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Inspection on 18/09/07 for St Dominic`s Nursing Home

Also see our care home review for St Dominic`s Nursing Home for more information

This inspection was carried out on 18th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is well managed. It has a good organisation structure that means all staff are clear about their roles and responsibilities. Staffing levels and staff training at the home are very good. Staff express a high level of job satisfaction and staff turnover is low. Staff morale is good and this is reflected in their positive approach to the residents. The residents are treated with a great deal of respect and their privacy and dignity is preserved. There are comprehensive care plans that promote individualised health and personal care for the residents. There is a very pleasant and welcoming environment. The accommodation is well maintained and is very clean and sweet smelling.

What has improved since the last inspection?

Since the last inspection major building work has begun. This will provide more single accommodation with en suite toilet facilities and improve other areas of the home such as the laundry. During this period the home has not admitted any more residents but has kept the staffing levels at nearly the same level as when it is full. New policies and procedures for the prevention and management of pressure sore have been introduced. These now include protocols for referral to the Primary care trust (PCT) tissue viability nurse. The home has carried out clinical audits of all aspects of medication and of the provision of continence aids. The home has introduced stricter fire precautions, including battery operated door closures. Once the new extension is complete new fire systems with doors linked to the main fire alarm system will be fitted throughout the home, along with a new nurse call system. More staff have achieved the National Vocational Qualification (NVQ) at level two or above.

What the care home could do better:

Whilst care plans are comprehensive, the layout of the plans could be improved to make them easier for staff to use. For example, a more prominent page recording life histories and likes and dislikes would help staff to support the residents in making informed choices and decisions. More attention to detail is needed to ensure that all documentation in respect of the care of residents includes their names, dates of birth and other relevant details. Staff should be diligent in ensuring every entry they make in any record is signed and dated. Whilst it is acknowledged that there are good reasons for the lack of access to the garden during the work on the extension, every effort should be made to ensure that access to the garden is accessible to residents by April 2008. It would be of great benefit to residents if there could be some sort of garden room where they could sit and enjoy the area but still have shelter from the prevailing winds.

CARE HOMES FOR OLDER PEOPLE St Dominic`s Nursing Home 71 Filsham Road St Leonards On Sea East Sussex TN38 0PG Lead Inspector Wendy Mills Key Unannounced Inspection 18th September 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Dominic`s Nursing Home DS0000014040.V348187.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. St Dominic`s Nursing Home DS0000014040.V348187.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Dominic`s Nursing Home Address 71 Filsham Road St Leonards On Sea East Sussex TN38 0PG Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01424-436140 01424 460767 stdominics@ukonline.co.uk St Dominic’s Ltd Mrs Margaret Dempsey Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51), Physical disability (51) of places St Dominic`s Nursing Home DS0000014040.V348187.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is fiftyone (51) Service users must be aged sixty-five (65) years or over on admission Service users with a physical disability may also be accommodated Date of last inspection 28th July 2006 Brief Description of the Service: St. Dominic’s Care Home is a large property in a residential area of St. Leonard’s-On-Sea. It is registered to provide personal and nursing care for up to fifty-one older people, including those with physical disabilities. However, there are some major building works in progress at present and during this time the home is only able to accommodate a maximum of forty residents The home is arranged over four floors. A large passenger lift enables access to all floors. The residents’ accommodation is currently arranged over the upper three floors and each floor has it’s own lounge. Most of the rooms are single, some with ensuite toilet facilities. Many of the rooms have lovely views, either towards the sea or over the surrounding countryside. Outside there are parking facilities to the front of the home and a large garden to the rear. However, the garden can currently not be used by the residents due to the building work in progress. There are plans to landscape the gardens once the work to provide additional accommodation is complete. The weekly fees range between £500 and £650. Fees are based on the assessed needs of the prospective resident. The fees do not include items such as hairdressing, newspapers and telephones in the rooms of residents. Further information can be obtained from the home on request. St Dominic`s Nursing Home DS0000014040.V348187.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was unannounced. It formed part of the inspection process of the Commission for Social Care Inspection (CSCI) under the regulations of the Care Standards Act 2000. This report has been complied using information gained during this visit and information supplied prior to the visit from a variety of sources such as relatives, visiting health and social care professionals and the home itself. During the visit in-depth discussion was held with both the Director of Nursing and the acting manager. Staff were spoken to both in private and during a tour of the home and residents and relatives were spoken to in the privacy of their own rooms. A tour of the home was made and documentation, including staff files and care plans, was examined. Both direct and indirect observation was used throughout the visit. Currently there is ongoing work in the grounds of the home to provide more single accommodation and communal space. This is being very well managed and disruption for the residents has been kept to a minimum. The Director of Nursing, Acting Manager and all staff are commended for the way they have coped with these changes. The domestic and maintenance staff are particularly commended for the way that they have maintained the home and run the laundry during this time. Residents and their relatives said that they believe the care in the home is very good. They said that the staff are lovely and that everyone tries hard to meet their needs. Staff also said that they like working in the home and are given a lot of support to improve their knowledge. Many of the staff have worked at the home for several years. The residents, their relatives and the management and staff of the home are all thanked for the welcome they gave and their assistance throughout this visit. What the service does well: St Dominic`s Nursing Home DS0000014040.V348187.R01.S.doc Version 5.2 Page 6 The home is well managed. It has a good organisation structure that means all staff are clear about their roles and responsibilities. Staffing levels and staff training at the home are very good. Staff express a high level of job satisfaction and staff turnover is low. Staff morale is good and this is reflected in their positive approach to the residents. The residents are treated with a great deal of respect and their privacy and dignity is preserved. There are comprehensive care plans that promote individualised health and personal care for the residents. There is a very pleasant and welcoming environment. The accommodation is well maintained and is very clean and sweet smelling. What has improved since the last inspection? What they could do better: St Dominic`s Nursing Home DS0000014040.V348187.R01.S.doc Version 5.2 Page 7 Whilst care plans are comprehensive, the layout of the plans could be improved to make them easier for staff to use. For example, a more prominent page recording life histories and likes and dislikes would help staff to support the residents in making informed choices and decisions. More attention to detail is needed to ensure that all documentation in respect of the care of residents includes their names, dates of birth and other relevant details. Staff should be diligent in ensuring every entry they make in any record is signed and dated. Whilst it is acknowledged that there are good reasons for the lack of access to the garden during the work on the extension, every effort should be made to ensure that access to the garden is accessible to residents by April 2008. It would be of great benefit to residents if there could be some sort of garden room where they could sit and enjoy the area but still have shelter from the prevailing winds. 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. St Dominic`s Nursing Home DS0000014040.V348187.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 St Dominic`s Nursing Home DS0000014040.V348187.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides the residents, their relatives and supporters, with the information they need in order to make a decision about moving into the home. Appropriate pre-admission assessments are made. This ensures that only those residents who are suited to the home and whose needs can be met are admitted to the home. EVIDENCE: The Resident’s Guide and the Statement of Purpose have been recently been updated. A copy of this guide is given to prospective residents and there is a copy in each resident’s room. Pre-admission assessments of all prospective residents are carried out by either the director of nursing, acting manager or senior nurse prior to a place St Dominic`s Nursing Home DS0000014040.V348187.R01.S.doc Version 5.2 Page 10 at the home being offered. This ensures that only those residents whose needs can be met by the home are admitted to the home. A ten percent sample of care plans was examined during this visit. Comprehensive pre-admission assessments were noted to be in place. Residents said that they had been invited to visit the home before making a decision about whether the home was right for them although due to circumstances some had been unable or did not wish to do this. St. Dominic’s does not provide Intermediate Care. On occasions residents are admitted for planned respite care. Emergency respite care is provided very occasionally. St Dominic`s Nursing Home DS0000014040.V348187.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 home promotes the health and well being of the residents. EVIDENCE: Residents and their relatives said that they are very well cared for. One said, “It couldn’t be better, the staff are very attentive”. Another said that the staff and managers not only care for the residents but they are supportive to the relatives. Both direct and indirect observation showed that the staff treat the residents with respect and that they respect their privacy and dignity. They were seen to knock on doors, speak kindly to the residents and give personal care in a discrete and gentle manner. St Dominic`s Nursing Home DS0000014040.V348187.R01.S.doc Version 5.2 Page 12 A ten percent sample of care plans was examined. These are comprehensive documents that contain the information needed to enable staff to care for the residents. There is good evidence to show that healthcare appointments are made on behalf of the residents. The care plans would benefit from some standardisation of the various forms that are being used. The design of one form in particular meant that it was difficult to see the name and date of birth of the resident and staff had omitted to sign some entries in the care plans. Infection control and nutrition in the home are very good. Nutritional assessments have been carried out and weight is monitored. Those needing help with eating are given the appropriate help in a discrete and kind way. Since the last inspection two clinical audits have been carried out. One audit looked at the way continence is managed in the home and the continence aids that are used. The other looked at the way medication is managed in the home and the interaction with the Pharmacy and GP practice. The aim of this audit was to identify areas where improved efficiency would minimise waste of medicines. The policies and procedures for the prevention and management of pressure areas have been revised. They now include protocols for referral the tissue viability nurse from the PCT. Since the last inspection no resident has developed a pressure sore whilst in the home. However, one resident had one on admission and this is now improving. There are at least two trained nurses on each shift. Records show that they maintain high standards in nursing procedures such as catheter care and continence management. Medicines are stored safely and there are sound policies and procedures for the management and administration of medicines within the home. The home liaises well with local GPs and other health and social care professionals. Arrangements are made for a medicines review for all new residents to ensure that they are receiving appropriate medication. None of the current residents chooses to self-medicate but some prefer to have their medicines at different times and arrangements are made to comply with their wishes. One resident said that she is particularly pleased about this and praised the staff for making sure that she got her tablets when she wanted them. St Dominic`s Nursing Home DS0000014040.V348187.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. The residents are supported to make informed choices and to lead fulfilling and interesting lives. EVIDENCE: Social and emotional needs are identified in the care plans. Residents said that they could choose how they spend their time. Some said that they prefer to spend time in their rooms with their newspapers and television whilst others prefer to meet up in the lounges. There are lounges on each floor. This means that it is easy for the residents to get to a lounge if they wish. Staff have worked hard to make the lounges attractive and there are plenty of pot plants both in the communal areas and it the residents’ own rooms. One resident called it her “indoor garden”. Videos, puzzles, books and games are available. Some residents like to visit each other in their own rooms. St Dominic`s Nursing Home DS0000014040.V348187.R01.S.doc Version 5.2 Page 14 On three afternoons a week there are organised activities such as Yoga and Tai Chi. Staff remind the residents of activities that have been arranged. The library service also visits the home. Relatives said that they are made very welcome when they visit and that they can visit at any time. Unfortunately, due to the building work, the residents have not been able to go out into the garden during the summer. One resident said that she had missed this. There are plans to landscape the rear garden once the work is completed. In the meantime, the home should consider supporting residents who wish to take short walks outside. Arrangements are made for residents to attend church if they wish, or to receive communion in the home. The home has information about the cultural and religious needs of people from different ethnic backgrounds. Meals can be eaten in the dining room or in the resident’s own rooms. There is a varied and nutritious menu. The home uses seasonal foods as much as possible. The main meal is served at lunchtime and there is a choice of food. The home uses the services of a firm that advises on food quality and standards. It ensures that the home is made aware of the availability of seasonal foods and the quality standards of suppliers. This means that food quality is consistent. Residents said that they enjoy their meals and that they always have plenty to eat. There are beverage stations on each floor so residents can have hot drinks at any time they wish. There are also plentiful supplies of individually wrapped biscuits should they wish to have a snack. Nutritional management is good. Nutritional assessments are carried out and weight is monitored. Food supplements are given as required and help with eating is given discretely for those who need it. Staff have a good understanding of the importance of nutrition. St Dominic`s Nursing Home DS0000014040.V348187.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 sound policies and procedures for the management of concerns and complaints and for the protection of vulnerable adults (POVA). The home listens to the concerns of residents, their supporters and staff and acts upon them. EVIDENCE: The complaints procedure is included in the Resident’s Guide. The complaints policy clearly identifies timescales for responding to any concerns or complaints. Residents and relatives said that they know how to complain but said that they had not felt the need to make a formal complaint. Residents said that they can speak to staff or the manager is they have any concerns. One relative said that he felt it would be unlikely that he would ever need to complain, as he was so pleased with the care at the home. A record is kept of complaints. The director of nursing said that nearly all complaints could be sorted out immediately. The one formal complaint that they home had received since the last inspection was discussed. It is clear that the home responded in an appropriate and timely way. St Dominic`s Nursing Home DS0000014040.V348187.R01.S.doc Version 5.2 Page 16 Sound Adult Protection policies and procedures are in place. Staff have received POVA training and Criminal Record Bureau (CRB) Disclosures are applied for as part of the recruitment process. A copy of the East Sussex multi agency guidelines is available in the home and the home has its own flowchart identifying Social Services as the lead agency in any investigation. All staff spoken with during this visit were clear about their responsibility to report any concerns in respect of protection of the residents from abuse. They said that the director of nursing and the acting manager are “easy to talk to” and have an “open door” policy. They said that they would have no hesitation is reporting any suspicion of abuse immediately. St Dominic`s Nursing Home DS0000014040.V348187.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Despite the building work in progress, the environment is safe, sweet smelling and well maintained. This gives the residents a pleasant place in which to live EVIDENCE: At present there is a large building project in progress at the rear of the home. This will provide more single accommodation with en-suite facilities as well as more communal space and a purpose built laundry. The home has taken great care to keep the disruption to a minimum and has managed to maintain good health and safety standards during this time. The décor in and soft furnishings in the home and rather tired and out dated. However, there are plans to completely refurbish the home once the new build St Dominic`s Nursing Home DS0000014040.V348187.R01.S.doc Version 5.2 Page 18 is complete. General maintenance and cleaning in the home is very good and domestic support staff are commended for the way in which they are working throughout the changes. Infection control measures in the home are good. The laundry has had to be re-sited on a temporary basis until the new laundry is ready. The home has managed to maintain sound infection control measures in this area despite the difficulties. The laundry assistant is commended for the way in she has continued to maintain high standards of laundry care. St Dominic`s Nursing Home DS0000014040.V348187.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 excellent. This judgement has been made using available evidence including a visit to this service. Staffing levels, staff training, and staff recruitment procedures are all very good. Consequently staff morale is high and there is a low staff turnover. This means that the residents receive consistent care from a cheerful and well qualified staff team EVIDENCE: Staff rosters show that there are good staffing levels. In the mornings there are three registered nurses (RNs) and five carers, in the afternoons there are two RNs and four carers and at nights there are two RNs and two carers. There has been very little reduction in staffing even though the home is twenty percent down on occupancy due to the building work. The good staffing levels mean that the residents can receive even more support during the disruption. A sample of staff files was examined. There was very good evidence that staff are taking the training opportunities offered to them. The director of nursing has had experience in the education sector and is very keen to promote and support continuing education for all staff. Fifty-five percent of staff now hold a National Vocational Qualification (NVQ), or equivalent, at level two or above. This percentage is predicated to rise to sixty-four percent in 2008. St Dominic`s Nursing Home DS0000014040.V348187.R01.S.doc Version 5.2 Page 20 Staff interviewed said that they are very happy working in the home. They said that they are well supported by the managers and that their views are listened to and acted upon. They confirmed that there are staff meetings and individual supervision. Staff files show that all appropriate pre-employment checks are made. These include a minimum of two references and a Criminal Records Bureau (CRB) check. The director of nursing said that there is also an in-depth interview and that other checks, such a telephone verification of reference source, are made if indicated. The registered providers are commended for the way in which they have supported good staffing levels and staff training. This has led to a low staff turnover and a very committed and motivated staff team. St Dominic`s Nursing Home DS0000014040.V348187.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interests of the residents. EVIDENCE: Since the last inspection the registered manager has retired. An Acting Manager has been appointed and she is currently in the process of preparing to apply to the CSCI for registration. She is well supported in her new management role by the Director of Nursing, who is also the Responsible Individual for the home. Direct and indirect observation showed that they work very well together and that there is a great deal of mutual respect. St Dominic`s Nursing Home DS0000014040.V348187.R01.S.doc Version 5.2 Page 22 Residents, their relatives and staff spoke very highly of both the Acting Manager and the Director of Nursing. They said that they run an open door policy and that they could talk to them and know that ideas and concerns would be taken seriously. One said, “I can talk to them about anything and know I will be taken seriously and that confidentiality will be respected”. The home does not act as appointee for any of the residents. All are supported by relatives or solicitors in this respect. The home holds small amounts of spending money for one resident but in all other cases these monies are managed by relatives of solicitors. The home has an administrative assistant who ensures that any money spent is carefully audited and accounted for. Staff said that the home is well managed and that they appreciated the fact that there was no need to use agency staff. They said that they had been nervous about how things would go when new owners took over. However, they now feel that they are very well supported by both the managers and the owners. The home has taken every precaution to ensure that the home is safe during the building work. No health and safety hazards were noted during a tour of the home. St Dominic`s Nursing Home DS0000014040.V348187.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 X X 3 St Dominic`s Nursing Home DS0000014040.V348187.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. Refer to Standard OP7 OP12 Good Practice Recommendations More attention to detail is needed when staff make entries in the care plans and other documentation. All entries should be signed and dated. Every effort should be made to ensure that residents have access to the garden by next spring. A garden room would be of great benefit to residents. St Dominic`s Nursing Home DS0000014040.V348187.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Dominic`s Nursing Home DS0000014040.V348187.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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