Inspection on 18/12/06 for Somerset Nursing Home

This inspection was carried out on 18th December 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.

Other inspections for this house

Somerset Nursing Home 22/05/07

Somerset Nursing Home 24/05/06

Somerset Nursing Home 17/02/06

Somerset Nursing Home 13/07/05

Somerset Nursing Home 09/03/05

Somerset Nursing Home 15/06/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Somerset Nursing Home Somerset Nursing Home 1 Church Lane Wheldrake York North Yorkshire YO19 6AW Lead Inspector Denise Rouse Key Unannounced Inspection 18th December 2006 09:30 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 Somerset Nursing Home DS0000045154.V324844.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. Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Somerset Nursing Home Address Somerset Nursing Home 1 Church Lane Wheldrake York North Yorkshire YO19 6AW 01904 448313 01904 448022 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) Roche Healthcare Limited *** Post Vacant *** Care Home 46 Category(ies) of Dementia (46), Dementia - over 65 years of age registration, with number (46), Old age, not falling within any other of places category (46), Physical disability (46), Physical disability over 65 years of age (46), Terminally ill (4) Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service Users in the category DE and PD must: (i) be aged 50 and over and (ii) require nursing care 24th May 2006 Date of last inspection Brief Description of the Service: Somerset Nursing home is a care home for older people providing personal & nursing care for up to 46 service users. The home is situated in the village of Wheldrake, approximately 8 miles from the centre of York, there are 14 elderly persons bungalows within the grounds of the home. The business is owned by Roche Healthcare Limited. The home provides both single and shared accommodation on two storeys and has a passenger lift. Fees range from social services rates to private rates of £525 per week for residential care and £625 for nursing. Fees include all services apart from hairdressing, dry cleaning, reflexology, newspapers, chiropody and private taxi hire. Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The accumulated evidence used in this report has included: • A review of the information held on the homes file since its last inspection. • Information submitted by the registered provider in the pre inspection Questionnaire • Surveys received from two service users. • An unannounced visit to the home, which lasted six hours and fifty minutes. This included a full tour of the premises. Evidence was gained by direct observation, talking with service users, management and staff. Inspection of records, including care profiles, medication administration records, staff files and the policy and procedure manual. What the service does well: What has improved since the last inspection? The information contained in the service user guide and statement of purpose has been updated to ensure that all parties were fully informed about the services the home provided. Care profiles for twenty five percent of the service users had been updated; all care profiles were being updated and would be reviewed monthly or as the service users needs changed. This ensured that service users needs were known and would be met. Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 6 Management had implemented internal auditing of how care was delivered. Better systems to monitor each department’s performance had been put in place. This had enhanced the quality of the service delivered to all service users. Staffing levels had been improved to ensure that there was more than one nurse in the home each early shift. Training in first aid, fire and dementia had been implemented and had improved the health safety and activities provided within the home. Outer door security had been increased and maintained to ensure that staff and service users health and safety was protected. Dining facilities have been increased within the conservatory and the nurse call system had been extended to cover this area. This has improved the independence of service users and ensured that those using this area could gain nursing assistance as required. The kitchen storeroom fly screen had been repaired and the tray stacker cleaned, the kitchen staff were wearing head ware as required, to ensure food hygiene and health and safety was maintained. A doorbell was fitted on the day of the site visit to aid access to the home. Management input had been increased and internal auditing and assessment of the service had been undertaken, this ensured that areas of concern had been addressed. The medication storage, ordering and medication rounds had been reviewed and improved to ensure a safe and thorough system was in place. What they could do better: Care profiles for all service users must continue to be reviewed and re evaluated, these must be kept up to date and reviewed at least monthly or as service users needs change. Clinical waste must be removed to an external bin daily to prevent any unpleasant aromas occurring. Data sheets for domestic cleaning products must be current and reflect the products in use within the home at all times. To ensure staff could act quickly and appropriately if a spillage occurred. Also a risk assessment must be created for mowing the lawn, Chopping boards and kitchen-flooring seams must be reviewed. The kitchen door must not be held open by inappropriate means. To ensure health and safety is maintained for staff and service users. Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 7 Care staff must receive supervision at least six times per year and annual appraisal, to ensure that service issues and training needs are monitored and any corrective action necessary must be taken by management to address any shortfalls highlighted by this process. 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. Somerset Nursing Home DS0000045154.V324844.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 Somerset Nursing Home DS0000045154.V324844.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): Standards 1 3 Quality in this outcome area is good. Service users received enough up to date information to be able to make an informed choice about the home. Service users were fully assessed prior to being admitted to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service users guide and statement of purpose had been fully reviewed and included service users views about the home. It also now contained information relating to the provision of care for service users with dementia and physical disabilities. This ensures that service users and their relatives could make a fully informed decision about the home. Four service users were case tracked, all had been assessed prior to being admitted, this ensured that their care needs were known and could be met. Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 10 Intermediate care was not undertaken. Somerset Nursing Home DS0000045154.V324844.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): Standards 7 8 9 10 Quality in this outcome area is adequate. Service users health care needs were met, however there were some issues relating to care profiles and medication systems to be addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The management team and staff had worked hard to review how care was being delivered. Changes to staffing levels and daily routines had been made to allow care staff more quality time delivering direct care and to keep care profiles up to date. Monitoring was on going. A team system and shift structure had been implemented to ensure that the team leaders were always updating and reviewing how the shift was progressing, to enable any areas of concern to be addressed immediately. One service user stated “ I am happy with the care I receive, things have been even better over the last few weeks”. Service users were seen to be treated with dignity and respect. Service users were addressed by their preferred name. Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 12 Four service users care profiles were inspected. The management team had undertaken a lot of staff training relating to care profiles. Twenty five percent of all service users care profiles had been reviewed and re written, they were comprehensive and detailed and included care plans for activities and all the service users activities of daily living. Risk assessments were up to date, reviewed and relevant and the management team stated that the rest of the service users profiles would also have been completely re written and evaluated by the end of March. Whilst staff should be commended at the quality of the reviewed care documentation, efforts must not be relaxed until all service users profiles were of the same standard and reviewed at least monthly or as the service users needs change. This was discussed with the management team who assured the Inspector that this would be undertaken and maintained. Service users who had nutritional needs had relevant care plans in situ and were weighed regularly; this ensured their condition was being constantly monitored. The home had also enhanced their dining facilities to enable service users to sit at dining room tables with chairs. This had decreased the number of service users who required full assistance with feeding and had increased the ability of frail service users to maintain their own independence with staff encouragement and assistance. The medication systems within the home were inspected. All medications being received and destroyed were recorded. A dedicated member of staff had been appointed to review and ensure that the medication systems within the home were maintained efficiently and effectively. This individual had created a thorough auditable system, and had worked very hard to achieve such a dramatic improvement in just a few months, this was commendable. The morning medication round was completed at lunchtime on the day of the site visit, by one nurse. This did not ensure medications were given timely. This was discussed with the management team. With immediate effect two nurses were allocated to undertake this duty. This would ensure that service users gained their medication in a timely manner and would allowed nurses to deliver nursing care to service users, once the medication round had been completed. The management of the home will continue to monitor the medication administration systems and keep the Commission for Social Care Inspection informed of their progress. Somerset Nursing Home DS0000045154.V324844.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): Standards 12 13 14 15 Quality in this outcome area is good. Service users received a wholesome nutritious diet, and had access to their preferred range of social activities, which were relevant to their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four service users were case tracked; their preferred social needs were documented within the pre admission assessment, which had formed the basis of their social care plan. This ensured that service users social needs were known to staff and were being met. The activities coordinator had completed dementia training. Following this she had implemented activities on a one to one basis for service users with dementia. This included memory jogging quizzes, or assisting service users to undertake activities within their own environment relating to house hold skills, for example light dusting. The activities coordinator stated that since receiving training in dementia she had felt more job satisfaction and more able to engage and gain the attention and interaction of the service users with Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 14 dementia, this was much improved. All activities undertaken with service users were recorded. Other activities were available within the home, these included board games, television and music. Hairdressing and reflexology was also available for a small charge. Concerts from entertainers were provided. On the day of the site visit a local school children’s choir came to sing carols for the service users. Shopping trips had been undertaken into York, and pub outings were available for service users and their family to attend. Family could take service users home and out for the day as they wished. Local clergy attended the home monthly and as required to provide religious services to all service users. This ensured service users social needs were met. The kitchen was inspected. The food being served looked appetizing and service users stated, “ The food is good”. Puree meals were available. Service users could dine in their own rooms, the lounge areas or in the two dining areas. A three-week seasonal menu had been created, the menu had been enhanced to offer a hot meal at night, supper was available to service users as they wished. All service users were offered alcoholic beverages before lunch, soft drinks were available in the lounges and menus were displayed on all the tables and on a larger chalkboard in reception. Service users were asked in the morning what they would like for their meals for the day. This ensured service users nutritional needs were met. A new dining room and tray menu card system had been introduced, This ensured that all staff were immediately aware, due to the colour coding, the special dietary requirements of service users. A new dietary information sheet was being produced for each service user within the home to ensure that the kitchen staff and chef were fully aware of each service users dietary needs. Staff were observed assisting service users with their food appropriately. If they did not eat their main course alternatives were offered. All service users received assistance with feeding as required, by patient and respectful staff. This ensured that service users nutritional needs were being met. Somerset Nursing Home DS0000045154.V324844.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): Standards 16 18. Quality in this outcome area is good. Service users were protected from abuse; they could be assured that any complaint would be dealt with thoroughly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three complaints had been received since the last inspection; all had been investigated and dealt with in the 28-day time scale. The investigatory notes and outcomes were recorded. All service users had access to the complaints procedure which was contained within the service users guide and a copy was displayed in reception. This ensured that service users and their families were aware of what action to take if they were dissatisfied with the service. A service user and their relative stated that they would be happy to speak to the management team if they had any complaints or concerns about the service. But that they were more than happy with everything at present. All service users were protected by the homes protection of vulnerable adults procedure, staff had received training in this during their induction period .All staff were about to receive a yearly update in house in this subject. A whistle blowing policy and procedure was in place. Staff spoken to were aware of the action they should take if an allegation of abuse was received. This ensured that service users were protected from abuse. Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19 26 Quality in this outcome area is good. Service users lived in a well maintained home, however there were some small issues that required to be addressed to ensure that health and safety was maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All outer doors were secure and prevented any unauthorized access being gained to the home. This ensured that service users and staff were adequately protected. Christmas music playing in reception for service users to enjoy whilst they were dining in the conservatory and dining area covered the fact someone was knocking on the door. Access to the home took a few minutes, the inspector finally knocked on the kitchen window to gain staffs attention. This was discussed with the manager. Whilst the site visit was being Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 17 undertaken a doorbell was purchased and fitted, this was demonstrated as being very effective to alert staff to visitors waiting at the front door. The home had been decorated for Christmas to a high standard, and the estates manager delivered a new large screen television for one of the lounges on the day of the site visit. This had been requested by service users and ensured that their needs were being met. The conservatory had two-nurse call buzzers fitted and was converted into additional dining space. This was well used and enhanced the facilities available to service users. A tour of the building was undertaken. The laundry and kitchen was inspected. There was a wooden wedge holding open a fire door leading from the kitchen. Management immediately removed this; a door guard was to be fitted to ensure that service users and staff were not placed at risk. The coloured chopping boards in the kitchen looked heavily scored and management must review them. Replacements must be provided if required to ensure that food hygiene is maintained. An area of vinyl flooring in the kitchen had stretched at the seam, this allowed dirt to become trapped. This was discussed with the management team; contractors were due to rectify this imminently. This repair must be completed to ensure that health and safety is maintained. The laundry had 10 yellow bags of clinical waste, which had not been taken out first thing in the morning this produced an unpleasant aroma. The handyman removed these bags immediately. Management put measures in place to ensure that this would be removed daily to prevent any nasty smells occurring. In the New Year 10 bedrooms are due to be refurbished, all will then have a lockable drawer for service users use. This will complete a total refurbishment of the home and ensure a high standard of furnishing is provided throughout the home. This ensured that the home would continue to provide a good environment for service users. The domestic cleaning trolleys were inspected, the product data sheets for cleaning products being used on one trolley was out of date and included items not used since 1997. The product data sheets contained in the folders were updated and this was completed during the site visit. This ensured that staff and service users health and safety was being adequately protected. The gardens were well maintained and were accessible for service users who utilized wheelchairs. Garden furniture was available within the grounds for service users and their visitors to utilize. Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 28 29 30 Quality in this outcome area is adequate. Service users were looked after by adequate numbers of well-trained staff, however staff supervision and appraisals were out of date and must be completed as required to ensure staff are adequately monitored. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Management had assessed staffing levels and systems of working and improvements had been made. The level of staffing had been increased to ensure that there were 2-3 qualified staff on duty in a morning, and two staff were undertaking the morning medication round as from the day of the site visit. This ensured service users received medications timely and staff were not placed under excess pressure by having to complete a long and complex medication round. This ensures service users health and safety was being maintained. Twelve staff were enrolled on a dementia course, 4 had completed this. A further 12 places were booked for the next course. All staff had undertaken fire training in line with the requirements of the fire service. First aid training and moving and handling training had also been implemented. This ensured that service users and staffs health and safety was protected. Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 19 The home had achieved a 50 ratio of care staff that held a National Vocational Qualification in Care at level two or three. This ensured that care staff had the correct underpinning knowledge required when delivering care to service users. Protection of vulnerable adults training had been implemented with new induction training .Two staff were scheduled to attend a training course in this subject, and would then deliver this training annually to all staff in house. This would ensure that all staff would be up to date and have the correct knowledge to help protect the vulnerable service users. Staff had worked as a team to tackle the issues highlighted in the last report. Staff spoken with had embraced the new systems put in place by the management team and stated that things were improving as far as staff morale and services provided to service users were concerned. This had helped to enhance the standards of service being delivered to service users within the home. Three staff files were inspected, all had criminal records Beuro checks undertaken and two written references were evident. This ensured that the home was undertaking safe recruitment practices to protect their vulnerable service users. Staff had not received annual appraisals and supervision; the dates for these were scheduled during the site visit for these three staff. A schedule of all staff supervisions was faxed to the Commission for Social Care Inspection. This must be undertaken to ensure that management are monitoring the service delivery given by care staff and to ensure that staffs performance is monitored. Staff would also be able to ask for further training and support as necessary to maintain and enhance the standards of care within the home. Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31 33 35 38. Quality in this outcome area is adequate. Service users live in a home, which has been managed to a higher standard since the last inspection, this has improved conditions for service users and staff. However these improvements must be maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The management team must be commended for auditing and implementing better working systems and reviewing the services available within the home. Staff have made commendable efforts to improve services within the home since the last inspection. The acting temporary manager and operations manager had worked well as an effective team, to rectify the shortfalls Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 21 highlighted by the lack of managerial continuity and auditing undertaken by the previous acting manager. A new full time manager was due to commence at the home in January 2007. This should ensure that with the correct induction the home would continue to improve. Management had implemented auditing care profiles for new service user after 2 weeks, to ensure that all basic care plans were completed and after 4 weeks to ensure that care profiles were fully up to date and reflect all the new service users needs. Care professionals relatives and service users were about to be surveyed for their views of the home. This quality assurance process was undertaken yearly. Internal auditing occurred in the kitchen, the chef completed a weekly and monthly audit relating to the standards of food provided and safe systems of food handling. This ensured that the kitchens performance was constantly reviewed by management, and ensured that the service provided was effective. The estates manager completed a monthly regulation 26 visit; a report of this was sent to the Commission for Social Care Inspection. This included any issues relating to the home, and ensured that the Commission for Social Care Inspection was kept fully informed of how the home was being operated. Staff, resident and relatives meetings had commenced and were undertaken every two months. Minutes were recorded and displayed for staff and service users to read. This ensured that they were fully informed of any issues within the home. A risk assessment for mowing the lawn was required to be created. To ensure that the health and safety of the maintenance man was maintained whilst undertaking this task. Two case tracked service users personal allowances balances were checked and found to be correct, this ensured that service users were protected from financial abuse. Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 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 2 X 3 X 3 X X 3 Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15 (1) (2) Requirement Timescale for action 30/03/07 2 OP9 13 (2) 3 OP19 16 (g) (k) 13 (4) (a) The remaining 75 of service users care profiles must be reviewed, re evaluated and rewritten as necessary to reflect the service users current care needs. Medication systems and 27/02/07 medication rounds must continue to be audited by management and any necessary improvements must be made. The chopping boards in the 27/02/07 kitchen must be assessed by management, and replaced if necessary. The vinyl kitchen flooring which is lifting at the seam must be repaired. The kitchen door must not be held open by inappropriate means. Yellow clinical waste bags must be removed from the sluice at least daily, to prevent unpleasant odours occurring. Cleaning chemical information must be current for all products being used within the home. Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 24 4 OP31 12 The management team must 27/02/07 ensure that the new home manager continues to maintain the improvements to the home, and continues to audit each department and rectify any areas of shortfall identified within the service. 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 OP31 Good Practice Recommendations The manager must create a risk assessment for mowing the lawn. Somerset Nursing Home DS0000045154.V324844.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Somerset Nursing Home DS0000045154.V324844.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. 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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