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Inspection on 13/04/07 for Rayners Residential Care Home

Also see our care home review for Rayners Residential Care Home for more information

This inspection was carried out on 13th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a very pleasant and comfortable environment in which service users can live. Individuals are encouraged to personalise their own rooms with their own furniture and personal belongings. Meals are of a good standard and presented in an appealing way. Comments made from people who use the service include, " the food is always very nice " and "there is always plenty of food and snacks in between meals". Medication is well managed in the home with relevant procedures in place for the administration of medicines. There is a motivated and established staff team that consists of care/support staff who respond to service users in a respectful and appropriate manner. Service users spoken to said that the staff were "very helpful and kind" and " nothing was too much trouble ". Communication between service users and visitors was observed to be positive and open . Training for care staff is good and service users benefit from a staff team who are appropriately trained to do the job. The care staff are undertaking relevant training and working towards their National Vocational Qualifications. There is an effective complaints procedure with all complaints and concerns being acted upon promptly, within stated time scales. There is a good range of policies and procedures, providing care staff with relevant information about all aspects of care and the home/organisation. There are effective Quality Assurance systems in place, including an annual service satisfaction survey and a monthly news letter which is to be commended. Health and safety policies and procedures are clear and informative.

What has improved since the last inspection?

The home have managed to maintain a good standard of care ensuring the personal, emotional and health care needs for service users continue to be met. Service users spoken to were very positive about the care they receive at the home. Improvements to the premises continue to be made to ensure a safe and homely living environment is maintained.

CARE HOMES FOR OLDER PEOPLE Rayners Residential Care Home Weedon Hill Hyde Heath Amersham Bucks HP6 5RH Lead Inspector Barbara Mulligan Unannounced Inspection 10:25 13th April 2007 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 DS0000023014.V330953.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. DS0000023014.V330953.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rayners Residential Care Home Address Weedon Hill Hyde Heath Amersham Bucks HP6 5RH 01494 773606 01494 793529 chris@careatrayners.co.uk 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) Rayners (Extra Care Home) Limited Mr Christopher James Matthews Mrs Jeanne Marie Mathews Care Home 45 Category(ies) of Dementia (5), Old age, not falling within any registration, with number other category (40) of places DS0000023014.V330953.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That as of the 5th of October 2005, the home is registered to care for 5 (five) service users with a dementia - type illness. 22nd February 2006 Date of last inspection Brief Description of the Service: Rayners (Extra Care home) is family owned and managed. The home was purpose built in 1990 for the care of older people within the county of Buckinghamshire. The home is situated in Hyde Heath, a Chiltern Village two miles from Amersham. The local amenities include a village store, public house and an attractive green. Access to the local town would be via the homes minibus. The home is registered for the care of forty-four older persons, not falling into any other category. The home has forty-four spacious single bedrooms a large percentage of which have en-suite facilities. All bedrooms have a hand washbasin and are in close proximity to toilet and bathing facilities. The second floor of the home is accessible via a five-person passenger lift. Communal space consists of a large lounge and dining area, which are both set in a homely and attractive fashion. A large glazed area opens out onto the terrace and landscaped gardens. The front entrance of the home is welcoming and contains a small-seated area for the use of visitors. Fees range from £549 per week to £645 per week. DS0000023014.V330953.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken on Friday April 13th 2007 at 10.25 am. The visit consisted of discussions with the registered manager, staff team and service users, a tour of the premises and an examination of the homes records, policies and procedures. The inspection officer was Barbara Mulligan. The registered manager is Christopher Mathews. Twenty-six of the National Minimum Standards for Older People were assessed during this visit to the home. Twenty-five of these are fully met, and one has been assessed as not applicable. As a result of the inspection the home has not received any requirements. The inspector would like to thank the registered manager, the staff team, service users and visiting relatives for their cooperation and assistance during this visit. Service users and relatives/representatives, both those interviewed and those who responded to the survey expressed a high level of satisfaction with the care received from support staff. Positive comments made about the service include, “ Staff are very patient and kind” and “the staff team have made strenuous efforts to ensure the GP has sorted out a medical matter recently” and “meals are always well presented and portions are of a suitable size. There is choice” and “ it is the only residential home I have been in where there is not a pervasive smell of urine and cleaning fluid when you enter the building. Everything seems to be washed and cleaned regularly”. Two comments were received regarding staffing and these are “sometimes I have to wait a considerable time for someone to come and help me when I have asked” and “sometimes a request is made but is forgotten because the member of staff is distracted by another request”. The evidence seen and comments received, indicate that this service meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals within the limits of its Statement of Purpose. The inspector would like to thank the service users, the staff team and the registered manager for their cooperation and help during the inspection. DS0000023014.V330953.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home have managed to maintain a good standard of care ensuring the personal, emotional and health care needs for service users continue to be met. Service users spoken to were very positive about the care they receive at the home. Improvements to the premises continue to be made to ensure a safe and homely living environment is maintained. DS0000023014.V330953.R01.S.doc Version 5.2 Page 7 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. DS0000023014.V330953.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 DS0000023014.V330953.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): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are thoroughly assessed prior to admission ensuring that staff are prepared for admission and have a clear understanding of the service users requirements. EVIDENCE: It is the responsibility of the clinical manager or the head of care to carry out the initial assessment of need. Staff will visit a potential service user either in the hospital or in their own home to undertake the initial assessment of needs. The inspector observed the assessment documentation for four service users, including those most recently admitted to the home. The admission tool covers personal details, medical history, medication, mobility, allergies, pressure area care, hearing, foot, sight and oral care and nutritional status. DS0000023014.V330953.R01.S.doc Version 5.2 Page 10 The admission documentation seen is fully completed, detailed and demonstrates that prospective service users, family members or representatives are included in the assessment process if this is appropriate. The home does not admit service users for intermediate care so this standard was not assessed during the inspection. DS0000023014.V330953.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning system provides staff with the information they need to meet the service users needs. Healthcare support for service users is good, which means that their health and well-being is promoted and protected. Medication procedures within the home are clear and there is consistent implementation resulting in safe working practices. The manner in which personal care is delivered ensures service users are treated with respect and dignity and that their right to privacy is upheld. EVIDENCE: The care of four residents was case tracked and their care plans were examined. Following the initial assessment a plan of care is developed. Care plans seen are detailed and include medical information, a life history, information regarding daily living, specialist intervention, information regarding personal care and likes and dislikes. Care plans acknowledge the holistic needs of the service users. DS0000023014.V330953.R01.S.doc Version 5.2 Page 12 Each care plan seen is in line with the service users current needs. There is good evidence of health screening taking place and how the home supports service users to access health advisors. There are risk assessments in place regarding moving & handling, tissue viability, nutrition, and in some care plans, falls assessment. The overall system is comprehensive The home ensures that each service user plan is reviewed regularly and involves the individual and where agreed their family or representative. There is evidence that risk assessments are reviewed on a monthly basis. Most service users are registered with a local GP Practice. Service users can register with their own GP if this is practical and agreeable to both parties. All have access to local NHS Services. Tissue viability assessments are in place for each service user. At the time of the inspection there was one individual that required pressure area care and the information contained within the care plan was up to date and in line with her present and changing needs. Pressure relieving equipment is obtained via the district nurse, occupational therapy or is purchased by the home. A domiciliary optical service visits the home on a six monthly basis. Referrals for a hearing test go through the service users G.P. The home works closely with the dietician and nutritional risk assessments were observed in care plans. Weight monitoring was observed in the care plans and this is undertaken monthly. Chiropody services visit the home on a six weekly basis. Dental services are accessed in the local village and they will visit service users in the home. At the time of the inspection there were approximately four service users who were able to self-administer their medication. The home uses a local chemist to supply and deliver the homes medication and the home uses a monitored dosage system. There were no out of date medications held in the service users home with a returns procedure in place. There are no controlled drugs in use at the time of the visit, however there are systems in place to ensure the procedures to administer controlled drugs are adhered to. Medication records show no omissions. Training records demonstrate that staff have undertaken up to date accredited training in the safe handling of medicines. Service users receive care from staff and health care professionals in complete privacy. Staff were observed during the inspection to knock on service users bedroom doors before entering. Preferred terms of address are identified at the initial assessment and the inspector saw evidence of this in care plans. DS0000023014.V330953.R01.S.doc Version 5.2 Page 13 The homes induction programme includes training regarding privacy and dignity. The Statement of Purpose and Service Users Guide include information about maintaining the privacy of service user’s. Service users can have a key to their rooms if they wish to use this facility and it is felt to be safe. . DS0000023014.V330953.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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems in the home ensure that where appropriate service users are supported to exercise choice and control over their lives. Individuals are able to receive visitors at the home and there are no restrictions imposed on visiting unless requested by the service user. Service users are encouraged to bring personal possessions in with them allowing personal space to reflect the character and interests of its occupant. The presentation and standard of food is good and meets the nutritional needs of service users. EVIDENCE: Care plans show routines of daily living and include bathing, rising and retiring times. Religious observance is recorded in care plans and service users interests are recorded in the initial assessment. As part of the admission process, the home ask service users and/or their families to complete a life history to give staff information about previous leisure pursuits, hobbies and other interests. On the day of the visit the inspector observed one lady having a manicure and there was a lot of one to one interaction and conversations taking place. DS0000023014.V330953.R01.S.doc Version 5.2 Page 15 Service users spoken to said there are regular activities that take place. The home produces a monthly newsletter and the activities organised for the month are displayed on the back of this. Examples of activities for April include outside entertainers visiting the home, sherry supper, exercise class, and a trip to the local pub. Examples of involvement in the home by local community groups and individuals are visits by mobile hairdressers, various visiting entertainers and a monthly church service. Service users are able to receive visitors in the privacy of their own rooms and are able to choose whom they see and do not see. There are no restrictions on visiting, and this is documented in the Service Users Guide. Family and friends are invited to participate in some of the social event organised. Service users and/or their families are encouraged to look after their own financial affairs whenever possible. If this is not practicable a chosen solicitor will be responsible for an individuals financial dealings. An invitation to bring in personal items of furniture and other belongings is included in the service users guide and this was evident during a tour of the premises. When questioned about service users having access to their personal records, the inspector was informed that this could be facilitated if it was requested. Service users are offered three meals a day. The inspector had the opportunity to join the service users for lunch. Lunch was relaxed, unrushed and well organised. All meals seen were attractively presented and plentiful. In discussions with service users it was confirmed that meals are always of a high standard and there are sufficient snacks and drinks available throughout the day. The inspector was told that service users can take their meals in their rooms if they wish and this was the choice of several individuals on the day of inspection. The nutritional needs of service users are assessed and there is evidence of regular monitoring in all care plans seen. DS0000023014.V330953.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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an effective complaints procedure to ensure that service users or their representatives are listened to. Policies and procedures to protect service users from abuse are in place, including financial protection. EVIDENCE: The home has a complaints procedure, which is accessible to service users and their representatives. A record of all complaints is maintained, and this was viewed. The home has not received any complaints since the previous inspection. A summary of the complaints procedure is included in the Statement of Purpose and Service Users Guide. No complaints or concerns have been received by CSCI. The registered manager is aware of the POVA register and would submit staff for inclusion if it became necessary. The home uses the Bucks Multi Agency POVA policy and an organisational policy in conjunction with this. This includes guidelines for staff about the responsibilities of the staff, types and signs of abuse and what to do if you suspect abuse. All care staff receive training about Adult Abuse and this forms part of their induction. The registered manager does not act as appointee for any service users. DS0000023014.V330953.R01.S.doc Version 5.2 Page 17 There are systems in place to look after small amounts of personal allowance or for the safekeeping of service users valuables. DS0000023014.V330953.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 25 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is excellent, providing service users with an attractive and homely place to live. The overall quality of the furnishings and fittings is good ensuring the safety and comfort of service users. Standards of cleanliness at the home are good meaning that service users live in an environment that is clean and hygienic, protecting their health, safety and welfare. EVIDENCE: Rayners (Extra Care home) is family owned and managed. The home was purpose built in 1990 for the care of older people within the county of Buckinghamshire. The home is situated in Hyde Heath, a Chiltern Village two miles from Amersham. The local amenities include a village store, public house and an attractive green. Access to the local town is via the homes minibus. DS0000023014.V330953.R01.S.doc Version 5.2 Page 19 The home has forty-four spacious single bedrooms a large percentage of which have en-suite facilities. All bedrooms have a hand washbasin and are in close proximity to toilet and bathing facilities. The second floor of the home is accessible via a five-person passenger lift. The front entrance of the home includes a reception area and this is welcoming and contains a small seated area for the use of visitors. Communal space consists of a large lounge and dining area, which are both set in a homely and attractive fashion. The internal decoration of the home is of a high standard and there are personal touches around the home such as flowers, plants, books and pictures. The lounge and dining areas have recently been redecorated and this has included new carpets and curtains. The kitchen is clean, spacious and well looked after. There is a small hairdressing room that is nicely decorated and suitable for its purpose. Lighting in communal areas is domestic in character and sufficient to facilitate reading and other activities. The furnishings observed in communal areas are of good quality and suitable for the range of interests and activities preferred by service users. A large glazed area opens out onto the terrace and landscaped gardens. These are well-maintained and accessible to service users. There are accessible toilets available for service users throughout the home and several are close to the lounges and dining area. All radiators have low temperature surface covers and are thermostatically controlled. Emergency lighting is provided throughout the home. Hot water control valves are fitted to all hot water outlets accessible to service users. Laundry facilities are very spacious and sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten and do not intrude on service users. The home has an infection control policy and the inspector observed this. Instructions are in place for the washing of soiled linen. DS0000023014.V330953.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing numbers are good, and ensure that the assessed needs of the service users are met. Service users benefit from a staff team who are up to date with their training, to ensure that staff are competent to do their jobs. There are effective recruitment procedures in place to ensure service users are protected from harm. Service users benefit from clarity of staff roles and responsibilities that results in a good quality care service being delivered. EVIDENCE: The home’s staff rota demonstrates that there are adequate numbers of staff on duty at all times to ensure the needs of the service users are always met. This includes sufficient numbers of ancillary staff. The registered manager is extra to these numbers. There are no staff working in the home who are aged under 18 years of age and there are no members of staff under the age of 21yrs left in charge of the home. The home continues to support staff on NVQ training and at the time of this inspection eleven staff had obtained NVQ level 2 training or above and a further two were working towards NVQ 2 training and another 2 staff level 3 training. DS0000023014.V330953.R01.S.doc Version 5.2 Page 21 A random selection of staff files were made available for inspection purposes, including those most newly recruited. All files looked at contain the necessary documentation as detailed in schedule 2. There is evidence that all staff CRB checks had been obtained. The home does not employ any volunteers. There is an induction programme in place to ensure that new staff members are familiarised with the organisation and their roles and responsibilities and provides the staff member with a personal development portfolio. This includes fire safety, moving and handling techniques and core skills training. Training records reflect that staff have received mandatory training and this appears to be up to date for all staff. There is specialist training available for staff, an example of this is Autism training, Epilepsy training and non-violent crisis intervention. Staff confirmed that there are regular staff meetings. DS0000023014.V330953.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager appears to be supported well by the staff team in providing clear leadership and demonstrating an awareness of their roles and responsibilities to the benefit of the service users. The home operates a consistent approach to quality assurance resulting in the home being proactive in identifying issues that may affect the well being of services users. Protocols and systems are in place to ensure service users financial interests are safeguarded. There are systems within the home that are used to ensure that service users health, safety and welfare are protected and promoted. EVIDENCE: DS0000023014.V330953.R01.S.doc Version 5.2 Page 23 Rayners (Extra Care home) is family owned and managed. There is a registered manager and a clinical manager. The manager has completed the Registered Managers Award. Examples of further training undertaken by the manager include fire prevention and all mandatory training. The manager is not responsible for any other registered establishment. There is an equal opportunities policy in place and this was looked at during the inspection. There are clear lines of accountability within the home with a registered manager, a clinical manager, two heads of care, one deputy manager and six care managers. The registered manager stated that service users satisfaction questionnaires are sent out to service users and their relative or representative on an annual basis. The results of the last annual quality control questionnaire have been published in the newsletter for March. This demonstrates that service users are overall happy and satisfied with the service provided. Accident and pressure sores and complaints are monitored on a regular basis. There is a folder containing compliments and thank you letters, mainly from the relatives of service users. The manager does not undertake the role of appointee for any service users. Most families look after their relative’s money and only a small number of individuals require the home to look after personal money. Relatives will bring in small amounts of personal money and written records are maintained of all transactions. Secure facilities are available for the safekeeping of valuables if required. Records were seen for fire safety. These cover the homes fire procedures, practice fire drills, fire prevention, fire alarm testing and emergency lighting testing. Testing of the homes fire alarm system is undertaken on a weekly basis and evidence was seen of this. There is a fire based risk assessment that is reviewed annually. Evidence of mandatory health and safety training demonstrates that staff are up to date with this training. Service reports are in place for the maintenance of hoists and the lift. There are service certificates for the gas appliances dated 13/06/06, PAT testing 20/10/06 and legionella 12/12/06. There are systems in place for water chlorination and kitchen hygiene. COSHH sheets are up to date and accurate. The inspector looked at Infection Control guidelines that are available for all staff. DS0000023014.V330953.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 3 3 X X 4 3 STAFFING Standard No Score 27 3 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 4 DS0000023014.V330953.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard Good Practice Recommendations DS0000023014.V330953.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 DS0000023014.V330953.R01.S.doc Version 5.2 Page 27 - 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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