Examination of care records evidenced that an opportunity to determine an element of choice was offered, through the pre-admission procedure. The admission process is carried through by the care manager, and/or a senior member of staff. Several admission records were examined and mainly offered a clear picture of the resident’s physical, psychological and social needs. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 9 Contracts were approved, usually through Social Services at the review period. At the time of inspection there were several residents on bed rest requiring, and identified as needing, high dependency care. It is advised that part of the assessment process should involve a more relevant social review, and an indicator as to sleeping and waking patterns. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 - 11 Overall the care assessment and planning system is an organised, yet homely process offering meaningful and valid documentation of care administered. A broad vision of needs is addressed through the care planning process, attempting to meet personal and health needs. The provision of a secure and safe medicines administration is managed efficiently by registered nurses. Staff were seen to demonstrate a personal empathy with residents through a respectful, yet friendly discourse. EVIDENCE: Seven service users were case tracked, with a full examination of care records, health records including general practitioners visits, risk assessments, dependency charts, records of reviews and action plans. The pre-admission assessment represented the foundation for a thorough and detailed care planning process. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 11 A profile of the service user’s social, physical and psychological status offered a Roper model of care, based upon a multiple-point activity of daily living, implemented and reviewed monthly. The social profiling is held separate from the central care plan which lessens the impact of individual assessment. The care management is advised to add this profile to the daily appraisal and regular review process. Evidence of health care professional visits showed an attentive awareness to service user’s needs. Daily event reports were acknowledged as a valuable process that have continued to provide meaningful source of communications. There was evidence of consultations from medical specialists and other professional support services. There was evidence that administration of drugs procedures were seen to be up-to-date and accurate. There were no residents self-medicating at the time of inspection. The practice of administering individual medicines were performed by the nurse direct to the resident. Records identified that any homely remedies had been identified. Examination of the accident records showed a diligent process of sensitive and positive action being taken. The spiritual orientation of each service user is recognised within care records. The policy of handling death and care of the dying was to offer a sensitive and supportive assurance that all care will be given. The prevailing personable atmosphere in the home is extended to encompass the needs of relatives and friends during a difficult time. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 It was evident that there is an element of institutional patterns of care emerging, in adjusting individual care patterns of daily life, to meet organisational routines. Although only a small number of residents were involved, it is a direction to be resisted. Each service user is to have an appraisal of their sleeping and waking patterns appending to care plans, to be implemented immediately. Generally service users’ life-styles and interests are recognised, discussed with their relatives prior to admission, and documented as far as possible to enhance a position of supported independence. Those who wish to bring in personal possessions are encouraged to do so. Service users were offered a varied and nutritious choice of meals from a rotating menu. Special diets were accommodated, with the cook making every effort to engage with service users to discuss personal preferences. EVIDENCE: The daily routine was discussed with staff and several residents and it was agreed that there needs to be a more sensitive approach to be seen to be flexible to acknowledge individuality, without dictating a regime, yet present a focal point for residents to offer the security of consistency. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 13 Through case tracking, resident’s life-styles and interests were recognised, discussed with their relatives prior to admission, and documented as far as possible to enhance a position of supported independence. This will be enhanced by clearly identifying a waking/retiring awareness for each resident, and a closer application of a social record to match regular care plans. Those who wish to bring in personal possessions are encouraged to do so; there was ample evidence to show that has been followed through, presenting a warmth and familiarity. Family and friends have freedom of visiting,those spoken to remarking on the importance of maintaining social contact. One resident who had been transferred recently to Needwood had a visiting restriction notice applied due to unacceptable behaviour by the family at the previous home. This resident’s case file was examined and found to provide a sound plan of care, although the lady was herself very frail and requiring full care and attention. Residents spoken to were generally complementary with the relaxed environment and the standards of care. During the inspection several residents and staff were seen to be engaged in social activities and discourse. Staff were observed to hold a friendly and sympathetic interaction with service users in lounge areas, and at mealtime in helping those who required assistance. Service users were offered a varied and nutritious choice of meals from a 4week rotating menu. It was pleasing to discuss with the cook the degree of involvement she had in the daily nutritional affairs of the residents, including accommodation of special diets and regimes. Staff were seen to offer discreet assistance to those who required it. The choice of dining room, lounge or bedroom was at the discretion of service users. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Residents and families have a clear avenue of expressing their concerns and/or complaints. Staff are aware of their right to express their grievances and are aware of whistle-blowing procedures. The policies and procedures protect the individual with a heightened awareness of the issues surrounding abuse. Staff training clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. EVIDENCE: The Home had a meaningful complaints policy, clearly identifying the CSCI as a resource to approach with a complaint or grievance. No formal complaints had been received via the Commission since the last inspection. There had been a point of concern expressed anonymously (the individual did not wish to make a formal complaint), regarding early rising which has been a feature of focus in this Inspection; of which some of the issues were upheld. A complaints book is maintained which shows a responsible approach in handling complaints appropriately. Advocacy service is available to those who require it, as indicated in the Statement of Purpose. Service users’ legal rights are protected by the systems in place, including a contract, the continual assessment of care planning and policies in place i.e. the complaints procedure. Two residents were presently under guardianship orders. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 15 The care staff and provider had showed satisfactory evidence of a protocol and response to anyone reporting any form of abuse, to ensure effective handling of such an incident. The accident reporting procedure ensured robustness of accountability. All staff are in possession of a General Social Care Council’s Code of Conduct, to help reinforce the induction and training programmes. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 - 26 The location of Needwood House is conveniently placed for a care home. The external state of repair and maintenance is generally very good, and the interior state of repair is at a high standard; bedrooms are well appointed. Communal areas are furnished and decorated to a good standard to present a homely and comfortable environment. Bathrooms and toilets are suitably equipped and adapted. The domestic services in the home were seen to be of a very high standard. The home presented a clean and pleasant, odour-free atmosphere, much to the credit of staff. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 17 EVIDENCE: The home is well appointed to meet the needs of an elderly population of service users. A traditional large town home setting provides a safe, comfortable, friendly and homely environment. External access is satisfactory for visitors parking; pathways and fencing were safe and recently attended to. There is a small garden facility for service users to take advantage of. Internal access was facilitated with ample fittings of hand and grab rails in adequate, well-lit and airy corridors. Continuing re-decoration and recent upgrades were inspected and found to be of a high standard, confirmation of the long-term commitment to improve services and establish Needwood’s good quality standard of care. The Home is preparing a development programme on refurbishment for 2006/07 for the next inspection. Wheelchair access was satisfactory throughout all areas of the home. Bedrooms were well maintained to meet service user’s personal preferences. It is the policy that on bedrooms becoming vacant, that each room is reappraised for redecoration. It was noted that there had been 16 new beds and mattresses provided. Communal areas were pleasantly furnished with facilities to accommodate social or reflective needs, in a homely setting. The conservatory offers a pleasant area with air conditioning, good standard of furnishing and a pleasing view of the garden area. Toilets are accessible to all, and within close proximity to all communal areas, the standard and presentation of all the toilets and bathrooms were of a high quality, clean, uncluttered and odour-free. There are adequate sluice facilities, each secure and with locked reagent cupboards. Policies for handling soiled and infected linen were satisfactory. Each room has adequate space to assist with personal care and dressing assistance, there is a good standard of furnishing complimented with a variety of personal belongings. The nurse-call alarm system was satisfactorily tested and service record checked. All personal electrical equipment were seen to be PAT tested. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 18 It was recognised that 7 new bedside tables/lockers have been delivered. The evidence seen on inspection of service user’s rooms, and on discussion with the individual service users and family, assured that this standard was well met. Several service users spoken to expressed a sense of belonging and satisfaction in the quality and presentation of their living areas. Those service users who require adjustable height beds have a nursing bed. The domestic services in the home were seen to be of a very high standard. The service users and relatives spoken to remarked that they find the environment always very clean and conducive. There was no evidence of unpleasant smells or unsightly debris anywhere throughout the inspection. The heating arrangements throughout the home are by central heating with guarded radiator convection. The laundry area was clean and very well organised; procedures were in place for coping with soiled/infected linen with the provision of alginate bags to minimise handling and cross-infection. COSHH signs were evident. Chemical cleaners were used appropriately throughout the home, and were seen to be secure and under COSHH recommended practices. The building complied with local fire service, Environmental Health and Health and Safety requirements. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30 Staffing stability has been maintained with consistent levels to ensure equilibrium between numbers, skills and qualifications, with a strong presence of long serving experienced staff. Agency staff and nurse bank, with agreed overtime and flexible rostering, accommodate shortfalls. The management have continued to deploy a comprehensive procedure for interview, selection and appointment of staff. The thoroughness of staff selection has a significant effect upon the provision of cares to ensure protection of service users. All staff receive training in care issues within the home from registered nurses and external trainers. EVIDENCE: Three weeks of off-duty were examined, i.e. 06/02/06 through to 26/02/06. The consecutive duty rotas were examined, providing evidence that the home is managing to maintain numbers, skills and qualifications to ensure the needs of the service users are met. On the day of inspection the staffing levels were: 0730 – 1500 1500 - 2100 2100 – 0800 Needwood House Nursing Home 1 Registered nurse 4 care assistants 1 Registered nurse 3 care assistants 1 Registered nurse 2 care assistants DS0000022355.V271381.R01.S.doc Version 5.0 Page 20 It was pleasing to recognise a stability in staffing levels. There are 7 registered nurses deployed working 218 hours/week, which exceeds recommended levels and 18 care staff working on average 543 hours/week. Agency staff and nurse bank with agreed overtime and flexible rostering meet identified shortfalls. The care manager will continue to fulfil the management responsibilities, whilst maintaining a working commitment to the shift rota. There was 3 housekeeping/laundry staff to provide 84 hours a week. The Home employs a maintenance man working 20 hours. There is 1 administrator working 40 hours per week. Two kitchen staff covered shifts between 0730 and 1500 amounting to some 52.5 hours per week established. Documentary evidence confirmed a continuing adherence to the quality of staff selection, recruitment effort and practice, which remains impressive. The management have established a comprehensive procedure for interview, selection and appointment of staff. This involves a standard application form to assess and profile, two references taken and CRB (enhanced) checks gathered before a contract is offered to successful candidates. The thoroughness of staff selection has a significant effect upon the provision of cares to ensure protection of service users. Service users are supported and protected by these practises and all new staff goes through an induction process that will ensure that they are going to be the right person for the home. All staff receive training in care issues within the home from registered nurses and external trainers. There was evidence of regular NVQ assessor visits and numerous certificates on display. . There are currently 13 care staff with NVQ II and/or III, with 3 undertaking training and 2 with an application in awaiting the next intake. It was pleasing to see a continued commitment to the educational process Staff induction programmes are well established; very well designed, forming the base upon which in-service supervision and training are planned and achieved. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 - 38 The care manager (designate), John Mansell is a very experience qualified nurse with a known track record of good standards and professionalism, is of good character and able to discharge his responsibilities fully to staff and service users. Arrangements are in hand to offer a fit-person interview with CSCI. Until this process is complete the Home is routinely placed at a higher risk status (code yellow). The registered provider confirmed commitment to Needwood House, and its future financial viability. This open style of management was mentioned by several service users, which provided a source of trust and mutual respect. There is a confidence apparent in the interaction of staff and the Home’s management that demonstrated a positive relationship that pervades throughout the Home. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 22 EVIDENCE: The inspector observed at first hand the confident interrelationship that exists between staff, service users and relatives. The easy and relaxed atmosphere created by a responsive care staff enabled that confidence. Evidence was secured to confirm that an effective quality monitoring system has been introduced, based upon audit of standards, care plans, general audits and feed back from service users and relatives. Care planning audit is recommended to enhance the resident’s daily living, and to ensure that individual requirements are maintained. Standards are discussed at staff meetings, daily handovers, direct observation and involvement and one to one staff meetings. Regular audits and on-site inspections by the provider’s offers evidence of a management firmly in control, well organised and prepared to facilitate meaningful. Examination of staff records showed that employment policies are effective. A sample examination of administrative, monitoring, planning and care records showed an organised and professional attitude to effective record keeping. All records and medical notes are kept confidential and secure. There is a willingness to create a training environment. A staff supervision policy and procedure is in place in the home, and will be maintained to form an established routine alongside a cascading training programmes The accident books for staff and service users were checked and found to be accurate, up-to-date and Riddor-sensitive. These issues and routines ensured the health, safety and welfare of service users and staff. The administration and management of the home is efficient, uncomplicated and sensitive to the needs of service users. Relevant legislation and prevailing care issues were discussed and are fully appreciated by the management. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 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 2 3 3 3 3 3 3 3 Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 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 Standard OP4 Regulation 12 (3) Requirement That an assessment of daily living be enacted. A waking, sleeping pattern is to be established for each resident. Timescale for action 01/03/06 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 2 Refer to Standard OP4 OP19 Good Practice Recommendations A social profile will be attached to the care planning package. A refurbishment developing programme for 2006/07 is to be prepared. Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Needwood House Nursing Home DS0000022355.V271381.R01.S.doc Version 5.0 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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