Inspection on 02/05/07 for Shire Lodge Nursing Home

This inspection was carried out on 2nd 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.

Other inspections for this house

Shire Lodge Nursing Home 21/07/09

Shire Lodge Nursing Home 27/04/09

Shire Lodge Nursing Home 01/11/05

Shire Lodge Nursing Home 16/06/05

Shire Lodge Nursing Home 25/11/04

Shire Lodge Nursing Home 22/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Shire Lodge Nursing Home 281 Rockingham Road Corby Northants NN17 2AE Lead Inspector Mrs Kathy Jones Key Unannounced Inspection 2nd May 2007 08:30 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 Shire Lodge Nursing Home DS0000012640.V335579.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. Shire Lodge Nursing Home DS0000012640.V335579.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shire Lodge Nursing Home Address 281 Rockingham Road Corby Northants NN17 2AE 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) 01536 200348 01536 447873 birchesterplc@yahoo.co.uk helenrussellrgn@AOL.com Birchester Medicare Limited Mrs Sharon Lorraine Goodall Care Home 50 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (50), of places Physical disability over 65 years of age (40), Terminally ill over 65 years of age (40) Shire Lodge Nursing Home DS0000012640.V335579.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Of the 50 residents, up to 20 may be in the category of Personal Care only in the categories OP, DE(E) and PD(E). In the category Personal Care only 3 named residents may be accommodated in the category Physical Disability PD under the age of 65 years. Four named service users who are below the age of 65 years. To accommodate one named service user who is under the age of 65 years within the category of DE (E) 1st November 2005 Date of last inspection Brief Description of the Service: Shire Lodge Nursing Home is a fifty bedded care home located on the outskirts of the town of Corby. Birchester Medicare own the home. Shire Lodge is registered to provide care for older people requiring personal care, nursing care and dementia care. The care home is a converted and extended farmhouse and is within walking distance of community resources, which include churches, shops, and pubs. Accommodation is provided across two floors, the home is divided into several areas each area consisting of bedrooms and lounge/dining facilities. The home has a rear garden, which is accessible to residents and car parking to the front. The following fees were provided by the registered manager as being current at the time of the inspection in May 2007. Local Authorities who are funding residents are charged at their set rate of £331.60 to £366.94 depending on assessed needs. Privately funded residents are charged between £400 and £500, with those requiring nursing care charged between £410 and £650 dependent on assessed need. The fees include personal care and where applicable nursing care, meals and accommodation. Chiropody, hairdressing services, and newspapers can be arranged and are charged separately. Other costs would include clothing and toiletries. Shire Lodge Nursing Home DS0000012640.V335579.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Standards identified as ‘key’ standards and highlighted through the report were inspected. The key standards are those considered by the Commission to have a particular impact on outcomes for residents. Inspection of the standards was achieved through review of the information held by the Commission for Social Care Inspection as part of the pre-inspection planning and an unannounced inspection visit to the service. The preinspection planning was carried out over the period of half a day and involved reviewing the service history, which details all contact with the home including notifications of events reported by the home, telephone calls, letters, and details of any complaints and concerns received. The report from the last inspection carried out on 1st November 2005 was also reviewed and the findings taken into account when planning this inspection. Information received in a questionnaire submitted by the registered manager has been taken into account as part of the inspection. The views of six residents and nine relatives who forwarded completed questionnaires have also been reflected in this report. The registered manager confirmed that questionnaires had been made available to relatives, however no responses had been received at the time of inspection. The unannounced inspection visit covered the morning and afternoon of a weekday. The inspection was carried out by ‘case tracking’ which involves selecting residents’ and tracking their care and experiences through review of their records, discussion with care staff and observation of care practices and the environment. The inspector spoke with several residents throughout the inspection three relatives and staff about the care provided. Observations were made of their general well being, daily routines and interactions between staff and residents. Records reviewed included a sample of staff files to check the adequacy of the recruitment procedures. The findings of the inspection were discussed with the registered manager at the time of the inspection. Information received after the inspection visit has been discussed and where necessary clarified in telephone conversations with the registered manager. A notice board in the foyer of Shire Lodge prominently displays information about the services provided including the complaints procedure. As detailed in the body of the report the statement of purpose is to be revised. Shire Lodge Nursing Home DS0000012640.V335579.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Information within the statement of purpose needs to be more detailed about the range of needs that the service intends to meet to provide a clear focus to the service and assist prospective residents’ and anyone assisting with the placement in making a decision about whether the home is able to meet their needs and expectations. Some of the care plans would benefit by being more detailed to ensure clear guidance is given to staff about meeting residents’ needs to ensure their needs are fully and consistently met. Consideration should be given to ways of making residents’ bedrooms on the dementia unit more easily identifiable and enabling them to have more independent access to their rooms during the day. Care should be taken to ensure that any aids and adaptations fitted are safe and appropriate for the needs of residents’. Shire Lodge Nursing Home DS0000012640.V335579.R01.S.doc Version 5.2 Page 7 The cleanliness of equipment used for transporting food to dining areas must be monitored. A questionnaire sent to relatives asks how they think the care home could be improved and these comments include “more care assistants on duty at weekends”, “maybe tea breaks could be staggered”. Improvements to the recruitment procedure are required to ensure that all required checks are made in all cases, and that a full employment history is obtained to ensure that residents’ are properly protected. 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. Shire Lodge Nursing Home DS0000012640.V335579.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 Shire Lodge Nursing Home DS0000012640.V335579.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, 3, std 6 was not assessed as intermediate care is not provided. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process provides assurances that the needs of residents entering the home can be met. EVIDENCE: Questionnaires from residents and relatives confirm that the majority feel that they received enough information about the care home to help them with making decisions. Relatives and a resident spoken with during the inspection were also satisfied that they had enough information to help make a decision about the home prior to admission. They said they had written information about the services provided from the home, but also some through word of mouth in the local area. The statement of purpose, which provides relatives and prospective residents with information about the services, provided was discussed with the Shire Lodge Nursing Home DS0000012640.V335579.R01.S.doc Version 5.2 Page 10 registered manager who was then able to identify required improvements. One of the key areas for development is to include more information about the range of needs, that Shire Lodge is able to meet, and details of how they will be met. This is particularly important as Shire Lodge caters for people with a range of different needs and it is important to have clear strategies for ensuring that the needs of all residents are met and that residents and their relatives understand the care that they can expect to receive. Prior to admission, an assessment of a prospective resident’s needs is carried out to establish if their needs can be met. Records show that assessments carried out by placing authorities such as social services are taken into account when ascertaining if a resident’s needs can be met. This reduces the risk of a resident’s needs not being met when admitted. A recently admitted resident confirmed that they were satisfied that their needs were being met. Shire Lodge Nursing Home DS0000012640.V335579.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 overall care provided appears to be good however in some cases care plans need to include more specific guidance for staff to ensure that, residents’ needs and preferences continue to be met appropriately. EVIDENCE: Comments received in nine questionnaires from residents identify that six feel that they always get the care and support and the medical support that they need while three say they usually do. Three relatives spoken with during the inspection and two residents were very happy with the level of care and support provided. Care plans are in place for each resident which take the form of a tick list with space for additional comments based on residents individual needs. A sample check of the plans identified that they are based on residents’ individual needs, however in some cases additional work is required to ensure that they are fully Shire Lodge Nursing Home DS0000012640.V335579.R01.S.doc Version 5.2 Page 12 reflective of residents needs and give staff clear guidance as to the actions required to meet them. For example, a care plan identified that a resident was “resistive to care”, however there was no guidance within the plan as to how staff were to meet this resident’s needs. Care records demonstrated that assessments are in place to identify health care risks such as nutritional risks and the risk of pressure sores. Staff advised that there were no residents with pressure sores and a sample check confirmed that pressure relieving mattresses were in place for residents’ identified as being at risk of pressure sores to help prevent them. Accident records showed that follow up checks for injuries are carried out which indicate appropriate monitoring of residents health and well being. However a sample check of records identified the need for a more thorough approach to reviewing and recording changes in residents’ care needs on an ongoing basis. Documents were in place to confirm that staff had reviewed care plans monthly. However a falls risk assessment, identified in July 2006 that the General Practitioner was to be informed of increased risks. It was not clear what the particular risks were and there was no additional guidance for staff as to the actions required to minimise risk. A sample check of residents’ medication against the medication administration records confirmed that prescribed medication was available and this was being administered to residents. Advice was given regarding the need to provide a clearer audit trail of medication in order that any discrepancies can be more easily identified. A check was made of the controlled drugs held against the controlled drugs register. While all the drugs were recorded in the register it was very difficult to check this due to inconsistent methods of recording creating a risk of error. Residents spoken with were happy with how they are treated by staff and described them as being very good. Staff were observed to be mindful of assisting residents’ and particularly those with dementia to maintain their dignity. Shire Lodge Nursing Home DS0000012640.V335579.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 some choice in their daily routines, they are happy with the meals and their visitors are welcomed and encouraged to visit enhancing their lives. EVIDENCE: Two residents spoken said they were happy that staff respect their preferences in relation to where they spend their day. One resident said they preferred to stay in their room, while another preferred to be more social and spoke of the social activities that were organised. The resident said that she had enjoyed a game of bingo that morning. In addition the resident was pleased that staff took her to the shops occasionally. Questionnaires received from two residents confirmed that suitable activities are usually provided. Observations on the dementia unit identified that magazines and newspapers are readily available and that materials had been provided for a resident who enjoyed colouring. The registered manager advised that as a result of some Shire Lodge Nursing Home DS0000012640.V335579.R01.S.doc Version 5.2 Page 14 dementia care training that she and some other staff are undertaking, they are reviewing the activities available for residents with dementia. Visitors confirmed that visiting arrangements are flexible and that they can visit as often and when they wish. They said that staff are always welcoming and questionnaires confirm that relatives are kept informed of important issues. One relative felt that staff were very helpful with the advice they gave when a resident was admitted to hospital. Residents’ do have choices in their daily lives, however for residents’ on the dementia unit their rights of independent access to their rooms is restricted as their rooms are locked during the day. Discussion with the registered manager identified that the rooms are locked as a resident had been wandering into other residents’ rooms. Advice was given to consider how residents could have more freedom of access to their rooms while protecting their belongings. Residents spoken with were happy with the meals provided which residents who responded to the questionnaire also confirmed. A hot meal with a cold meat alternative was provided at lunch time and at tea time residents were also offered the choice of a hot meal or sandwiches. Residents’ are able to eat in the dining room or if they prefer in their rooms. Shire Lodge Nursing Home DS0000012640.V335579.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. There are procedures for dealing with concerns and complaints which residents’ and their relatives are aware of which provide protection for residents. EVIDENCE: The Commission for Social Care Inspection have received one complaint since the last inspection in November 2005. The complaint was referred to the provider for investigation under their complaints procedure. The registered manager advised that two other complaints had been investigated through their complaints procedure and another investigated by social services. Records show that complaints are responded to and where applicable the records show the action taken to address the concern. Questionnaires received from residents confirm that they have someone they can speak to if they are unhappy and comments from relatives identify that they are aware of how to raise concerns. The complaint procedure is readily available and was displayed in the hall. One relative stated, “They always help with any problems that arise promptly”. Shire Lodge Nursing Home DS0000012640.V335579.R01.S.doc Version 5.2 Page 16 Residents spoken with said they felt safe and the registered manager was clear about her responsibilities for acting on any concerns raised in order to protect residents’. Shire Lodge Nursing Home DS0000012640.V335579.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, 22, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall the premises were found to be satisfactory in meeting residents’ expectations, however more consideration needs to be given to equipment and the premises to ensure the needs of all residents are fully met. EVIDENCE: Three residents bedrooms randomly selected were viewed during the inspection and found to be clean and comfortable. One resident spoken with in their room said they were happy with their room and that it was always kept clean. Questionnaires received from five residents’ state that the home is always fresh and clean while one said it usually is. A relative described Shire Lodge as having a “home to home feel”. There are several lounges and dining areas throughout the home and these areas were Shire Lodge Nursing Home DS0000012640.V335579.R01.S.doc Version 5.2 Page 18 found to be clean. A trolley used for taking meals to residents’ on the first floor was very dirty. The manager advised that all the trolleys would be checked as part of a deep clean of the kitchen which was due to take place the following day as part of the cleaning rota. The manager confirmed that she would monitor the cleanliness of kitchen equipment to reduce any risk to residents. A requirement was made at the last inspection about the need to take action regarding the risks of burning in the event of a resident falling against an uncovered hot radiator. This inspection was carried out on a relatively warm day for the time of year and therefore a sample check found that radiators were not excessively hot. Some of the radiators have now been covered and the registered manager confirmed radiator covers would continue to be fitted where required to reduce the risk to residents’ based on individual risk assessment. The pre-inspection questionnaire identifies that regular maintenance checks are carried out on equipment such as the hoists and the lift. Dates were not given for the electrical wiring certificate and checks on the emergency lighting, however written confirmation has been received that quotes are being obtained for these checks prior to the work being carried out. The brief tour of the premises identified that an electrical socket was hanging off the wall leaving electrical wires exposed. The registered manager advised that this appeared to have been left following some work to attend to a leak and contacted the electrician during the inspection and promptly arranged for this to be attended to in order to eliminate any risk. Staff have learnt through dementia care training the importance of appropriate carpeting and furnishing for residents with dementia and the registered manager advised that she would put forward suggestions for improvements to the owner. The inspector also noted that currently all the bedroom doors on the dementia unit all look the same making it difficult for residents to identify their own room. This may exacerbate the problem of residents’ wandering into other peoples’ rooms, if they are left unlocked. It was identified that a new chair hoist had been fitted in the bathroom on the dementia unit. Observations of the chair and discussion with staff identified that the chair is unsuitable for some of the residents on that floor and that there is a risk of them falling. This was discussed with the registered manager who confirmed that she would ensure that individual risk assessments were carried out and until something more appropriate to residents’ needs could be installed residents at risk would be bathed in a different bathroom. Shire Lodge Nursing Home DS0000012640.V335579.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements appear to meet the needs of residents, however the recruitment procedure needs to be reviewed to ensure the risk to residents is minimised. EVIDENCE: Comments received from residents and some relatives indicate that staff are committed to meeting the individual needs of residents’ and include “ kind and considerate”, “very caring”. Two residents’ said that they particularly enjoyed some friendly ‘banter’ with staff, which livened up their day. The majority of questionnaires from residents stated that staff are always available when they are needed, however some additional comments received from relatives indicate that this needs to be monitored. The questionnaire asks relatives how they think the care home could be improved and these comments include “more care assistants on duty at weekends”, “maybe tea breaks could be staggered”. The registered manager advised that tea breaks should be staggered, however confirmed that she will monitor this to ensure that staff are always available to meet residents’ needs. Shire Lodge Nursing Home DS0000012640.V335579.R01.S.doc Version 5.2 Page 20 On the day of the inspection there appeared to be sufficient staff to meet the needs of residents and discussion with staff and residents indicated that there are generally sufficient staff planned to be available to meet residents’ needs, however that there have been shortfalls which have occurred when staff have been ill. The shortfalls could not be evidenced through the rota, which indicated that where staff have been ill, alternative arrangements have been made to replace staff to reduce the impact on residents. The registered manager confirmed that she would continue to monitor staff availability. The adequacy of the recruitment process in protecting residents was reviewed through a sample check of staff files. This identified the need to review the process in line with the regulations. For example the application form only requests details of the last three employers, whereas the regulations require a full employment history to be obtained. Records also indicated that a member of staff had started work prior to receipt of a satisfactory criminal record bureau clearance, however this was in place at the time of inspection and no risk was identified at the time. Advice was given that in the exceptional case where it is necessary to start staff prior to receipt of the criminal record bureau clearance a check against the protection of vulnerable adults register must be made and there must also be evidence of the supervision arrangements in place to protect residents. Discussion with staff and a sample check of records identifies that training is planned to meet the needs of residents. At the time of the inspection several staff were undertaking a sixteen week dementia course which was providing staff with a more in depth understanding of residents needs. A relative describes staff as being well trained. Shire Lodge Nursing Home DS0000012640.V335579.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Shire Lodge is managed by an experienced manager who is supportive of the needs of residents’. EVIDENCE: The registered manager has been at Shire Lodge for sixteen years and is a qualified nurse. Residents, relatives and staff refer to the registered manager as ‘Matron’. A relative describes Matron as being friendly and supportive and very approachable. Another says that the needs of the residents at Shire Lodge are always put first. Shire Lodge Nursing Home DS0000012640.V335579.R01.S.doc Version 5.2 Page 22 Quality assurance systems are in place and the last quality review was carried out in October 2006. This involved gathering views from relatives, residents and staff about the quality of care provided. The organisation has appointed a consultant to carry out monthly, unannounced visits to Shire Lodge to report on the quality of care provided. Review of one of the reports identified that residents’ care is reviewed and where appropriate recommendations made for improvement. Records for the management of residents’ monies are held at head office and not reviewed during this inspection, however no concerns have been identified about how they are managed. Staff training records and discussion with them confirm that they receive training in safe working practices. Confirmation has been received that action is being taken to address health and safety concerns about a newly fitted bath hoist. Shire Lodge Nursing Home DS0000012640.V335579.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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Shire Lodge Nursing Home DS0000012640.V335579.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement Timescale for action 30/07/07 2. OP7 12 (1) (a, b), 15 19 3. OP29 The statement of purpose must be revised to give people clear details of the range of needs that the service intends to meet and tells them how they will be met. Care plans must be specific 30/07/07 about the actions required of staff to meet residents’ needs to ensure they are fully met. 15/06/07 Prior to employing a new member of staff, information obtained must include a full employment history and criminal record bureau clearances. In the exceptional circumstance where it is necessary to employ someone prior to receipt of the criminal record bureau clearance, there must be evidence that all other checks including the protection of vulnerable adults register have been made and of the supervision arrangements to protect residents’. Shire Lodge Nursing Home DS0000012640.V335579.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. 1. Refer to Standard OP14 Good Practice Recommendations Consideration should be given to ways of making residents’ bedrooms on the dementia unit more easily identifiable and enabling them to have more independent access to their rooms during the day. Care should be taken to ensure that all aids and adaptations are appropriate for the needs of residents’ before use. 2. OP22 Shire Lodge Nursing Home DS0000012640.V335579.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Shire Lodge Nursing Home DS0000012640.V335579.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. 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