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Inspection on 08/05/07 for Sanford House Nursing Home

Also see our care home review for Sanford House Nursing Home for more information

This inspection was carried out on 8th May 2007.

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

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

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

What the care home does well

People receive good standards of care. Staff are trained so that they understand what people need and how their specific needs should be met. This includes health care and all aspects of personal care. People are able to take part in activities if they wish and there is a good activities program in place. People feel their choices and preferences are well supported by staff. This includes how and where they wish to spend their day and also about the food they like. People said staff treated them with respect and protected their privacy and dignity.

What has improved since the last inspection?

People now have a much better assessment of their needs before they move into the home. The assessment considers all their needs, including physical, social and emotional needs. This means that people can feel confident staff know and understand about them and how they should be cared for. Staff now receive formal supervision at least 6 times per year. This means they feel well supported and can discuss any concerns they may have in a timely way. Staff have worked hard to try and improve the environment for people and especially those living on the Shannon Unit. Efforts have been made to obtain photographs and other effects to help people find their way about and to their own personal space independently.

What the care home could do better:

Better maintenance is required of the entire external environment so that weeds do not mar the views from people`s bedrooms. Weeds are also beginning to grow again between the paving slabs in the courtyard garden and need to be removed to ensure the risk of trips is reduced. Thought needs to be given to improving storage space so that boxes containing continence wear and pieces of equipment are not stored in bathrooms.

CARE HOMES FOR OLDER PEOPLE Sanford House Nursing Home Danesfort Drive Swanton Road East Dereham Norfolk NR19 2SD Lead Inspector Mrs Geraldine Allen Unannounced Inspection 8th May 2007 09:00 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 Sanford House Nursing Home DS0000015678.V339249.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. Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sanford House Nursing Home Address Danesfort Drive Swanton Road East Dereham Norfolk NR19 2SD 01362 690790 01362 690890 sanford@caringhomes.org 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) Sanford House Limited Mrs Susan Lancaster Care Home 43 Category(ies) of Dementia - over 65 years of age (42), Old age, registration, with number not falling within any other category (42), of places Physical disability (1) Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The home will only receive patients who are not liable to be detained under the Mental Health Act 1983. The home may accommodate one (1) male person with a physical disability, named in the Commission`s records, who is under 65 years of age. The home may accommodate up to forty-two (42) elderly people over the age of 65 years, of either sex, who may or may not have dementia. Maximum number not to exceed forty-three (43). Date of last inspection 8th May 2006 Brief Description of the Service: This home provides care with nursing to a maximum of 43 older people. The home is located on a private driveway close to the centre of the market town of East Dereham. The home was purpose built in 1998 and all accommodation is located on the ground floor. Wheelchair access and car parking are located at the front of the home. The building is divided into 2 units. The Carrick Unit cares for older people plus one person with a physical disability; the Shannon Unit cares for older people with dementia. There is a secure courtyard garden in the centre of the home, with access from some bedrooms. There are shrubs, flower borders and lawn areas to the front of the home. Garden seats and tables are located in the courtyard garden. Mrs Lancaster confirmed that the fee range for the home was between £446 and £650 dependent on needs. Additional charges are listed in the Service user Guide. Prospective residents and their representatives are advised of the fee rates at the time of enquiry and also when assessments and other contacts take place. Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the morning and afternoon of 8th may 2007. Information was obtained from various sources. Before the inspection took place, Mrs Lancaster provided information about the day-to-day running of the home. Questionnaires were sent out by the Commission, however on this occasion only 2 completed questionnaires were returned. During the course of the day, information was obtained by looking at various records and documents. Six people who live at the home and 3 visitors were spoken to in private. Four staff were also spoken to in private. Other residents and staff were spoken to as they were seen. A tour of the premises was undertaken with Mrs Lancaster and observations of practice were made throughout the day. There was evidence that there has been improvement in many areas over the last 10 months and this is down to the hard work of Mrs Lancaster and the staff team. People living at the home spoke about their experiences and felt they were well cared for by staff who were kind and caring. People felt the experience of living in this home was good. The service providers had met the requirement about the environment. Work is in hand to provide people living in the Shannon Unit direct access to a safe and appropriate sensory garden. What the service does well: What has improved since the last inspection? Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 Page 6 People now have a much better assessment of their needs before they move into the home. The assessment considers all their needs, including physical, social and emotional needs. This means that people can feel confident staff know and understand about them and how they should be cared for. Staff now receive formal supervision at least 6 times per year. This means they feel well supported and can discuss any concerns they may have in a timely way. Staff have worked hard to try and improve the environment for people and especially those living on the Shannon Unit. Efforts have been made to obtain photographs and other effects to help people find their way about and to their own personal space independently. 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. Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No person is admitted to the home until a full assessment of their physical, social, emotional and spiritual needs has been completed. This home does not provide intermediate care. EVIDENCE: Previous inspections had highlighted concerns about the standard of assessment being carried out before a person moved into the home. It was not possible to feel confident that all of the person’s needs were understood and therefore met properly. At this inspection, 4 care plans were looked at in detail. These showed that each person had received a pre-admission assessment of his or her needs. The assessment included all aspects of physical, social, emotional and spiritual needs. Each of the assessment documents was dated and signed and there was evidence that the information gathered was used to inform the care plan. There was also evidence seen that information was obtained from other placements and health professionals as Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 Page 9 appropriate. This means that people can feel confident that all their care needs will be met. Sanford House Nursing Home DS0000015678.V339249.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have care plans that are holistic and reflect their individual needs. People have good and timely access to all health care and support services as they need them. The home operates good practice in respect of the control, administration and recording of medicines. People said they were treated with respect and their privacy and dignity was protected. EVIDENCE: A requirement was made at the last inspection about ensuring that all care needs are met. This has been met in full. Four care plans were looked at in detail. These showed that admissions take place only after a thorough assessment of needs has been completed. Each care plan reflected the needs of the individual. Care plans included evidence that the needs of the person were kept under review and the plan changed as it was necessary. There was good practice seen and significant improvement in the care plan information available. Where staff are Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 Page 11 developing their own care plans rather than using the generic templates, information is detailed and very individualised. The biography format is good and where it has been completed gives valuable information about the person and the things that are important to them. All of this information helps to ensure that people receive the right care in the way they prefer. There was evidence seen on each care plan that health care services are used as needed and in a timely way. Good records of GP interventions were seen and these were cross-referred to daily records to ensure all staff were up to date with visits and treatments. Mrs Dymond, Head of Care, discussed the arrangements for the storage, dispensing and recording of medicines. Good practice was seen. For example care plans were in place that gave important information to staff about when it was appropriate to give medicines that should not be given routinely. The controlled medicines were kept properly and good records were seen. The medicine fridge was locked and the daily record of temperatures showed that the fridge was operating within range and medicines kept in prime condition. Staff were observed during the day. Interaction between staff and residents was good and appropriate. People were being treated with dignity and respect. Personal care was being provided discreetly. Sanford House Nursing Home DS0000015678.V339249.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at the home can access a wide range of activities and occupations within the home and are supported by staff to do so. Visitors are welcomed at any time. People said they felt they could make choices around their daily living and staff would respect these. People said they enjoyed their meals. There was a good and varied choice menu available and meals appeared nutritious. EVIDENCE: Two requirements were made at the last inspection about keeping good records of activities and also access to a safe garden. The first requirement has been met but the second has not and has been repeated. There were a lot of photographs displayed in the entrance hall showing residents and staff engaged in very varied activities and fund raising. Information was also displayed on a resident’s notice board about resident meetings and local services available. Details of visiting entertainers and other activities were displayed on a notice board by the front door. Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 Page 13 The activities co-ordinator was seen engaged in group activities in the morning and afternoon. During the morning, people were happily engrossed in craftwork, and in the afternoon they were playing bingo. Both activities were well attended. The opportunity was taken to speak with the activity coordinator. She described the wide range of activities that take place. A record is kept for each person, detailing the activities they have taken part in and enjoyed, including 1-1 sessions such as nail painting or hand massage. She also described some of the meaningful occupation that takes place including cooking, dusting and wiping down tables. Care staff undertake activity with residents when the co-ordinator is not at the home. In total, 6 residents were spoken to in detail about their experiences of living at the home. They were all happy and felt the staff cared for them well. They enjoyed the food and the variety on offer. One resident was very pleased with her room, although the aspect from her window was less than pleasant as it was overgrown with nettles and cow parsley. People said staff were always about and always spoke to them politely and respectfully. People said they would speak to Mrs Lancaster or one of the staff if they had any concerns or worries. People said that staff respected their wishes and the choices they make around daily living. Three relatives were spoken with during the day. The visitors said they were happy with the care provided and said staff were pleasant and anxious to please. They all said staff made them feel welcome. However, 2 said they felt the language skills of some of the overseas staff was a problem at times. Two visitors were not aware of the complaints procedure. The cook was spoken with during the day. She described the meals available for the day of inspection and there was a good range of choices including cottage pie, vegetable quiche and cottage pie made with quorn mince for vegetarians. Several people had soft diets and diabetic diets were also catered for. The cook described one person who preferred to eat her main meal in the evening rather than at lunch time and how she ensures this preference is always met. Certificates about food hygiene were displayed in the dining room. Lunchtime was observed on both units. There were plenty of staff available to assist people. Staff sat beside each person and spoke with him or her as they were giving assistance. The components for those having soft diets were served separately so that people could distinguish what they were eating. People spoken to said they enjoyed their meals and were aware of the choices available each day. People also said they could eat their meal where they wished. Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Most people who use the service were aware of the complaints procedure. This is displayed in the entrance hall. People said they were confident the manager would deal with their concerns. The home operates good recruitment practices that help to protect people from abuse. Staff are trained about abuse awareness. EVIDENCE: The complaints procedure was displayed in the entrance hall and was also contained within the Service User Guide and Statement of Purpose. Some visitors said they were not aware of the complaints procedure but felt they could speak with Mrs Lancaster or any member of staff if they had concerns. The complaints records were seen and the investigation into the last complaint was looked at. This was well recorded and showed that a response was made well within the 28 day time period. The response had been appropriate. Details about advocacy services were clearly displayed on the resident’s notice board. This is good practice as it helps people to seek support and advice if they need it. Staff files showed that the manager operates a good recruitment procedure that helps to safeguard residents. All staff are subject to a Criminal Records Bureau disclosure. Staff have received training about abuse awareness and Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 Page 15 had a good understanding of abuse issues. Practice was observed throughout the day and was appropriate and supportive. Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The internal environment is well maintained although there needs to be an improvement in the storage facilities so that communal areas are not used for this purpose. All areas of the home were clean and tidy and there were no unpleasant odours. The external environment is under development, with access to additional space being arranged at the time of this inspection. EVIDENCE: Two requirements were made at the last inspection. There were about improving the signage on the Shannon Unit so people could find their way about independently and also about the laundry room. Both requirements have been met. A tour of the premises was undertaken with Mrs Lancaster. All areas of the home were in a good state of décor although the corridor carpets were looking faded and stained in places. Mrs Lancaster confirmed that the carpets were Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 Page 17 scheduled to be replaced. Good signage was seen to all communal rooms. The dining room in Carrick Unit was attractively laid ready for lunch. Real efforts have been made to aid orientation and personalisation of personal space on the Shannon Unit. Picture frames are now fixed to the wall by each bedroom door. At the time of inspection, most did not contain any photographs and the relatives of residents had been asked to supply these. Once these photographs have been provided, they will give each person a visual clue to the location of their room and help them to find their way about independently. Bathrooms now have pictures on the walls and also some artwork completed by the activities organiser and residents. There continues to be a problem with the storage of continence wear and hoists, with the bathrooms being used for this purpose. The need to obtain another shed to store continence wear was discussed as a possible solution to the storage problems. Until this is resolved, bathing will not be a pleasant and enjoyable experience for people Lounges were domestic in style and the lounge on the Shannon Unit also contained photographs that would be of interest and provide a talking point for people living on that unit. An area of garden to the rear of the home has now been enclosed and it is intended this will be developed into a sensory garden for people in the Shannon Unit. French doors were due to be fitted to the dining room later in the week of inspection to allow easy access to this garden. The compliance date for the provision of accessible outdoor space was August 2006 and it is disappointing to note that this work has still not been completed. All residents can access the courtyard garden. Weeds were growing between the paving slabs and need to be removed to ensure trip hazards are reduced. Other parts of the garden need attention, especially around the sides. The view from one bedroom was of overgrown nettles and cow parsley. The resident prefers to spend her day in her room and is unable to enjoy attractive aspects from her window. The laundry room was well-organised and contained industrial washers and dryers. There is also now access to an external area, where washing lines are due to be put up shortly. On the day of inspection, the home was clean and free of unpleasant odours. Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff are employed to ensure that all people’s needs can be met effectively. Staff receive training that is relevant to their role. The home operates a robust recruitment process. EVIDENCE: A staff rota was provided prior to the inspection. This shows that 2 nurses and 6 care staff are employed between 0800 – 1400, 2 nurses and 5 care staff between 1400 – 2000 and 1 nurse and 3 care staff between 2000 – 0800. These levels do not include Mrs Lancaster and were the levels in evidence on the day of inspection. In addition, the home employs ancillary staff and an administrator. This means that sufficient staff are available to support and assist people when they need it. Three staff files were looked at in detail. In each case, good recruitment practice was in evidence. Each had completed an application form and 2 written references. Interview notes were also seen on each file. Good recruitment practices help to safeguard people who use the service from abuse. There was evidence that an overseas appointed carer had completed an English Skills Program. Mrs Lancaster said that all staff from overseas are expected to speak English at all times. She said that those staff for whom English is not their first Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 Page 19 language are attending a Norwich City College course that is being conducted at the home. Some people expressed concerns about language difficulties but there was evidence that the home is trying to ensure language difficulties are resolved so that there is good communication between residents and staff. Staff training profiles were seen and these showed all training undertaken by each staff member. This includes induction training. There was evidence seen that the training undertaken by staff reflects the needs of the people living at the home and helps staff to provide good standards of care. For example, Mrs Lancaster said that 16 staff were currently doing a Certificate in Dementia Awareness through the Otley College. Staff also said there were plenty of training opportunities available although 1 person said more in-depth training about dementia care would be good. The service provider has a regional trainer for the Eastern region homes who is based in Ipswich. It is this person’s role to undertake training audits, provide training and to flag up training opportunities that may be of relevance to each staff group. Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is experienced and competent to carry out her role. There is a quality assurance process in place that seeks the views of all people who use the service. There are good practices in place around the control and recording of people’s personal allowances and valuables. Staff receive formal supervision at least 6 times per year. The home operates good health and safety practices and keeps good records. EVIDENCE: A requirement was made at the last inspection about staff supervision. This has been met. Mrs Lancaster has been the manager at this home for some years and is competent and appropriately qualified to fulfil her role. Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 Page 21 The last questionnaires for the quality assurance process were sent out to residents, relatives, advocates, staff and stakeholders very recently. Some had already been returned and the raw data was looked at. Positive comments about the service were seen. Mrs Lancaster said the questionnaires would be sent to head office where the information will be collated, a report written and an action plan for the home developed. This will ensure that the service continually improves and responds to the views of people using the service. A copy of this report and action plan will be sent to CSCI. Staff supervision is now taking place regularly and has done so since October 2006. The supervision process is formalised and uses company documentation to record each supervision event. The supervision records were seen and demonstrated increased frequency of supervision where there are performance concerns. Staff confirmed they are receiving supervision every 8 weeks. This ensures that staff are well supported to carry out their roles. The arrangements for resident’s personal allowances were looked at with the administrator. Good records were seen. The money held for 1 person was checked randomly against the records held and this was correct. There was evidence that the monies held are checked periodically. All receipts were kept for transactions made on behalf of the resident. This meant that people are protected from possible financial abuse. Various health and safety records were looked at, including Control Of Substances Hazardous to Health (COSHH), fire and accident records. The COSHH folder included risk assessments and data sheets. There was evidence that these had recently been reviewed and updated. The fire records showed that maintenance and training are up to date. Different call points are used each week when the alarms are tested. The accident records were seen and cross checked to resident’s files. There was evidence of good practice. The records were completed in full and the information duplicated within the care plan and daily records. This provided evidence that people are cared for in a safe environment. Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 2 X X 3 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 3 X 3 3 X 3 Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 Page 23 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 OP20 Regulation 23(2)(o) Requirement People in the Shannon Unit must have access to a sensory garden that is safe and offers enjoyable experiences. This should be easily accessible so that people can access it independently. Timescale for action 31/08/07 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. 2 3. 4. 5. Refer to Standard OP7 OP16 OP19 OP19 OP21 Good Practice Recommendations It is recommended that staff write care plans rather than use the generic templates so that each care plan is individualised and specific to the person’s needs. It is recommended that consideration is given to making the complaints procedure more visible so that all people know where it can be found. It is recommended that weeds between paving slabs in the courtyard garden are removed. It is recommended that attention is given to all parts of the garden so that people can enjoy pleasant views from their bedroom windows. It is recommended that alternative storage space is DS0000015678.V339249.R01.S.doc Version 5.2 Page 24 Sanford House Nursing Home provided so that people can enjoy a bath without being surrounded by packing boxes and pieces of equipment. Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Sanford House Nursing Home DS0000015678.V339249.R01.S.doc Version 5.2 Page 26 - 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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