Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 15/06/05 for Saltshouse Haven Nursing And Residential Home

Also see our care home review for Saltshouse Haven Nursing And Residential Home for more information

This inspection was carried out on 15th June 2005.

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

The home has an experienced and enthusiastic team of staff who work well together and enjoy taking part in training and development sessions. The staff are motivated and keen to ensure that residents receive high standards of care. The home offers residents the opportunity to make choices and decisions around their daily lives. Two residents spoken to said `we try hard to be as independent as possible, and it is so nice to be able to make decisions about the care being given and have the staff respect these`. Residents are provided with a warm, safe and comfortable environment that welcomes visitors and makes them feel at home. The home is clean and staff work hard to make sure the building is odour free.

What has improved since the last inspection?

Staff have worked hard to create detailed and informative care records that reflect the care being given, the progress made by the individual residents, and which clearly show the residents choices, preferences and decisions about their daily lives. Residents are pleased with the way care is being given and said `the staff are very supportive and encourage everyone to be as independent as possible`. Staff morale is high and individuals have a better idea of their roles and responsibilities within the home. Management training is available for those people in charge of the lodges and there is a definite feeling of team spirit on the lodges. One resident said that `care has improved over the past few months and staff are much happier when doing their work`.

What the care home could do better:

The intermediate care residents do not have dedicated communal space within Preston lodge, so the individuals receiving this type of service tend to stay in their bedrooms most of the time. This means that some residents could become socially and emotionally isolated during their time at the home.

CARE HOMES FOR OLDER PEOPLE Saltshouse Haven Nursing & Residential Home 71 Saltshouse Road Kingston upon Hull East Yorkshire HU8 9EH Lead Inspector Eileen Engelmann Announced 15 June 2005 9:30 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 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. Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Saltshouse Haven Nursing & Residential Home Address 71 Saltshouse Road Kingston upon Hull East Yorkshire HU8 9EH 01482 706636 01482 376216 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes Limited Position Vacant Care Home 150 Category(ies) of PD(E) Physical Disability - over 65 (150) registration, with number OP Old Age (150) of places DE(E) Dementia - over 65 (150) T(E) Terminally Ill (150) Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registration includes one younger disabled person in Preston Lodge and two younger disabled in Coniston Lodge. 2. A maximum of 7 people under 65 years of age, excuding those people referred to in condition 1 & 3, may be accommodated in PD, DE or TI categories. 3. A maximum of 5 people under 65 years of age may be accommodated in the intermediate care facility in Preston Lodge. Date of last inspection 5/1/05 Brief Description of the Service: Saltshouse Haven is a large registered care home with nursing, caring for service users with a wide range of needs, covering old age, dementia, physical disability and terminal illness. It is part of the BUPA group of care homes. The home is located on the outskirts of Hull, close to arterial and ring roads. Car parking is provided and a number of bus routes stop close by. The home is based in six separate lodges; all connected by footpaths and covered walkways. Five of the lodges are individually named and can accommodate up to thirty people. The Lodges are named Preston, Meaux, Sutton, Coniston and Bilton. The remaining lodge contains the central facilities of laundry, kitchen, staff training, administration and management functions. In total, one hundred and fifty places are available, but at present Bilton Lodge is closed and not operational. All Lodges that accommodate service users provide ground floor, single bedroom accommodation, large communal lounge/dining area and a smaller quiet room. There are well-kept, landscaped grounds around each Lodge.The home provides 15 intermediate care beds on Preston lodge, which are for rehabilitation purposes. Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out with the acting manager, staff and residents of Saltshouse Haven. The inspection was conducted over two days and took 9.25 hours and included a tour of the premises, examination of staff and resident files and records relating to the service. Eight of the staff on duty and nine residents were spoken to during the inspection and comment cards were received from 13 service users and 12 relatives/visitors; their comments and views have been included in this report. What the service does well: What has improved since the last inspection? Staff have worked hard to create detailed and informative care records that reflect the care being given, the progress made by the individual residents, and which clearly show the residents choices, preferences and decisions about their daily lives. Residents are pleased with the way care is being given and said ‘the staff are very supportive and encourage everyone to be as independent as possible’. Staff morale is high and individuals have a better idea of their roles and responsibilities within the home. Management training is available for those people in charge of the lodges and there is a definite feeling of team spirit on the lodges. One resident said that ‘care has improved over the past few months and staff are much happier when doing their work’. Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 6 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. Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 6. All residents undergo a full needs assessment and are given sufficient information about the home and its facilities prior to admission, to enable them to be confident that their needs can be met by the service. EVIDENCE: Each resident has their own individual file and all nine of those looked at had a full needs assessment completed within them. The information from the assessment process is used to formulate the individuals care plan. Four residents spoken to were able to give detailed information about their care needs and the input they required from the staff, service and outside professionals, and this was found to be accurately documented within their care plans. Those residents at the home who receive nursing care have undergone an assessment by a NHS registered nurse from the Health Authority, to determine the level of nursing input required by each individual. Preston lodge has fifteen intermediate care beds that are constantly in demand and have a regular turnover of residents. Average stays on the lodge are two to three weeks and residents referred here receive regular input from the Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 9 physiotherapist and occupational therapy team. A member of the intermediate care team visits the lodge every day and liaises with the staff about the care and progress being made by the residents and each week there is a visit from the GP’s/Consultants involved in the residents care. Two service users spoken to were looking forward to going home and were pleased with the improvement made in their walking since coming onto the lodge. Care plans for the intermediate care residents are kept in their own bedrooms and those spoken to were aware of the information within them and they are given the opportunity to discuss the content and input to them. Communal facilities remain the same as at the last inspection, where the intermediate care residents share the same lounge/dining room as the permanent residents. Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10. The health, personal and social care needs of the residents are clearly documented and are being met by the service and staff. The staff have a good understanding of the residents support needs. This is evident from the positive relationships, which have been formed between the staff and residents. EVIDENCE: Individual care plans are in place for all residents and clearly set out the health, personal and social care needs identified for each person. Seven of the nine plans looked at have been evaluated on a monthly basis and any changes to the care being given is documented and implemented by the staff. The care plans are well written and included detailed information about the needs and expectations of the residents and the care being given on a daily basis. Sutton lodge has made good progress in implementing a new care plan format and ensuring that the staff have received training and development in completing the new paperwork. Their care plans are much improved from the last inspection and the other three lodges are getting ready to alter their paperwork format to match Suttons. All of the residents spoken to were aware of their care plans and although the majority were not interested in reading them, they were aware that they could Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 11 talk to their key worker about their care and input to their own plans. Five of the residents said that ‘staff respect our choices and decisions and we are able to be as independent as possible’. Six individuals said’ the home has arranged for us to have a local doctor and he/she comes to see us whenever we need him’. Seven of the residents who were spoken to were very satisfied with the access to chiropodists, opticians and dentists. One individual said that she has access to the dietician as she has a PEG tube in place and has liquid food/water given daily via this equipment, her nutritional intake is monitored regularly by the staff. Documentation of the wound care being given in the home shows that staff are making good progress in healing wounds and staff spoken to said they had good links with the tissue viability nurse for advice when needed. The medication policy for the home says that individuals can self-medicate if they want to and after a risk assessment has been completed and agreed. All nine of the residents spoken to prefer to have staff administer their medication. Checks of the medication records and the system used showed that these are up to date, accurate and well managed. The nine residents spoken to were extremely pleased with the way that care is given at the home. Six people living at the home said ‘the staff are very kind and caring, they make sure that we have input to the way we receive care and they respect our privacy and dignity at all times’. Observation of the interaction between the staff and residents showed there is a friendly atmosphere and good communication between all parties. Five staff spoken to demonstrated a good understanding of the individual needs of the residents and said ‘we have a good team of staff at the home who are committed to giving the best care possible’. Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15. Residents are provided with choice and diversity in the meals and activities provided by the home. Individual wishes and needs are catered for and people have the option of where, when and how they participate in both eating and leisure activities. EVIDENCE: Discussion with the nine residents showed that they all have different interests and likes/dislikes regarding activities and keeping busy. Two individuals enjoy going for a walk around the gardens, one person likes to have a smoke in the small lounge near the entrance to the lodge and the others join in with the daily activities when and if they feel in the mood. One resident spoken to is very skilled at knitting and crocheting and also likes to watch television in her room, and a number of individuals were seen to be reading the daily newspapers or magazines. All those spoken to were happy with the level of activities and appreciated the fact that they were able to follow their own wishes regarding time alone or participating in a group event. One resident spoken to is very pleased with her change of room, she has now got a patio door and access onto the garden. She showed the inspector her garden ornaments, bird table and spoke about the plants she is hoping to grow over the summer months. Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 13 Three individuals wrote on the comment cards that they had some concerns over the food being bland and lacking in variety. Discussion with the manager indicated that the menus have been altered recently and the cook is very good at going onto the lodges to ask the residents what changes they would like. Discussion with the residents showed that they are always offered a choice of meal, and although there are some things individuals do not like they are offered an alternative and the food is of good quality and well presented. The home has tried to cater for a wide range of tastes and has introduced pasta dishes and curries as well as more traditional foods. Each unit has its own dining room and residents are able to choose to eat here or in their own rooms. One person was seen to be having a late breakfast and staff said that this individual had asked to have her main meal in the evening, so this had been arranged for her. Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The home has a satisfactory complaints system with some evidence that residents’ views are listened to and acted upon. Staff and residents are confident about reporting any concerns and the acting manager acts quickly on any issues raised. EVIDENCE: There have been three complaints since the last inspection, two informal and one formal, all have been investigated by the acting manager and resolved. Information within the care plans shows that staff record niggles and grumbles received from residents and also document the action taken to deal with the issues. A copy of the complaints policy is displayed on the individual lodge’s notice boards and copies of the complaints form were seen next to the information areas and easily available on each lodge. Three residents showed a clear understanding about how to make their views and opinions heard and said that ‘the staff and the acting manager were quick to take action’ where needed. The acting manager said staff have made progress in developing their awareness of the complaints policy and procedure and now consulted as a group on how to improve the process. There have been no Protection of Vulnerable Adult (POVA) incidents since the last inspection and the home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of service users money and financial affairs. All the staff spoken to displayed a good understanding of the vulnerable adults procedure. They were confident about reporting any concerns and certain that Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 15 any allegations would be followed up promptly and the correct action taken. Information in the staff files show that they have all received in-house training in POVA. Four residents spoken to said ‘ we feel safe and protected here and the staff and acting manager make sure that we are well looked after’. Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 24 and 26. Residents are provided with a safe, comfortable and clean environment. They are able to personalise their own rooms, and the provision of door locks since the last inspection means that their personal belongings can be kept secure. EVIDENCE: The main kitchen for the home was totally refurbished in April 2005 and ongoing decoration at the home has ensured that bedrooms and communal areas remain clean and well presented. The acting manager said that she intends to alter the colour scheme on some units to make the environment brighter and more welcoming, and further refurbishments are planned within the yearly maintenance and renewal budgets. Sutton lodge communal areas are to be painted and have new curtains and Preston lodge is to have new communal carpets by December 2005. Observation of the premises showed that there are some areas needing attention including a number of the intermediate care bedrooms that have frayed and stained carpets, the smoking-lounge carpet in Meaux lodge is badly burnt and needs replacing, the corridor and dining room carpets on Meaux are Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 17 stained and need cleaning and the fridge door in the Meaux servery is rusty and needs replacing or repainting. Action has been taken since the last inspection to make safe the broken tiles in the Meaux bathroom and a safety strip is now in place to prevent further damage occurring. Each lodge has a large lounge/dining room for service users to sit in and enjoy the company of others at the home. These facilities are provided with wide screen televisions, music centres and comfortable furnishings. Residents on intermediate care placements (Preston Lodge) do not have any dedicated communal space provided for their service group, although the lodge managers have altered the seating areas in the main lounge to create a more relaxing and welcoming atmosphere. Gardening hours have been increased since the last inspection, and there are now two gardeners working hard to bring the planted areas under control and work has been done to repaint the seats and benches around the home. Three residents said how pleased they were with the outside facilities and they all enjoy walking around the home for exercise, using the flat paths and covered walkways for this purpose. Work is in progress to create a sensory garden near to Sutton Lodge and this is due to be opened in August 2005. New equipment has been purchased for the lodges since the last inspection including several pressure mattresses, three profiling beds and a new electric hoist. Residents said that the new beds were comfortable and staff felt that their adjustable heights made care giving easier. Plans are also in place to convert one bathroom on each lodge into a shower room; this should be completed by December 2005. Seven residents spoken to were very pleased with their individual rooms and said that they had ‘brought in a number of personal possessions to make them feel more homely’. All bedrooms are supplied with door locks and lockable storage space to ensure resident’s valuables are kept safe. Staff have a master key, which can be used to gain access in an emergency. The home is clean, warm and comfortable and no malodours were present. Domestic staff spoken to said that they ‘follow a deep cleaning rota to ensure that all bedrooms are thoroughly cleaned from top to bottom on a regular basis’. Five residents said that they were satisfied with the laundry system at the home and that there was a quick turn around on the clothes sent for cleaning. Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 30. Staff morale is high resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. EVIDENCE: The staffing rotas show that the home provides each nursing lodge (when full with 30 residents) with 6 staff am, four staff pm and 3 staff at night with 2 trained nurses during the day shift and one at night. Meaux lodge is residential and has 5 staff am, four staff pm and two at night. Residents spoken to were happy with the staffing levels and felt that they did not have to wait long for assistance when using the call bell system. Discussion with the staff showed that they felt that they were working well as a team on each lodge and that due to internal rotation onto other lodges they were gaining insight and experience of a wide range of care needs that helped them develop their own practice and approach to care giving. The staff-training programme offers staff access to mandatory training and a wide range of specialist subjects linked to the needs of the service users. The home is a recognised centre for adaptation students and has a number of foreign nurses who are doing or have gone through this programme of development and training. Staff talked about the home’s own individual training programme called Personal best and they were proud of the changes they had made to practice as part of this course. Individual training plans are kept on each lodge and staff are responsible for updating their own and developing their portfolios. There is an induction and foundation course that meets NTO specification for new members of staff, and 73 of the care staff have achieved an NVQ 2 or 3. Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37 and 38. The acting manager is supported well by the senior staff in providing clear leadership throughout the home, with all staff demonstrating an awareness of their roles and responsibilities. The home regularly reviews aspects of its performance through a good programme of self-review and consultations, which include seeking the views of residents, staff and relatives. EVIDENCE: The acting manager has made application to be registered with the Commission for Social Care and Inspection (CSCI). She has nearly completed her NVQ 4 in Management and is a Registered Nurse with an active Personal Identification Number (PIN). There is a new senior management team on each lodge and staff/residents spoke about the ongoing changes within the home. Discussion with the staff and residents indicates that they felt the changes were necessary for the service to move forward and they have had a positive impact within the home. Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 20 Individual staff members felt that the acting manager was supportive and responsive to their opinions and suggestions. Comments made by individuals revealed that the acting manager is strict, but fair; she has high expectations of the staff and the service and the changes made reflect this. The home has an up to date quality assurance award from the local council (QDS 1 and 2). Feedback is sought from the staff, residents and relatives through regular meetings and satisfaction questionnaires. Policies and procedures are up dated and reviewed as an ongoing practice and action is being taken to ensure the requirements of the previous inspection reports are met. Staff supervision files show that individuals receive formal supervision with their line managers on a regular basis and staff appraisals are also completed each year. Staff said that a more experienced worker mentors new employees for their probationary period, and every effort is made to make them a part of the team from day one. The responsible individual completes a monthly Regulation 26 report, and sends a copy to the Commission. Records required for the protection of residents and the running of the business are in place, reviewed and up dated as required. Residents are aware that they can access their personal records as and when they wish to do so. Maintenance certificates are in place and up to date for all the utilities and equipment within the building. Accident books are filled in appropriately, and staff have received training in safe working practices. Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x 2 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 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 2 3 3 x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 3 x x 3 3 3 Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 22 yes Are there any outstanding requirements from the last inspection? 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 6 Regulation 23 Requirement Where residents are admitted only for intermediate care, dedicated accommodation must be provided, together with specialised facilities and equipment to deliver short-term intensive rehabilitation and enable residents to return home (action timescales of 7/6/04 and 1/4/05 were not met). Timescale for action 12/9/05 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 19 Good Practice Recommendations Carpets on Preston and Meaux lodges should be cleaned and/or replaced and the fridge in Meaux servery should be repainted or replaced to ensure the health, safety and welfare of the residents is maintained. Where intermediate care is provided, dedicated space should be made available for this service group. The acting manager should achieve an NVQ 4 in management by 2005. 2. 3. 20 31 Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 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 Saltshouse Haven Nursing & Residential Home J54_s951_Saltshouse Haven_v221196_150605_Stage 4.doc Version 1.30 Page 24 - 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!