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Inspection on 21/05/07 for Richmond Heights Nursing Home

Also see our care home review for Richmond Heights Nursing Home for more information

This inspection was carried out on 21st May 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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

Accurate comprehensive assessments were in place from some of the care management team and from the staff of the service. This ensured that the service have sufficient information to be aware of the service user`s needs prior to admission. Accurate care plans will contribute to the delivery of care. Service users and relatives were satisfied with the care. Their opinions were; `The care is good`. `It`s ok`. `They look after me very well`. `I have no concerns about my wife`s care`. The storage, ordering, administration and disposal of medication procedures were satisfactory, except for the door to the medication room, which needs attention. Activities were organised within the service, which would provide stimulation to service users and enhance their quality of life. Service users were given the opportunity to exercise their right of choice regarding the activities and provision of meals. Positive comments were received from the service users and relatives regarding the food provision. The general comments were that; `The food is ok.` (3 service users stated) `We get a choice`. The service is well managed and well organised. An experienced registered manager is in post. This will contributed to the effective organisation and operation of the service. Extensive quality assurance systems were in place that should assist the managers and company to measure the service against expected outcomes.

What has improved since the last inspection?

The service had complied with 6 of the 7 requirements from the Random inspection, which occurred on the 07/09/06. The 1 requirement, regarding door locks, which had not received full compliance, the service had moved positively towards achieving compliance and the timescale was still outstanding (01/09/07) The requirements act upon were: The care plan must involve the service users and relatives, and the risk assessments revised. This requirement had been resolved as service users and relatives were involved and the risk assessments had been revised. The corridors and stairwells and some rooms had been redecorated. The manager was aware of the gaps in employment history and staff records from the 07/09/06 had no gaps. The manager had undertaken the Registered Managers Award. Fire drills were undertaken 6 monthly and recorded in the fire book. Regulation 37 notifications were received at the CSCI office.

What the care home could do better:

Continue to progress with the door locks to achieve compliance, and act upon items which are broken, examples: the shower and sluice, as these had been broken for sometime prior to the inspection. Produce a programme of decoration in the form of a rolling programme, for the whole of the building, because as stated some area were `tired` and will need redecoration in the near future.

CARE HOMES FOR OLDER PEOPLE Richmond Heights Nursing Home Woodhouse Road Intake Sheffield South Yorkshire S12 2AZ Lead Inspector Ivan Barker Key Unannounced Inspection 21st May 2007 10.40 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 DS0000021800.V332003.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. DS0000021800.V332003.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Richmond Heights Nursing Home Address Woodhouse Road Intake Sheffield South Yorkshire S12 2AZ 0114 253 1992 0114 253 1994 richmond.heights@craegmoor.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) Speciality Care (REIT Homes) Limited Mrs Angela Kaye Care Home 55 Category(ies) of Old age, not falling within any other category registration, with number (55) of places DS0000021800.V332003.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user named as part of the application to vary registration who is under the age of 65 may reside at the home. 27th May 2006 Date of last inspection Brief Description of the Service: Richmond Heights is a purpose built, 55 bedded home for older people. There are 53 single en-suite rooms and one double room. It is built over two floors all accessed by a lift. The home has a number of lounges and dining rooms. The gardens are landscaped and it has a car park. It is in a residential area of Sheffield with good access to public services and amenities (e.g. bus and tram services, shops, libraries etc). The weekly fees are: £429 to £599. The home charges extra for chiropody, toiletries, clothing, telephone, holidays and hairdressing. The Statement of Purpose and Service User Guide were available within the entrance to the home. DS0000021800.V332003.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Only a limited number of the National Minimum Standards were examined at this inspection (with emphasis on the ‘key standards’), and the previous requirements. The person present at the inspection was: Ms A Kaye, manager. Within this site visit, which occurred over a six hour period, the inspector toured the building, examined requirements relating to the previous inspection, case tracked 3 service users (Case tracked means looking at the care and service provided to specific service users living at the home; checking records relating to their health and welfare, care plans and other records; by talking to the service users themselves; viewing their personal accommodation as well as communal living areas), and spoke with other service users, and relatives and also 3 staff and examined assessments, care plans, risk assessments, menus, complaint files, staff files and quality monitoring documents. The history of the service was examined prior to the site visit. This included the telephone contacts, letters, notifications etc. What the service does well: Accurate comprehensive assessments were in place from some of the care management team and from the staff of the service. This ensured that the service have sufficient information to be aware of the service user’s needs prior to admission. Accurate care plans will contribute to the delivery of care. Service users and relatives were satisfied with the care. Their opinions were; ‘The care is good’. ‘It’s ok’. ‘They look after me very well’. ‘I have no concerns about my wife’s care’. The storage, ordering, administration and disposal of medication procedures were satisfactory, except for the door to the medication room, which needs attention. Activities were organised within the service, which would provide stimulation to service users and enhance their quality of life. Service users were given the opportunity to exercise their right of choice regarding the activities and provision of meals. DS0000021800.V332003.R01.S.doc Version 5.2 Page 6 Positive comments were received from the service users and relatives regarding the food provision. The general comments were that; ‘The food is ok.’ (3 service users stated) ‘We get a choice’. The service is well managed and well organised. An experienced registered manager is in post. This will contributed to the effective organisation and operation of the service. Extensive quality assurance systems were in place that should assist the managers and company to measure the service against expected outcomes. What has improved since the last inspection? What they could do better: DS0000021800.V332003.R01.S.doc Version 5.2 Page 7 Continue to progress with the door locks to achieve compliance, and act upon items which are broken, examples: the shower and sluice, as these had been broken for sometime prior to the inspection. Produce a programme of decoration in the form of a rolling programme, for the whole of the building, because as stated some area were ‘tired’ and will need redecoration in the near future. 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. DS0000021800.V332003.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 DS0000021800.V332003.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 3 and 6. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Accurate comprehensive assessments were in place from some of the care management team and from the staff of the service. This ensured that the service have sufficient information to be aware of the service user’s needs prior to admission. EVIDENCE: On examination of the care management assessments within three care plans, it was established that all three had care management assessments or transfer documentation from the hospital. On discussing the receipt of the assessment with the manager, she advised that the majority of assessment were either written or faxed documents, however some assessments were delivered over the telephone by the care DS0000021800.V332003.R01.S.doc Version 5.2 Page 10 management team. Standard 3 identifies that; a summary of the assessment and a copy of the care plan produced for care management purposes, are obtained by the registered person. Therefore the giving of information over the telephone regarding assessments would be poor practice. The manager advised that this matter had been discussed with the Social Services. Despite this fact, the manager or senior staff had undertaken extensive assessments of each service users prior to their admission. These assessments detailed the service user’s needs that would assist in providing sufficient information for care plans to be drawn up. The manager advised that no intermediate care, only respite care was provided within the service. DS0000021800.V332003.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Accurate care plans will contribute to the delivery of care. Service users were satisfied with the care they received. EVIDENCE: On examination of the care plans, from three service users, it was established that all three care plans were up to date, and had been evaluated on a monthly basis. There were daily entries within the care plans, these entries recorded the care delivered on a daily basis. Comprehensive risk assessments were included within the documentation and included moving and handling, nutrition, skin integrity, and other risk factors. DS0000021800.V332003.R01.S.doc Version 5.2 Page 12 The manager advised that the format of the care plan documentation was changing and the staff were in the process of changing over the information to the new documentation, therefore some care plans contained the old and new style of documentation. It was discussed that although there was a change over of documentation, it was important to ensure that an accurate care plan was readily available for staff to access so that they were aware of the expected care to be delivered. Service users and relatives expressed their views, during the inspection. Their opinions were; ‘The care is good’. ‘It’s ok’. ‘They look after me very well’. ‘I have no concerns about my wife’s care’. Whilst touring the building it was observed that many of the service users were in a frail condition and in bed. All the service users who were observed to be in bed appeared to be comfortable and well cared for. The storage, ordering, administration and disposal of medication procedures were discussed with the manager. The procedures explained by the manager were satisfactory. However on examination of the storage cupboards and discussing the storage with the manager and the qualified nurse, it was established that the medications for each service user had been stored together, and then when there was limited space, medication had been placed wherever there was a space in the cupboard. This had created an untidy storage system. Also because of the increase in medications for service users receiving palliative care, the storage of these medications was becoming difficult. On raising this issue of storage of medications, the manager agreed that the provision of a new storage cupboard would be beneficial. The door to the medication room requires attention. This matter is addressed in the environment section of this report. There was a signature-checking document, which contained the initials as written on the medication administration document and the member of staff’s signature. On examination of the medication administration records it was found that there were no omissions of signatures. All medication records had been signed when being checked in from the pharmacy. DS0000021800.V332003.R01.S.doc Version 5.2 Page 13 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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Activities were organised within the service, which would provide stimulation to service users and enhance their quality of life. Service users were given the opportunity to exercise their right of choice regarding the activities and provision of meals. EVIDENCE: The manager advised that an activities co-ordinator was responsible for the activities, entertainment and outings and employed for 25 hours per week. There was a programme of planned social events displayed. The plan consisted of certain ‘fixed items’ for example bingo was a regular item. The manager advised that bingo and dominoes were sessions, which the service users preferred and were the predominant activities within the home. She advised that other activities included the garden club, baking club, music therapy, holistic therapy, ‘knit and natter’ bi monthly church group, church services, which were well attended by service users and relatives and a monthly DS0000021800.V332003.R01.S.doc Version 5.2 Page 14 entertainer who was a singer. A pie and pea super was provided at the monthly entertainment session. Outings consisted of barge trips, trips to Crystal Peaks and Meadowhall shopping centres and to the local community facilities i.e. shops, public houses / restaurants etc. On discussing the activities with the service users, their opinions were that; ‘We do enjoy the bingo’. ‘I do things when I want to’. ‘I play dominoes and scrabble to keep my mind active’. Regarding the meals, the manager advised that a choice of continental or full English breakfast was available. The main meal of the day was at midday and offered two choices. The ‘dining room’ staff asked the service users their choice of meal and this was recorded on a meal planner and taken to the kitchen. The planner for the day of inspection was observed. Also relatives were able to purchase meals. At teatime, service users were offered the choice of soup, a variety of sandwiches, chip butties or light meal i.e. scrambled egg. Copies of four weekly menus were seen, within the kitchen, and the food on the date of the visit was being prepared according to this menu. A considerable amount of soft or pureed diets were listed. This would be reflected in the number of frail service users who had difficulty eating a ‘normal’ diet. Positive comments were received from the service users regarding the food provision. The general comments were that; ‘The food is ok.’ (3 service users stated) ‘We get a choice’. During the discussions with the service users and relatives, one relative raised the issue that he did not get a choice and accepted what was given. The manager agreed to discuss this matter with the relative, following the inspection. DS0000021800.V332003.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service had a complaints procedure in place, and it was operating according to the company policy, including the referrals to the Safeguarding Adults team. This would provide confidence that complaints were taken seriously and acted upon to address any shortfalls in care or service provision. The service was able to evidence that the staff had received safeguarding adults training. Therefore staff would be aware of their responsibility regarding the protection of vulnerable adults. EVIDENCE: The service had a complaints procedure displayed at the entrance. The complaints book and the complaints file kept by the manager for her investigations were examined. There were three entries, one relating to care, one to staffing and one to the environment. The manager identified that she had received a written complaint in the post the morning of the inspection. The complainant visited the home, during the inspector and requested to speak with the manager. The complaint was resolved at this meeting and recorded within the complaints file. DS0000021800.V332003.R01.S.doc Version 5.2 Page 16 Regarding safeguarding adults, the safeguarding policies and procedures were available within the manager’s office and the staff room. Staff had undertaken safeguarding adults training, and the manager was able to evidence this by showing computerised training records and certificates within staff files. DS0000021800.V332003.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): Standards 19, 21 and 26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment, monitored at the site visit, had not been maintained to a good standard and required repairs to provide a safe, well-maintained environment for services users. EVIDENCE: On touring the building, the home was found to have reasonably decor in most areas but some areas of the service looked ‘tired’ and will require redecoration in the near future, and some areas required repair. The following areas required attention. DS0000021800.V332003.R01.S.doc Version 5.2 Page 18 The door to the kitchenette on the first floor and the door to the medication room had large holes in the doors where previous locks had been removed. These doors were fire doors and the fire integrity of these doors has been compromised. Within the shower room on the first floor, the shower was not working. The manager identified that the pump had broken and was awaiting repair. The manager offered a timescale of the 30th June for the completion of the repair. This date was accepted. The mechanical sluice machine had broken. The manager advised that the repair was quite extensive and may take sometime to achieve or a new sluice machine may be necessary. She advised that an interim cleaning procedure, using chemicals had been introduced. Whilst this was accepted as an interim measure, concern was raised that with so many service users receiving palliative care, then the repair or replacement of the sluicing machine needs to be addressed. The manager identified that at the latest the proposed date for completion would be three months. Adjacent to the laundry, there were laundry bins and other items stored on the corridor, because the storage room where the items were normally stored was full of old care plans, and other records. The manager identified that the service was struggling for storage space, and she had made a judgement that the paper records, should be stored securely within the room, and the laundry brought out onto the corridor. The manager accepted that the whole of the storage areas within the home needs to be reviewed, and items removed, as deemed necessary, from the home and the laundry storage moved back into the designated room and off the corridor. It was accepted that because of the shape of the corridor, the items did not block a means of escape. However should the items be the centre of the fire then the laundry staff might have a limited means of escape. Positive comments were received from the service users and relatives regarding the home. The general comments were that; ‘It’s nice and clean and tidy’ ‘My wife’s room is always clean, we spend most of our time in here’. ‘Most of the people stay in their rooms, because they are poorly’. The service users’ rooms had been personalised and contained photographs, personal belongings, which the individual or the family had provided. DS0000021800.V332003.R01.S.doc Version 5.2 Page 19 Regarding the previous requirement identifying that all bedroom doors must be fitted with locks. The manager advised that 12 had now been fitted. She had worked on the basis of having discussions with the service users and relatives and those who had expressed a wish for a lock had been given the first batch of locks. It was agreed that the timescale was still current, and the manager stated that it was the company’s commitment to provide all the bedrooms with locks before the timescale of 01/09/07. As the requirement and timescale were current the requirement was repeated within this report. DS0000021800.V332003.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): Standards 27, 28, 29 and 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager provided evidence that all staff had received training, which could reflect on the quality of care being delivered to the service users. The staff recruitment process should provide protection for the service users. EVIDENCE: On examination of the staff rotas and examination of staff on duty, the following was established: Am / Pm shift – (8am to 8pm) Night shift – (8pm to 8am) Plus A manager An administrator Activities Co-ordinator Ancillary staff included. DS0000021800.V332003.R01.S.doc Version 5.2 Page 21 3 qualified nurses and 9 care assistants, plus 2 ‘dining room’ carers 8am to 2pm. 2 qualified nurses and 3 care assistants. Domestics, catering staff, and a handyman. Caring for a present occupancy of 54 service users. The ‘dining room’ carers were staff who undertook such jobs as assisting in feeding service users to eat their meal, and to take the order from service users for the choice of their meal. A full assessment of the dependency levels of the service users was not undertaken and compared with the indicated staffing levels. However the manager identified that the staff numbers stated above had to change to meet the needs of the service user. She advised that previously the staff for the Am / Pm shift had been 2 qualified nurses and 10 care assistants, but as the palliative care needs of the service users had increase the skill mix of staff had been changed to 3 qualified nurses and 9 care assistants. It was recognised that the service did have a considerable number of frail service users receiving palliative care, and it was discussed with the manager that she should continue to review the numbers of staff as well as the skill mix to ensure that the needs of service users were being met. On discussing the complaint regarding staffing, the manager evidenced that the staffing had on occasions been reduced by sickness, at short notice, but the ‘dining room’ carers had been used to supplement the carers giving personal care. Also from the complaint there was a discussion regarding the need to examine working practices to ensure that all staff were aware of their responsibilities. The manager agreed to discuss working practices with the staff. On examination of the three staff files, all contained the required documentation, including Criminal Records Bureau and POVA (Protection of Vulnerable Adults) checks. On examination of the staff training records there were records and certificates that indicated the staff had received moving and handling, fire training and other relevant training. DS0000021800.V332003.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): Standards 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. An experienced registered manager is in post. This will contributed to the effective organisation and operation of the service. Extensive quality assurance systems were in place that should assist the managers and company to measure the service against expected outcomes. EVIDENCE: There was a registered manager in post. She advised that she had completed the Registered Manager’s Award in October 2006, but was still awaiting verification and certification for the course. DS0000021800.V332003.R01.S.doc Version 5.2 Page 23 Regarding the monies held by the company on behalf of the service users, there was a credit and debit system. The importance of ensuring the use of service user’s money to enhance their quality of life, and not being left accumulating in the account was discussed. Regarding Quality Assurance, the manager undertook the quality monitoring of the service, on a bi monthly basis. The manager produced copies of audits and she advised that the system included ‘hot topics’, which were produced by head office. The ‘hot topics’ may be issues raised within; critical factors identified by the company, CSCI inspections or Government legislation. Also analysis of the care and service provision was undertaken by the Clinical Governance Department of the company. Regulation 26 documentations, which are a record of the registered person’s monthly visits, was complied on a monthly basis, evidence of this was seen at the visit. Regulation 37 notices, which are documents that are sent to the Commission regarding untoward occurrences, including falls, accidents etc; have been received by CSCI (Commission for Social Care Inspection). DS0000021800.V332003.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 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 X 3 X 3 X X 3 DS0000021800.V332003.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP24 Regulation 16 Requirement All bedroom doors must be fitted with locks suitable for service users capabilities and accessible to staff in emergencies to provide privacy and dignity to service users. Timescale for action 01/09/07 2 OP19 23 This requirement has been outstanding since 2005. The doors require repair. These 21/06/07 repairs need to ensure they comply with the standard required for fire protection to protect the service users, relatives and staff in the event of fire. The shower facility must be repaired and in working order so that service users may use the facility. The mechanical sluice machine must be repaired or replaced, so as to provide adequate cleansing facilities to control the spread of infection. 30/06/07 3 OP21 23 4 OP26 23 31/08/07 DS0000021800.V332003.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000021800.V332003.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 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 DS0000021800.V332003.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!