Inspection on 14/08/07 for Sandridge House Nursing Home

This inspection was carried out on 14th August 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.

Other inspections for this house

Sandridge House Nursing Home 14/08/08

Sandridge House Nursing Home 23/05/06

Sandridge House Nursing Home 13/10/05

Sandridge House Nursing Home 19/04/05

Sandridge House Nursing Home 16/11/04

Sandridge House Nursing Home 19/08/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sandridge House Nursing Home London Road Ascot Berkshire SL5 8DQ Lead Inspector Sally Hall Unannounced Inspection 14th August 2007 08:45 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 Sandridge House Nursing Home DS0000011014.V339933.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. Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sandridge House Nursing Home Address London Road Ascot Berkshire SL5 8DQ 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) 01344 624404 01344 874474 sandridgehouse@btconnect.com Amberbrook Limited Mrs Gillian May Elston Care Home 38 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (38) of places Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 2 (two) service users within the overall registered numbers can be between the ages of 60 - 65 years. 23rd May 2006 Date of last inspection Brief Description of the Service: Sandridge house is owned and managed by Amberbrook management Ltd, a private company, who are registered to provide nursing care for up to 38 older people. The property is a large old prestigious Victorian building that is situated in a prime location near to Ascot racecourse. Heatherwood Hospital and the premises of the primary care trust are also in the immediate vicinity. The home is clearly signposted and there is space for car parking on the site. Ascot village is close by and there is access to public transport. The fees range is from £495 to £595 per week currently but is dependent on the assessed level of care needs for each individual service user. Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection at Sandridge House took place on the 14th August 2007, starting at 8.45am. The lead inspector was Sally Hall. On the day of the inspection the inspector agreed and explained the inspection process with the registered manager. Time was spent reading a sample of care plans, assessments and records kept within the home. Staff and service users were spoken with and a tour of premises was undertaken. The focus of the inspection was to assess Sandridge House in accordance with the National Minimum Standards for Older People. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. An observational tool, SOFI (Short Observational Framework for Inspection), was also used to capture the experience of the older people living in the care home, particularly focusing on service users with dementia. The home was asked to complete an AQAA (Annual Quality Assurance Assessment). This, plus the surveys that were returned from service users, their families and other health professionals before this inspection, also form part of the evidence used in this report. What the service does well: What has improved since the last inspection? Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 6 The home has improved its assessment of needs for all service users. The care plans have also improved and are signed by the service users or family members to show that they agree with the care to be provided. A bathroom has been refurbished and others will now follow. However, it has been suggested that the decor should be more homely as the first bathroom looks very clinical. What they could do better: The staff should endeavour to communicate with all of the service users no matter how limited each service user’s ability to communicate might be. Service users should be encouraged to stay in control of their lives through choices being offered by staff whenever possible. Evidence was seen that even basic choices, such as whether service users wanted to go to the toilet or move to the dining room for lunch were not always offered to service users by staff. This type of approach by staff tended to undermine service users’ privacy and dignity and created an impression that the staff were task orientated rather than trying to meet the individual needs of service users. One service user surveyed commented ‘some staff don’t understand that some days my condition means I am better than others. Some days I do need more help’. The daily records maintained by the home sometimes lacked detail and in some cases did not always cross reference with service users’ care plans. The records also showed the times they were written up rather than the times actual events occurred. Given that the daily records should be regarded as contemporaneous notes it is recommended that this be done when the event occurred and the pages of the records should be numbered. Whilst care plans are reviewed monthly any changes/updates should be properly recorded and not written down as additional entries within the existing documentation. The management and outcomes of complaints should always be fully documented. The need to store wheelchairs and hoists in the service users’ lounge should be reviewed by the home. The lunchtime menus in terms of the range of meals offered should be reviewed to ensure that they fully reflect the preferences and choices of the service users and staff should ensure that service users are informed of what is on the menu and what choices are available to them. When soup is served it should be served in dishes/containers that are appropriate and suitable for each individual service user taking into account their particular needs and abilities. Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sandridge House Nursing Home DS0000011014.V339933.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 Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that their needs will be fully assessed prior to their admission and that the staff at the home will be capable of meeting those needs. EVIDENCE: Eight pre-admission assessments were viewed. The assessments seen were comprehensive and supplied the information required to make a judgement as to whether the home would be able to meet each service user’s needs. The manager confirmed that currently she assesses all potential service users and makes the decision whether to offer a placement on a trial basis. The home does not provide intermediate care. Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users can feel confident that their health, personal and social needs will be detailed within a care plan and that they will be enabled to access external health care. Service users cannot always be confident that they will always be treated respectfully by staff because on occasion the tasks and routines undertaken by staff appear to take precedence over communicating effectively with service users as to how those tasks and routines are being carried out. EVIDENCE: The service users’ care plans seen were good and very comprehensive. They included a risk management and it was apparent that service users or their family had signed to say that this was the care provision to which they had agreed. Care plans are reviewed by the nurses on a monthly basis. Whilst the outcomes of the reviews noted, examples were seen when such outcomes were written seemingly as notes within existing care plan documentation Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 11 rather than being more properly recorded. There is an attendant risk to this approach that information could get lost or overlooked. It was also noted that new assessments were not being reviewed six-monthly or before if there was a change in a service user’s needs. The daily records were, in some cases, informative but many lacked detail of the actual care provided and did not always cross-reference well with service users’ care plans. The records also showed the times they were written rather than the times actual events occurred. Given that the daily records should be regarded as contemporaneous notes it is recommended that this be done when the event occurred and the pages of the records should be numbered. During a SOFI (Short Observational Framework for Inspection) observation it was evidenced that a number of staff did not appear to have the skills or confidence to communicate with service users with dementia. It was also evidenced that some communication witnessed between a number of staff and other service users who did not have dementia was heard to be inappropriate and showed a lack of respect for service users’ privacy and dignity. The evidence suggested that the staff were not deliberately intending to engage in inappropriate forms of communication with service users but rather were engaging in forms of habitualised behaviour which, it was subsequently agreed with the manager, needed to become a focus of future staff training. Much evidence was seen which indicated that a range of health professionals regularly visited the service users at the home. These included chiropodists and physiotherapists. It was also evident that the GP’s regularly review service users’ medication. At the time of the inspection the medication trolley and cupboard were situated in a busy entrance hall. Although the storage of medication was secure it was recommended that the siting of it be reviewed. An audit of medication was undertaken and it concurred with the documentation. The home does not have a dosage system in place and administers the medication from the original containers sent from the pharmacy. The controlled medication is kept in a suitable locked cupboard within a locked cupboard. The manager confirmed via the AQAA (Annual Quality Assurance Assessment) that medication audits are carried out and that the documentation regarding ordering and receipt of drugs had recently been improved. Weekly audits of the medication charts enable any omissions not accounted for to be highlighted and the relevant nurse informed. This has led to much improved medication administration. Pharmaceutical advice is sought when required and a good relationship has been built up with the home’s pharmacist who will offer advice when required. The pharmacist has also provided training to staff. Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users can feel confident that there are activities available on a regular basis through the week and that family and friends will be made welcome when they visit. Service users cannot be fully confident that they will be encouraged by staff to stay in control of their lives. Service users cannot always feel confident that they will be offered appropriate choices at mealtimes. EVIDENCE: There is a range of activities offered in the home, with two activities co-ordinators employed to facilitate these. Examples of the activities offered include craftwork, sing along, soft exercise and games. The record of activities was in the form of boxes which were completed daily by using codes. These did not really convey the nature of the activities being offered or describe the outcomes for service users. Also, items like watching TV or listening to the radio did not appear to be something that was chosen purposefully by the Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 13 service users themselves but were offered because there was little else for service users to do. One activity observed on the day seemed to exclude service users with dementia. However, the manager confirmed that one activity co-ordinator was just starting a course which should give the co-ordinator the skills to communicate more effectively and better understand the needs of people suffering with dementia. It has been recognised by the home that not all service users benefit from group activities and the activity co-ordinators do spend time with those particular service users on a one-to-one basis. Outings are arranged periodically and a trip had been arranged to the coast on the day of inspection. However, the weather was so bad it had to be cancelled. A number of relatives were seen in the home during the day. One spoken to said that she is always made to feel welcome whenever she arrives. Messages received from relatives over the phone were passed on to service users and examples of these were heard. The menus seen covered a six-week period. The cook confirmed that much of the food offered is home cooked from fresh ingredients. However, it was noted that the choice for the main meal at lunchtime appeared to be limited to two main choices, one of which was a vegetable pasta bake. Service users spoken to said that they were asked what they wanted but, as one said, “I like a dinner at dinner time not a meal like a bowl of pasta”. Although service users had been asked what they wanted for lunch, on the day every one had sausage and mash with onion gravy. Staff did not ask service users what vegetables they wanted to go with the meal. The lunch meal began with soup and this was given out in plastic beakers with handles suitable for people with a disability which affects their hands. Most of the service users were more than capable of taking the soup from a bowl in the normal way. Staff did not inform the service users what flavour the soup of the day was. As has been evidenced previously staff on occasion were working to routines in which communication with service users was overlooked by them. The tables had been set for lunch with place mats and cutlery and no condiments or sauces were on the tables for use by service users. The service users questioned the quality of the sausages served at the meal. They commented that they were very sticky, and not very meaty. The cook later confirmed that these were a butcher’s own sausage. The sponge for pudding was homemade and was received well by the service users and was very nice. The cook caters for special diets when needed. She said that she always tries to ensure that the service users who, for example, suffer with diabetes have the same meals as the other service users. For this reason the custard is made with sweeteners rather than sugar. Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 14 Staff were seen feeding a number of service users who could not manage to eat for themselves. They sat beside the service users and were seen to be patient with those service users who found it difficult to eat. In only one case was it seen that a member of staff asked the service user if they liked what was being fed to them. The observations done via SOFI and during lunch showed that the staff give the service users little opportunity to stay in control of their lives through being offered choices whenever possible. It is acknowledged that there can be particular difficulties in maintaining effective communication with those suffering with dementia, but the observations made suggest that staff are perhaps not trying to communicate with service users as well as they should. It was also observed that for those service users who did not suffer with dementia they too were often only offered limited choices since staff were seen telling them rather than asking service users what they wanted to do. Sandridge House Nursing Home DS0000011014.V339933.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): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst service users can be confident that their complaints will be taken seriously the home needs to ensure that full documentation is maintained as to the management and outcomes of the complaints for the protection of the service users and the staff of the home. Service users are being protected by the home’s commitment via staff training to POVA and to following the local authority’s safeguarding adults protocols. EVIDENCE: The home’s complaints record was seen. Complaints are currently recorded in a dedicated hard-backed book. The inspector was informed that it did not confirm the outcomes of the complaints in writing and all communications regarding complaints was done on a face-to-face basis or over the telephone. The manager was advised that it would be better that the management and outcomes of complaints should be more fully documented so that in the event of any future dispute about the way any particular complaint was handled then there would be a proper record to refer to. The complaints procedure is in the service user guide which is given out to all service users and their families. The manager confirmed that they adhere to the local authority safeguarding adults protocols. She also confirmed that this is kept current as they Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 16 download updates from the Internet. It was difficult to assess whether all staff had POVA training because the training record system lacked clarity. However, the staff records looked at showed that most staff had undertaken this training and the manager confirmed that those who had not had been were booked on suitable courses. The manager was aware that this training is required for all staff every three years. Sandridge House Nursing Home DS0000011014.V339933.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): 19, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a safe, clean and hygienic home which will be greatly improved when the refurbishment, including new furniture, has been completed. EVIDENCE: A tour of the building was undertaken. The home is a large period house that has various levels. There is a passenger lift and a stairlift but not all areas are available for those with a mobility problem. The manager explained that they have a motorised wheel chair, a stairmatic, if these break down. Many of the period features have been preserved, but some areas are looking tired and in need of decoration. Bathrooms are being refurbished. The first one to be completed was seen and it had new equipment but looked very cold and clinical and lacked a homely feel. Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 18 The laundry is situated in an outbuilding at the end of the drive. There are two washing machines. One has a sluice facility, and the red sack system is used in the home for soiled linen to ensure that it is handled as little as possible. There are also two tumble dryers and all the laundry is done within the home. One family member commented via the survey that she found the laundry a problem at times when not all the right items are put in her mother’s bedroom. However, the laundry seen that was ready to be put in the rooms was mostly labelled. The laundry lady did say that staff time was limited for attaching labels, but every effort is made to ensure that each service user gets their own items returned. The main lounge, as well being the sitting area for service users, has become a storage area for wheelchairs and hoists. The manager explained that there is a plan to divide a section of the lounge off and put a curtain up though this would restrict available space and cut out some light. It was also planned that the hairdresser would use the section behind the curtain though the inspector challenged the appropriateness of the proposed arrangement. The chairs in the lounge were too close together, making it difficult to help service users out of the chairs or to lift service users in the hoists. The lounge has had new curtains and décor. The conservatory that is also used as a lounge was cold, but being August the heating was not on and on the day of the inspection the weather was unseasonably cold. There were no offensive odours throughout the home and this reflected well on the committed domestic staff team. Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can be confident that they are protected by the home’s recruitment procedure, and that there will be staff in sufficient numbers and with the skills to meet their care needs. EVIDENCE: The home employs 23 care staff and of these 11 have gained their NVQ (National Vocational Qualification) Level 2 award. The manager confirmed that there are a further four staff starting the award. The training records in the home are kept on an individual basis and it was therefore difficult to see at a glance who had done what training. The manager has devised a chart for the wall in her office which shows the courses staff need to be booked on this year for training, but it did not give the dates. In the files looked at most staff had undertaken many of the required courses. Specialised training such as stroke awareness, deafness, challenging behaviour and dementia, for example, are being made available to ensure that staff have the skills and understanding to meet the needs of the service users at the home. Nurses also receive training to ensure that their qualifications are kept up to date. Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 20 Induction follows the Skills for Care induction programme. The manager and her deputy undertake part of the training themselves and they are trained, for example, in training for manual handling. Other training such as food hygiene is done by outside trainers. The rota was seen for the previous and current week. Concern was voiced at the number of long days that some staff are doing on a regular basis. The manager confirmed that they are continuing to recruit staff and that two nurses were starting the following week. Staff files were seen at random for six people who had been recruited in the last year. Each file contained application forms, a POVA first check and had had CRB checks sent for if these had not already been returned. References were seen but it was noted that these were not always from the last employer and some opportunities were missed by not sending for two work references when the person had worked in the care field previously. The files also included a summary of the interview, and ID. However, not all files contained photos and the manager confirmed that these had been asked for along with copies of the signed contracts. Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users cannot be confident that the home will be run in their best interests at all times. EVIDENCE: The manager came to the home with a wealth of experience in managing a previous nursing home and has gained the RGN, BSC and RMA, and is an NVQ assessor. The manager at this home also runs a second home. She has a deputy manager in each to support her in the running of the homes. Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 22 Concerns were raised with the manager about whether the home is being run in the best interests of the service users, given that very little choice was seen to be given to the service users during the inspection process. The staff appear to be very task orientated, and the importance was about the physical care rather than the social and psychological care. The manager has been working hard to improve things at the home and she was able to explain problems that she has encountered. The institutional approach of some of the staff was identified in the last report, and needs to be seen as a priority. The quality of care varies from staff to staff, and mainly it is about the staff who are not communicating with service users appropriately and need further training. The surveys sent out to service users and families by the Commission were generally positive about the care that they receive, and all families said that they were kept informed about their relatives. The COSHH (Chemicals or Substances Harmful to Health) file was seen. The manager said that it is kept up to date, with new items being added as they came into the home. Staff are made aware of the file during their induction training. The fire log is completed by the handyman and showed that the alarms are tested weekly. Documents were not seen for the emergency lighting and fire extinguishers, as these were with the handyman, but the manager confirmed that they are done regularly. The building risk assessment was not seen for the whole building, as the manager could not locate it all, having completed the task recently. Generic assessments were seen for the events that happen daily, such as hoovering. There was also one for the laundry. The policies and procedures are available and have been reviewed in the last year according to the AQAA (Annual Quality Assurance Assessment). The home’s accident book was seen, and staff are having health and safety training and other related courses. Those who have not had the training are booked on courses before the end of the year. Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 23 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 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 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 2 X X X X 3 Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 24 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 OP10 Regulation 12(4)(a) Requirement The registered manager must provide further instruction and training for staff to prevent any service users’ dignity, respect and privacy being compromised, specifically in relation to the approach of staff when attending to service users in their rooms, the lounge and at Mealtimes. Timescale for action 30/09/07 2. OP12 16 (2)(n) 30/09/07 The registered manager must review the range and frequency of activities for service users with a significant memory problem and then implement an appropriate activities programme to ensure that such service users’ social and psychological needs are fully met. Also review the way activities are recorded to include the outcomes for individual service users. Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 25 3. OP15 12(1)(a) and 17(2) The registered manager must ensure that systems are developed to ensure that food and drink is presented to service users so as to meet their individual needs and abilities, and protect their dignity whilst offering a real choice. The registered person must ensure that there is a simple, clear procedure for recording complaints that meets the legal requirements of data protection, and includes follow up confirmation in writing within the timescales for the process. The registered person shall so far as practical enable service users to make decisions with respect to the care they are to receive and their health and welfare. The registered person shall make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users. 30/09/07 4 OP16 17(2) schedule 4 30/09/07 5 OP33 12 (2)(4)(a) 30/09/07 Sandridge House Nursing Home DS0000011014.V339933.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. 1. Refer to Standard OP7 Good Practice Recommendations That daily records need to show the care provision and events pertaining to each service user as individual and reflect the service user’s care plan. The entries should also show the time of events, not the time the staff wrote the entries. All pages should be numbered. Consideration should be given to including activities in the lounge with service users with significant memory problems (dementia) to assist them to engage in organised activities. 2. OP12 Sandridge House Nursing Home DS0000011014.V339933.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Sandridge House Nursing Home DS0000011014.V339933.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. 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