Inspection on 19/10/06 for Shouldham Hall Nursing Home

This inspection was carried out on 19th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Shouldham Hall Nursing Home 02/05/07

Shouldham Hall Nursing Home 28/06/06

Shouldham Hall Nursing Home 23/02/06

Shouldham Hall Nursing Home 03/08/05

Shouldham Hall Nursing Home 22/06/05

Shouldham Hall Nursing Home 16/11/04

Shouldham Hall Nursing Home 08/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Shouldham Hall Nursing Home Shouldham Norfolk PE33 0DF Lead Inspector Kim Patience Unannounced Inspection 19th October 2006 10:40 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 Shouldham Hall Nursing Home DS0000015681.V317585.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. Shouldham Hall Nursing Home DS0000015681.V317585.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shouldham Hall Nursing Home Address Shouldham Norfolk PE33 0DF 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) 01366 347276 01366 347658 shouldhamhall@tiscali.co.uk Shouldham Hall (Registration) Limited Natasha Obolewicz Care Home 48 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (34), Old age, not falling within any other of places category (14) Shouldham Hall Nursing Home DS0000015681.V317585.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate forty-eight (48) people in total, all of who are older people. Of these, thirty-four (34) Service Users will fall in the category of dementia and fourteen (14) Service Users will have needs associated with old age, not falling in any other category. One Service User under the age of 65 years who has dementia and is named in the Commission`s records may be accommodated. 28th June 2006 2. Date of last inspection Brief Description of the Service: Shouldham Hall is a 48 bedded care home with nursing for the elderly, and elderly mentally frail. The home consists of two wings, the original hall, and the new wing. There are a total of 44 single rooms and 2 double rooms on the ground and first floors. The home receives its medical services from the local G.P. centre. There is an enclosed garden and large grounds, and ample car parking on the front drive to the home. The home is situated at the edge of the village of Shouldham, which is 10 miles from Kings Lynn. The fees charged at this home range from £393 - £525 Shouldham Hall Nursing Home DS0000015681.V317585.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection that took approximately 7 hours to complete. During the inspection the acting manager Glynis McClusky, training coordinator Tracy Cursons and the homes consultant Vicky Hurlock were present and available for discussion. The management and staff were helpful in facilitating the inspection and providing relevant information. In order to assess the standards a tour of the building was completed, records relating to staff, residents and the running of the business were examined. Staff and residents were spoken with and observations of people engaged in daily routines were made. The registered manager was not present at this inspection and has been absent from work since August 2006. Since the last inspection two random inspections have been completed, one by the pharmacist inspector on the 5/07/06 and one completed by the pharmacist inspector and the lead inspector on the 31/08/06. Following the pharmacy inspection in July a statutory notice was issued due to continued noncompliance with the regulations resulting in ongoing concerns about the safe administration of medicines. This home has made significant improvements over a relatively short period of time and the management and staff are to be commended on their effort and commitment to achieving best outcomes for service users. What the service does well: What has improved since the last inspection? The home has introduced new care plan summaries, care plans and risk assessments. Medication arrangements have improved and are now considered safe. Shouldham Hall Nursing Home DS0000015681.V317585.R01.S.doc Version 5.2 Page 6 Detailed information has been gathered about people’s life history, interests and social and emotional needs. Individual activities plans have been written drawing on the information given. The home has a structured plan of group activities drawn from common interests. An activities coordinator has been employed for 30 hours per week. Nutritional needs assessments are completed and people’s needs are being met in this respect. The whole mealtime experience has improved making it more relaxing and enjoyable. Significant effort has been put into the environment to make it more homely, safer and enabling. The home has employed a training coordinator who has made major improvements to staff training and driving up the standard of the delivery of care. The recruitment practices have improved and are now considered to protect people. The management of the home has become more effective and efficient. What they could do better: There are no statutory requirements made in this report and this is in recognition of the hard work that has been completed. However, the home needs to continue to make progress with care planning. There needs to be some further training and education of staff to improve their practice. There needs to be a period of sustained improvement before the home can progress to a rating that is overall good. Please contact the provider for advice of actions taken in response to this Shouldham Hall Nursing Home DS0000015681.V317585.R01.S.doc Version 5.2 Page 7 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. Shouldham Hall Nursing Home DS0000015681.V317585.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 Shouldham Hall Nursing Home DS0000015681.V317585.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good as the home can demonstrate that the pre-admission procedure provides sufficient information from which to meet people’s needs on admission to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been no change to the pre-admission process since the last inspection and therefore the findings remain the same. The home has a pre-admission procedure that includes the completion of a pre-admission assessment and a visit by the resident and representatives to the home to view the accommodation. Either the manager or the deputy will complete the assessment. The pre-admission assessment contains basic information from which care plans can be written. Family or advocates are invited to take part in the planning process and to view accommodation. The home has a brochure that Shouldham Hall Nursing Home DS0000015681.V317585.R01.S.doc Version 5.2 Page 10 contains the service users guide and this is sent to all prospective residents or given to them when coming to view the home. All personal items are listed on admission and people have a six-week trial period of stay at the end of which a placement meeting is held to review whether a permanent placement is appropriate. Full care plans are developed during the first two weeks, during which time information can be gathered. Any immediate care plans and risk assessments are written within a few days of admission. For instance, moving and handling assessments and risk assessments relating to any special requirements. The home does not provide intermediate care services. Shouldham Hall Nursing Home DS0000015681.V317585.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 and 10 Quality in this outcome area is adequate, as the home has made significant progress. However, there is still work to be done to fully implement the new systems and to demonstrate sustained improvement before the home can progress to a rating that is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A random inspection was conducted on the 31/08/06 to assess compliance with the requirements made at the last key inspection. At this time progress was seen but further work needed to be done and therefore the requirements were carried forward to this key inspection. Four care plans were inspected. The home has introduced a new care plan format and significant improvements have been made here. The care plans now provide clear detailed information as to how resident’s needs should be met, while focusing on building on the strengths of the individual and establishing aims and goals. A care plan summary has also been introduced Shouldham Hall Nursing Home DS0000015681.V317585.R01.S.doc Version 5.2 Page 12 providing clear succinct information to care staff. The new care plan system has not been fully implemented as yet, however, the home has made good progress and has shown commitment to meeting the requirement. In view of this a recommendation is made that the home continues to implement the new system and comply with the homes own target set on the action plan. See recommendations. Nutritional needs assessments and risk assessments have now been introduced in full, however, some development of risk assessments is still needed. Again these are much better, but the home needs to ensure that all risk assessments are written and easy to access. It is acknowledged that work on the risk assessments is still in progress so, as with the care plans a recommendation is made that this continues until they comply with the homes own targets set on the action plan. See recommendations Since the last key inspection the medication arrangements were inspected by the pharmacist inspector on the 5/07/06 and concerns were still found. As a result, a statutory notice was issued on the 24/07/06 to be complied with by the 07/08/06. The pharmacist inspector returned on the 31/08/06 to assess the compliance with the notice and found that the home had taken positive action and the arrangements were deemed to be safe. At this inspection the arrangements were inspected very briefly with the acting manager and although the system is in the process of being changed, the arrangements appeared to be safe and the home are continuing to conduct regular audits to ensure the improvements are sustained. During the inspection, it was observed that improvements had been made in respect of resident’s privacy and dignity. Positive changes have been made to the environment that offer people more choice and privacy. In addition, some areas, such as the corridors leading to resident’s rooms, are being redecorated to promote dignity and respect. The new care plans also promote dignity and encourage a culture of care that considers issues around respect, choice and independence. Observations of interaction between staff and residents during the inspection confirmed that there has been an improvement in the way that care staff approach residents and some good practice was seen here. Training has been provided to all staff and this has been addressed through the various forms of supervision that are taking place now. Shouldham Hall Nursing Home DS0000015681.V317585.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 and 15 Quality in this outcome area is adequate, as the home has made significant improvements. However, further progress is still to be made in respect of activities and the home needs to demonstrate sustained improvement before they can achieve a rating that is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As already mentioned, a random inspection was conducted on the 31/08/06 and improvements could be seen. The home had implemented a new lunch routine of two sittings so that residents needs could be better met, particularly those that require assistance with their meals. People were being offered meaningful choice of what to eat and drink. The use of plastic bowls to serve softened food had ceased and there was a range of drinking vessels as opposed to the blanket use of plastic beakers. While progress had been made the home were asked to make further improvements in relation to ensuring there was adequate staff on duty at peak times and to consider how the mealtime could be better organised. Shouldham Hall Nursing Home DS0000015681.V317585.R01.S.doc Version 5.2 Page 14 During this inspection it was found that further positive changes have been made to mealtimes. The home has created two dining rooms and this is much better for residents. Each dining room is staffed with designated staff and although the staffing levels were low on the day, the mealtime experience was still much more organised and calmer. The home has so far managed to sustain the improved practice and there was still clear evidence of choice being offered in all respects. Assisted meals were given in a caring sensitive way and care staff demonstrated good practice in this respect. Since the last inspection the home has appointed an activities coordinator for 30 hours per week. Unfortunately on the day of inspection this person was not available for interview. Much improvement has been made in this area and evidence of this can be seen in resident’s records. The home has gathered lots of information in respect of peoples social needs, interest and hobbies and for those that are unable to provide this information it has been gathered from members of the family. The activities coordinator has used information to write individual activities plans for each person that includes one-to-one time and also a group activities plan that incorporates people’s interests and hobbies. Each resident has a record of the activities they have participated in each week. In addition to the work of the activities coordinator, the care staff are being educated as to the meaning of activity as a part of every day life. Residents are being given the opportunity to participate in the activities associated with daily living such as tidying their room, folding laundry and setting the tables. This is a positive move towards providing care in a way that meets people’s holistic needs. Shouldham Hall Nursing Home DS0000015681.V317585.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 and 18 Quality in this outcome area is adequate, as the home can demonstrate that they have procedures in place to enable people to raise concerns and adult protection issues with the confidence that a positive outcome will be achieved. However, there is still some work to be done with the re-education of staff in matters of adult protection before the home can achieve a good rating in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure has not changed since the last key inspection and therefore the findings are the same. The home has a policy and procedure in place for the handling of complaints and a log of all complaints and concerns is maintained. The complaints policy is well-publicised and service users and relatives are aware of how to make a complaint if needed. Since the last inspection the home has developed various consultation processes for service users and relatives. For instance a resident/relatives meeting was held recently and a number of suggestions were made as to how the service could be improved, the home has also conducted surveys. In respect of adult protection, all staff have been trained in this area and update training is planned. Four of the nursing staff are to attend POVA Shouldham Hall Nursing Home DS0000015681.V317585.R01.S.doc Version 5.2 Page 16 training for trainers and will then be able to provide training to care staff inhouse. During the inspection an issue arose with the conduct of a member of staff who used inappropriate language with a resident. While she was well meaning and was attempting to assist the resident to understand why she could not do something, the language was demeaning and negative. This raised two concerns, one in respect of the staff understanding of what constitutes abuse and another about understanding how to support people with dementia. The acting manager was informed of these concerns at the inspection and asked to investigate the incident fully. Based on their findings the home must make a decision about any appropriate action that needs to be taken and at the very least this must include education. Shouldham Hall Nursing Home DS0000015681.V317585.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 and 26 Quality in this outcome area is adequate, as the home have made significant improvements to Bexwell unit. However, there is further work, such as redecoration and improved signage to be completed in Bexwell and Marham units before the home can move to a rating that is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The random inspection conducted on the 31/08/06 showed that the home had made positive changes to enhance the environment in the dementia unit. One positive change was to the name of the unit, which is now called Bexwell as opposed to the EMI unit. This will reduce the stigma of labelling and encourage a different attitude to the people who live there. Shouldham Hall Nursing Home DS0000015681.V317585.R01.S.doc Version 5.2 Page 18 Areas of the home had been redecorated and made more homely. The lighting has been improved in the corridors and in the dining area and signage had been improved. At the key inspection it was evident that further improvements have been made in Bexwell unit. The unit has now been divided into two smaller units with their own dining room and lounge area. The lounge/diner area in Rose has been vastly improved providing a nice homely environment. The décor has been improved and work was underway to redecorate the corridor in rose wing with colours that match the lounge/diner. The other lounge has also been improved and is much more homely, one of lounges in Bexwell has been turned into another dining area that overlooks the rear garden providing a pleasant outlook. The home still needs to improve the signage to aid orientation and recall. Signs on residents door are not robust enough or necessarily aid memory and recall. A tour of Marham wing was undertaken on this occasion and some work is needed here to improve the environment. However, it is acknowledge that the home has been focussing its attention on Bexwell to provide a safe enabling environment and the manager has confirmed that the organisation will be attending to Marham wing in due course. The random inspection determined that the requirements in respect of the environment had been met and this inspection has the same outcome. Shouldham Hall Nursing Home DS0000015681.V317585.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 and 30 Quality in this outcome area is adequate, as the home is able to demonstrate significant progress in relation to staffing. This improvement needs to be sustained over a longer period of time and the home needs to progress with its training plan before the home can move to a rating that is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The random inspection on the 31/08/06 showed that significant progress had been made in the overall area of staffing. The appointment of a training coordinator has been instrumental in driving up standards in this area. The training coordinator has introduced the skills for care induction and all staff have completed this. 10 staff have been registered for NVQ training and although the home will not meet the target for the number of staff to be trained at this level they are showing a commitment to meeting this. Four staff are undertaking the A1 assessors course so that staff can receive more effective in-house support with their NVQ. Shouldham Hall Nursing Home DS0000015681.V317585.R01.S.doc Version 5.2 Page 20 Mandatory training is on a rolling programme and is delivered in- house. Many other training courses have been identified and staff are being provided with the opportunity to enhance their knowledge and skills in areas of personal interest. The training coordinator has completed a training needs analysis with all staff and has developed a individual training plan, a central training plan and a matrix to easily identify what training each member of staff is undertaking. In respect of dementia training, four members of staff are undertaking the Alzheimers society training programme, yesterday, today and tomorrow with the intention of training, supporting and guiding staff on best practice in this area. The acting manager is in the process of completing the registered managers award and is considering training in dementia care at an enhanced level. During the inspection there were no issues about the lack of available staff apart from the fact that staffing levels were lower than usual due to staff sickness on the day. Even so, staff still managed to meet people’s needs adequately at the peak times. Since the last inspection, the issues of staff deployment have been addressed. Staff are now designated to the various wings making more efficient use of the numbers of staff on duty. The current staffing ratio is 10:9:5, which appears to be adequate at present. The home will continue to conduct staffing reviews to ensure that the levels remain at a sufficient level to meet need. The issues identified at the last inspection in respect of recruitment have now been resolved. The home has introduced a staff file checklist to ensure that all relevant checks have been received prior to anyone commencing work. The files relating to 4 new employees were inspected to support this finding. Shouldham Hall Nursing Home DS0000015681.V317585.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 and 38 Quality in this outcome area is adequate, as the home has made significant progress in improving the overall management and management systems in this home. However, the registered manager is currently not working in the home and the home needs to demonstrate that this recent improvement is sustained in the longer term before it can move to a rating that is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the last inspection there were concerns about the management of the home and this was a reflection of the competence of the registered manager. At the inspection in August there were still concerns about the management of the home and as a result requirements were carried forward and a notice was Shouldham Hall Nursing Home DS0000015681.V317585.R01.S.doc Version 5.2 Page 22 issued in respect of medication. Following this inspection the manager became absent from work and at the time of this key inspection had not returned. Since the manager has been absent from work significant improvements have been made and it can be said that the home has met the majority of the requirements made at the previous inspections. The home currently has an acting manager who previously held the position of deputy, a consultant was employed to advise the home on how to achieve compliance, a training coordinator has been employed and more recently another consultant who is employed to drive progress and implement the improvement plan. The operations manager has also had a significant input and has worked hard to maintain good communication with the Commission, providing regulation 26 reports in accordance with the regulations and updated improvement plans showing the progress to date. The management are to be commended on their effort and commitment to improving the service and achieving better outcomes for people who use the service. Good progress has been made with quality assurance and stakeholders have been surveyed for their views on the service. The results have been published in the homes first newsletter, which was sent to the stakeholders involved and to the Commission. Again, the home has shown that they value the views of those that use the service and are committed to making improvements. The home has systems in place for monitoring health and safety, risk assessments are now in place and other health and safety checks are being completed in accordance with the regulations. Shouldham Hall Nursing Home DS0000015681.V317585.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Shouldham Hall Nursing Home DS0000015681.V317585.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 OP7 OP8 Refer to Standard Good Practice Recommendations It is recommended that the registered person continue to implement the new system in respect of care planning. It is recommended that the registered person continues to implement the new risk assessment process and ensures that they are accessible to care staff. Shouldham Hall Nursing Home DS0000015681.V317585.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shouldham Hall Nursing Home DS0000015681.V317585.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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