Inspection on 18/02/08 for St Johns House

This inspection was carried out on 18th February 2008.

CSCI found this care home to be providing an Good service.

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 Johns House 27/06/06

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE St Johns House 1 Westwell Road Approach Streatham London SW16 5SH Lead Inspector Lynne Field Unannounced Inspection 09:00 18 February 2008 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 DS0000067463.V353119.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. DS0000067463.V353119.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Johns House Address 1 Westwell Road Approach Streatham London SW16 5SH 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) 020 8679 7849 valcie.lewis@sanctuary-housing.co.uk www.sanctuary-care.co.uk Sanctuary Care Ltd Valcie Eltina Lewis Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (0) of places DS0000067463.V353119.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2006 Brief Description of the Service: The home provides care for 20 older people and is set over five floors in total, although only four are used by the service users. The top floor is given over to office space and sleep-over accommodation. The home is located opposite Streatham Common off the main road between Streatham and Thornton Heath. Parking is available in a small car park to the rear of the home and public transport routes and shops are near by. The aims and objectives of St John’s House are stated as being to provide ‘a ‘home for life’ within a warm, caring Christian environment. We aim to enable our service users to live their lives to its full potential, treating them with respect and dignity at all times. We provide them with privacy, freedom of choice and involve them in decisions concerning their rights, personal welfare and the running of the home’. The registered manager said the current range of fees is charged from £432-61 to £572-25 per week. Additional charges are made for things such as hairdressing and newspapers. DS0000067463.V353119.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This unannounced inspection took place in March 2008. The registered manager and four members of staff were present on the day the inspector visited the home. The inspection included a tour of the home and was facilitated by the registered manager. The inspector checked records, including care plans, staff records and building maintenance records. The AQAA was completed and returned in good time and used as part of the inspection. During the inspection the inspector met and spoke to sixteen residents who live at the home and was invited to attend the planned residents meeting. This was attended by fourteen residents and facilitated by the senior carer. All residents said they liked living at the home and liked the staff, particularly their key worker. One resident said, “I’m never bored” another said, “Its very special here, you get a good choice of food”. The inspector found that the home offers a high level of care and support to the residents. The manager and staff continue to give a good service. Staff were observed to be competent and caring. Staff interaction with residents was observed to be knowledgeable and was conducted in a respectful manner. What the service does well: The home gives the residents choices and they are consulted on all issues in their lives and on how the home is run. The registered manager and staff make the home as comfortable and homely as possible. Residents are able to be individual and make daily choices about how their day will be. For example, one resident said he liked his own company and he is able to stay in his room till he is ready to go down to the lounge. Care plans, risk assessments and goals are all reviewed and evaluated. These reflect the residents’ health and social care needs and give information about how the resident likes their care to be given. Staff help residents to make decisions and include relatives and other professionals when difficult decisions need to be made. DS0000067463.V353119.R01.S.doc Version 5.2 Page 6 Staff know what food residents like and support residents to choose and eat a balanced healthy diet. Staff are encouraged to take responsibility for the training and development and are offered training to help them meet the needs of the residents. 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. DS0000067463.V353119.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 DS0000067463.V353119.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): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service users’ guide are good at providing residents and prospective residents with details of the service the home provides. Long-term residents have their needs assessed by senior staff before they move to the home and know that staff have decided that the home can meet their needs before they move there. Prospective residents and their relatives can come and look around the home and meet staff before they decide to move there. Standard 6 is not applicable, as this home does not provide intermediate care. DS0000067463.V353119.R01.S.doc Version 5.2 Page 9 EVIDENCE: We were given copies of the home’s statement of purpose and service users’ guide. This had been reviewed and updated since the new company had taken over and is individual to the home. It had all the information about St Johns House that would help residents and their family and friends decide if the home would be suitable for them and whether it would be able to meet their needs. The registered manager told us that a copy of each is given to prospective residents at the time their assessment is done. One copy of each stays on the residents file and one copy of each is given to the resident or their representative. The manager told the inspector that she went with another member of staff to visit residents in their home to carry out a full assessment of the person before it is agreed the home can meet their needs and prospective residents are invited to spend time in the home to see if they like it. There had been two recent admissions and we spoke to both residents at length. They told us they had spent the day at the home prior to admission to see if they liked it. Their personal files had a record of their personal history, details of their interim care plans and risk assessments that had been signed by the resident and the manager. Each resident had a signed contract in place. Standard 6 is not applicable, as this home does not provide intermediate care. DS0000067463.V353119.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): 7,8,9,19,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents health and personal care needs are fully addressed in their care plans and action is in place to describe how staff will meet needs and manage or minimise risks. Service users’ social care needs are well met. Medication administration was clear and found to be well documented. Residents administer and control their own medication where appropriate and are protected by the homes policies and procedures for dealing with medicines. Residents are treated with respect and their privacy is protected at all times. EVIDENCE: We case tracked three residents, two who had recently been admitted to the home. There were good concise histories. The resident’s files have preassessment information that was used on admission to draw up a care plan. DS0000067463.V353119.R01.S.doc Version 5.2 Page 11 This is an interim care plan that is drawn up with the resident and their named key worker. The placement is reviewed after six weeks with the resident, their family, social worker and key worker. The care plan also included risk assessments in relation to mobility and falls as well as nutrition. There is a section where the resident’s wishes are recorded of what they want to happen in the event of their death. The resident and the manager had signed this. We were told the organisation is in the process of developing a new care plan system and this will be introduced after the staff have been trained in the new format. Two residents told us about coming to live at the home. They both said they had visited the home before deciding to live there. They said they “like it here” and “staff are kind and listen to us”. One resident said, “They enjoy their own company and like to stay in their room for most of the time which they are allowed to do”. There is a contacts sheet overview folder on each floor where there is an over view sheet kept for each resident. This outlines their daily routines and special needs. These were clear and set out for morning, afternoon, evening and night. The health of each resident is continually monitored and, where needed, specialist advice is sought. This may involve their doctor, visiting optician, dentist, district nurse and other specialists. Professional visits are recorded along with the out come of the visit. There were copies of monthly reviews, risk assessments and medication reviews on file. One resident is able to self medicate at the present time. There is a risk assessment is in place and staff discreetly check the resident has taken their medication. The home has a medication cupboard in each of the small day rooms on each floor, which are securely locked. These contain the resident’s morning and nighttime medication. Lunchtime and teatime medication is stored in the dining room in a locked medication cupboard that is in a suitable cupboard. This ensures that medication is not carried around the house between dispensing and administration. The home uses the blister pack system and has recently changed its provider. The registered manager told us that their pharmacist came to the home to provide the staff with refresher training in the dispensing of medication. We observed the team leader dispensing the medication and noted the medication charts are signed as the medication is given out. During the inspection eight residents medication was checked and all medication was correct. There was a copy of all staff signatures that dispense medication and information about the medications in use. DS0000067463.V353119.R01.S.doc Version 5.2 Page 12 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. Residents are supported to access the local community and maintain contact with family and friends as they choose. Residents are supported to retain control over their lives in areas such as finance as long as possible and their families are encouraged to support and assist them. Meals are nutritious and well balanced. Residents are consulted about menus and expressed preferences are current and up to date. EVIDENCE: On the day of the inspection there was a residents meeting planned that we were invited to sit in on. These are held every month and all residents are encouraged to attend. Twelve residents attended the meeting that is chaired by a member of staff. The minutes of the last meeting were circulated and agreed. On the agenda to be discussed were a number of issues such as new furniture and curtains were to be chosen, samples of the material would be DS0000067463.V353119.R01.S.doc Version 5.2 Page 13 available, when the fountain was to be installed, activities residents would like to take part in and entertainment over Easter and any other business. There was a discussion about using the lift and the doors closing too quickly. This registered manager said she would ask if the time delay on closing the doors could be extended. The meeting lasted for about an hour and residents were encouraged and able to say what they felt. Residents spoke to the inspector individually after the meeting. They made comments such as “they were happy with every thing” another said “it had given them back their life” and the food was excellent. Families and friends are actively encouraged to participate in the daily life of the home with no restriction being placed on visiting times. The bedrooms we were shown by residents were individual and personalised with the use of photographs, small items of furniture. Visitors told us that they are able to come and go as they wish and are always made welcome. They can use the kitchenettes on each floor to make drinks and small snacks but are always offered a drink by the staff. Residents are able to have visitors in their own rooms and rooms are large enough for this purpose. The registered manager said there was not a relatives group at the present time but the home hope to organise one and have regular relatives meetings. The registered manager told us that residents keep control of their finances as far as possible and when not possible relatives are asked to manage their money. The home is not an appointee for any resident. The home holds small sums of money for residents but is not allowed to keep more than £100-00 per person on the premises. We checked the financial records of resident’s money, which were all correct. Receipts are given for all money issued and for all money received on behalf of residents from family or social services. The checking systems of these accounts are robust and open. A varied and nutritious menu is offered with the provision of three main meals each day. Snacks and drinks are available at all times. The meals are served in a way that encourages good appetite. Residents have breakfast served to them in the small day rooms on each floor. Main meals are served in the communal dining room on the ground floor of the home. Residents are given a copy of the menu each week to choose what they would like to eat and each morning they are able choose their meals from the menu, which is shown to them again each morning by the staff at breakfast time. This is displayed on the notice board and showed that a range of food is available which includes fresh fruit, vegetables and home made cakes. Where necessary, special diets are catered for, such as whose who are diabetic are given a choice of food that is suitable for them and nutritional supplements offered as needed. Ethnic meals are provided for those of a different culture. For those who are unable to manage themselves, help is offered in a sensitive and discreet manner. The residents told us that if there is not anything on the menu they like they are able to ask for something else they would prefer. There is a record kept of the resident’s choice of meals and they are encouraged to have varied healthy diet. DS0000067463.V353119.R01.S.doc Version 5.2 Page 14 We were invited to join the residents for a midday meal and spoke to three residents during the meal, who said the food was very good and there was plenty of it. The food was well presented and tasty to eat. The manager said she likes the residents to comment on the menu and uses the comments to ensure the menu reflects the tastes of the residents. Residents are able to have meals in their rooms if they choose and several residents always have breakfast in their rooms. There is a healthy living group, which included discussions on healthy eating and food they would like put on the menu. DS0000067463.V353119.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. Residents and their families are given information on how to complain to the home and to independent bodies and their complaints are taken seriously and investigated fully. Complaints within the home are handled properly and residents feel confident that their concerns will be listened to. Resident’s legal rights are adequately protected. Residents are protected from abuse. EVIDENCE: The complaints policy has been updated to reflect the new provider details and procedures. There is a separate Adult Protection policy and Whistle Blowing policy, which is made available to residents and their representatives, at admission. The manager told the inspector staff have had POVA training and this is ongoing. All the complaints were taken seriously and appropriate action taken to ensure residents’ needs were addressed. We checked the home’s register of complaints and that showed there have been eight complaints reported and investigated since the last inspection in June 2006. The manager told the inspector she investigates all complaints in accordance with the homes DS0000067463.V353119.R01.S.doc Version 5.2 Page 16 complaints policy and procedure. This is documented and the outcomes are fed back to the resident and their family member. We were told the regional manager follows up all complaints during the organisations monthly quality control visits. During the residents meeting all the residents were asked if they had any complaints and they all said they had no complaints. During the course of the inspection we spoke to thirteen residents told us if they had a complaint they would go to their carer or the manager. Residents are given a copy of the organisations complaints procedure “A guide on how to complain” that includes contact numbers for the organisation, the local authority and CSCI as well as a form they can complete and give to the home. DS0000067463.V353119.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): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home is safe, well maintained and comfortable. There are enough bathrooms and they are decorated in a non-institutional manner. Bedrooms are large enough and all have en-suite bathrooms. Residents have personalised their rooms to their own tastes and can bring in some of their own furniture if they choose. The communal areas are bright and airy and the whole home is clean and free from unpleasant smells. EVIDENCE: DS0000067463.V353119.R01.S.doc Version 5.2 Page 18 The home is located in a residential street within walking distance of shops and public transport. The registered manager gave me a tour of the building. The home is clean, well decorated and comfortably furnished. The resident’s accommodation is on four floors of the five floors. There are two lifts to provide access to all four levels but not to the fifth floor where there is office accommodation and the staff sleep in room. There is a dining area and large sitting area on the ground floor. The large central kitchen is where all the main meals are prepared and this leads off the dining area. There are small dining tables and chairs set up in groups of four here residents eat their main meals. The furnishings are of good quality and overall the communal areas are pleasant places to sit. The home has ordered new armchairs and curtains for the communal area. This was discussed in the residents meeting and residents are involved in choosing the fabric for the chairs and curtains. There is a small garden to the front of the home off the lounge area and the residents and staff are planning to install a small fountain. They have chosen the one they like and the workmen were due to come to install it in the next few weeks. On each floor there is a lounge/dining area and kitchenettes that have recently been refurbished. Residents have breakfast in these rooms or in their bedrooms if they prefer. There is a small locked medicine cabinet that hold the morning medication that is dispensed at breakfast time. As well as each resident’s room having an en suite toilet, level access shower and wash hand basin, there are bathrooms on each floor with accessible baths and hoists are available to help residents with mobility needs. All resident’s rooms are wheelchair accessible. Toilets are fitted with grab rails. There are handrails on all corridors. A call bell system is provided. All the bedrooms meet the minimum space requirements and had at least 12 sq m, which also ensured that there was adequate space for those using wheelchairs. There are no shared rooms. Most residents have personalised their bedrooms and they contain photographs, pictures and ornaments. We met and spoke to a number of residents during the tour. When we asked one resident why they did not have many possessions and pictures around their room they said, ”that was because they had lived in a number of bed sits all their life”. One resident was sitting in the hall overlooking the common. They said, “I enjoy the view and it is interesting to see what people were doing”. Another resident said they liked to stay in their room and read their newspaper and another said they spent time in the morning in their room, went down for lunch but liked to come back afterwards. A number of adaptations were made for one resident before she came to live in the home to enable her to be more independent. These were identified when she came for her assessment visit before moving to the home. DS0000067463.V353119.R01.S.doc Version 5.2 Page 19 The home has door guards for all the bedroom doors. Each bedroom has a water temperature chart and the water temperature is taken and recorded daily. DS0000067463.V353119.R01.S.doc Version 5.2 Page 20 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 good. This judgement has been made using available evidence including a visit to this service. Policy relating to the recruitment of staff is good. The home protects residents by obtaining references, CRB checks, and obtains employment histories. There is an effective staff team, they are experienced in the care of the elderly and have access to training that meets their needs and supports the residents. EVIDENCE: On the day of the inspection there were four staff on the early shift and three staff on the late shift plus the registered manager who was supernumerary. This was adequate numbers of staff on duty to meet the needs of the residents. We looked at three staff files. The home operates a good recruitment process, following the organisations recruitment policy and procedures. This includes formal interview, taking up two references, CRB checks and POVA checks prior to appointment. All staff has an employment contract, which include details of their terms and conditions of employment and has been signed by them. Staff DS0000067463.V353119.R01.S.doc Version 5.2 Page 21 are given a copy of the staff handbook, which includes the “Code of practice for Social Care Workers”. We were shown a copy of the annual training programme, which is given to each member of staff and their personal and professional development is discussed in monthly supervision where staff are encouraged to reach their potential. Copies of supervision sessions were seen on staff files and the manager and the member of staff signed these. Staff training and development is reviewed at supervision and appraisal sessions. Staffs said they had access to a range of training and are encouraged to attend training courses. Each staff has a training file that indicated that staff receives adequate training to equip them to meet the needs of the residents of the home. Recent training has included POVA, Fire Training, Food Hygiene, Manual Handling and Infection Control. Certificates for these are kept in the training files. Staff training records, which were confirmed by the manager, show that five staff have gained NVQ level 3 in Care, eight staff have gained NVQ level 2 in Care and two staff are currently working towards NVQ level 2 in Care. All staff have had POVA training in Lambeth’s Policy and Procedures. The home’s records show that there have been no referrals under POVA to date. DS0000067463.V353119.R01.S.doc Version 5.2 Page 22 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): 31,32,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well managed by a manager of good character, long standing experience in care of the elderly. Working practices and associated records ensure that the resident’s finances are safe guarded. The home is operating safe working practices and is following all aspects of the health and safety legislation that protects the health and safety of residents, staff and visitors. EVIDENCE: DS0000067463.V353119.R01.S.doc Version 5.2 Page 23 St Johns House is part of the Sanctuary Care group. The manager is a qualified nurse and also has a Certificate in Management Studies and has completed the Registered Managers Award. She is also an NVQ assessor. Regular staff meetings are held and recent minutes were examined and found to reflect a variety of relevant issues. There is a formal staff supervision system in place which is recorded and staff receive supervision on a regular basis. We checked three residents personal finance records and these were correct. Resident’s money is kept in a locked safe in a separate named locked cash box. Each resident has a personal financial recorded in separate books. The manager said when the residents’ capital builds up it is transferred to the residents’ own named bank account. All financial transactions need two staff signatures and the service user will sign if they are able to. There was a copy of the unannounced financial audit by the organisations head office on file and this was a good report. We were told the home had been checked for asbestos and shown the report which showed the home had no adverse issues that need to be dealt with. The summery reported there was “low risk” to the service users. We checked the fire records and noted different floors are checked each week. There is a fire evacuation program in place and the fire evacuation is done every six months at a different time of day and one is done with the night staff. We were told the fire office was coming in to check the building the next day. There was a fire risk assessment on file. There were fourteen points that had been raised that had all been actioned. All other health and safety checks were inspected and there is a range of certificates available to show these are being properly addressed in the home. The organisation completes the monthly monitoring required by the National Minimum Standards and sends copies of these reports to the Commission. DS0000067463.V353119.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 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 4 10 3 11 3 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 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 3 X 3 DS0000067463.V353119.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. 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 DS0000067463.V353119.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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