Inspection on 11/01/07 for Netherfield Court

This inspection was carried out on 11th January 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

Netherfield Court 16/03/09

Netherfield Court 01/02/06

Netherfield Court 29/09/05

Netherfield Court 09/11/04

Netherfield Court 06/07/04

Netherfield Court 10/03/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Netherfield Court Eldon Road Eastwood Rotherham South Yorkshire S65 1RD Lead Inspector Ramchand Samachetty. Key Unannounced Inspection 11 January 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Netherfield Court DS0000047778.V312154.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. Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Netherfield Court Address Eldon Road Eastwood Rotherham South Yorkshire S65 1RD 01709 336793 01709 336794 NONE None Rotherham Metropolitan Borough Council 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) Yasmin Allen Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users aged 50 to 64 years are accommodated on a specific unit for this age range. Service is for Intermediate Care only. Date of last inspection 1st February 2006 Brief Description of the Service: Netherfield Court is registered as a care home to provide Intermediate Care. Accommodation is provided for a maximum of 21 persons aged from 50 years, and over pensionable age who require Intermediate Care. The service is jointly provided and jointly funded by Rotherham Borough Council (RMBC) and Rotherham Healthcare Trust (RHCT). There is no nursing care or long stay care provision on site. Referrals and admission may be from hospital or the community. A multidisciplinary team work at the home to provide care and rehabilitation. The team consists of care enablers, physiotherapists and occupational therapists. Support and interventions are also received from social workers and medical/nursing staff, as required. The home is situated in Eastwood area and within walking distance from the town centre. It is well served by public transport and a range of local facilities and shops. Service users referred to the home are not charged any fees. The cost of the service is met by both the Rotherham Borough Council and the local Primary Health Care Trust. Further information about conditions of admission to the home and other facilities can be obtained by contacting the home. Netherfield Court DS0000047778.V312154.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 was carried out on the 11th. January 2007, starting at 10.00 hours and finished at 18.30 hours. Prior to the inspection, the home had provided a pre-inspection questionnaire with the required information. The home’s service history was also used to complement the information required for this inspection. The inspection included a tour of the premises, inspection of a sample of records including individual service users’ care plans, medicines administration records, staffing rotas, training records and quality assurance records. The inspector observed the serving of a meal and some aspects of care being provided. Discussions took place with the registered manager, three therapists, seven members of staff and four service users. The inspector would like to thank the manager and all the staff, the therapists and service users for their assistance with this inspection. What the service does well: What has improved since the last inspection? Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 6 The manager stated that the service user guide had been reviewed to reflect the purpose, facilities and services provided by the home. Health and safety issues have been addressed to make sure service users and staff are free from avoidable risks. Maintenance and decoration of the building have been ongoing. The grounds and car parking facilities around the home have been improved. What they could do better: Although service users stated that they had enough information about the home, there is still a need to improve the statement of purpose and the service user guide in line with the relevant guidance and regulations. The registered provider must ensure that the intermediate care team operating at the home includes sufficient therapists in order to provide the planned rehabilitation of service users. It is also necessary for all aspects of rehabilitation care to be provided as stated in individual service user plans, and also for reviews of such care and support to be carried out as required. All care and rehabilitation provided must be appropriately recorded. The necessary and planned therapeutic activities, which are integral to the rehabilitation programme of individual service users, must be appropriately undertaken and recorded. The problem with the lack of storage facilities in particular for equipment, must be addressed for the benefit of both staff and service users. As the service is jointly provided by the local health and social care agencies, it is recommended that a protocol is developed and agreed with regards to the management of complaints. Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 7 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. Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Although service users had enough information about the service, its statement of purpose and service user guide lacked details about the arrangements in place to meet its aims and objectives. Service users’ s needs were assessed prior to their admission to the home to make sure that their needs could be met. There was a draft protocol for service users, relatives and staff about eligibility for the service and methods of referral to it. The service is provided by a team of various health and social care professionals. However, there was currently insufficient contribution from occupational therapy towards the rehabilitation programme of a number of service users. This shortfall meant that the potential for service users to participate in more active rehabilitation was reduced. Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 10 EVIDENCE: Service users said that they were informed by the hospital staff that they would be transferred to the intermediate care service and their placement would depend on where a bed was available. Service users said that they had received information about Netherfield Intermediate Care Service from hospital staff and the home’s staff. They had been provided with a copy of the home’s statement of purpose and its service user guide. They thought the information was helpful in order to understand the type of service they were being referred to. These documents were checked. They contained information about the aims and objectives of the service but lacked details about arrangements in place to meet them. The service is provided jointly by Rotherham Social Services and the local NHS Trust and a draft protocol has been produced to guide service users, staff and other professionals about the special features of the service including who is eligible for the service and how service users are referred to it. These procedures were being followed to improve the service as a whole and in particular communication among all the interested parties. It was noted that although the cost of the service was not charged to service users, they were offered a service user contract to outline the roles and responsibilities of both the service provider and themselves. Three service users’ files were checked. They showed that their needs were assessed by various therapists and by the home’s staff, before their admission to the home. They were admitted for rehabilitation in order to regain their independence and to return to their home. Service users were satisfied that the home had the necessary equipment and facilities to help them in their rehabilitation. However, there was insufficient contribution from occupational therapists to the rehabilitation programme of a number of service users. Occupational therapy staff had not participated in some multidisciplinary care reviews of individual service users. Care plans indicated that a number of service users were only seen by an occupational therapist at the initial stage and subsequent interventions were very limited. Other therapists in the team were trying to provide the rehabilitation planned for service users but their efforts were limited. Although one service user was waiting for a home assessment, there was no indication that delays were occurring in discharging service users to the community. Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 11 A number of care and therapy plans identified needs that were to be addressed by occupational therapy but the latter was not always provided. Individual and group therapeutic exercises were not taking place as initially envisaged in care plans. These shortfalls meant that the potential for service users to participate in more active rehabilitation was reduced. In discussion with relevant staff and managers, it was noted that the number of occupational therapists had gone down in the last three months and this shortage was causing difficulties in the rehabilitation service. Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Care plans were in place for individual service users to ensure that identified needs could be catered for. Such needs included aspects of personal, health, social and rehabilitative care. However, interventions for rehabilitation of some service users were not always carried out in a timely fashion, as planned, in particular the occupational therapy aspects of their care. This could potentially affect the rehabilitation of service users. Service users were able to access a range of health care professional including a GP and district nurses as required. Service users received personal care and support, which promoted their privacy, dignity and independence. A policy and procedures for the safe management of medication was in place. Staff were able to support service users to administer their own medicines in order to regain their independence. Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 13 EVIDENCE: Three service users’ individual plans of care were checked. They were based on the assessment of needs undertaken by members of the multidisciplinary team. The assessments included areas of risks, nutritional needs and focussed on aspects of rehabilitation. Actions to meet the assessed needs were specified and this helped carers and other staff to provide the necessary care and support. However, interventions for rehabilitation of some service users were not always carried out as planned, in particular the occupational therapy aspects of their care. Care reviews for individual service users were held five days after their admission, to make sure that their care and support were appropriately arranged and provided. In cases where there were important issues regarding occupational therapy, these were referred back to the occupational therapists for action and therefore more time was needed. Service users stated that they were able to see a GP and other health care professionals as and when necessary. Service users’ care records showed that district nurses, chiropodists and community nurses were attending to service users at the home. At the time of this inspection, all the service users in the home were self administering their medicines, which helped with maintaining their independence. They had been assessed for their ability to do so and had consented to take responsibility for their own medication. The care staff were offering support as necessary. Service users had custody of their medicines and these were stored in a lockable cabinet in their own bedrooms. There were appropriate records for the receipt and transfer of medicines from the home staff to service users. These records were checked and found to be satisfactory. Service users commented on the valuable support they were receiving from their key workers, which they felt, helped them to settle down at the home and to cope better with their recuperation. Service users also stated that all the staff were “caring, kind and helpful. Personal care was offered in the privacy of their bedrooms or in bathrooms and this ensured that the privacy and dignity of service users were protected. Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The routines at the home were varied and flexible and met service users’ individual needs and promoted their choice and independence. There was a programme of leisure and social activities for the benefit of service users. A good choice of meals was offered and special dietary needs were catered for, which thereby promoted the health and wellbeing of service users. EVIDENCE: Service users said that routines at the home were flexible and this helped them to be more independent. They could get up and retire to bed as they choose. There were specified times when they had to meet therapists and to carry out tasks or exercises as part of their rehabilitation. Both care staff and other therapists were observed spending time with service users on a one to Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 15 one basis. Service users described these interactions as “very helpful and very reassuring”. Staff explained that service users were consulted about which recreational activities they preferred before organising such activities. There was a programme of leisure and social activities for service users to participate in. However, both service users and staff confirmed that there were less and less therapeutic activities being organised at the home and this was felt to be potentially detrimental to the rehabilitation of service users. A number of service users said they preferred to spend time in the privacy of their own bedrooms and staff respected their choice. Service users were satisfied with meals and drinks served at the home. The main meal was served in the afternoon. This consisted of lamb grills, meat and potato pies vegetables, deserts and beverages. Care staff were observed assisting service users with their seating arrangements. The meals was unhurried and proved to be an enjoyable occasion. One service user said ‘ we see more of each other at mealtimes and I enjoy the conversation”. Buffet areas were provided in each lounge to allow service users and their visitors to make their own snacks or drinks. Service users said that there were no specific visiting times and that their relatives and friends were always welcomed at the home. Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 16 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has use of the Rotherham borough Council’s complaints procedure. This was accessible to service users and their representatives in a manner to encourage service improvement. However, as a joint service between Rotherham Social Services and Rotherham Healthcare Trust, there was a lack of clarity in the responsibilities of each agency with regards to the handling of complaints from service users. There was an adult protection procedure in place at the home to make sure that vulnerable adults were protected at all times. EVIDENCE: There was a corporate complaints procedure in place and it was that of the Social Services of the Rotherham Borough Council. Service users stated that they had been made aware that the procedure featured in the service user guide. In discussion, staff pointed out that, service users’ concerns and complaints, with regards to matters that are the responsibilities of the NHS Trust, would be dealt with by the latter. Concerns and complaints about the service at the Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 17 home would be considered within the Rotherham Council procedures. However, this information was not contained in the complaint procedure in use at the home. The home had not received any complaints since the last inspection. Staff stated that they sought regular feedback from service users and were therefore able to address any concerns straight away. A corporate adult protection policy was also available to promote the safety and welfare of service users from harm and abuse. Staff had received appropriate training, and were knowledgeable, on issues of adult protection. Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 18 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, 22 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home was clean, tidy and well maintained and provided a pleasant and safe environment for service users. Specialist equipment were available for rehabilitation of service users but their storage and use along a corridor was inappropriate. An infection control policy and procedures was in place. Staff were aware of the policy and adhered to it so that that the risk of infection at the home, could be minimised. EVIDENCE: The home was wheelchair accessible and had various aids to assist mobility. These helped with promoting the independence of service users. The building Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 19 appeared well maintained and well decorated. The home was clean and free from unpleasant odours. Service users stated that they found the home “warm and comfortable”. There were four kitchenettes, one in each wing and these were part of the rehabilitation facilities for service users. All bedrooms are single with en suite facilities and this enhanced the privacy and independence of service users. Two of the four bathing facilities were provided with hoisting equipment to assist service users with impaired mobility. Some specialist equipment to assist the rehabilitation of service users was inappropriately stored and often used along a corridor. These included a set of exercise stairs with handrails, parallel bars and other walking aids. This equipment had to be moved around to other communal areas, for example, to allow enough head space, before they could be used. Therefore this practice impinged on the use of such areas by service users. Three bedrooms were seen with the permission of the service users. The bedrooms were well maintained and well decorated. They were adequately furnished and had access to a staff call system. Laundry facilities were provided and appropriate laundry equipment was provided, ensuring that items could be washed at the required temperature to reduce the risk of infection. Staff were aware of the infection control policy and procedures used at the home and made sure they adhered to them. The grounds outside the home were adequately maintained and were tidy. Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The number of staff appeared sufficient to meet the care needs of service users. The full rehabilitation team, which included physiotherapists and occupational therapists, was often working below capacity, due to a shortage of occupational therapists. Over 60 of the care staff held their National Vocational Qualification (NVQ) level 2 in Direct Care and this contributed to the skilled and committed workforce at the home. Although care workers commented that they had picked up skills in connection with rehabilitation techniques, they had not been provided with any training on rehabilitative care. EVIDENCE: Service users were satisfied that they were getting all the care and support they needed from the staff and some health care professionals at the home, in order to regain their independence. They described care staff as “caring and helpful”. There were three carers and one senior carer on duty at the time of this visit and there were fourteen service users in residence. Three therapists were Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 21 noted to be in attendance at the home as part of the rehabilitation team. The skill mix was good but service users commented on the gap in their rehabilitation plan due to a shortage of occupational therapists. Three weeks staffing rotas were checked. They showed that for at least one hour every morning the service was staffed with only two care workers. The manager explained that a senior member of staff was always on call for that period of time. A third care worker was deployed, if service users had high dependency needs. It was noted that the therapists assigned to the home would usually work from 9.00 am to 5.00 pm on weekdays, although they could work more flexibly if required. In discussion, care staff stated that they were satisfied with the training they were receiving in order to provide good standard of care. They had undertaken both core and refresher training on a range of topics including moving and handling, first aid, fire lectures, food hygiene, infection control, adult protection and health and safety measures. They added that they had received induction, which included specific aspects of intermediate care provision. Care staff commented that they had picked up some skills by working alongside other therapists. However, none had been provided with formal training on rehabilitative care. Care staff confirmed that they were receiving regular supervision which helped them provide a good standard of care and also helped them in their personal development. A staff training and development programme for the coming year was available. It included topics like “communication in care, person centred care and care recording”. The recruitment and selection policy of Rotherham Borough Council was in use at the Home. There had been no new staff recruited since the last inspection. All staff at the home, including the therapists had undertaken a criminal Records Bureau Check at the enhanced level to ensure the protection of service users. Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users and staff were satisfied with the leadership and management of the home, which they felt was in line with its objectives and values. A quality assurance system was in place in order to get regular feedback about the service from service users and their representatives. Appropriate health and safety policies and procedures were in place to safeguard the well being of service users and staff. Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager is qualified to NVQ level 4 in Management and Care and also holds various other qualifications, including a Trainers Certificate. She is well experienced in the care of the elderly and is able to provide good leadership. All staff and service users spoke positively about the way the home is managed, which they felt was in line with the objectives and values of the home. A quality assurance system was in place. Service users were asked for their satisfaction ratings about the service and their views were analysed on a quarterly basis. The results for the last quarter of 2006 were available. They showed that service users were satisfied with most aspects of the service. The areas of less satisfaction were around the issue of timely access to therapists and to the provision of activities and recreation. A quality assurance action plan for 2006/07 was in place to make sure work in this area is progressed. Care staff stated that they were receiving appropriate supervision and support from the manager and her team of senior officers. They confirmed that they had supervision at least every six weeks and that notes were kept in their personal and development file. Service users confirmed that they looked after their own money while they are at the home, although they could request the safekeeping of any valuables or money if they wanted. Staff stated that there was documentation to allow the safekeeping of service users’ money at the home. Service users also confirmed that they had a lockable cabinet in their bedrooms to make sure their money was kept safe. Procedures were in place for the regular maintenance and servicing of appliances and equipment. Fire systems were checked on a weekly basis and staff had undertaken regular fire drills so that they could take appropriate action in the event of a fire. The home was also subject to regular internal health and safety inspection by Rotherham Borough Council. These helped to make sure that the environment was safe for both service users and staff. Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 24 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 2 X 3 X X 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 4(1)c schedule1 Requirement The statement of purpose and service user guide must be further improved in line with the guidance and relevant regulations. The Registered Provider must ensure that the intermediate care team includes sufficient therapists in order to provide the planned rehabilitation of service users. All aspects of rehabilitation care must be provided as stated in individual service user plans and reviews of care must also be carried out as required. The necessary and planned therapeutic activities must be appropriately undertaken and recorded. The storage of equipment at the home must be improved for the benefit of both staff and service users. Timescale for action 19/02/07 2. OP6 18 (1) 22/01/07 3. OP7 15 (3) 22/01/07 4. OP12 16 19/02/07 5. OP19 23 19/02/07 Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 26 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 OP16 Good Practice Recommendations A protocol for the management of complaints should be developed and agreed by the joint providers of the service. Netherfield Court DS0000047778.V312154.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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. 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