Inspection on 15/01/08 for Partnership In Care, Sherrington House

This inspection was carried out on 15th January 2008.

CSCI found this care home to be providing an Good service.

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

Partnership In Care, Sherrington... 18/01/07

Partnership In Care, Sherrington... 30/01/06

Partnership In Care, Sherrington... 21/04/05

Partnership In Care, Sherrington... 22/02/05

Partnership In Care, Sherrington... 13/01/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

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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 Sherrington House 71 Sherrington Road Ipswich Suffolk IP1 4HT Lead Inspector Mary Jeffries Unannounced Inspection 15th January 2008 14:30 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 Sherrington House DS0000029250.V358046.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. Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sherrington House Address 71 Sherrington Road Ipswich Suffolk IP1 4HT 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) 01473 464106 01473 464107 sherh.tpic@btinternet.com The Partnership in Care Limited Vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (33), Old age, registration, with number not falling within any other category (40), of places Physical disability (5) Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One place in the category of DE (E), is to accommodate and provide care for one named person, as stated in the application of September 2005. 18th January 2007 Date of last inspection Brief Description of the Service: Sherrington House is registered to provide care for 40 older people. It is set within a residential development in Ipswich, close to shops and the main town. The town offers a range of facilities including cinemas, public houses, restaurants, shops, swimming pool, and a library and has good rail, bus and coach transport links. The home is divided into 4 areas called units. At the time of inspection Sunset, Park view and Horizon units provided care for a total of 30 older people, three of whom had a diagnosis of dementia. Dales View unit provided care for 10 older people with dementia. Each unit has their own lounge, dining room, communal bathroom and toilets. All bedrooms are single, and have a wash hand basin, 2 also have en-suite toilets. Residents can access all areas of the home by stairs or passenger lift. The large garden has seating areas, and there is car parking to the front and rear of the home. The home is a non-smoking home. Fees are currently 450.00 per week. The fees are reviewed in March each year. Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was an unannounced key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection. An annual quality assurance assessment (AQAA) was sent to us by the service. Pre inspection Surveys were returned to us by fourteen residents. The inspection took place on one afternoon and early evening in January and took five hours. The acting manager facilitated the inspection, and other staff participated. There were 37 residents in occupancy at the time of the inspection, one was in hospital. Three residents were tracked, and an additional file was inspected in respect of admission procedures. Two of these tracked had dementia. All of the residents tracked were spoken with, one with a group of three others. A relative visiting the home was also spoken with. The medication round was observed and a tour of the communal areas and some bedrooms was undertaken. A number of records were examined including residents’ care plans, medication records, training records and records relating to health and safety. The homes Quality Assurance exercise was inspected. What the service does well: The homes quality assurance is very thorough and had identified areas for improvement and set timescales. A good level of managerial support is being given to the acting manager. Prospective residents receive detailed information about the home and have the opportunity to stay for a trial period before admission. Feedback from residents indicates that they are happy with the care they receive. Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 6 Staff are suitably trained. Observations during the inspection and discussions with staff and residents indicated that they were competent in their jobs and committed to providing good quality care. Residents feel that they are consulted and listened to. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sherrington House DS0000029250.V358046.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 Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6. Quality in this outcome area is good. Residents can expect appropriate information about the home will be sent to them or their relatives, and will have the opportunity to make an informed decision about whether or not it can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s Statement of Purpose and Service User Guide had been recently updated. The complaints information in the Statement of Purpose had incorrect details of CSCI. The Service User Guide gave a summary of the most recent survey of their views, which was on the food provided, and gave a summary of ‘Terms and Conditions’ of residency, which covers ‘Payment terms, and extra charges’. This included information on what was and what was not included in the fees (toiletries, hairdressing, chiropody, physiotherapy, dry cleaning). Feedback from residents, records examined and discussion with the manager confirmed that appropriate assessments of need were undertaken before residents moved into the home including local authority assessments where Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 9 appropriate. Files of three recently admitted residents were inspected. All contained assessments although one was not dated so that it was not possible to evidence that this one had been done pre admission. The AQAA states that when a potential resident is identified, they and their family/representatives are invited to view the home and when ever possible a trial period is arranged. Prospective residents are invited to spend time in the home, and this period usually incorporates at least one mealtime and the offer is made to join in with the activities that are organised for the home that day. A resident with dementia said, “I came to have a look and they treated me like one of the family.” Seven people who returned a pre inspection survey said that they received enough information to enable them to decide if the home was right for them before they moved in, five said that they did not. The AQAA states that the home plans to develop a brochure and website which details the activities and amenities on offer in the next twelve months. The relative of a resident who came to live at the home eight months ago was spoken with. They advised that they had been sent all of the information before a decision was made for their parent to move into the home, and that they, the relative, had been to the home to have a look round before the decision was made. Sherrington House DS0000029250.V358046.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. Residents are protected by the homes medication policies and procedures, and can expect to have their privacy and dignity respected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All residents tracked had care plans which had been recently reviewed. The plans are reviewed monthly. The home’s quality assurance exercise had however identified that some residents’ care plans had not been reviewed in December. Residents have care plans in their rooms and full care plans are stored electronically. The electronic care plans were thorough. Staff have access to terminals them throughout the home. In one case the information about GP appointments was not on the electronic record, but this was recorded elsewhere. Records examined covered areas such as nutrition, pressure care, continence, hearing and sight. Daily records evidenced that the home ensures residents have access to health care services such as GP’s, community nurses and hospital outpatient services. Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 11 One of the residents tracked had regular contact with their G.P. and district nurse. This was recorded and the resident spoke about the contact. Observations during the inspection and discussion with staff and residents indicated that care workers had a good understanding of resident’s needs, interests, likes and dislikes. Residents have key workers. Twelve residents indicated on their surveys that they always or usually receive the care and support that they require. The home has documentation which compares accidents rates each month, these were reasonably low. The activities worker was working on a life history with one resident during the afternoon. The resident recalled some family history that they had forgotten, which stimulated and a lively discussion between the residents on sports interests. The person who had been involved in doing their life history said that they really enjoyed doing it, and liked the way it stimulated them to remember things. Medication Administration Records examined and observations made during a medication round confirmed that the home had appropriate procedures in place for the safe storage, handling and administration of medications. No errors were found on the medicine administration records. A senior carer advised that these were audited regularly by the deputy manager. This is also stated in the AQAA. The carer administering medication had a good manner and took the time each resident needed for this to be done in an unhurried way. A relative spoken with advised that they visited regularly, and at different times of the day, and considers that the carers are very good with their mother. Staff were observed knocking on residents bedroom door’s before entering, and the activities worker asked for a resident’s permission to go into their room to return the life story work they had been completing together. One resident said that they had never been asked what named they liked to be addressed by, but commented that staff were always polite. This resident advised that on one occasion she had used her call bell because another resident had fallen, and that the carers came straight away. Sherrington House DS0000029250.V358046.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. Residents can expect their visitors to be made welcome in the home. They can expect the for homes social and recreational activities to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Communal areas were appropriately equipped with televisions, books, board games and music systems. Eleven residents’ surveys indicted that there are always or usually activities arranged by the home that they can take part in, two indicted that there are sometimes. Activities listed on the surveys included games, bingo, and days out. The AQAA states that the home has access to the company minibus and when it is available trips out to local events and attractions are organised. The home’s activities worker advised that they sometimes visit another home which is owned by the same people for joint activities. They advised that they made efforts to engage every one, but some do not want to participate. The home has an activities room was well equipped with table and chairs, craftwork, flip chart and tea making facilities. Residents from different parts of the home can get together in this room for activities. One of the residents spoken with said that they preferred to occupy them self; one the day of the inspection they were seen clearly enjoying the company of others, but then choose to go for an afternoon nap. Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 13 One of the group of residents spoken with said that they had had a marvellous Christmas, and others agreed. The home’s AQAA stated that the activities team would continue to compile a list of local religious leaders who can be accessed independently. The group of residents spoken with said they were not aware of church services in the home, although they used to have communion. A carer advised that there were services at Christmas and Easter but not each week or month. Another resident from beyond the group added that arrangements were made for their priest to visit them. One of the group of residents was very interested in this and asked if they could also see their parson, they were very focused on this and a carer was asked to ensure it was followed up. Residents spoken with said that their guests were made welcome and were offered a cup of tea when they were. A relative spoken with advised that they visited often said that they always felt comfortable coming into the home. The group of residents spoken with advised that they were taken a cup of tea at 8 o’clock in the morning in their rooms, and encouraged to come down to the dining room for breakfast. Two residents confirmed that they could have a cooked breakfast if they wanted. Residents spoken with said that they get plenty of drinks, one noted that the carers don’t assume that they want one, they ask. Feedback from residents, observations made and menu’s seen indicated that the home provides healthy, balanced and appetising meals. Twelve resident’s surveys noted that they always or usually like the meals at the home. One commented, “ First class, dinners are lovely.” Another commented, “Sometimes they are not nice and I wish there was more choice.” One resident spoken with did not like the sandwiches at teatime; these were egg or cheese on the afternoon of the inspection, all on white bread and without salad or garnish. They said that they had cakes, but that they were “the same old cakes”. She said that she had told the carers her views on this, but nothing had been done. Residents could, however, have something different; the resident who had said they did not like sandwiches had baked potato that evening. Another residents asked about teatime meals said that they weren’t particularly interested in the later meal, and that the lunchtime meals were the main meals and were good. The results of the last food survey published in the Service User Guide stated that residents were mostly happy with food provided. The home’s most recent quality assurance report identified that cooks must be involved with residents to ensure that their requirements are being met, and had set a short timescale within which this improvement is to be achieved. One resident was seen having beans on toast for their time meal, in their bedroom, and said that this was their preference. One resident who has dementia commented that what they particularly like about the home is the Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 14 freedom they have. Another resident advised that they can go to bed when they liked, and generally choose to do so at about 9 o’ clock. Sherrington House DS0000029250.V358046.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. Service users can expect to have their complaints listened to, taken seriously and acted upon. They can also expect to be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes complaints procedure was prominently displayed in the entrance to the home. It included appropriate details about how to make a complaint and the stages and timescales of the complaints procedure. The complaints policy summary in the home’s Service User Guide did not give a timescale within which people can expect a response, and it gave the wrong address for the CSCI; this needs amending. The CSCI has not received any complaints about the home since the last inspection. Ten residents’ surveys stated that they know how to complain, four that they did not, but one of these added the comment, and “I’ve never had to.” Thirteen resident’s surveys indicated that they always or usually know who to speak to if they are not happy. Twelve residents responding to the survey thought that staff always listen to them and acted on what they say. A resident with dementia said, “I like it here….. You can say what ever you want, and they will listen to me. I’ve heard them talking about things I’ve said. It’s such a good atmosphere here.” Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 16 The AQAA stated that 15 complaints had been received in the last twelve months, and four upheld. The home maintained a log of complaints outlining these. The AQAA stated that all had been dealt with within 28 days. The homes Quality Assurance report for January showed that the complaints were reviewed during these visits. The AQAA states that the current manager has been invited onto the Adult Safeguarding Board for Suffolk to represent Older Peoples Services. Staff spoken with had a good understanding of Safeguarding matters and knew how they must respond. There had been no safeguarding investigations or referrals in the last twelve months according to the home’s AQAA and our records. Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. Quality in this outcome area is adequate. Residents can expect to live in a homely environment but cannot be assured that it will be maintained to meet their needs at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Sherrington House has a very homely feel. The home was adequately decorated, although some areas showed signs of wear and tear or lack of good maintenance. During the late afternoon a resident entered a lounge, looking for a light switch for the wall lights. At 4pm it was dim outside and the light level was still low despite the overhead lights being on. A resident who had been sitting reading during the afternoon, sitting with the large window behind them, said, “The lights no good.” Staff advised that the wall lights which are cited all around the room around the room weren’t working, which is why none of the switches tried had any effect. Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 18 Some maintenance work had been completed in the home. Internal doors to individual rooms had been replaced. Work had been done in the kitchen in response to a recent environmental health officer’s inspection; five requirements had been made which had to be completed by 29th December 2007. All of these had been addressed, although part of one of the requirements had not. The wall behind a small sink in the kitchen was still marked, and the seal behind the sink was not to a good standard. The manager advised that maintenance had been identified as an issue and was being addressed. This was also noted in the home’s regulation 26 visiting manager’s report. The home lacked features that would be helpful to those with dementia. None of the bedrooms doors had meaningful signs on them, although residents’ name in large print were on each door. During the afternoon one resident came along the corridor saying, “ I can’t find my room.” A carer spoken with thought that this was just this person, and that changing the signage wouldn’t help. The menus in the home were not available in picture form. During a tour of the building two mattresses were seen to be stacked in a corridor, which is a fire risk. These were new mattresses which still had covers on, a note attached indicated that they had been delivered in December. They were removed when pointed out. A certificate to show that the passenger lift had been tested within the last six months was seen, as was a recent planned maintenance report for the hoist lift. Nine residents’ surveys indicated that the home was always fresh and clean, four that it usually is. One resident noted, “It smells nice sometimes but could be better”. The home was odour free and clean on the day of the inspection. A carer wearing a blue plastic apron and gloves advised that these blue protective clothing is worn by staff when assisting with food, and white when involved with personal care. Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. Residents can expect there to be sufficient staff on duty, and for staff to be appropriately trained. They can be assured that they are protected by thorough recruitment procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of the staff rota and discussion with the manager and care workers on duty evidenced that the home had six care staff, including one senior, on duty in the mornings, afternoons, and additionally had care staff who they call support workers had been employed to cover busy periods. At night there are three carers including one senior on duty. The home also had a range of support staff including an activities co-ordinator, cooks and kitchen assistants, domestics, an administrator, two maintenance/grounds men and a laundry assistant. Residents spoken with and observations made during the inspection indicated that resident’s needs were met by the homes staffing levels. Eleven residents who responded top the survey said that staff are always or usually there when they need them. The files of two recently recruited staff members were inspected and were found to contain all of the required documentation. There was evidence that a proper recruitment process had been followed, and induction provided. Files included photographs, verification of identity, declarations of health, written references and satisfactory Enhanced Criminal Record Bureau checks. Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 20 The AQAA states that the home provides a comprehensive training package to all its employees, which ensures they receive the necessary knowledge and information in order to be deemed confident and competent to carry out their job role. The home had maintained a training record and records of staff training was evidenced on individual staff files. Four files were inspected and found to include training. Staff training included fire prevention, infection control, protection of vulnerable adults, first aid, moving and handling, medication, dementia care and nutrition. Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is good. Residents can expect the home to have an open atmosphere and can be assured that the management structure of the organisation will identify and respond to shortfalls. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager had left since the last inspection. The CSCI have been notified of this in writing. An acting manager had been appointed. A senior manager was visiting the home on the day of the inspection, and stayed to give support to the acting manager in the inspection process. A notice displayed gave notice of staff meetings, and stated that all staff should attend. The meetings occurred twice on the same day to make this Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 22 easier to achieve. A residents’ forum had been introduced, although the AQAA stated that the home could encourage residents to have a greater say in how the home is run by promoting attendance and participation in the resident forum. Regular section 26 quality assurance (QA) reports are undertaken. A copy of the most recent (January 2008) report was provided. It was very thorough document which was well laid out and summarised findings. The report raised a large number of matters, some small, that required attention. Some matters raised required immediate attention, the manager confirmed that these had been acted on, and a tour of the premises supported this, for example doors containing substances hazardous to health were found to be locked. Residents confirmed that they could lock their doors and had a locked draw in their rooms. The monies held for three residents were inspected and found to tally with records kept. The manager advised that an ongoing check is made to ensure balances are not too high. Full records are kept on a computer system which require with finger print recognition to access. A valid employers liability insurance certificate was displayed in the home. Fire extinguishers had been services within the last twelve months. The fire risk assessment was dated December 2005, and did not indicate it had been reviewed. Two members of staff spoken with had different understandings of the action to be taken regarding moving residents in the event of a fire. Homes must have clear procedures to follow in these circumstances. The acting manager advised that she was aware that environmental risk assessments required updating, as this had been picked up by the homes quality assurance in January. Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 24 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 2 Standard OP25 OP38 Regulation 23(2)(p) 12(1)(a) Requirement Adequate light must be provided in the home so that residents can see clearly to read. The fire risk assessment must be reviewed, and all staff must be aware of emergency procedures so that the risk to residents will be minimised in the event of a fire. Timescale for action 14/02/08 28/02/08 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 OP19 Good Practice Recommendations The environment should be developed to best meet the needs of those with dementia. Sherrington House DS0000029250.V358046.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Sherrington House DS0000029250.V358046.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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