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Inspection on 30/05/06 for St James Park Nursing Home

Also see our care home review for St James Park Nursing Home for more information

This inspection was carried out on 30th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

People considering moving into St James Park receive a full assessment and are provided with the opportunity to visit and spend time at the home to make sure that it is able to meet their needs. Residents are offered a menu that provides a varied and well balanced diet served in pleasant surroundings. A menu to order breakfast, lunch and supper is provided for the following day and is currently being further improved to include a late supper. On the days of inspection the home was very clean, of comfortable temperature and adequately staffed. The home is well equipped, attractively decorated and suitably furnished. The standard of care provided by trained nurses is very good, and a programme of recreational and social activities is provided.

What has improved since the last inspection?

For long-term residents the standard of care planning is now very good and in accordance with requirements of the previous report staffing levels have been increased and faulty aspects of the premises remedied, including effective treatment and redecoration of damp spots and discreet storage of personal items.

What the care home could do better:

A care plan based on essential assessment must be drawn up for each resident, including those accommodated for only a short period of time, to ensure that staff know what to do for each resident to meet their personal, social and health needs. The home must ensure that residents receive prompt attention, are protected from risks associated with medicine errors and their dignity is promoted.

CARE HOMES FOR OLDER PEOPLE St James Park Nursing Home Bradpole Bridport Dorset DT6 3EU Lead Inspector Gloria Ashwell Key Unannounced Inspection 12:00 30 May & 1st June 2006 th 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 James Park Nursing Home DS0000020498.V296121.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 James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St James Park Nursing Home Address Bradpole Bridport Dorset DT6 3EU 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) 01308 421174 01308 427564 www.bupa.co.uk BUPA Care Homes (CFC Homes) Limited Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46) of places St James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2005 Brief Description of the Service: St James Park is a large care home registered to provide nursing care to a maximum of 46 older people, owned by BUPA Care Homes (CFC Homes) Limited. The nominated Responsible Individual; is Mrs Greenwood. The home is situated in the quiet country village of Bradpole, a short drive away from the town of Bridport. The home is close to a bus route, with a bus stop within walking distance for buses to and from Bridport. The accommodation is arranged over three floors and a passenger lift provides access to all floors of the home. Currently available for use are 30 single and six double bedrooms; most have en-suite facilities. (Some rooms registered for use as bedrooms are not routinely used for this purpose.) Communal rooms include a lounge, library, conservatory style dining room, three communal lounges (including one with a large dining area), five assisted bathrooms and one assisted shower. Laundering of clothing and household linen is carried out at the home and arrangements can be made for chiropodists, opticians and other health and social care professionals to visit individual residents. Fees are charged weekly; at present fees range between £500 and £722 per person. St James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a statutory inspection required in accordance with the Care Standards Act 2000. The inspection was unannounced; the inspector arrived at 12.00 on 30 May 2006, toured the premises and spoke to residents and staff and Mrs Walters to arrange the next visit which took place at 10.00 on 1 June 2006 when documentation relating to care provision and the premises was discussed and examined. The duration of the inspection (both days combined) was 7 hours. The previous registered manager left the home’s employ during February 2006; since that time the day to day running of the home has been overseen by Mrs Melody Walters, the registered manager of The Hyde, being a nearby care home registered to the same provider organisation. During the inspection the inspector spoke to Mrs Walters, nursing, care and household staff and 17 of the 32 residents accommodated at the time. The inspector observed staff interaction with residents and the carrying out of routine tasks. During the inspection, particular residents were ‘case tracked’; for example, for evidence regarding Standards 3, 7 and 8, records relating to the same resident were examined, and the resident spoken with. Additional information used to inform the inspection process included the monthly reports regularly sent to the Commission by the provider organisation, the Pre-inspection Questionnaire completed in advance of the inspection by Mrs Walters and comment cards completed and sent to the Commission by doctors, social care professionals and the relatives of service users. During this inspection compliance with all key standards of the National Minimum Standards was assessed. What the service does well: People considering moving into St James Park receive a full assessment and are provided with the opportunity to visit and spend time at the home to make sure that it is able to meet their needs. Residents are offered a menu that provides a varied and well balanced diet served in pleasant surroundings. A menu to order breakfast, lunch and supper St James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 6 is provided for the following day and is currently being further improved to include a late supper. On the days of inspection the home was very clean, of comfortable temperature and adequately staffed. The home is well equipped, attractively decorated and suitably furnished. The standard of care provided by trained nurses is very good, and a programme of recreational and social activities is provided. 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. St James Park Nursing Home DS0000020498.V296121.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 James Park Nursing Home DS0000020498.V296121.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (The home does not provide intermediate care so Standard 6 does not apply) Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. Prospective residents (or their representatives) are provided with information about St James Park and are encouraged to visit in advance of admission to establish their impressions of life at the home and the standard of available accommodation. Prior to admission, the needs of each proposed resident are assessed and the home then writes to prospective residents confirming the ability to properly care for them. EVIDENCE: The records of two recently admitted residents included details of preadmission assessment which had been carried out by the Deputy Manager when she visited the hospital where the residents were at the time accommodated. St James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 9 Because both prospective residents were unwell a close relative of each visited St James Park to view the premises, in advance of admission. The inspector spoke to one of these residents who confirmed satisfaction with the home and said “The staff are very nice…it’s very nice here”. St James Park Nursing Home DS0000020498.V296121.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is frequently poor; from discussion with residents and staff there is evidence of generally good care provision but a number of areas for improvement were identified from these discussions and direct observation. This judgment has been made using available evidence including a visit to the service. Care plans for permanent residents are well written, but residents accommodated for a short period of time do not have a care plan so staff may have insufficient information to guide their actions. Resident’s health needs are mostly met and periodic audit of accidents is recorded to minimise risks of recurrence. Residents with complex health needs including wound management receive good nursing care. Handling of medicines prescribed by doctors must be improved to ensure the safety of residents, the correct administration of medicines and consequent provision of good care. Residents feel they do not always receive an acceptable level of respect and their dignity is not properly protected. St James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 11 EVIDENCE: In general residents believe they are properly cared for; comments made to the inspector included “I can’t praise it enough, everybody’s so kind, they do so much for us”. However, some residents said they sometimes have to wait a long time for a response after ringing the call bell; “there is a delay – they’re (the staff) having their lunch, they’re having their tea, and you have to be patient and that is a little weakness…”, “they don’t answer my bell (but do come eventually)” and “they anticipate what is wanted and think ‘Oh they can wait…’”. Residents were unaware of the provision for two types of ‘nurse call’, one for less urgent needs, and one for emergency. It is recommended that the call bell information is reliably imparted to all residents, to ensure they understand that emergency calls will receive a rapid response. For most residents there is a written plan of care ensuring that staff have sufficient information upon which to base their care practice but for residents receiving short term (‘respite’) care there was no care plan with reliance placed on the pre-admission assessment. An associated requirement is included in this report, to ensure that staff have sufficient information to properly meet each residents needs. Medicines prescribed by doctors are safely stored and carefully administered to residents by trained nurses, thereby protecting residents from medicine errors. In general, residents receive prescribed medicines at the correct times and in correct amounts but on some recent occasions medicines have not been given because the home had run out of stock; the manager said that the home is contemplating changing to another dispensing pharmacy because the one currently used frequently fails to deliver medicines on time. It is required that appropriate arrangements are made to ensure that the necessary medicines are at all times available for administration, to ensure that residents health needs are properly met. Residents wishing to do so can manage their own medicines in accordance with a risk assessment process; none have chosen to do so at present. During the second day of inspection the nurse administering lunchtime medicines left the trolley containing the medicines wide open and unsupervised in a communal room, which at the time accommodated residents of varying needs and abilities, including some with mental confusion. One of these residents might have unwittingly picked up a container of medicine and consumed the contents, or given them to another to consume; to leave an St James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 12 opened medicine cabinet unsupervised is a very dangerous act, and always considered to be very bad nursing practice. The manager closed the trolley and undertook to address this serious oversight with the nurse in question. During the first day of the inspection staff were heard to respond to a resident’s repeated requests to be assisted to a toilet by saying “There’s someone in there, you’ll have to wait a minute”. In that vicinity were 4 toilets; only one was in use. When questioned by the inspector staff first said that the other toilets were not for general use, because one was for persons with a particular infection, one was for staff and visitors, and the other only for residents not requiring the use of a hoist to transfer from wheelchair to chair. The particular resident did not require a hoist so this matter was brought to the attention of the manager who confirmed that staff would receive urgent retraining regarding the need to meet resident’s needs promptly, and to make proper use of the available facilities. On this same day many residents were moved from the dining table after lunch and seated in easy chairs, without residue of food being wiped from their mouths; staff agreed with the inspector that the convenient positioning of tissues for this purpose would encourage them to clean resident’s faces when necessary, and as often as necessary. This matter was also discussed with the manager who agreed to meet this need; on the second day of inspection all resident’s faces were free from food residues. Some residents do not think that all staff are suitably polite, in particular one commented “the younger ones….some have bad manners…grumpy…the older ones are my friends”. St James Park Nursing Home DS0000020498.V296121.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The quality of daily life in the home is good with residents assisted to maintain as much independence as possible. Social and leisure activities are suited to the preference and ability of each resident. Residents are encouraged to maintain contact with the local community and visits by their friends and relatives are welcomed by the home. Meals are appetising and of good quantity and quality. Most residents take meals in the large dining room on the ground floor; others receive them in their bedrooms. St James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 14 EVIDENCE: The inspector spoke to a number of residents; all those able to express an opinion indicated satisfaction with the range of activities and meal provision. The home employs an Activities Organiser for 30 hours each week to arrange local excursions, visiting entertainers, one-to-one and small group social and recreational activities. Few of the frail and seriously unwell residents were able to express an opinion regarding the standard of recreational activities and social life within the home. A number of more able residents said that because the very frail residents use the main lounges and dining room they rarely go into these rooms and prefer to remain in their bedrooms; a recently admitted resident observed “when I went downstairs there was no-one to talk to, because the ones who can talk stay in their rooms…”. This was confirmed by other residents who said “there are things to do, but we don’t take part…we remain in our room” and “we could go downstairs (to the activities)…but we like our own company”. Other residents said they are very satisfied with the standard of recreational and social activities; one said “I’m wholly in favour of them…(the Activity Organiser) thinks of a lot of things…day trips…birthday cakes with candles…”. On the day preceding the inspection some residents had visited nearby West Bay, being transported by a hired minibus with dedicated driver, and accompanied by a number of staff from the home including a nurse. Visitors are welcome at any time and those the inspector spoke to said they are always made to feel welcome and placed at ease by the staff. On the first day of the inspection the inspector observed the serving of lunch in the dining room. Residents appeared to be generally satisfied with the quality, choice and quantity of food provided; one resident described it as “not bad…a menu every day from which we choose what we want…” and another said “it’s excellent”. The home is in the process of introducing ‘satellite kitchens’ to ensure provision of healthy finger foods, sandwiches, yogurts and ‘smoothies’ (fruit based milk drinks) at times when the main kitchens are closed e.g. late evening and during the night. Also, the menu is being reviewed, to include a separate evening menu in addition to the 3 main meals of the day, and desserts based on fresh fruit. St James Park Nursing Home DS0000020498.V296121.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The complaints procedure provides information on the procedure to follow to persons wishing to make complaint; all complaints are recorded and properly investigated. The home protects residents from harm and abuse. EVIDENCE: During the 12 months preceding the date of this inspection the home has received 12 complaints. On investigation 3 were substantiated, 5 partly substantiated, and the remaining 4 were not substantiated. The number of complaints received against the home has recently diminished; none have been received since 1 February 2006, and no written complaints have been received since September 2005. To ensure residents and their representatives have access to the complaints procedure it is included in the service user guide to the home and a copy is provided to each resident. St James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 16 Residents able to converse knew how to complain and indicated they would feel confident in doing so. One explained, “I’d go to the head one…but I haven’t had anything to complain about…”. The home adheres to a policy/procedure for the prevention of abuse and staff have received training in this subject to ensure that they remain vigilant to protect vulnerable residents from risks of abuse and know how to properly manage any allegation or suspicion of abuse. St James Park Nursing Home DS0000020498.V296121.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. St James Park is a well-appointed and comfortable home, being almost entirely purpose-built and thereby suited to the needs of frail, elderly people. On the days of inspection the home was clean, pleasant and hygienic and there was evidence indicating that this is the usual standard of provision. EVIDENCE: St James Park is a spacious and well designed home, with wide corridors, good sized bedrooms, bathrooms equipped for the use of persons requiring assistance and comfortable communal rooms. The home was clean, tidy and comfortable throughout; there were no unpleasant odours. St James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 18 Residents stated that this was the usual high standard; one described the cleanliness of the home as “excellent”. Household staff said they had suitable and sufficient equipment and cleaning materials and felt well supported in their role. St James Park Nursing Home DS0000020498.V296121.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. The home employs enough staff to meet the needs of residents and to ensure their safety and comfort and the good condition of the premises. Recruitment practices ensure the protection of residents from potentially unsuitable staff. Staff receive appropriate training and are competent to carry out their jobs, thereby ensuring that residents are cared for by persons trained in this work. EVIDENCE: Trained nurses lead the care teams and at all times the home is in the overall charge of a trained and competent nurse. Staffing levels are provided in accordance with the assessed needs of residents to ensure that at all times sufficient staff are available to properly meet their needs. The inspector spoke to a number of staff, including registered nurses, care workers and household staff. All were enthusiastic about their work and felt that they provided a good standard of care to residents and are properly supported by the management and training provision. St James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 20 The records of 3 recently employed staff members were examined and found to contain all essential information including two written references, an interview assessment, health details, evidence of identity and of induction training. The provider organisation has an enthusiastic approach to staff training; recent topics for trained nurses have included catheter management and imminent subjects include nutrition, medicine handling and care planning. A nurse described the training provision as “very good”. At present 64 of the care staff currently employed by the home hold a National Vocational Qualification in care; the home thereby meets the standard for at least 50 of the care staff to hold an NVQ. St James Park Nursing Home DS0000020498.V296121.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the service. During the current absence of a permanent manager the home is regularly monitored by a visiting manager. Staff understand their work and receive training appropriate to their needs. Residents and their representatives are satisfied with the home and feel staff care for them well and put them at their ease. The home has implemented a quality assurance system to ensure that residents remain satisfied with all aspects of the home. With the exception of the personal allowances of some residents, the home does not manage the finances of residents. St James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 22 The premises and equipment are properly maintained in good condition to ensure they are safe and suited to their purpose. EVIDENCE: The previous registered manager left the home’s employ during February 2006; since that time the day to day running of the home has been overseen by Mrs Melody Walters, the registered manager of The Hyde, being a nearby care home registered to the same provider organisation. As a short term and temporary resolution this is acceptable to the Commission. The provider organisation is at present seeking to recruit a full-time manager for St James Park. Mrs Walters is supported in her role by a deputy manager who is an experienced nurse employed at St James Park on a full time basis. The home has ongoing systems for quality assurance; a satisfaction survey is periodically issued with responses audited by the provider organisation and a consequent action plan implemented by the manager to ensure any shortfalls in provision are met. It is recommended that the outcome of these surveys is made known to service users and that the home undertakes specific quality assurance work to ensure that residents are satisfied with the response to calls for assistance (as described for Standard 8 of this report). Periodic meetings for residents and their relatives take place; the most recent was on 5 April 2006 and the next is planned for July 2006. It is recommended that records be kept of these meetings to enable monitoring of progress to meet suggestions and areas identified for improvement. With the exception of the personal allowances of some residents (for which all transactions are confirmed by receipt), the home does not manage the finances of residents. Staff trained in First Aid and health care are on duty in the home at all times. All staff are supervised and each has a personal profile containing records of appraisal. Details of equipment servicing and maintenance were provided to the Commission in a questionnaire. The inspector examined some records to verify this information including the following: - records of regular checks/tests of fire safety equipment St James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 23 - passenger lift: routine service 4 November 2005 (arrangements have been made for the next service visit; these take place at approximately 6 monthly intervals). St James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 24 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 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 2 X 3 X X 3 St James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 25 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 & OP8 Regulation 15 & 13 Requirement For each resident a care plan must be drawn up from a comprehensive assessment including reference to nutrition and skin condition. Appropriate arrangements must be made to ensure that the necessary medicines are at all times available for administration. At all times all medicines must be securely stored. Staff must ensure that residents do not experience undue delay when requesting assistance to go to toilets. Staff must at all times maintain residents dignity and comfort. Timescale for action 01/07/06 2. OP9 13 01/07/06 3. 4. OP9 OP10 13 13 01/07/06 01/07/06 5. OP10 12 01/07/06 St James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 26 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. 3. 4. Refer to Standard 7 33 OP33 33 Good Practice Recommendations It is recommended that call bell usage information be reliably imparted to all residents. It is recommended that the outcome of quality assurance and satisfaction surveys be made known to service users. It is recommended that the home undertake specific quality assurance work to ensure that residents are satisfied with the response to calls for assistance. It is recommended that records be kept of Residents Meetings arranged by the home. St James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 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 James Park Nursing Home DS0000020498.V296121.R01.S.doc Version 5.2 Page 28 - 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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