Inspection on 30/07/08 for Sandalwood Court

This inspection was carried out on 30th July 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

Sandalwood Court 01/02/08

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Sandalwood Court Butland Road Oakley Vale Corby Northants NN18 8QA Lead Inspector Irene Miller Unannounced Inspection 09:30 30th July 2008 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 Sandalwood Court DS0000070474.V370237.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. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandalwood Court Address Butland Road Oakley Vale Corby Northants NN18 8QA 01536 424040 01536 747890 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) www.shaw.co.uk Shaw Healthcare (de Montfort) Ltd Care Home 60 Category(ies) of Dementia (60), Dementia - over 65 years of age registration, with number (60), Old age, not falling within any other of places category (60) Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE and DE(E) The maximum number of service users who can be accommodated is: 60 1st February 2008 2. Date of last inspection Brief Description of the Service: Sandalwood Court is a purpose built residential home opened in August 2007. Sandalwood Court is a residential home providing personal care for up to 60 older people including people with dementia. There are bedrooms, lounges and dining rooms on each of the three floors with twenty residents accommodated on each floor. There is a passenger lift, which provides people with access to all floors. Sandalwood Court is situated in the centre of a new housing estate on the outskirts of the town of Corby. Forty beds at Sandalwood Court come under a contract between Northamptonshire County Council and Shaw Healthcare and twenty beds are available for purchase directly through Shaw Healthcare. The fees agreed as part of the contract with Northamptonshire County Council are based upon the assessed level of need. Currently there are three fee levels, which are linked to the residents’, assessed needs as follows: Low £444.84 per week, medium £465.54 and high £486.24. The fee paid by Northamptonshire County Council includes the cost of accommodation, meals, laundry and personal care. Additional costs were identified as personal items, such as toiletries, clothing, newspaper and private Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 5 chiropody treatment. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The focus of all inspections undertaken by the Commission for Social Care Inspection (CSCI) are based upon seeking the outcomes for people using the service and their views of the services provided. This visit was unannounced and focused on the ‘key standards’ under the National Minimum Standards and the Care Standards Act 2000 for homes providing care for older people. The care records of three people using the service were sample checked this involved looking through written information available on their care, such as their individual care plans (a care plan sets out how the home aims to meet the individual service users personal, healthcare, social and spiritual needs). During the course of the visit people using the service were consulted on how they view the care provided at the home, and discussions with staff gave an insight into the support and training provided at the home. Observations made during the visit gave an indication on the quality of staff interactions with people using the service. Records in relation to the homes management and administration systems, quality assurance, staffing and general policies and procedures were viewed. Prior to this visit the Commission for Social Care Inspection sent out to the provider the Annual Quality Assurance Assessment (AQAA) this document allows the provider to supply us with information on how they view their own performance, such as what they do well, what they could do better and plans for future improvements. The date of return of the completed AQAA to the Commission for Social Care Inspection was set for 18th July 2008 we did not receive the AQAA within the timescale, therefore information on how the service view their own performance was not made available prior to this inspection visit. The provider has been made aware that it is an offence under Regulation 24 and 43 of the Care Homes Regulations 2001 not to fill in and send to us the information we ask for in the AQAA when they are asked to do so. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 7 People using the service, visors and staff were asked to provide feedback on how they view the service provided through the completion of a questionnaire, three surveys were returned from people using the service and two surveys were returned from staff. Comments received from the surveys are incorporated within this report. What the service does well: What has improved since the last inspection? The information contained within the care plans on how the home is to meet the health and personal care needs of people using the service has improved. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 8 There was evidence that the advice of other healthcare professionals is sought to improve on the care provided. 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. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 9 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 Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 10 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): Standard 3 (standard 6 is not applicable to this service) Quality in this outcome area is good. The range of peoples needs are assessed prior to admission, this ensures that their full needs can be met at the facility. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During a recent random unannounced visit by CSCI, the homes statements of purpose and service users guide were viewed. Sandalwood cares for people living with dementia and keypad locks are fitted to doors leading to the various communal areas of the home, it was recommended at the random inspection visit that this be reflected within the homes statement of purpose. The manager confirmed during the visit that following this recommendation the statement of purpose had been reviewed and further information had been included in this document to ensure people are aware that there is some areas Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 11 within the home that has limited access, based upon the individual risks to the person and their mental and physical abilities. Information was available within the service users guide on the homes scale of charges; this information assists prospective and current people who use the service and their families to make an informed decision. Within the care plans viewed there was records of pre admission assessments having been carried out by a representative from the home and information was available on the needs of the person from the placing authority. The assessment information had formed the basis of the care plans in place. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 12 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 & 19 Quality in this outcome area is adequate. Further action to address shortfalls in relation to medication matters would ensure that the health, safety and welfare of people using the service is fully promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was information within the care plans to inform staff on the medical background of people using the service and information on basic healthcare needs. There was documentation available to demonstrate that the nutritional needs of people using the service were closely monitored, such as records of weight taken on admission, and records of the daily food and fluid intakes of people identified at risk in this area of the care. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 13 There was information within the care plans on pressure area care prevention and treatment, which included records of turn charts, and treatment provided by the district nurse. Were identified that pressure relieving equipment was required this had been obtained via a referral from the district nurse, and pressure relieving equipment was seen to be in use. The advice of specialist healthcare support services had been sought and there were records of people having regular access to their general practitioner, the district nurse and other healthcare professionals. The care needs of a person diagnosed with dementia was looked at there was records of the home seeking information on the persons social history, to include their cultural and religious needs, family contacts, important people and events in their lives, past and present hobbies and interests, occupation, and their personal choice and preferences. Staff had gained this information using sensitivity, they had acknowledging that for some people sharing this information may be difficult in this situation choice had been respected. In this situation the home seeks the involvement of families and close friends. There were records available of accidents and incident reports, which included near misses, and the individual dependency levels of people using the service, were identified and reviewed regularly. Within the care plans there was records on the gender of staff that the person using the service wished to provide their personal care. The company use a standard tick box form for staff to record when people using the service have received support in meeting their personal hygiene needs, such as hair washed, bathed, saved, dental hygiene etc. On checking these records there was some inconsistencies on the frequency of these forms being completed on a daily basis. In discussion with staff they confirmed that for one person using the service they were in the main self-caring in terms of their personal hygiene needs and had difficulty in accepting staff intervention in this area. Staff had undergone recent medication administration refresher training during the training each member of staff had been observed on a number of occasions whilst administering and recording the medication given to people using the service. During the observations assessment were carried out on each of the staffs competency to safely administer medication, records of the assessments were available to view during the visit. In an effort to ensure that any shortfalls in the administration of medication are picked up on swiftly, a further safeguard has been introduced a ‘daily medication record checklist’ with the aim of carrying out daily checks of medication administration records against the medication stocks. This involves the medication systems being double-checked on each staff shift change. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 14 Within one of the unit medication stores it was found that shortfalls on the medication administration record charts had been detected and a record of the discrepancies had been entered into the log, however this information had not been communicated any further within the staff team or brought to attention of the manager to be followed up. It is of concern that within the care plan of one person using the service there was records within the ‘daily notes’ section were staff had recorded that this person had received ‘one tablet too many tablets’, that they had ‘ran out’ of stock ‘ and ‘one tablet being missing’. This informed did not appear to have been communicated further as there were no records of the action taken following the discrepancies being noted. During the random visit one of the medication storerooms was found to be excessively hot records of the room temperature was 30 degrees, which is above the recommended temperature for the storage of medication. On this inspection visit there was evidence that the manager had taken action to reduce the temperature within this area by the use of an oscillating fan. Temperature readings of the medication storage refrigerator were seen to be satisfactory. Within the care plans and the medication administration records (Mar) charts there was information on any medication allergies. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 15 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 & 15 Quality in this outcome area is adequate. A greater understanding of how staff actions can influence the ill being and well being of people in their care needs to be know. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One of the people being case tracked was being for in their bedroom due to a risk of a spread of infection. This person had temporary restrictions imposed upon them which resulted in them being confined to their bedroom and unable to socialise with other people using the service. On examination of the daily notes within this persons care file, there was records where staff had recorded that the person had been ‘asking for help non stop wandering around the unit irritating other residents’, of them being ‘very rude to staff’ and being ‘very unsettled in and out of room all afternoon, one of the notes stated that ‘the staff kept telling them to stay in their room but they kept coming out’. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 16 These comments recorded in the daily notes strongly indicate that some of the staff team who are caring for people with dementia do not fully understand the condition of dementia, how behaviour may be influenced by their actions, and the difficulty people living with dementia have in holding on to information. Within the care plan there was little information on how the staff were to meet the social and emotional needs of this person whilst the restriction to engage in group social interactions was imposed. The home employs an activity organiser and there was records of people being generally involved in group activities such as gentle exercises, bingo, reminiscence sessions, attending performances (in house) of visiting entertainment, musicians / singers. Within the care plans viewed there were records of some people being engaged in 1-1 activities. Visiting arrangements are flexible and during the visit the staff were observed to make visitors welcome to the home. People using the service were observed receiving the lunchtime meal, during this time the staff were observed to support people who require feeding with tact and sensitivity. People using the service said they were satisfied with the meals provided and that they have choices in relation to things such as their meals. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. People using the service can be assured that any concerns or complaints they may have will be taken seriously and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Records of complaints were viewed, the Commission for Social Care Inspection had received two anonymous concerns since the last key inspection of 1st February 2008, which were both in relation to inadequate staffing levels at the home. The manager confirmed that one complaint had been received at the home and there were records available to demonstrate that the complaint had been investigated following the homes own complaints procedure. Within the Statement of Purpose and the Service User Guide there was information on the how people using the service or their representatives can raise any concerns or complaints they may have, direct with the provider and the contact details are provided for the Commission for Social Care Inspection and the Ombudsman. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 18 Surveys from relatives identified that they all know how to make a complaint. Training is provided on safeguarding during the staff induction period this training looks at what events constitute abuse and the whistle blowing procedure in reporting abuse. The organisation has demonstrated that they act responsibly in protecting people that use their service and relatives spoken with during the visit had no concerns about how they are treated by staff. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 Quality in this outcome area is excellent. People using the service are provided with a clean and pleasant environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The facility is built over three floors, each floor provides accommodation for twenty people, and comprises of two lounge/diners with small open plan kitchenettes. All bedrooms are single with large en-suite shower facilities. In addition to the en suite facilities each unit has an assisted bathroom, which is spacious and equipped to meet the dependency needs of residents. The bedrooms are comfortably furnished with good quality furnishings and people using the service are encouraged to personalise their rooms. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 20 The home is fully accessible to people with physical disabilities and specialist equipment and adaptations are provided. There is a small secure garden at the front of the building, which has a large patio area with outdoor seating available. A t the time of the inspection all areas of the home viewed appeared clean, it was noted that within the bedroom of a person who was diagnosed of having an infectious disease that staff were using personal protective equipment (PPE) and following cross infection control procedures. Within the laundry area the staff spoken with were familiar with the hygiene and cross infection control measures, and within the kitchen daily food hygiene control systems were in place. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 & 30 Quality in this outcome area is adequate. The staff employed at the home that are dedicated to providing quality care, however the heavy reliance on agency staff can place people using the service at risk of their needs not being fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staffing levels on the day of the visit were satisfactory to meet the needs of the people living at the home. There has been a staff recruitment drive and some new staff had been appointed. The home continues to use a large number of agency staff mainly to act as shift leaders and in discussion with the manager it was established that it is anticipated that in time this position will be filled by staff employed by the company. Two staff recruitment files were sample checked at the random inspection visit and were seen to contain the necessary information to demonstrate that the recruitment procedures was robust. There was evidence of interview records being retained and criminal records bureau (CRB) clearances and references having been obtained. However on this visit the recruitment file of one new staff member could not evidence that character references had been obtained. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 22 Concerns brought to the attention of the Commission for Social Care Inspection (CSCI) in April 2008 were in relation to insufficient staffing levels at the home. The manager confirmed that the staffing situation had been addressed by the company and that staffing levels are maintained to an appropriate level by the use of agency staff. Comments received from surveys sent to people using the service were: • ‘All staff are first class • ‘The kitchen staff do a very good job’ • ‘The home is kept fresh and clean, the domestic staff keep the home in a very good and clean condition’. One person using the service expressed concern about the staffing levels, with the following comment: • ‘Now that the Wellingborough patients have moved back to their refurbished home the staffing levels have been cut. When the vacancies have been filled management have been informed there will be no increase in staff. This will be a concern to all patients’ and staff alike. I think this will put extra-added pressure on staff and patients alike’ There was a mixed response within the surveys received from comments detailed below: • • ‘ It is important that staff have up to date knowledge of all residents in the building. ‘I was thrown in at the deep end I walked into a full 60 bedded new environment on my first shift as night with full responsibility of staff, residents, building, medication etc. There was no member of staff to give me an induction or indeed nobody ever asked. I felt that there was too many teething troubles going on at the time and I was forgotten’. ‘I have had extensive training with Shaw and always willing to train in all areas’. ‘The quality and accuracy of information passed between staff shifts depends on the competency of the staff. We have encountered problems with agency Team Leaders and staff who are not as committed to Sandalwood because they ‘come and go’. The staff are trained to document, record and report verbally. If all staff follows the correct procedures communication will be excellent and service would improve. ‘We have extreme situations that surface; the unit is very unpredictable changes from day to day this particularly with the high level of dementia care. The management are too slow at reassessing individual service users needs and listening to the staff concerns, when floors are seriously and unsafely understaffed. Sandalwood has been open for one year and was traumatic for residents and staff, I feel we have greatly improved the service. The results are DS0000070474.V370237.R01.S.doc Version 5.2 Page 23 • • • • Sandalwood Court • having a quality 24 hr care. We employ some very loyal and supportive staff members that interact extremely well with the people using the service’. ‘The food and diet offered to people using the service is of a high standard and the laundry service has dramatically improved. Working closely with medical professionals is always a priority service at Sandalwood’. Comments in relation to areas where the staff thought the home could do better were: • • • • • • • • • ‘New staff must be fully trained and inducted with close support and guidance and able to feel valued as part of the team’. ‘We need more management support’ ‘Provide more activities to enable residents to have more stimulation and one to one quality time’. ‘Build upon the staffs self esteem within the team to recognise and acknowledge the achievers’ ‘To take action when staff are under performing, which has resulted in poor quality care and team work issues’ ‘Provide team building sessions’ ‘To involve residents and families to build on relationships and rapport’ ‘Provide all the necessary training for staff’ ‘The night staff team runs with 5 five care staff over three floors, if a resident is admitted to hospital at night a member of staff has to escort them. This leaves the night staff team and residents very vulnerable. We have no contingency plan to call for assistance. Provide all the time enough staff on shifts’ the home could give more training on infection control and food hygiene’ • From observations, review of records, discussion with staff during the inspection and review of the comments, which are summarised by those above, it would appear that many of the shortfalls identified during the inspection may be linked to staffing. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 24 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 & 38 Quality in this outcome area is adequate. Through the employment of a permanent manager at Sandalwood Court steps have been taken to improve on the services provided at the home, to ensure that the health, safety and welfare of people using the service is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been in position since May 2008 and an application to register with the Commission for Social Care Inspection (CSCI) is in progress. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 25 Through discussion with the manager and observations made during the visit it was evident that he is engaging with people who use the service, relatives and staff and has plans for making further improvements. Prior to this inspection the Annual Quality Assurance Assessment (AQAA) was sent to the home for completion, and a timescale given for the return of the completed AQAA, however this was not returned within the timescale. The AQAA provides the opportunity for the home to self assess where they meet the outcome areas to identify strengths and areas for further improvement. It is important that this document is completed within the timescales given. The systems in place to protect the financial interests of people using the service were sample checked, money held on behalf of people using the service was stored securely and records of all transactions are retained. It is acknowledged that much work has taken place within the company to ensure that the staff receive training and are fully competent to administer medication and that medication is managed well. However there is still some concern in this outcome area as indicated within the ‘Health and Personal Care’ outcome group that needs to be addressed. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 26 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 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement Medication administration records must be completed accurately. This is to eliminate the likelihood of medication errors, and to ensure that service users receive their medication safely. Timescale for action 30/09/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP30 Good Practice Recommendations Dementia care awareness training should be made available to all staff to ensure that staff are fully aware of how their actions may influence challenging behaviours. Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sandalwood Court DS0000070474.V370237.R01.S.doc Version 5.2 Page 29 - 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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