Inspection on 04/09/07 for Saxonwood

This inspection was carried out on 4th September 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

Saxonwood 15/01/09

Saxonwood 04/09/06

Saxonwood 01/11/05

Saxonwood 31/05/05

Saxonwood 14/12/04

Saxonwood 13/07/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Saxonwood Saxonwood Road Battle East Sussex TN33 0EY Lead Inspector Sally Gill Key Unannounced Inspection 09:30 4 September 2007 th 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 Saxonwood DS0000021203.V345913.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. Saxonwood DS0000021203.V345913.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Saxonwood Address Saxonwood Road Battle East Sussex TN33 0EY 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) 01424 774336 01424 774336 aclemen@btconnect.com www.sxhousing.org.uk Sussex Housing and Care Angela Sims Clements Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Saxonwood DS0000021203.V345913.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users must be older people aged sixty-five (65) years or over on admission. That the maximum number of service users to be accommodated will not exceed thirty-six (36). 4th September 2006 Date of last inspection Brief Description of the Service: Saxonwood is registered to provide accommodation for up to 36 older people and admits residents with low to medium dependencies. It is owned by a housing association, Sussex Housing and Care. Mrs Angela Sims Clements is the registered manager and has day-to-day responsibility for the home. The premise is a detached property situated in a quiet cul de sac in Battle. There are 36 single bedrooms situated on three floors. There are two shaft lifts to enable access to all floors. Eighteen bedrooms have ensuite facilities and 18 have a wash hand basin. There are four bathrooms one of which is assisted and another has a shower. The home has a large dining room, lounge with views across the gardens and activities room. The home is non-smoking. There are 3.5 acres of garden which are well maintained, accessible to residents and include lawns with some bench seating, established borders, a fish pond, patio area with seating, greenhouses, vegetable patches and fruit trees. There is a good-sized car park to the rear of the property. The home is situated within walking distance of the town centre, its shops and access to bus and rail routes. The staffing compliment consists of the manager, carers and ancillary staff. There is two staff on a wake night duty. The fees range from £340 - £533 per week. Additional charges are made for hairdressing, newspaper/magazines, telephone, transport and chiropody. Previous inspection reports are available from the Provider or can be viewed and downloaded from www.csci.gov.uk Saxonwood DS0000021203.V345913.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was carried out over a period of time and concluded with an unannounced visit to the home between 9.30am and 4.40pm. The registered manager assisted throughout. Residents and staff were spoken to. Observations included interactions between residents and staff. Thirty-three people were living at the home on the day of the visit with three vacancies. Surveys were sent to the home to distribute to residents, relatives and professionals. Feedback was received from residents, on the whole was very positive regarding the home although there was some concern was raised about confidence in the higher management of the organisation. The care of three residents was tracked to gain evidence. Various records were viewed during the inspection and a tour of parts of the home undertaken including the communal areas, some bedrooms, a bathroom, the laundry, managers and duty office and garden. The Annual Quality Assurance Assessment (AQAA) was returned within timescales. Information was adequate and parts were discussed during the visit. Information supplied has been used in this report. What the service does well: The atmosphere at Saxonwood is relaxed and a real community spirit amongst some of the residents. Residents confirmed they are very happy living at Saxonwood and with the care they receive. Comments included “can’t complain at all”, “it’s a very nice home”, “when you ring the bell they come even at night”, “they are very good to me”, “the girls work very hard”, “I like it very much, the atmosphere is friendly”, “staff are kind and helpful”, “its a wonderful place”, “can’t speak highly enough of the girls”, “X (key worker) is absolutely wonderful”, “it’s a happy home”, “everybody is very kind”, “Angela (manager) is very good” and “if you complain they sort it out”. Relative’s comments were on the whole very positive. Comments included ‘I am a X and have cause to visit numerous homes in the course of my job. I would have no hesitation in recommending Saxonwood’, ‘health care seems to achieve high standards’, ‘generally good all round, difficult to fault’ and ‘I am very satisfied with the care’. Residents are involved in the running of the home. They help organise the activities and the library facilities. They are encouraged to join in although privacy is respected when they want to spend time alone. Saxonwood DS0000021203.V345913.R01.S.doc Version 5.2 Page 6 There is real choice about where you can have your meals. Mealtimes were a relaxed and sociable time. There is an emphasis on home cooking with good food and choice. The home is well maintained, comfortable and homely. The lounge has views across the gardens, which are well kept. Staff are committed to providing good care which was confirmed by very good comments from residents, good interactions were also observed with the use of good humour. Staff feel well supported and say the manager listens. What has improved since the last inspection? What they could do better: The skills of staff should be checked regularly and records maintained. All staff must be trained in adult protection and aware of the routes of reporting abuse both inside and outside of the home to fully protect residents. A review of staffing levels must be undertaken and minimum staffing agreed and implemented at all times. Records relating to residents must be individual to maintain confidentiality. Saxonwood DS0000021203.V345913.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. Saxonwood DS0000021203.V345913.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 Saxonwood DS0000021203.V345913.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): 1, 2, 3, 4, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information needed to choose a home, which will meet their needs. EVIDENCE: The home has a statement of purpose and service user guide in place. Both documents were reviewed in July 2007. The manager advised that copies are given to prospective residents and also held in the lounge and dining room of the home. A resident confirmed that they felt they had sufficient information about the home prior to moving in. Residents confirmed that they had been able to visit the home, view their room and meet the staff and residents prior to moving in. Saxonwood DS0000021203.V345913.R01.S.doc Version 5.2 Page 10 Residents confirmed that they have agreements in place with the home and are advised by letter of increases in fees. Last fee increase was April 2007. Staff undertake a needs assessment prior to admission. Assessments are thorough and used to develop a care plan. The manager advised that where residents are funded by social services a copy of their assessment is obtained. Intermediate care is not offered by this home. Saxonwood DS0000021203.V345913.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care, which a resident receives, is based on their individual need. The principles of respect, dignity and privacy are put into practice. Residents could be better protected if regular checks are carried out on staff that administer medications. EVIDENCE: A care plan is in place for each resident. These are detailed and cover all aspects of residents care. Resident confirmed that their key worker reviews these regularly with them. However care plans could be more person centred rather than talk about the resident. Staff maintain good records in relation to residents health but there is a lack of evidence monitoring social care/needs. Reports should reflect care needs as identify in the care plan. Care plans contain risk assessments in relation to tissue viability, medication, manual handling and nutrition. Saxonwood DS0000021203.V345913.R01.S.doc Version 5.2 Page 12 Falls are monitored on a monthly basis. Records and discussions with residents confirmed that the health needs of residents are well met. Resident’s are encouraged to attend appointments outside of the home where possible and home visits arranged when needed. One resident discussed a recent visit by the Physiotherapist and equipment now on order to aid independence. Equipment is in place to aid tissue viability. Advice and guidance is sought from the continence nurse. A chiropodist visits the home every six weeks. The medication systems were examined. The policy has been re-written by and outside organisation that have also conducted an audit of medication. Four recommendations were made and all have been implemented. The home has obtained an up to date BNF. Medication Administration Records (MAR) charts was appropriately kept with the use of signatures and codes. Medication is logged into the home and there is also an audit of medicines given to residents for self-administration. Risk assessments are in place for the four residents that self-administer and those that part self-administer. Medication is supplied in blister packs. Staff that administer medication have received training. Although some competency checks are carried out these have not been evidenced. Therefore this requirement remains outstanding. Residents confirmed that staff always treat them with respect and ensure privacy and dignity is upheld. One relative said ‘they treat my x as an individual’. Good interactions between residents and staff were observed during the visit with plenty of good humour. Saxonwood DS0000021203.V345913.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to a variety of social and recreational activities or can choose to spend time alone. Residents enjoy a healthy and varied diet with an emphasis on home cooking in pleasant surroundings. EVIDENCE: Nine residents are able to come and go as they please and access the local community, which they do. Some residents rely on families to take them out and about. The mini bus has been upgraded and is used to drive residents out and about stopping for tea etc. Residents confirmed that ‘there is plenty to do and enjoy for those who are active and willing to participate’. However one said ‘sometimes I get a little bored and it might be nice to have some more activities such as bingo, quizzes and music etc.’ This was also echoed by a relative who also thought ‘perhaps a gentle exercise group’ would be good. There is an activities group twice a week, which is evidently a very social affair and residents could not praise highly enough the staff member that helps organise the group. Activities Saxonwood DS0000021203.V345913.R01.S.doc Version 5.2 Page 14 include quizzes, arts and crafts, reading and writing. A staff member organises a pantomime each year and a resident organises music afternoons. Bookshelves are well stocked and a resident is responsible for changing books regularly, which includes large print books. Some residents choose to spend time alone either in the lounge or their own room and this is respected. Daily newspapers are delivered. Most residents have a telephone in their room to help maintain contact with each other, friends and families. Religious beliefs are enabled with visits from two different denominations. Routines are flexible and residents can choose to have their meals in their rooms or in the dining room. Residents confirmed that friends and families are made welcome when they visit. One relative said ‘communication between the home and residents families/friends is good’. Residents or families handle all finances the home is not involved in any resident’s finances. Residents confirmed that they were able to bring in their own possessions when moving into the home. Feedback from residents about meals was on the whole very good. Lunch was observed during the visit. There was a choice of drinks available with the meal. The dining room is spacious and pleasant. Tables are laid with linen table clothes, napkins and silk flower arrangements made by the residents. Lunch was homemade steak and kidney pie, mashed potato, broccoli, cauliflower, runner beans and gravy followed by chocolate sponge and chocolate sauce. The vegetables and gravy were served on the table so residents could help themselves. An alternative is available to the menu and one resident was seen having fish, which she said, was her choice and was very enjoyable. The atmosphere was very relaxed with plenty of conversation. Staff were on hand and assisted when necessary. Residents confirmed that they have a say in what goes on the menu and changes are made following discussions. Residents said, “If you ask for something different such as a jacket potato with cheese they will do this” and “X is a good cook, its home cooking and nice homemade cakes in the afternoon” and ‘I like milky coffee but the coffee here is strong’. Apples, pears and tomatoes are produced from the garden. Special diets are catered for. Bowls of fresh fruit were available in the dining room. Saxonwood DS0000021203.V345913.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 good. This judgement has been made using available evidence including a visit to this service. Residents are confident that any concerns will be addressed within the home. However they are not confident that the organisation listens to their concerns and takes appropriate action. A lack of some staff training is leaving residents as risk of possible abuse. EVIDENCE: The complaints procedure is displayed both in the home and duty room. Three complaints have been received by the home since the last inspection. These have been investigated and appropriate action taken. It is suggested the home maintain a complaints log so complaints can easily be tracked and numbered. All residents spoken to say they would be confident in complaining to the manager and when they have she has dealt with any concerns quickly. However residents did not reflect this confidence with the organisation. One felt that concerns raised last year were not dealt with properly. The organisation didn’t really take any notice of what residents said or take any action in relation to the concerns raised. Residents should have confidence that their views will be listened to, taken seriously and acted upon by the whole organisation. It is suggested that consideration be given to ways in which this confidence can be rebuilt. Saxonwood DS0000021203.V345913.R01.S.doc Version 5.2 Page 16 Adult protection and routes to report abuse was discussed with staff on duty. Staff spoken to say they had not received training in adult protection. They were clear about whom to report abuse to in the home but were not clear where to report outside of the home and must be. There was also confusion about what was abuse and whether it always warranted reporting. This shows a lack of knowledge, which could put residents at risk. All staff must have adult protection training. The manager advised that only six care staff are currently training and ten places are booked for November. Saxonwood DS0000021203.V345913.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, 20, 21, 22, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident benefit from an environment, which is well maintained, clean, comfortable and homely. EVIDENCE: The premise from the outside looks well maintained. It has three and a half acres of gardens, which are well maintained and accessible to residents. Gardens include a patio area and seating, lawns with some beaches for seating, established borders, a fishpond and vegetable patches (which are currently not used) and greenhouses. Inside the home is also well maintained and decorated to a good standard providing residents with a nice, comfortable and homely place to live. Residents confirmed “any problems the maintenance man sorts them out” Saxonwood DS0000021203.V345913.R01.S.doc Version 5.2 Page 18 Since the last inspection some bedrooms have been redecorated. Residents all confirmed that they are happy with their bedrooms. Bedrooms were individual and personalised to suit resident’s needs. The lounge has views and patio doors to the garden. The dining room is spacious and pleasant. All areas of the home were light, clean and tidy. A resident said, “Its spotless and never smells”. There were two comments about the lighting in the home being inadequate. One comment was that energy saving light bulbs did not give sufficient lighting to those with sight problems. Staff demonstrated a good knowledge of infection control and clinical waste procedures. Residents said, “The laundry service is excellent”. Key safes have been fitted for keys to the sluice rooms. Bathrooms are spacious with one is fitted with an assisted bath and another a shower. Saxonwood DS0000021203.V345913.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 adequate. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from qualified staff that are caring and kind. A review of minimum staffing numbers could improve quality of time spent with residents. EVIDENCE: On the day of the visit in addition the manager and ancillary staff four-care staff were on duty in the morning and three in the afternoon. As the manager was tied up with the inspection and the senior carer tied up with a drugs delivery or medication administration this only left three to help residents in the morning and two in the afternoon. Discussions with staff highlighted they felt the senior was often tied up in the office with paperwork etc leaving the floor short. This could be because of the continued lack of a deputy manager. In the inspectors opinion these staffing levels seem very low especially as several residents spend the majority of their time in their room. This was echoed in a comment by a relative who said ‘I know it is difficult to involve my X in activities but she/he would be more stimulated if she/he could be involved in greater social interaction’. The laundry person also runs the activity groups twice a week, which is a great benefit to residents, but this can leave a shortfall in completing the laundry, which would then fall to care staff. Current sickness has affected staffing levels and agency staff has been used to cover the rota. Residents confirmed “Can’t complain at all apart from we do get Saxonwood DS0000021203.V345913.R01.S.doc Version 5.2 Page 20 short staffed and have a lot of agency”, ‘occasional lapses of availability of staff occur at weekends and bank holidays when there may be staff shortages which are rectified as soon as possible, agency staff can be bought in’ and ‘sometimes I think they are short staffed because I don’t see many of them about’. The home must agree minimum staffing levels, which are always in place and are determined by a formal tool and based on residents needs. Sickness had also affected the domestic cover that day which meant only one domestic was on duty. Resident’s felt although the home was at times short staffed, the staff worked very hard, was very kind and are on hand to help them and answer call bells as needed. Fifty percent of staff have obtained a National Vocational Qualification (NVQ) level 2 or above with another four currently undertaking it. Staff files demonstrated a robust recruitment process is followed with all checks in place. Staff undertake an induction which is to Skill for Care specification. Staff said they had received training in mandatory subjects. Training is planned for care of the dying and bereavement, diabetes, challenging behaviour and POVA. See earlier comments regarding further adult protection training. Saxonwood DS0000021203.V345913.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, 32, 33, 34, 36, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a home, which is run in their best interest. Minor improvements are needed to some records to ensure confidentiality. EVIDENCE: Residents spoke very highly of the manager and had confidence in her ability to run the home efficiently. She has obtained her Registered Managers Award NVQ level 4 in care. Staff confirmed that she is supportive, firm but fair. Quality assurance systems are in place. Residents said they have regular meetings and when issues are raised action is taken. Their only issue was they have no confidence in higher management. Questionnaires are sent to Saxonwood DS0000021203.V345913.R01.S.doc Version 5.2 Page 22 residents so they can feedback about the quality of care. A questionnaire was sent out early August and the results are still to be analysed. In addition a questionnaire was sent regarding food and entertainment during the year. The home has also gained the Investors in People award this year. Policies and procedures are in place but these would benefit from annual review, information showed that some have not been reviewed for some years one not since 2000. Staff feel well supported and have access to regular supervision. Some spot checks are carried out to check competency but these need to be recorded. The home does not take any responsibility for resident’s finances. Up to date insurance cover was displayed within the home. Residents confirmed that they have regular invoices when privately funded. Some record keeping must be reviewed such as the accident book and reports and the staff handover book. Records must be individual to maintain confidentiality and sensitive information must not be recorded in a communal book. Residents confirmed that health and safety checks are carried out regularly. Staff are trained in mandatory subjects. Further training is planned. Saxonwood DS0000021203.V345913.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 3 3 3 3 3 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 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 N/A 3 2 3 Saxonwood DS0000021203.V345913.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 OP9 Regulation 18 (1) (c) (i) Requirement That staff must receive training in the handling of medication and there must be evidence that this has taken place. There should be regular competence skills assessment, which must be evidenced. Previous timescale of 30/10/06 partly met in relation to training All staff must be trained in adult 16/10/07 protection and aware of the routes of reporting abuse both inside and outside of the home. Action plan in place by A review of staffing levels must 16/10/07 be undertaken using a formal tool and taking into account residents needs etc. A minimum staffing must then be agreed and implemented at all times. Records must be individual to 16/10/07 maintain confidentiality Timescale for action 16/10/07 2 OP18 13 (6) 3 OP27 18 (1) a 4 OP37 17 Saxonwood DS0000021203.V345913.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Saxonwood DS0000021203.V345913.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Saxonwood DS0000021203.V345913.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!