Inspection on 20/02/08 for Potton House Nursing Home

This inspection was carried out on 20th February 2008.

CSCI found this care home to be providing an Adequate 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

Potton House Nursing Home 10/10/07

Potton House Nursing Home 19/04/07

Potton House Nursing Home 11/05/06

Potton House Nursing Home 26/10/05

Potton House Nursing Home 04/07/05

Potton House Nursing Home 24/01/05

Potton House Nursing Home 08/06/04

Potton House Nursing Home 06/01/04

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

CARE HOMES FOR OLDER PEOPLE Potton House Nursing Home Potton Road Biggleswade Bedfordshire SG18 0EL Lead Inspector Mrs Louise Trainor Unannounced Inspection 20th February 2008 10:30 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 Potton House Nursing Home DS0000017688.V360035.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. Potton House Nursing Home DS0000017688.V360035.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Potton House Nursing Home Address Potton Road Biggleswade Bedfordshire SG18 0EL 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) 01767 314782 01767 314862 potton.house@craegmoor.co.uk Health & Care Services (NW) Limited Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (24) Potton House Nursing Home DS0000017688.V360035.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home can accommodate a maximum of 24 service users. The home can continue to accommodate the identified service user who is aged under 65 years. The home cannot admit any other service users aged under 65 years. Date of last inspection 10th October 2007 Brief Description of the Service: Potton House is a purpose built care home with nursing situated in the grounds of Biggleswade Hospital on the outskirts of Biggleswade, a rural village, in mid Bedfordshire. Biggleswade has good road access and there is a limited bus service with the nearest train station in Sandy. Potton House provides places for up to twenty-four older adults with mental health care needs. The home is single story with accommodation separated into three wings. Each wing has eight bedrooms and its own living areas. There is also some additional communal space. The home has a large fenced garden and there is ample parking area at the front. All the beds at Potton House are block purchased by the Primary Care Trust. Potton House Nursing Home DS0000017688.V360035.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 1 star. This means the people who use this service experience adequate quality outcomes. This was the second unannounced Key Inspection for this service this year. It was carried by out Regulatory inspectors Louise Trainor and Sally Snelson on 20th February 2008 between the hours of 10:30 and 15:30 hours. The focus of this inspection was to look at all the key standards and to follow up on progress and compliance of requirements made at the previous inspection on the 10th of October 2007. The manager’s post is presently vacant in this home, however, Sue Burton the Clinical Governance Support Manager and Alison Lovelock, the Area Manager who is presently based in the home, were present for part of and all of the inspection respectively. During this visit the communal areas of the home were inspected alongside some of the individual accommodation. One of the inspectors spent time most of the visit in the day area, where care practices and communication between the people living at the home and staff was observed. The care of two people picked at random by the inspectors was examined in more depth, and we had the opportunity to talk informally, to both, staff and visitors to the home. We also reviewed staff training, recruitment and supervision, complaints and quality assurance documents. Information from the home had been provided to assist in assessing the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit, feedback from people who live at the home and are a variety of stakeholders, including the PCT. We would like to thank everyone involved for their support and assistance during this visit to the home. Potton House Nursing Home DS0000017688.V360035.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? One member of staff told us, “ there have been a lot of changes, yes we are getting there”. The Statement of Purpose and Service User Guide documents have been reviewed and updated since the previous inspection, to reflect the present management of the home. Assistive and preventative aids are accessed for individuals as and when required, one nurse stated, “this place is so different, when we ask for a pressure mattress for someone we get it right away”. Staff were spending time with residents to encourage socialisation. Since the last inspection, in addition to the regular musicians’ visit, a group of Gospel singers had provided entertainment. A pet therapist was also found to be beneficial and staff were now considering purchasing an interactive pet for the home. The refurbishment of this home is well under way and there are undoubtedly vast improvements. We look forward to seeing the completed works. The home was generally clean and homely. Potton House Nursing Home DS0000017688.V360035.R01.S.doc Version 5.2 Page 7 Work has been done, involving the families of the residents in this home, to make individuals’ bedrooms more personal and reflective of their life history. There is consistently enough staff on duty to meet the needs of the people living in this home at present. New staff training is being introduced with a focus on the dementia care the home provides. Accidents and incidents are now being appropriately reported, via the regulation 37 notification, and the safeguarding processes. We viewed the report and action plan from a recent annual quality survey. It identified new systems such as a relatives comment book being set up, invitations to relatives regarding care plan meetings being sent out, and senior carer roles being allocated as key workers. These improvements were all generated from the survey responses. 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. Potton House Nursing Home DS0000017688.V360035.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 Potton House Nursing Home DS0000017688.V360035.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5, 6 Quality in this outcome area is good. This home provides a statement of purpose that is specific to the home and the resident group they care for. This is supported by a service user guide, which is available in pictorial format, and is issued to every person who lives in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service User Guide documents have been reviewed and updated since the previous inspection, to reflect the present management of the home. The documents are displayed in the entrance to the home, and in individuals’ bedrooms, so that they are easily accessible to anyone entering the home. Potton House Nursing Home DS0000017688.V360035.R01.S.doc Version 5.2 Page 10 The Service User Guide is also impressively displayed in pictorial / sign format on laminates on the main notice board in the entrance hallway. This home has not received any new admissions since the previous inspection in October 2007, however the area manager informed us that the pre admission process is now more robust. Whereas previously the local Primary Care Trust, who commission all the beds in the home, would ‘dictate’ placement allocations with limited input from the manager of the home. There is now a detailed pre admission document, which will be completed by the manager or senior nursing staff on an assessment visit. They will then make the decision as to whether or not the home can fully meet the needs of each individual. We look forward to seeing this process operating effectively. This home does not provide an intermediate care service. Potton House Nursing Home DS0000017688.V360035.R01.S.doc Version 5.2 Page 11 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, 11 Quality in this outcome area is adequate. Care plans had been completed in sufficient detail to ensure that staff could provide consistent care. In order to ensure that medications can be regularly audited, to ascertain that mistakes are not occurring, staff must record the exact dose given of any variable dose medication that is administered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the care plans of two residents in detail. It was apparent that the staff had worked hard to ensure that there were care plans in place for all of the activities of daily living, and any specific needs. For example one resident had plans for personal care, eating and drinking, elimination, health Potton House Nursing Home DS0000017688.V360035.R01.S.doc Version 5.2 Page 12 promotion, chest infection, eye infection, keeping active, safety, including fire safety and senses. The care plans had been written in a person centred style, had been reviewed at least monthly, and where possible a representative of the resident had agreed the plan. However, care must be taken to ensure that the staff update the plans as individuals’ needs change. One of the residents’ plan stated, that to prevent choking, fluids must be thickened. At lunchtime we noted that they were given a drink without the thickening agent. The staff were able to confirm that this person had recently improved, and that they could decide whether the agent was necessary. This was not written into the plan, and a situation like this could result in the wrong care being given. The care plan process included relevant risk assessments. For example the care plan for mobility was written taking a falls risk assessment into account, and the eating care plan corresponded to the Malnutrition Universal Screening Tool (MUST). This is a tool that has been designed to help identify adults who are underweight and at risk of malnutrition as well as those who are obese. There was clear documentation to support that residents that were at risk of developing pressure sores had been regularly turned, and that those who were at risk of weight loss or dehydration had been provided with sufficient nutrition and fluids. We were disappointed that the night staff were not completing these documents. Consequently it appeared that the residents were not being offered drinks or snacks from before 20:00 hours until at least 08:00 hours. Alison Lovelock, the Area Manager, confirmed that she had already discussed this matter with the night staff, and was expecting an improvement in the completion of this documentation during the night, in the future. Residents had been registered with a local GP and the two files examined indicated that visiting chiropodists, opticians and dentists had been used as necessary. Assistive and preventative aids are accessed for individuals as and when required, one nurse stated, “this place is so different, when we ask for a pressure mattress for someone we get it right away”. The medication records of the two residents were looked at in detail. The Medication Administration Record (MAR) charts had been completed when medications had been administered and there were no gaps. However we were unable to reconcile those medications where variable doses were prescribed and administered. One resident was prescribed one or two paracetamol four times a day. 70 of the 100 tablets that were received into the home had been taken. However there were 81 signatures, including those used where the medicine had been refused. This made it impossible to reconcile, as we could not always identify if one or two tablets had been administered when the record was completed. We also noted that one of the residents’ temperature chart indicated when paracetamol had been given, however this did not correspond with the MAR chart. Potton House Nursing Home DS0000017688.V360035.R01.S.doc Version 5.2 Page 13 It was evident that not all staff were correctly using the alphabetical omission codes to indicate the reason a medication had not been given. No residents were self-medicating or having a controlled drug at the time of the inspection. Throughout the inspection we observed staff interacting and speaking to residents in a dignified and respectful manner. All residents were taken from communal areas when personal care was given. The Liverpool Care Pathway (LCP) was being used correctly to the benefit of a resident at the end of their life. Staff had been trained by the local PCT to use the LCP, which allows all those involved with a resident to plan the end stage of the residents’ life, and focuses on the physical, psychological and spiritual care of the resident. Staff should be complemented on the way that this had been introduced. Potton House Nursing Home DS0000017688.V360035.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate Staff were spending time with residents to encourage socialisation. However the residents were not being offered sufficient choices in an appropriate style at mealtimes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Resident’s were able to go to bed and get up at a time that they chose; this was evident as some people were still finishing their breakfast as the inspection started at 10:30 hours. Staff, with the help of families, had worked on care files to ensure that they included information about the person’s likes and dislikes and previous interests, reflecting a person life history. The activity co-ordinator had planned an activity programme, which was being followed. We witnessed reminiscence therapy in the morning and sensory work in the afternoon. A real improvement was that the activities were now coPotton House Nursing Home DS0000017688.V360035.R01.S.doc Version 5.2 Page 15 ordinated by the activity person, but involved the whole staff team. This meant that those residents who needed one-to-one support were getting it, and everyone was encouraged to be part of an activity each day. The mini bus had been used to take a resident, accompanied by two staff, to a garden centre. More trips were planned for when the weather improved. Throughout the home there was evidence of artwork that the residents had done. Residents had been supported to make a framed collage depicting their interests and personal life history, which were to be hung on the wall. Since the last inspection, in addition to the regular musicians’ visit, a group of Gospel singers had provided entertainment. A pet therapist was also found to be beneficial and staff were now considering purchasing an interactive pet for the home. We witnessed an interactive doll being used appropriately and effectively for a resident to tend. Throughout the inspection there was appropriate background music playing and the television was not on. We also noted that visitors were welcomed into the home, and helped staff by supporting their loved ones at lunchtime. At lunchtime residents were encouraged to help staff prepare the table for the meal. The tables looked homely with bright tablecloths and flowers in vases. China crockery, including cups and saucers were being used. It was encouraging to see that at coffee time the residents were offered a choice of tea, coffee or hot chocolate. However at lunchtime it appeared that most residents had Spaghetti bolognaise. The choice was limited, with an alternative of mince beef and onion pie. These were both minced beef dishes, and there was no evidence of the latter being cooked or served. Staff told us that they had given people a verbal choice the day before, as there was no pictures prepared of these particular dishes at present. However we were disappointed that the use of picture menus at mealtimes was still not operational, despite it being discussed at the last inspection and staff telling us that it was almost in place. There is a file of some photographed plated meals, and the handyman confirmed that he had been taking photographs of the meals and had about 60 photos on his camera waiting processed. Potton House Nursing Home DS0000017688.V360035.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This service has a complaints procedure that is easy to understand accessible to everyone entering the home. Staff working in this home, recognise when incidents need external input, and know where to report them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure and details relating to Whistle blowing are clearly displayed in the home. There had been no complaints to this home since the previous inspection. We were shown a beautiful ‘Order of Service’ card, for a resident who sadly passed away recently. It sited a special thanks to the home for ‘their care and devotion, and the love they shared’ with this resident. The training matrix identified that the majority of staff had done safeguarding training within the last eighteen months, and training for refresher and up date courses are planned on the matrix. Potton House Nursing Home DS0000017688.V360035.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, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is adequate. This home provides a comfortable environment and presently has a refurbishment programme in progress. The home is working hard with residents and their families to personalise the individual bedrooms. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The refurbishment of this home is well under way and there are undoubtedly vast improvements. We look forward to seeing the completed works. The home was generally clean and homely. Potton House Nursing Home DS0000017688.V360035.R01.S.doc Version 5.2 Page 18 The lounge areas had been decorated with artwork, some of which aided reminiscence, as well as some that had been created by the art group as part of an activity. There was new furniture in the main lounge including two-seater sofas; some residents appeared to enjoy the closeness of sitting on these, sharing it with a staff member or another resident. The corridor walls have been painted and appear clean and brighter, the bathrooms have been decorated and an impressive new wet room installed. Flooring was in the process of being laid during our visit, and risk assessments were displayed throughout the building to identify how risks should be minimised whilst this work is in progress. Work has been done, involving the families of the residents in this home, to make individuals’ bedrooms more personal and reflective of their life history. One persons’ room had a photograph of the ‘Ashes’ on the wall. This person had had an interest in cricket throughout his life. Another room had a large collage on the wall, with photographs and messages from different members of the family. The Area manager showed us some samples of new signage that she is proposing to put in the home, and talked to us about her ideas for themed areas in the home, such as ‘a coffee shop’ and ‘a nursery’. Potton House Nursing Home DS0000017688.V360035.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. There is consistently enough staff on duty to meet the needs of the people living in this home at present. New staff training is being introduced with a focus on the dementia care the home provides. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff in this home are a well-established team, many of whom have worked here for many years. At the previous inspection we were concerned that the morale of this team was so low. We were pleased when we visit this time, to see such a change. The morale in general seemed much improved, and staff were showing more positive confidence in their work. Staff who had previously appeared to be fed up and frustrated, were coming to us and making positive comments about their roles. One nurse was very proud of the work she had done with the Liverpool Pathway, another commented on how the resource of assistive aids had improved. It was encouraging to see that staff were more empowered, and a reflection of the leadership values of the area manger presently based in the home. Staff are being encouraged to attend weekly staff meetings, giving them ownership and involvement in the introduction of new systems in the home. Potton House Nursing Home DS0000017688.V360035.R01.S.doc Version 5.2 Page 20 These meetings are being held on different days each week, to ensure that all staff have the opportunity to attend. Staffing numbers on duty are presently good, although the home has presently got eight empty beds; the staff ratio has not been decreased. The rotas for January were inspected and indicated that there are always two qualified nurses on duty during the daytime shifts, and no staff appeared to be working excessive hours. In addition to the care staff team there were two cleaners, two kitchen staff, a handyman and an office administrator on duty. A training matrix identified that mandatory training is arranged on a rolling programme, and new dementia training, is being introduced. Staff now receive one-day dementia awareness training and a one-day training session on delivering activities to people with dementia. The Yesterday, Today, Tomorrow (Alzheimer’s programme) is planned for mid March. Some of the trained staff had completed the Liverpool care pathway training, which was seen being used effectively in two residents files. The files of three recently appointed staff were inspected. Appropriate recruitment documents were signed off on the recruitment checklist, however some documents could not be viewed as the home was waiting for Head Office to send the file copies to the home. It also appeared that one member of staff had commenced work on a POVA first check, prior to receipt of the full Criminal Records Bureau check. The home must remember this is only acceptable under extraordinary circumstances, following discussion with the Commission for Social Care Inspection (CSCI) and not as routine. The area manager did however confirm, that this person did not work unsupervised until his full CRB was received. Potton House Nursing Home DS0000017688.V360035.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, 32, 33, 35, 36, 37, 38 Quality in this outcome area is adequate. The area manager for this home is working effectively to implement the necessary changes, however the need for a new home manager to maintain stability in this home is essential to promote the health, safety and welfare of the residents and staff in this home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Unfortunately, the manager that was appointed to this home in November 2007 terminated his employment within a month. However the Area Manager Potton House Nursing Home DS0000017688.V360035.R01.S.doc Version 5.2 Page 22 is presently based at the home and is working hard to introduce new systems and a cultural change. Another manager has just been appointed, and it is hoped they will come into post early April. The area manager has a very positive and enthusiastic approach to these changes, and is passionate about delivering person centred care to this specialist client group. She is constantly striving to resource new training programmes and ideas, particularly focusing on the environment and activities. Evidence identified in the care plans, activities and observations of care, indicates that the team of staff in this home are embracing and supporting her style of care. However it will take time, for the new home manager to establish herself in Potton House, and demonstrate her own abilities to sustain the improvements that have been achieved so far. Accidents and incidents are now being appropriately reported, via the regulation 37 notification, and the safeguarding processes. Staff supervision documentation was examined. Since the area manager has been based in this home, the staff all appear to have had an appraisal carried out, and those inspected had supervision sessions recorded. There is a new supervision matrix in place that links the key worker system to the supervision plan. This is a good idea, however it will take time to monitor its’ effectiveness. The personal expenditure accounts are managed by the company’s head office on the computer system. A small amount of petty cash is accessible seven days a week, however for larger amounts, it is only accessible Monday to Friday. The area manager is going to address this by displaying ‘banking hours’ and increasing the present petty cash facility. We viewed the report and action plan from a recent annual quality survey. It identified new systems such as a relatives comment book being set up, invitations to relatives regarding care plan meetings being sent out, and senior carer roles being allocated as key workers. These improvements were all generated from the survey responses. Potton House Nursing Home DS0000017688.V360035.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 3 X 2 2 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 2 3 3 3 Potton House Nursing Home DS0000017688.V360035.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. Standard OP9 Regulation 13(2) Requirement The exact amount of medication, including variable dose prescriptions, given to people in this home, and any reasons for omissions must be clearly recorded. Timescale for action 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 OP15 Good Practice Recommendations Different methods of offering service users with dementia a choice of meal should be considered and implemented. Potton House Nursing Home DS0000017688.V360035.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 Potton House Nursing Home DS0000017688.V360035.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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