Inspection on 19/04/07 for St George`s Witham Nursing Home

This inspection was carried out on 19th April 2007.

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

St George`s Witham Nursing Home 22/05/09

St George`s Witham Nursing Home 31/01/06

St George`s Witham Nursing Home 11/01/05

St George`s Witham Nursing Home 05/07/04

St George`s Witham Nursing Home 24/07/03

Similar services:

Sun Court Nursing Home

Park House Holiday Hotel

Grangewood

Hill Barn

Henrietta House

Pemdale

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

CARE HOMES FOR OLDER PEOPLE St George`s Witham Nursing Home 18 - 20 Avenue Road Witham Essex CM8 2DT Lead Inspector Diane Roberts Key Unannounced Inspection 19th April 2007 09:00 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 George`s Witham Nursing Home DS0000015352.V338329.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 George`s Witham Nursing Home DS0000015352.V338329.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St George`s Witham Nursing Home Address 18 - 20 Avenue Road Witham Essex CM8 2DT 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) 01376 512258 01376 502790 witham@stgeorgescare.com www.stgeorgescare.com Newton Chinneck Limited Amanda Keen Care Home 31 Category(ies) of Physical disability (31), Terminally ill (15) registration, with number of places St George`s Witham Nursing Home DS0000015352.V338329.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 50 years and over, who require nursing care by reason of a physical disability (not to exceed 31 persons) Persons of either sex, aged 18 years and over, who require general palliative care (not to exceed 15 persons) No more than 5 persons may attend the home on a daily basis in addition to the 31 accommodated 31st January 2006 Date of last inspection Brief Description of the Service: St George’s Nursing Home is registered to provide nursing care to adults over the age of 50 years with a physical illness or disability. The home can also take people over the age of 18 who require palliative care. The home is situated in a quiet avenue within walking distance of Witham town centre and local facilities, including the train station. Car parking is available at the home. The home has a courtyard garden with wheelchair access and gardens to the rear. The home has a service user guide and statement of purpose available for information. Fees currently range from £600.00 to £800.24 per week depending upon need. Additional charges are made for chiropody, newspapers, hairdressing and toiletries and the costs are variable depending upon the service. St George`s Witham Nursing Home DS0000015352.V338329.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 7 hours and was carried out as part of the planned inspection programme for this home. The registered manager was available on the day of the inspection along with the managing director/responsible individual and operations manager for the home. The inspection focused upon all of the key standards. A partial tour of the premises was undertaken. Evidence was also taken from the Pre Inspection Questionnaire completed by the home and submitted to the CSCI. Two residents and 3 staff were spoken to during the inspection and a nursing needs assessor who visits the home regularly. Eight residents completed feedback sheets, some with the help of staff. Six relatives and three visiting doctors also completed feedback questionnaires. All these comments were taken into account when writing the report. At the time of the inspection the home was undergoing major building works in order to develop the home for the future and increase the number of beds available. This work is due for completion in late 2007. This has involved moving a number of residents to other homes and reducing the number of beds overall. From discussion and observation of information available, this has been completed in a sensitive and efficient manner. Co-operation from residents, relatives and staff has been good and to date there have been no concerns raised. Residents spoken to at the time of the inspection stated that the changes and building works have not caused them any concern or disturbance. What the service does well: The home provides a high standard of care to the residents. The team provide individualised care and take residents wishes into account. Residents are very happy living at the home. The home has a stable and caring staff team who are knowledgeable. Staff recruitment and training is good. The management team at the home are committed to improving the services they offer and developing the business. St George`s Witham Nursing Home DS0000015352.V338329.R01.S.doc Version 5.2 Page 6 Relatives commented that the team have a good rapport with residents and relatives and treat people as individuals and they care. One said ‘excellent care nothing too much trouble for the staff at St Georges’. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St George`s Witham Nursing Home DS0000015352.V338329.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St George`s Witham Nursing Home DS0000015352.V338329.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management team at the home ensures that they only admit residents whose needs can be met by the team at the home. EVIDENCE: Due to the current building work currently in progress at the home, it was not possible to assess this standard fully. However there have no previous issues in this outcome section and the CSCI feels that residents are appropriately admitted to the home. The manager has a good assessment tool in place and discussion took place around developing a person centred approach to assessment especially with younger long-term residents who may be admitted to the home in the future. St George`s Witham Nursing Home DS0000015352.V338329.R01.S.doc Version 5.2 Page 9 A service user guide and statement of purpose is available to prospective residents. The management team plan to review and update this during the year in line with completion of the building works. Residents who commented all felt that they had the information they needed before coming into the home. St George`s Witham Nursing Home DS0000015352.V338329.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care is provided by a caring, knowledgeable and committed staff team, which gives good outcomes for residents in relation to personal care and healthcare. EVIDENCE: The home has a good care planning system in place. Regular and informative reviews are evident and care plans are individual to each resident, with plenty of detail and information on resident choice. Care plans were also seen to promote resident independence and self worth. A range of risk assessments are also completed and regularly reviewed. Daily notes are informative and evidence resident choice, the care provided and how residents have spent their time. St George`s Witham Nursing Home DS0000015352.V338329.R01.S.doc Version 5.2 Page 11 The care planning system evidences a proactive approach to care and good monitoring and follow up. Where possible the team should work on making the care plans more accessible to residents or their representatives. Discussion was held with the manager on developing person centred care planning and this may help with the gap that the team have on bringing together the social side of care the home, in relation to records. See Standard 12. The manager currently audits the care plans on a monthly basis, sampling at random and this she feels is helping to maintain a good standard at the home. 97 or residents who commented in the homes satisfaction survey in September 2006 said that the care at the home met their needs and care standards were consistent. All of residents who commented to the CSCI said they always received the care and support they needed. It was possible to meet a nursing needs assessor who regularly visits the home. She feels that staff know the residents well and records are good. She also feels that staff are knowledgeable and medication records are always clear. She observes that families obviously have a good rapport with the staff at the home and any meetings that she needs to have with them are well organised by the staff team. Relatives who commented said that communication from the team at the home was good and that ‘nothing was too much trouble for the team at St Georges. Other relatives said ‘ they put the residents first’ and that ‘residents are treated as individuals’. The healthcare needs of residents are met and dealt with in a proactive manner. Records show that where necessary advice is sort from community healthcare professionals. Visiting doctors to the home that commented felt that residents’ healthcare needs were met by the staff at the home and they had the knowledge and skills to provide good care. Comments from visiting doctors included ‘the home provides good individual attention to clients’ and ‘excellent home, no complaints’. Records show that residents’ healthcare needs are addressed promptly and monitored, as required, using regular assessment. Nutritional risk assessments have been put in place and show good input and follow through. The regular weighing of residents has improved but is still a little inconsistent at times. This was discussed with the manager. The home does not have any home acquired pressure sores but is actively caring for residents who have acquired them whilst in hospital. The provision of pressure relieving equipment at the home is good and records show that wound management at the home has a good consistent approach and monitoring. Records state the ongoing condition and size of the wound. The St George`s Witham Nursing Home DS0000015352.V338329.R01.S.doc Version 5.2 Page 12 team have a good link with the tissue viability nurse for advice. Staff have attended wound management courses in and out of the home. The home risk assesses residents in relation to pressure sores and if a risk is identified then there is evidence that this is followed through with the appropriate action taken. This is good practice. Records show that residents have regular access to chiropodists, dentists, optician etc and that they also receive the annual ‘flu jab’. Good risk assessments are in place for manual handling and give good detail on the equipment and slings to be used. These are regularly reviewed. Falls risk assessments are in place and also those relating to the use of bed rails. The home uses a bottle to mouth medication system, which was seen to be well-managed and stock control was good. MAR sheets were maintained in good order and reviews by visiting doctors were evident. Medications are checked in and out of the home via the disposal system, which provides a good audit trail, if required. Controlled medications were checked and found to be maintained in good order. Monthly audits of the medication system are undertaken and the management team are currently reviewing the medication policy and procedures. The care of residents on regular pain relief is good. Records show regular review and assessment, with active input form doctors and Macmillan nurses. Pain control care plans are in place and where necessary in order to monitor more closely, pain assessments are in use. The individual and diverse needs of residents are well identified in the care and activity records. Resident choice is obviously respected and this is evident in the daily records and residents confirm this. 97 or residents who commented in the homes satisfaction survey in September 2006 said that the team at the home respected them and residents spoken to confirmed this. St George`s Witham Nursing Home DS0000015352.V338329.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 good. This judgement has been made using available evidence including a visit to this service. Services provided at the home ensure that outcomes for residents are generally good in relation to social care and meal provision. EVIDENCE: From feedback comments and discussion, residents are generally happy with the daily routine at the home and feel that staff do listen to them and act upon what they say. Residents who were able to comment said that they had choice regarding how they spent their time and whether they participated activity events. From discussion with residents, more flexibility may need to be given to more able residents regarding rising and bed times, but this is a minor issue. Residents commented positively on the activities programme provided by the home on both a group and individual basis. The homes last residents’ satisfaction survey showed that 84 of residents were happy with the activities offered. Comments to the CSCI included ‘I like my room visits and St George`s Witham Nursing Home DS0000015352.V338329.R01.S.doc Version 5.2 Page 14 looking at family photos’, ‘I enjoy most of the activities, I don’t join in with all but I am always invited’, ‘I enjoy the quizzes, bingo, bowls and going out’ and ‘I enjoy the activities very much’. Residents’, who stayed in their rooms, enjoyed the 1:1 visits by the activities officer and records showed that an individual approach had been taken to the event provided. Relatives who commented said that their family member was always help to write cards, read letters and help with sending and receiving emails. Records show that a range of group activities are provided and on the day of the unannounced inspection residents were enjoying karaoke with the activity officer and a keyboard player. From discussion and records, the activities officer is very aware of residents’ individual choices, needs and abilities. Her records are good and show an individual approach. A review should be undertaken to link the activity records in with the social side of the care plan in order to make all staff aware of residents needs in this area. The home has good links with local churches and schools and visitors are made welcome at any time. Records show that residents are on the electoral register. Menus show that a good range of meals are offered. Whilst there is no daily alternative, staff know the residents well and alternatives are offered individually. Residents confirmed this. The management team have recently consulted residents regarding their individual needs in relation to the meal service, as part of the homes quality assurance programme. Individual information was requested regarding residents’ preferences, regarding food and mealtimes, which will feed into the care planning process. Results showed that overall, residents felt that mealtimes were not rushed and that they felt that how the tables were set was important and that mealtimes were peaceful and they had the companionship of others. In addition to this satisfaction questionnaires have been completed in September 2006 which show that 71 of residents are happy with the meal service at the home. Variation and choice of food was an issue and from discussion with the manager, action has been taken following the results in order to improve satisfaction levels. These systems are a good way of obtaining resident feedback in order to affect the management of the home and individual care. Residents who commented on CSCI feedback forms were generally happy with the food at the home but there were regular comments that there were ‘too many mince and chicken with mash’ dishes and some residents would like ‘more modern food’ as they were younger and ‘more fish’. These comments should be considered. St George`s Witham Nursing Home DS0000015352.V338329.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 excellent. This judgement has been made using available evidence including a visit to this service. Residents can be reassured that their concerns would be listened to and dealt with objectively. Staff are trained and systems are in place to help ensure the protection of vulnerable adults. EVIDENCE: The home has a satisfactory complaints procedure in place and quality assurance feedback shows that both residents and relatives are aware of the procedure. The manager has an objective approach to complaints and maintains good records on all concerns and complaints however minor. Records inspected show that all ‘complaints’ were minor and were dealt with promptly and to the residents’ satisfaction. Residents and relatives who commented all said that they would contact the manager in the first instance and were aware of the procedure. The team receive regular compliments and comments include ‘ standards second to none and no other nursing home surpassed their attention to detail’, ‘ quick to recognise when medication changes were needed’, ‘anticipated needs well’, ‘everyone so kind and helpful’, ‘made to feel at home, such a caring nursing home’, ‘everyone so kind and it makes a huge difference at a St George`s Witham Nursing Home DS0000015352.V338329.R01.S.doc Version 5.2 Page 16 difficult time’, ‘good nursing care meant my relative had extra years of quality life’. The home has up to date policies and procedures in place for the protection of vulnerable adults. Training records show that staff are provided with training on this subject and updated when required. From records and discussion with staff, they are aware of residents’ rights and how these need to be taken into account when planning care. Records show that where needed residents are helped to have an independent representative or advocate as required. St George`s Witham Nursing Home DS0000015352.V338329.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 good. This judgement has been made using available evidence including a visit to this service. Although dated with regard to décor in some parts, the home is clean, pleasant and safe. EVIDENCE: Due to the building work and temporary reduction in bed numbers, only the older part of the home is currently in use. This was inspected and found to be clean with no odours. Temporary facilities are in place for the laundry and the kitchen although the latter has been provided by a specifically hired kitchen, which has been placed in the car park at the front of the home. This is working well and staff are happy with the arrangements and outcomes for residents have not been unduly affected. The older part of the building is looking tired and dated in some places. This mainly relates to the bedrooms and bathrooms. St George`s Witham Nursing Home DS0000015352.V338329.R01.S.doc Version 5.2 Page 18 The home has a very pleasant lounge. Plans are in place to refurbish this as part of the build when the new rooms are ready, so that residents can be moved to accommodate this work. The fire risk assessment had been updated to reflect the current building works and other fire safety arrangements were found to be in order. Other maintenance certificates such as gas and wiring were seen to be up to date. It was noted that the home has quite a few oxygen cylinders in use around the home. Correct information was available with the fire safety risk assessment to show that the placement of the cylinders was correct. All senior staff should know where this information is kept. Residents who commented said ‘ my room is immaculate’, ‘my room is cleaned every day’ and ‘the home is always clean and tidy’. The home has up to date infection control procedures in place and the majority of staff have had infection control training in the past couple of years. St George`s Witham Nursing Home DS0000015352.V338329.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 excellent. This judgement has been made using available evidence including a visit to this service. Residents’ needs are well met by a caring and knowledgeable staff team. The management team recruit staff efficiently and are committed to providing a good training programme. EVIDENCE: Despite the temporary reduction in bed numbers the management team have retained the full staff team, recognising the value of the stable team at the home and all the training that has been invested in them. At times, staffing levels are high for the number of residents in the home with 7 – 10 staff on in the mornings, 5 – 6 in the evening and 3 at night. The management team plan to use this valuable staff time to review systems and policies and procedures. The registered provider is committed to providing a well trained and supervised staff team. A training officer is in post and records show that a good staff supervision and appraisal system is in place. The manager has recently had training on providing supervision and plans to develop these systems further with peer/group supervision, with individual supervision available. From discussion and records, staff turnover at the home is low St George`s Witham Nursing Home DS0000015352.V338329.R01.S.doc Version 5.2 Page 20 Staff files were checked at random and found to be in good order with all the required documentation and checks in place. However records show that CRB checks could be sent off more promptly, as in some cases there was a 3 to 4 month delay in getting a result, from the start date of working at the home. In some cases this may be out the homes control. Staff training records submitted to the CSCI show that 39 of the care staff have a NVQ qualification and staff records also show that several staff are currently undertaking this qualification. Records show that trained nursing staff are up to date with regard to both statutory and additional training, such as infection control and palliative care. Care assistant training records also show that there is generally good compliance with statutory training, although some shortfalls are noted in relation to manual handling training. This should be addressed. It is good to see that a significant number of care assistants have been completing a training pack in relation to palliative care. Residents, relatives and visited doctors all commented positively on the staff team. Comments included ‘ always willing’, although they are often busy, they come as quickly as they can’, ‘they actually care’, ‘staff always helpful and friendly’, ‘nothing too much trouble for the staff at St Georges’. St George`s Witham Nursing Home DS0000015352.V338329.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 excellent. This judgement has been made using available evidence including a visit to this service. The management team at the home is stable and experienced. They ensure that the home is run in the best interests of the residents and staff and that outcomes are good for residents. EVIDENCE: Records show that the registered manager keeps herself up to date with regard to statutory and additional training. The manager has a very open approach and from discussion, is keen to ensure that she runs the home with the residents best interests at heart. From discussion with staff she is approachable and very supportive. Regular staff meetings are held along with St George`s Witham Nursing Home DS0000015352.V338329.R01.S.doc Version 5.2 Page 22 representative meetings who have an input into the management decisions made in the home. A wide variety of subjects are covered and detailed minutes are maintained. The management team have significantly progressed the homes quality assurance systems over the last year and appreciate the value that they have in maintaining and improving standards in the home and developing the business. Different staff complete monthly audits on medication, care planning, health and safety and the environment, catering and infection control. Action plans are then produced and dated when completed and signed off by management. Completed audits and action plans were seen. A six monthly in depth audit by the Director of training and development is also undertaken in relation to medication and care planning. Audits are discussed at management meetings and in addition to this, satisfaction questionnaires are given regularly to a wide to a range of people including residents, relatives, visiting professionals etc. At the current time the team are developing a staff satisfaction questionnaire and looking at completing more focused feedback for residents that can feed into the care planning process. Since the last inspection the management team have introduced a more robust system for recording the handling of residents monies. Only small amounts are held on behalf of some residents. These were inspected and found to be in good order. From discussion and records, it is clear that the management team at the home have a proactive approach to health and safety. Environmental and safe working practice risk assessments are in place and the team have completed risk assessments to cover the current building works and temporary changes in services. Accident records are well maintained and there is evidence that management have followed up accidents where required. Accident trend monitoring and individual accidents are discussed at the monthly management team meetings. St George`s Witham Nursing Home DS0000015352.V338329.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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 4 St George`s Witham Nursing Home DS0000015352.V338329.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. Refer to Standard Good Practice Recommendations St George`s Witham Nursing Home DS0000015352.V338329.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 George`s Witham Nursing Home DS0000015352.V338329.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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