Inspection on 21/08/08 for Ravenstone Nursing and Residential Home

This inspection was carried out on 21st August 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

Ravenstone Nursing and... 10/12/07

Ravenstone Nursing and... 19/01/07

Ravenstone Nursing and... 25/05/06

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 13/11/2008.

CARE HOMES FOR OLDER PEOPLE Ravenstone Nursing and Residential Home 7 St Andrews Road Droitwich Worcestershire WR9 8DJ Lead Inspector Chris Potter Key Unannounced Inspection 21st August 2008 11:30 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 DS0000065965.V370222.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. DS0000065965.V370222.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ravenstone Nursing and Residential Home Address 7 St Andrews Road Droitwich Worcestershire WR9 8DJ 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) 01905 773265 01905 778890 ravenstone@schealthcare.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Justine Hewitt Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46), Physical disability over 65 years of age of places (46) DS0000065965.V370222.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th December 2007 Brief Description of the Service: Ravenstone Nursing and Residential Home is registered to accommodate 46 older people who require 24 hour personal or nursing care. The home is conveniently situated within central Droitwich Spa, close to local amenities and resources. Limited parking is available outside the home, but car parks are with in a short walking distance from the home. Ravenstone is a large detached Victorian building providing accommodation for residents in predominantly single bedrooms. Some double bedrooms are available for married couples. The home provides communal lounges, a communal dining room and specialist bathing facilities. A passenger lift assists residents to access all areas of the home. Information regarding the home can be obtained from the statement of purpose and the service users’ guide which are available from the home. The home belongs to Southern Cross Healthcare, which is a large organisation that own homes all over the country. The registered manager is Justine Hewitt, who is a registered nurse and holds additional professional qualifications. Information about the fees is not included in the service user guide, for up to date information about the fees please contact the home direct as the fees are based on individual needs and assessments. DS0000065965.V370222.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. We, the commission undertook an unannounced inspection of this service over two part days. This was a key inspection – this is an inspection where we look at a wide range of areas. Before the inspection an Annual Quality Assurance Assessment (AQAA) document was posted to the service for completion. The AQAA is a self-assessment and a dataset that each registered provider has to complete each year and send to us within agreed timescales. The document tells us about how providers of services are meeting outcomes for people who use the service and is an opportunity for them to share with us what aspects of the service they believe they are doing well. Some of the provider’s comments have been included within this inspection report. During the visit to the home care records, staff records and other records and documents were inspected. Surveys were sent out and received from residents (eight), staff (nil). There was a tour of parts of the accommodation and interviews with staff, including the recently appointed manager, and an area manager. Time was spent speaking privately with residents in their rooms as well as spending time out and about in the home observing what was happening and talking to residents and their relatives. What the service does well: Staff address and care for residents’ in a sensitive manner, which ensures their privacy and dignity, is maintained. Residents receive a good quality varied diet and residents are consulted regarding food preferences and choice of menu. For example, at breakfast, they have a good choice of a cooked breakfast, cereals, porridge, toast and bread and butter with fruit juice, tea and coffee to drink. Residents are able to eat in the dining room or in the privacy of their bedroom. The management of medication is well organised, and the nurses adhere to their policies and procedures. Positive feedback was received about the home and the staff, comments included: • • • “they made me feel so welcome” “the home is excellent” “staff are very nice” DS0000065965.V370222.R01.S.doc Version 5.2 Page 6 • • • • “staff are very polite, some language barriers” “always prompt when ringing me with health changes” “since the new manager has taken over the whole atmosphere of the home has improved” “they appreciate the choice between male and female staff”. The home take complaints seriously and follow their complaints procedure. Residents and relatives were aware of the homes complaints procedure and were confident that their complaint would be listened to. The home is clean and tidy and the management of odours is generally good. Residents are able to bring some of their own personal possessions into the home. What has improved since the last inspection? What they could do better: The environment would benefit from a redecoration program, including upgrade of furniture and furnishings to further enhance the homes appearance. To offer residents’ with more complex needs more choice, a specialist bath should be provided and used to meet people’s hygiene needs. The home should review a method of controlling the temperature of the treatment room, which should not exceed 25˚C. DS0000065965.V370222.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. The summary of this inspection report can be made available in other formats on request. DS0000065965.V370222.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 DS0000065965.V370222.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): Standards 1,2 and 3 (standard 6 is not applicable to this home) Quality in this outcome area is good. Residents are confident that the care home can support them. This is because there is an accurate assessment of their needs that they have been involved in. This tells the home all about them and the support they need. Residents who stay in the home know about their rights and responsibilities because there is a contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We saw copies of the home’s Statement of Purpose and Service User Guide in the reception area of the home and a copy of the Service User Guide was seen in residents’ bedrooms. The Service User Guide and Statement of Purpose had been updated since the last key inspection and this included the details of the DS0000065965.V370222.R01.S.doc Version 5.2 Page 10 new manager. The manager told us that the Service Users’ Guide is also available in audio format to assist people with sensory impairments. Surveys received from people using the service confirmed that they were provided with sufficient information to assist them with their choice of home. Two new residents told us that the home had been chosen for them, but they were pleased with the choice. Comments received from residents included the following; “My son chose the home for me”, “they painted my room for me at short notice”, “they made me feel so welcome” We looked at three people’s pre-admission assessments, which had been completed before the person moved into Ravenstone. The manager told us she completes pre - needs assessments, and provides the basic information for the staff before the person being moves into the home. The assessment assists in determining that they are able to meet the health and personal care needs of the individual. The assessments’ were clear and contained sufficient information for the home to develop a plan of care based on the initial assessment. The assessment showed that the person and their relatives had contributed and agreed to the contents. Surveys received before the inspection confirmed that they had been assessed, before moving into the home. We saw copies of the contracts between the home and the resident; the administrator is responsible for reviewing these. The majority of surveys received confirmed that they had a contract of terms and conditions; two residents’ were not sure. The Annual Quality Assurance Assessment completed by the manager indicates that the home is aiming to incorporate families more in the assessment process, and monitor the quality of the assessment process through reflective practice. DS0000065965.V370222.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): Standards 7,8,9 and 10 Quality in this outcome area is good. The people’s health and personal care needs are met. The home has a plan of care that, where possible, the person or someone close to them has been involved in making. The home supports people with their medication in a safe way. Peoples’ right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the care records for three people who use the service, and these showed that the care records had been agreed with the person or if appropriate their relative. The record provided clear information of why each person was being cared for in a nursing home, and how the home was meeting the health, welfare and psychological needs of each person. DS0000065965.V370222.R01.S.doc Version 5.2 Page 12 Appropriate risk assessments had been completed on admission, and provide a baseline for monitoring the individual’s health. This enables the nurses and carers’ to identify any changes that may need additional resources. An example of this is cited as follows; a person at high risk of developing skin pressure damage had a care plan in place, which advised how to minimise the risk. It included the equipment being used to assist in preventing skin damage. The person had also been referred to the tissue viability nurse for advice on best practise. The risk assessment was being updated at least monthly. The care plan belonging to a person with a diagnosis of diabetes provided clear guidance for the nurses and the nurse confirmed that the condition was well controlled. A resident who was poorly had a care plan stating that the person was on a fluid monitoring chart, a position chart and these were seen to have been kept up to date by the staff. These showed that the person was being turned regularly, and fluids were being given frequently. The care records for that person also recorded their wishes about their funeral. The nurses record meaningful daily statements about the person and the care provision. The manager told us that the care records still required some additional information and that she would be monitoring the progress through monthly audits. We received positive feedback from people who use the service and their relatives, who feel that the service has moved forward. Comments received included; “the home is excellent”, “staff are very nice”, “staff are very polite, some language barriers”, “always prompt when ringing me with health changes”, “since the new manager has taken over the whole atmosphere of the home has improved”, “they appreciate the choice between male and female staff”. We looked at how medication was being managed for the three people we were case tracking and found the system to be well organised. A copy of the original prescription was available to check that the details on the medication record were correct. A record is maintained of who had completed the medication on each shift, which assists the manager with the monthly audit. The medication administration records seen were well documented with no gaps on the record. The balance of medication was correct for those residents checked. It was recommended that the temperature of the treatment room was reviewed it was very warm at the inspection. The temperature records showed DS0000065965.V370222.R01.S.doc Version 5.2 Page 13 that when warm, the air temperature is in excess of 25˚C, which is the safe recommended temperature for the storage of medication. We observed staff respecting residents’ privacy and dignity - for example, knocking on doors before entering private rooms, and speaking to them courteously. We were told by residents and relatives that all staff were respectful and courteous when addressing them. The Annual Quality Assurance Assessment completed by the manager stated plans for improvements and how all staff are being developed professionally as part of the homes improvement plan through appraisal and supervision. They state that care planning and the accuracy of documentation have improved greatly since the last inspection. The home’s planned improvements in the next 12 months state that the manager will continue to audit medication, clinical areas, the environment, nutrition and financial aspects of the home frequently. DS0000065965.V370222.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): Standards 12,13,14, and 15 Quality in this outcome area is good. The provision of social and recreational activities for residents has improved and is now more person-centred depending on the person’s needs. People keep in touch with family, friends and representatives. They are as independent as can be. People have nutritious meals and snacks, at a time and place to suit them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a part-time activity organiser who covers 25 hours over the week including, some evenings and weekends. They develop a planned weekly calendar of social events for the individual, based on their choice and capabilities. Residents told us that their wishes are respected, if they chose not to participate this is respected. Some residents advised us that they prefer to stay in their bedrooms for meals, and they confirmed that this choice is respected. DS0000065965.V370222.R01.S.doc Version 5.2 Page 15 Staff told us that the activities were suited for the residents - dependent on their needs. During the inspection, the “pat–a–dog” was visiting the home, and residents were observed enjoying this. The person responsible stated that it is therapeutic for the residents. Photographs are displayed around the home of the various activities held for the residents. Regular residents’ meetings take place at the home, and the next one is arranged for the 22nd of August. Comments received from the residents and relatives about the activities included; “The activities are fairly good”. “I prefer not to join in, but they are available if you wish to.” “Vicky is wonderful” The manager told us that they try to protect meal times so that residents’ are not disturbed by doctor’s visits, and all staff can focus on assisting the residents with their food. Residents and staff told us that the quality and choice of food was good. The chef confirmed that the menus have been reviewed since the last inspection, offering the residents a more varied choice. Menus cited the following options and choices; Breakfasts- the home offers a cooked breakfast seven days per week, or cereals, porridge, toast, fruit juices etc. Dinner – the home offers a hot main course including a vegetarian option or the residents can have a choice of salad, jacket potatoes, omelettes, cheese and biscuits. Tea – The home offers soup, sandwiches or a hot dish. We looked at the menu, which was varied in content, and the residents were able to select their choice from the menu the day before. The chef also monitors the nutritional values in each meal, which the person chooses, to ensure that they have the correct nutrients. They received a four star rating from the Environmental Health Officer’s most recent inspection in May 2008. Comments about the food included; • • “The food is excellent, I am overfed and the porridge is lovely”, “I prefer to have my meals in my room”, DS0000065965.V370222.R01.S.doc Version 5.2 Page 16 • • • “We have a choice of meals if we don’t like what’s available there is always an alternative”, “The food is very good” and “Proper home cooked food”. The lunch being served at the time of the inspection looked appetising, and the soft diets were attractively presented. We saw staff supporting residents in a respectful and sensitively manner. The Annual Quality Assurance Assessment completed by the manager stated how they had improved the quality of the service in the last 12 months through the activities co-ordinator developing a strategy to meet the needs of all residents including those with more complex needs and by spending time equally and equitably between client groups. DS0000065965.V370222.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18 Quality in this outcome area is good. People who use the service are able to express their concerns and have access to the home’s complaints procedure. Ravenstone safeguards people who use the service from abuse and neglect, and takes action to follow up any allegations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We have received no complaints about this service since the last key inspection in December 2007. The home’s complaints procedure and records were seen. The manager has a weekly surgery where she is available to meet people using the service and their relatives, and this assists in ensuring that the service is meeting their expectations. Residents and relatives spoken with were aware of the home’s policy and who to report concerns to. Comments from them were positive and complimented the manager for listening and addressing any issues, which they raise. Records showed that four complaints had been received by the home since the last inspection. These related to issues around personal care, slow response to DS0000065965.V370222.R01.S.doc Version 5.2 Page 18 answering the buzzer, food choice and no hot water. The records held include the investigation and the outcome of the complaint. Comments from people using the service included: “I did complain to start with, but they soon put it right” and “I would speak to Justine” (the manager). Staff told us that they had received “safeguarding” training and were aware of the home’s whistle blowing policy. Staff also confirmed that they would have no hesitation in reporting any concerns to the manager. The Annual Quality Assurance Assessment completed by the manager stated that plans for improvements over the next 12 months include continuous monitoring of complaints to ensure issues do not re occur. The manager stated, “We build on good relationships with residents and others”. The organisation (Southern Cross) has launched a national helpline in partnership with Action for Elder Abuse to increase their profile on abuse prevention. DS0000065965.V370222.R01.S.doc Version 5.2 Page 19 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): Standards 19, 21 and 26 Quality in this outcome area is adequate. Minor improvements have been made to the décor of the home and some equipment has been purchased to provide a more homely and comfortable environment. Some further improvement is needed to ensure all areas of the home are pleasant, homely and are adapted to meet the needs of the people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ravenstone is a large detached Victorian building providing accommodation for residents in predominantly single bedrooms. Some double bedrooms are available for married couples. The home provides communal areas for people using the service including lounges, a dining room and bathing facilities. A DS0000065965.V370222.R01.S.doc Version 5.2 Page 20 passenger lift assists residents to access all areas of the home. The design and layout of the home does not enable staff to use specialist equipment in all areas. The corridors in parts are narrow, and people using these areas are carefully assessed. The home would benefit from reviewing their bathing facilities to assist residents with complex needs, and by offering the choice between a bath and shower. We saw that the home was generally clean and tidy and many residents’ rooms were personalised with their own possessions, which gave a more homely atmosphere. The home’s appearance would be further enhanced with an upgrading program of decoration and replacing furniture and carpets where needed. The furniture and carpets in many areas of the home presents as being tired and worn. People using the service and their relatives told us; • • • • • “I would like to change the colour of my room and have the carpet cleaned”, “My room is very nice”, “Some carpets are a little stained”, “The laundry is excellent” and “The room was painted at short notice”. The Annual Quality Assurance Assessment completed by the manager states that the home has just employed an additional maintenance person to drive forward decoration and furnishing programmes to lift the presentation of the whole home. DS0000065965.V370222.R01.S.doc Version 5.2 Page 21 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): Standard 27, 28, 29 and 30 Quality in this outcome area is good. There are sufficient numbers of experienced and qualified staff available to provide residents with the support they need. Staff recruitment procedures are robust and safeguard residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at the home’s duty rotas, which confirmed that the home is providing sufficient numbers of staff and proportionate to the number of residents and their care needs. Residents, relatives and staff told us that there was enough staff available. Staff stated that the only exception to this was when staff went off sick at short notice. We observed staff responding promptly when the nurse call bells were activated. Residents stated that staff were “Always prompt in answering the buzzer”. DS0000065965.V370222.R01.S.doc Version 5.2 Page 22 The manager showed us the training matrix, which the organisation has provided to assist in ensuring that staff receive appropriate training and refresher courses. The nurses told us that they receive regular training updates including wound care, infection control and diabetes. A query about nurses taking blood samples was raised during the inspection. The manager confirmed that three nurses are now trained to undertake this procedure. The home employ male and female staff from diverse cultural backgrounds, and respects the preferences of the people using the service for male or female staff. Comments received from relatives included; • • • • “Compliments to all staff with grateful thanks for all the care”, “Staff are excellent”, “Staff are very polite, there are some language barriers” and “Staff respect our privacy”. We looked at the personnel record files belonging to two staff members and records showed that the home had carried out all the appropriate security checks before the staff had started working at the home. The Annual Quality Assurance Assessment stated, to further improve the service they aim to ensure that all staff are registered with the General Social Care Council and increase the ratio of staff with NVQ qualifications. They are also planning improvements aimed at offering more level three and four NVQ qualifications, and ensuring that catering staff have the opportunity to gain recognised qualifications in food and hygiene. DS0000065965.V370222.R01.S.doc Version 5.2 Page 23 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): Standards 31,32,33,35,36 and 38 Quality in this outcome area is good. With the appointment of the new manager, people have the confidence that the home is being managed appropriately. The environment is safe for people because appropriate health and safety practises are followed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff told us that the manager had made a good start in improving the home, and they found her to be supportive and approachable. She is a registered nurse and has a diploma in Adult Nursing. DS0000065965.V370222.R01.S.doc Version 5.2 Page 24 Comments from staff, residents and relatives included, • “She listens and actions our comments” • “you can really see the difference Justine has made to the home” The manager demonstrated good knowledge and understanding about the residents and their needs. We are provided with copies of the monthly monitoring audit known as Regulation 26, which provides a review of how the home is progressing. A new administrator had recently started at the home from another one of Southern Cross’s homes. She has been reviewing all the staff personal files and setting up the residents’ personal financial accounts. The finances are audited weekly and monthly. The company have an internal auditing team who reviewed the system last in June 2008. The home has a quality auditing system in place and surveys are distributed annually to the residents, relatives and professionals who use the service. The results are positive from the last survey completed in July 2008. The manager also holds weekly surgeries with the families who wish to see her. The Annual Quality Assurance Assessment completed by the manager stated the plans for improvements over the next 12 months, and how they are meeting these standards. They stated that the budget would be used to benefit the health, safety and welfare of the residents and staff - to improve both working lives and the home life of the residents. The assessment also provides dates for the servicing of systems and equipment. Fire records were reviewed and all appropriate checks were being completed. DS0000065965.V370222.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 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 2 X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 N/A X X 3 DS0000065965.V370222.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 OP21 Good Practice Recommendations To assist in meeting the residents’ needs, it is recommended that the bathing facilities are reviewed. The baths are not suited for the more dependant residents. DS0000065965.V370222.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 DS0000065965.V370222.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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