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Inspection on 21/08/06 for Seely Hirst House Care Home

Also see our care home review for Seely Hirst House Care Home for more information

This inspection was carried out on 21st August 2006.

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

Residents benefit from a comfortable, appropriately furnished and decorated environment, which provides specialist equipment to meet individual residents needs. There is a pleasant and relaxed atmosphere within the home. Seely Hirst House provides a good quality of care to the residents. Residents spoken with reported that they were happy at the home and liked the staff. One staff member spoken with also reported that they felt they provided a good quality of care. Care plans examined provide a clear overview of individual residents care needs. The staff team are committed to providing a good standard of care for residents and were observed carrying out tasks efficiently. Members of staff spoken with stated they enjoyed working at the home. Residents were offered a choice and variety of meals, and residents` commented that they enjoyed the meals.The health and safety of residents is promoted and protected through staff training and provision of equipment.

What has improved since the last inspection?

No requirements or good practice recommendations were set at the last inspection. The home continues to operate at a good standard.

What the care home could do better:

Seely Hirst continues to operate at a good standard. There are a few areas where they can improve on. A requirement has been set to ensure that all times staff adhere to procedures for handling medication. One good practice recommendations have been set. The registered manager should ensure all running records are up to date; this is in relation to the one named resident who`s running records contained no entries for a number of days.

CARE HOMES FOR OLDER PEOPLE Seely Hirst House Care Home 62-68 Mapperley Road Mapperley Park Nottingham NG3 5AS Lead Inspector Rehana Rashid Key Unannounced Inspection 21st August 2006 10:00 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 Seely Hirst House Care Home DS0000002218.V306560.R02.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. Seely Hirst House Care Home DS0000002218.V306560.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Seely Hirst House Care Home Address 62-68 Mapperley Road Mapperley Park Nottingham NG3 5AS 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) 0115 960 6610 0115 9856283 The Trustees of Seely Hirst House Miss Lynda Dyer Care Home 38 Category(ies) of Dementia (12), Old age, not falling within any registration, with number other category (38) of places Seely Hirst House Care Home DS0000002218.V306560.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: Seely Hirst House is registered to accommodate up to 38 older people some of whom may be suffering from dementia. The accommodation is provided over two floors with a passenger lift providing independent access. Seely Hirst House is maintained to a very good standard with well-maintained enclosed gardens. Seely Hirst House is situated in a residential area with good public transport links to the city centre. At the inspection on 21st August 2006 the registered manager stated that Seely Hirst House’s current weekly fee range is £303 to £343. She also stated that there are additional charges for hairdressing, personal newspapers and a minimal contribution towards social outings. Information about Seely Hirst is available through a brochure and the service user guide. Seely Hirst House Care Home DS0000002218.V306560.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out on 21st August 2006 for the duration of 5.5 hours. The main method of inspection was case tracking, which involved randomly selecting three residents and examining their care records. Case tracking is used to establish if the needs of the residents are being appropriately assessed by the home and their needs are being catered for. Indirect and direct observation of practice and interaction between staff and residents was also carried out as part of the inspection methodology. The communal areas, shower room, bathrooms, kitchen, four bedrooms and gardens were viewed during this site visit. Other documentation including health and safety records were also examined. The management of medication was assessed. The Registered Manager assisted in the inspection process. Two members of staff were spoken with and three staff files were examined. Residents were briefly observed during lunch, and three residents were spoken with. Nine surveys from residents at Seely Hirst House have been received by the Commission for Social Care Inspection. The focus of the inspection was to concentrate on the key standards, which were assessed under the new methodology of Inspecting for Better Lives (IBL). What the service does well: Residents benefit from a comfortable, appropriately furnished and decorated environment, which provides specialist equipment to meet individual residents needs. There is a pleasant and relaxed atmosphere within the home. Seely Hirst House provides a good quality of care to the residents. Residents spoken with reported that they were happy at the home and liked the staff. One staff member spoken with also reported that they felt they provided a good quality of care. Care plans examined provide a clear overview of individual residents care needs. The staff team are committed to providing a good standard of care for residents and were observed carrying out tasks efficiently. Members of staff spoken with stated they enjoyed working at the home. Residents were offered a choice and variety of meals, and residents’ commented that they enjoyed the meals. Seely Hirst House Care Home DS0000002218.V306560.R02.S.doc Version 5.2 Page 6 The health and safety of residents is promoted and protected through staff training and provision of equipment. What has improved since the last inspection? 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. Seely Hirst House Care Home DS0000002218.V306560.R02.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 Seely Hirst House Care Home DS0000002218.V306560.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective residents individual aspirations and needs are assessed prior to moving to the home, which provide assurances that their needs can be met. Intermediate care is not provided by the home. EVIDENCE: Procedures were in place to ensure prospective residents and relatives were given the opportunity to visit the home prior to admission. Discussion with a visitor confirmed that they had visited the home prior to their relative moving in. Two residents spoken with confirmed that they visited the home prior to the admission, to ensure the home was suitable for them. On the day of the site visit, a prospective resident was visiting for the day with the view of moving to the home. Case tracking confirmed that a structured admission process was completed for all prospective residents, and provided reassurances that their individual needs could be met at Seely Hirst House. Documentation supported that prospective residents were assessed prior to them moving into the home. The Seely Hirst House Care Home DS0000002218.V306560.R02.S.doc Version 5.2 Page 9 registered manager carries out pre- admission assessments on all prospective residents and obtains any relevant information from social services. The preadmissions assessments were detailed providing information about the individual’s social and health care needs Prospective residents are able to view the home prior to moving in, and they are able to visit for the day or stay over night, so they are able to make an informed choice about moving into the home or not. The assessments of needs were comprehensive, and contained details of both medical and social needs. Seely Hirst House Care Home DS0000002218.V306560.R02.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 at least once during a 12 month period. 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 care of residents was planned and given in a way that respected individuality and privacy. Staff practice in relation to some aspects of the administration of medication needs to improve, so that residents are not place at risk from cross infection. EVIDENCE: Care plans for three randomly selected residents were seen as part of the case tracking process. These care plans were based on comprehensive assessments of need. Care plans and risk assessments were reviewed regularly, and had been signed and dated. Risk assessments were detailed, and identified the risk and the action to be taken to minimise the identified risk. The care plans and risk assessments reflected the individual needs of residents, and incorporated advice from other health care professionals. Running records contained significant information relating to individual residents for instance if a GP was contacted. No entries had been made in one residents running records for a number of days. The files supported that residents had access to input from other health care professionals Visits by GP and District Nurses are recorded in the individual Seely Hirst House Care Home DS0000002218.V306560.R02.S.doc Version 5.2 Page 11 resident files. Staff contact the relevant health care professional as and when required. Case tracking supported that regular input from District Nurses was provided as required. A relative visiting stated they has been involved in reviews and the staff are very good at informing them if there is a change in their relative’s needs. The three residents spoken with stated they are happy with the level of care received by the staff. Good policies and procedures were in place with regards to the administration of medication. At this inspection one incident was observed regarding the practice of medication handling. Medication administration record were signed after the staff member had visibly observed the resident take the medication. The medication administration record charts were well organised in a file and there were no gaps in the entries, supporting that residents received medication as prescribed. Photographs of residents were attached with the medication administration records, enabling staff to identify the correct resident with the medication record. Training records supported that staff responsible for the administration of medication had received medication training. A member of staff observed administrating medication confirmed they had received training in medication administration. All medication was stored securely Discussion took place around staff handling medication and placing medication on the dining table, as this was observed during this site visit. One member of staff was observed handling medication with their hands and placing it either on the dining table or picking it up to put on the spoon. This practice is not acceptable due to the risk of cross infection. If a spoon is to be used to administer medication to residents, the medication must be placed in the medication pot and then tipped on the spoon. Residents spoken with confirmed that staff respected their privacy and dignity. Residents confirmed personal care takes place in their bedrooms or in the bathrooms. They stated staff knocked prior to entering their rooms, and both staff and the registered manager were observed knocking on bedroom and bathroom doors prior to entering. A relative spoken with stated that staff are always friendly and polite. One of the residents spoken with stated they are able to deal with their own correspondence which they receive unopened. Residents are assisted to keep in touch with family and friends, as there is a post box in the foyer, where they can leave mail to be posted on their behalf, and a pay phone available to use. . Seely Hirst House Care Home DS0000002218.V306560.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A range of suitable activities was being provided, which met the leisure and recreational interests of residents. The meals were good offering both choice and variety and catering for individual likes and dislikes. EVIDENCE: Residents spoken with said there were no set routines for the day. They got up and went to bed at their choice. The registered manager stated that the routines of the home are flexible, to suit the preference of individual residents. During this site visit a couple of residents were sitting in the patio area in the garden, others were in the lounge watching television or snoozing, whilst some were talking with fellow residents and staff. The visitor and residents confirmed that people were made very welcome at the home. The inspector observed positive interaction between staff and residents. Once a month the home has Holy Communion and on Sundays representatives from two of the local churches accompany several of the residents to the church service. There was evidence to support that there are weekly and monthly planned events. Residents spoken with stated the social activities organised by the Seely Hirst House Care Home DS0000002218.V306560.R02.S.doc Version 5.2 Page 13 home are suitable. One resident commented they prefer to spend time in their own bedroom as they have everything to keep themselves socially stimulated including books and magazines. Photographic displays of both residents and staff taking part in activities outside the home, including a boat trip on the crusader and a visit to Nottingham Castle, were on display. One resident spoken with confirmed they enjoyed going out on trips. Other social activities at the home include the hairdresser, singers and musicians and scrabble bingo. One day each week a dedicated staff member facilitates activity and stimulation, including going out to the local shops. Seely Hirst House was observed to be welcoming and friendly. Residents spoken with confirmed that visiting times were flexible and staff are welcoming of visitors. Visitors were observed to be visiting throughout the inspection. Residents commented that they are encouraged to make their own choices including what they wish to wear and how they wish to spend their time. Resident’s rooms were very personalised, which was observed when four bedrooms were viewed. Lunch was briefly observed, which the residents stated they enjoyed. The home has a four weekly menu, which appeared to contain nutritional and wellbalanced meals. Two residents spoken with said that the food in the home was excellent. Whilst another resident stated the “meals were ok”. Residents spoken with stated if they did not like a meal they are offered an alternative choice. There was evidence to support that food with a short shelf is dated on the day it is opened. The required temperature records were maintained. Storage and supplies of food stocks were good. Seely Hirst House Care Home DS0000002218.V306560.R02.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 inspected at least once during a 12 month period. 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. A comprehensive complaints procedure was in place with some evidence that people felt that their views were listened to and acted up. Staff had a good knowledge and understanding of adult protection issues which protects residents from harm. EVIDENCE: The home has a comprehensive complaints procedure, which is appropriately displayed, throughout the home. No complaints have been received by the Commission for Social care inspection or by the home since the last inspection. Residents spoken with stated they have no reason to complain but if they were unhappy they would either speak with the manager or other staff members. A relative spoken with stated she was aware of the complaints procedure but has no reason to complain. Residents and relative spoken with stated they were confident that their complaints would be taken seriously. The two members of staff spoken with demonstrated a good understanding of the whistle blowing procedure. A copy of the Nottinghamshire Committee for the Protection of Vulnerable Adults Policy and Procedure is available in the home. Training certificates in respect of safeguarding vulnerable adults were observed on staff files, staff stated that this is also covered during the induction process. The registered manager confirmed no referrals had been made to the adult protection unit. Seely Hirst House Care Home DS0000002218.V306560.R02.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Sealy Hirst House is well maintained and furnished, providing residents with a homely and spacious environment to enjoy, which meets the particular needs of the residents. EVIDENCE: All parts of the home were observed to be well furnished and maintained. All residents spoken with stated how impressed they were with the homes décor and furnishings. There was evidence to support ongoing investment in the furnishing and décor. Since the last inspection the dining room has been refurbished which included new chairs, carpets and décor. The first and second floor corridors have also been redecorated and carpeted. A relative visiting on the day of the inspection was very complimentary of the refurbishment. The quiet lounge was furnished and maintained to a high standard. Picture frames were hanging throughout the home along the corridors, some of which have been donated to the home from the families of previous residents. Seely Hirst House Care Home DS0000002218.V306560.R02.S.doc Version 5.2 Page 16 Seely Hirst House offers its residents a very clean and well-maintained environment. The atmosphere throughout the home is calming and relaxing. The garden is situated at the rear which is very well maintained with attractive plants and seating for the residents. Inspection of bathrooms, bedrooms and communal areas such as the lounge and kitchen were found to be suitable for residents. The bathroom and toilet facilities viewed were in a good state of condition and decorated to a good standard. They were also clean and free from odour. The kitchen was clean and well maintained. The four bedrooms viewed were very well personalised with resident’s personal possessions including photographs, ornaments. Each room viewed was individually decorated and very clean. Some rooms contained televisions and stereos. Residents are able to keep their own furniture in their rooms to make them more personalised and homely. Residents spoken with stated they liked their rooms and they were comfortable. All the bedrooms viewed each had its own individual character. Lockable storage was available in each room for the safe keeping of personal possessions. Most of the bedrooms at Seely Hirst House have en-suite facilities. Bedrooms viewed were fitted with window restrictors. The home has a passenger lift. Seely Hirst House provides its residents with specialist equipment to meet their needs, which includes grab rails in the bathrooms and toilet facilities and raised toilet seats. The laundry area was viewed, which was well organised and clean. The laundry facilities included industrial washer with sluicing facilities and a drier. During the tour of the building no potential health and safety hazards were seen. Seely Hirst House Care Home DS0000002218.V306560.R02.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. 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. Resident’s needs are met by the number and skill mix of the staff team. Residents are in safe hands. Residents at Seely Hirst House are supported and protected by the home’s recruitment policies. EVIDENCE: The staffing rota viewed was an accurate record of the staff on duty. A staff member spoken with stated staffing levels are adequate ensuring residents are supported. The staffing team consists of registered manager, deputy manager, senior carers, care assistants, housekeepers, cleaners, cook, kitchen assistants and a maintenance person. Residents and a relative spoken with stated there are sufficient staff on duty. Staff were observed to have positive relationships with the residents. A member of staff spoken with demonstrated a good understanding of the needs of the resident. Staff were observed interacting positively with residents. Residents spoken with commented that staff are helpful and friendly. One resident stated, “staff are very nice.” Three staff files were examined at the time of the inspection, including the file of the most recently recruited member of staff. From the three staff files viewed, one file did not contain a Criminal Records Bureau (CRB) check for the newly employed member of staff. There was evidence that the CRB check had been sent off for this staff member, and a satisfactory Protection Of Vulnerable Seely Hirst House Care Home DS0000002218.V306560.R02.S.doc Version 5.2 Page 18 Adults check was in place. Procedures were in place to ensure that this member of staff was supervised at all times. The registered manager stated the staff member would be closely monitored until a satisfactory Criminal Records Bureau check has been received. Staff training certificates for two staff members confirmed they had received training in Food Hygiene, fire Safety, Moving and Handling, First Aid and medication handling. A staff member commented that the training provided is good and relevant which has included Food Hygiene, Moving and Handling and protection of vulnerable adults. Induction records were not seen but one staff member confirmed he was currently undergoing a program of induction. The registered manager stated that over 50 of the staff team have undertaken National Vocational Qualification in care. One staff member spoken with confirmed she had undertaken this training. Seely Hirst House Care Home DS0000002218.V306560.R02.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Seely Hirst House is managed by a competent and experienced registered manager. Seely Hirst House is run in the best interest of the residents. Resident’s financial interests are safeguarded. The health, safety and welfare of residents and staff is promoted and protected. EVIDENCE: The registered manager has worked for Seely Hirst for twenty three years, for nine years she has been the registered manager. She stated she has completed the Registered Managers award. A member of staff spoken with stated the manager is very supportive and approachable. Staff and residents commented positively about the leadership style of the manager. This was reflected in the very well organised office and files inspected. Files were kept in good order and easily accessible for inspection. Seely Hirst House Care Home DS0000002218.V306560.R02.S.doc Version 5.2 Page 20 Residents at Seely Hirst House are given the opportunity to contribute to the running of the home through residents meetings, and quality assurance systems. Residents meetings take place every two months, where issues are raised and suggestions are made. Minutes from the last residents meetings were seen topics included menu changes. The registered manager operates a quality assurance system that includes questionnaire to residents, families or representatives and health care professionals; results are analysed annually. During the most recent quality assurance audit in June 2006 comments from residents included “ I think you do well”, another stated “Its nice to have breakfast in bed.” One of the responses from relatives when asked if there was any area for improvement the response was “I honestly cannot think of one.” The overall results are included in prospective resident enquiry packs and displayed within the home. The feedback overall was positive. There is also a suggestion box, which can be used by visitors and residents. The registered manager stated she has an open door policy should residents, visitors or staff need to raise anything. Resident’s financial interests are safeguarded by the financial procedures in place. The financial records for two residents were examined, money and records tallied. Records are kept detailing the balance and all the receipts for amounts spent are attached to individual resident sheets. Prior to the site visit the registered manager completed the Pre-Inspection Questionnaire and provided details of maintenance and associated records. A range of records relating to health and safety were examined. Files were well organized and easily accessible. Records of fire system tests, water temperatures and other health and safety records including portable appliances testing were observed and were found to be carried out at the required intervals. Seely Hirst House Care Home DS0000002218.V306560.R02.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 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 4 X 3 X X 3 Seely Hirst House Care Home DS0000002218.V306560.R02.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13.2 Requirement The registered manager should ensure that at all times staff adhere to procedures for handling medication. Staff member on duty was observed handling medication when assisting a resident, therefore putting residents at risk of cross infection. Timescale for action 21/08/06 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 YA37 Good Practice Recommendations Ensure all running records are up to date; this is in relation to the one named resident who’s running records contained no entries for a number of days. Seely Hirst House Care Home DS0000002218.V306560.R02.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Seely Hirst House Care Home DS0000002218.V306560.R02.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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