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Inspection on 04/01/07 for St Quentin Nursing Home

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

This inspection was carried out on 4th January 2007.

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

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

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

What the care home does well

The home continues to provide a high standard of care to the residents. Residents were very complimentary with regards to the service and provisions provided within the home. Staff were observed during the process of the inspection to interact and communicate with residents in a respectful and professional manner. Recruitment of staff was in line with the guidelines of the National Minimum Standards. Documentary evidence confirmed a continuing adherence to the quality of staff selection, recruitment effort and practice, which remains impressive. The management have established a comprehensive procedure for interview, selection and appointment of staff. This involves a standard application form to assess and profile, two references taken and CRB (enhanced) checks being returned before a contract is offered to successful candidates. No staff would be employed prior to a POVA check.

What has improved since the last inspection?

Improvements have been made in relation to care planning records pertaining to pressure area care. Bedroom 1 and 19 have received new furniture. A new hoist/stand aid has been purchased.

What the care home could do better:

A programme of maintenance is ongoing but slow in some areas. Several doors were badly marked and scratched and in need of attention. Many of the external windows were showing signs of wood rot and in need of replacing or making good. Several carpets in the home were badly stained and either need deep cleaning or replacing. The hot water supply to the home is not sufficient and several rooms do not have a supply of hot water. Some areas were reported to be too cool. Staff are currently transporting hot water from room to room manually, to meet personal hygiene requirements of the residents. This is a real hazard and could be dangerous for residents and staff alike. A requirement for this to be rectified was left on the day of the inspection. Hot water outlets must have water available as near to 43.C as possible. The home has been asked to supply the Commission with a report on the progress of this work. The thoroughness of staff selection has a significant effect upon the provision of care to ensure protection of residents. However, residents were not fully supported and protected by these practices, as not all new staff undergoes a thorough induction process. The two most recent members of staff recruited had not been subject to an induction programme. This is a requirement of the report. Training for the protection of vulnerable adults has been delivered to some of the staff but this needs to be completed for all staff, to fully protect the service users. This is required to raise awareness and promote positive practices. Not all care staff have received two monthly supervision as outlined in the National Minimum Standards. This is a requirement of the report.Not all night staff have received four fire drills a year in line with the Fire Authorities requirements. This is a requirement of the report.

CARE HOMES FOR OLDER PEOPLE St Quentin Nursing Home Sandy Lane Newcastle Staffordshire ST5 OLZ Lead Inspector Mrs Sue Mullin Key Unannounced Inspection 4 January 2007 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Quentin Nursing Home DS0000026964.V317321.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 Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Quentin Nursing Home Address Sandy Lane Newcastle Staffordshire ST5 OLZ 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) 01782 662911 01782 620255 St. Quentin Residential Homes Limited Angela Harrison Care Home 33 Category(ies) of Dementia (2), Old age, not falling within any registration, with number other category (33), Physical disability (4) of places St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 2 DE(E) 33 PD over 60 years Date of last inspection 14 December 2005 Brief Description of the Service: St Quentin Nursing Home is registered for 33 residents who require twentyfour hour nursing attention. The home is a large detached property that has been extended to provide comfortable accommodation on two floors. A passenger lift provides access between the floors. There are two lounges and a dining room situated on the ground floor. The aim of St Quentin Nursing Home is to provide a high standard of nursing care provided by an experienced and competent team of staff. The home is set in approximately one acre of very pleasant gardens, a mile or so from the wide range of community facilities provided in the town of Newcastle under Lyme. There are adequate parking facilities. Weekly fees start at £469 and go up to £500. St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspection officer undertook this unannounced key inspection. The methodologies used to ascertain the quality of the service delivery and the effectiveness of the management of the home, involved the interviews of residents and staff. Records with reference to the home policies, procedures and practices were examined, in view of establishing the robustness of care and support provided to service users. A sample tour of the premises was undertaken with reference to the suitability of the environment in meeting the needs of the resident group and to ensure that equipments in use complied with health and safety, to promote the welfare of individuals accessing the service. The home provides a good quality of care and support to the residents in their care. Residents spoken to expressed their contentment with regards to the service and the assistance provided by the staff team. Unfortunately no surveys were completed by residents or returned to the CSCI despite being handed out. There were no comment cards completed by other health professionals but relatives returned 5. All 5 had ticked the boxes with positive points and two made additional comments as quoted below – ‘My mother had to be moved into nursing care in September last year and she has very fragile skin which breaks down easily. She is nursed on an Airflow mattress and is turned every two hours day and night. The staff are very kind and caring and work to exceptionally high standards. When I visit the home is spotlessly clean and the staff appear happy in their work and the residents appear happy. The manager leads a good team, who have all tried very hard to get to know mum through the dementia’. ‘My mum is looked after by very caring staff’. What the service does well: The home continues to provide a high standard of care to the residents. Residents were very complimentary with regards to the service and provisions provided within the home. Staff were observed during the process of the inspection to interact and communicate with residents in a respectful and professional manner. Recruitment of staff was in line with the guidelines of the National Minimum Standards. Documentary evidence confirmed a continuing adherence to the St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 6 quality of staff selection, recruitment effort and practice, which remains impressive. The management have established a comprehensive procedure for interview, selection and appointment of staff. This involves a standard application form to assess and profile, two references taken and CRB (enhanced) checks being returned before a contract is offered to successful candidates. No staff would be employed prior to a POVA check. What has improved since the last inspection? What they could do better: A programme of maintenance is ongoing but slow in some areas. Several doors were badly marked and scratched and in need of attention. Many of the external windows were showing signs of wood rot and in need of replacing or making good. Several carpets in the home were badly stained and either need deep cleaning or replacing. The hot water supply to the home is not sufficient and several rooms do not have a supply of hot water. Some areas were reported to be too cool. Staff are currently transporting hot water from room to room manually, to meet personal hygiene requirements of the residents. This is a real hazard and could be dangerous for residents and staff alike. A requirement for this to be rectified was left on the day of the inspection. Hot water outlets must have water available as near to 43.C as possible. The home has been asked to supply the Commission with a report on the progress of this work. The thoroughness of staff selection has a significant effect upon the provision of care to ensure protection of residents. However, residents were not fully supported and protected by these practices, as not all new staff undergoes a thorough induction process. The two most recent members of staff recruited had not been subject to an induction programme. This is a requirement of the report. Training for the protection of vulnerable adults has been delivered to some of the staff but this needs to be completed for all staff, to fully protect the service users. This is required to raise awareness and promote positive practices. Not all care staff have received two monthly supervision as outlined in the National Minimum Standards. This is a requirement of the report. St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 7 Not all night staff have received four fire drills a year in line with the Fire Authorities requirements. This is a requirement of the report. 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 Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives are provided with the information they need to choose a home, which will meet their requirements. EVIDENCE: The Statement of Purpose and Service user Guide was available. The Statement of Purpose was recognised as a reflection of the organisational and professional philosophy to meet resident’s needs and enhance their quality of life. Staff continued to complete full assessments of individuals prior to admission. Prospective residents details were recorded on appropriate documentation. Two recent admission records were examined and these offered a clear picture of the resident’s physical, psychological and social needs. The pre-admission assessment represented the foundation for a thorough and detailed care planning process. St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 10 The resident or their relative receives written confirmation to ensure that the home can meet their individually assessed needs. Residents spoken to at the inspection felt very comfortable in the home as they were reassured and supported by the staff. They felt the home was well managed and stated that the staff were very friendly. They felt the quality of the home was good and that the home offered suitable therapies and activities for them in the home. One relative commented on a pre inspection comment card that she was always made welcome when visiting. She also stated that her mother had settled in very well since her admission in September 2006. The home offers a contract of terms of residency to all residents/relatives as soon as practicably possible after admission. St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual health, personal and social cares needs of residents had been established and these were being met by the staff, which were evidenced to have the necessary skills and experience to carry out their duties. EVIDENCE: A selection of care plans were examined during the inspection and it was identified that these were developed well. There was a full initial assessment, which identified individual problems/needs, and care plans had been developed in respect of these and all residents had working care plans in place. Evaluations had been documented in the care plan and referred to in the daily report. There were clear daily entries when there were any incidents had occurred and action plans and risk assessments had been formulated and implemented to manage those clearly identified issues. There was evidence of regular reviews for all care planning activities. St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 12 The information in the care records demonstrated that social workers and health professional are regularly consulted about the ongoing requirements of residents and there was evidence that professional advice was recorded and acted upon. Where significant changes in care needs had been determined, multi disciplinary meetings/reviews are undertaken to ensure that these issues are appropriately addressed. Weights were regularly recorded in the care plan. Care staff when questioned were very knowledgeable about individual disabilities. Senior staff were seen to be very diligent in deploying and directing junior members of staff. The home continues to deliver high quality standards of care. The spiritual orientation of each resident is recognised within care records. Privacy and dignity were high on the agenda and residents agreed that the staff were polite and respected their dignity. St Quentin Nursing Home DS0000026964.V317321.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): 12,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was providing residents with a good quality of life. Residents were provided with a varied lifestyle, which took consideration of individual’s wishes and previous interests. Meals were of a good standard and provided residents with choice. EVIDENCE: The home provided residents with a range of activities based on their choices and previous interests and following discussion with relatives. All the staff were aware of residents’ likes and dislikes and were committed to provide residents with a good service. Residents had the opportunity to take part in small group activities and the staff provided some individual time to residents. This may have been doing manicures or sitting talking to residents. The home had a hairdresser that visited the home and residents had the opportunity to have their spiritual needs met. Residents were encouraged to make choices over their lives. Those who wish to bring in personal possessions are encouraged to do so; there was ample St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 14 evidence to show that has been followed through, presenting a warmth and familiarity. The home’s routines were quite flexible with residents able to take breakfast when they got up. Three residents stated that they could choose how to spend their time and could do things when they wanted. They were complementary with the relaxed environment and the standards of care. During the inspection several residents and staff were seen to be engaged in lively banter. Staff were observed to hold a friendly and sympathetic interaction with residents in lounge areas, and at mealtime in helping those who required assistance. The home was cosy and there was a friendly atmosphere throughout. Visitors were welcomed at any time. All residents spoken to stated that they liked the meals and confirmed that there was always a choice. In addition a resident could always have something that was not on the menu if they wanted and discussions with the cook on duty confirmed that they did make specific meals for some residents that requested it. Observation showed that these meals were well presented and looked appetising. There was always a good choice available and two main meals were cooked each day. These consisted of a variety of fresh vegetables and good quality meat or fish. Fresh fruit was also encouraged with a choice of puddings. The setting for meals was particularly pleasant with attractive table settings and condiments. The home provided a diabetic menu and provided food for residents that needed a soft or pureed diet. The home also provided a range of snacks and there was always food available for residents to eat between meals and during the night if required. St Quentin Nursing Home DS0000026964.V317321.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 adequate. This judgement has been made using available evidence including a visit to this service. Residents and their representatives have access to the complaints procedure, which is on display in the home. Not all staff have been provided with the appropriate training to fully protect the residents. EVIDENCE: The home had a robust complaints process, which included all the details of the CSCI. There had been no complaints made about this home to the Commission since the last inspection. One had been made to the management of the home and was partially substantiated relating to low bed rails and insufficient bed rail bumpers. There were two incidents relating to POVA both concerning standards of care one was not substantiated and one was partially substantiated. Training for the protection of vulnerable adults has been delivered to some of the staff but this needs to be completed for all staff, to fully protect the service users. This is required to raise awareness and promote positive practices. St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some parts of the environment were in need of refurbishment and internal maintenance. Generally, residents were provided with a warm comfortable home. EVIDENCE: The home is able to meet the needs of an elderly population of residents and provides a safe, comfortable, friendly and homely environment. External access is satisfactory for visitors parking, pathways and fencing were safe and there is a very pleasant garden facility for residents to take advantage of. Communal areas were pleasantly furnished with facilities to accommodate social or reflective needs, in a homely setting. Internal access was facilitated with hand and grab rails in adequate, well-lit St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 17 and airy corridors. Wheelchair access was satisfactory throughout all areas of the home. Bedrooms were personalised to meet personal preferences. Three residents spoken to expressed a sense of belonging and satisfaction in the quality and presentation of their living areas. Toilets are accessible to all, and within close proximity to all communal areas. There are sluice facilities available and practices of handling soiled and infected linen were satisfactory. The domestic services in the home were seen to be of a good standard. The residents spoken to remarked that they find the environment always very clean and conducive. There was no evidence of unpleasant smells or unsightly debris anywhere throughout the inspection. The heating arrangements throughout the home are by central heating with guarded radiator convection. The laundry area was clean and organised; procedures were in place for coping with soiled/infected linen with the provision of alginate bags to minimise handling and cross-infection. COSHH training had been provided and data sheets were available. Chemical cleaners were used appropriately throughout the home. A programme of maintenance is ongoing but slow in some areas. Several doors were badly marked and scratched and in need of attention. Many of the external windows were showing signs of wood rot and in need of replacing or making good. Several carpets in the home were badly stained and either need deep cleaning or replacing. The hot water supply to the home is not sufficient and many rooms do not have a supply of hot water. Some areas were reported to be too cool. Staff are currently transporting hot water from room to room manually, to meet personal hygiene requirements of the residents. This is a real hazard and could be dangerous for residents and staff alike. A requirement for this to be rectified was left on the day of the inspection. Hot water outlets must have water available as near to 43.C as possible. St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home are deployed in sufficient numbers with a good skill mix to meet the needs of present resident group. The training programme is ongoing to meet the development needs of all the staff employed at the home. The arrangements for the induction of new staff are poor. EVIDENCE: Staffing levels were satisfactory to meet the diverse health needs of the residents in the home. At any one time there was always trained qualified nursing staff on duty; supported by committed care and housekeeping staff. St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 19 Agency staff and bank staff were deployed to meet identified shortfalls. The care manager continues to have some supernumerary time to meet her management responsibilities, whilst maintaining a working commitment to the shift rota. There was adequate ancillary staff employed in the home, although it was recommended that domestic cover be extended to weekends. The owners undertake maintenance and administration duties. Recruitment of staff was in line with the guidelines of the National Minimum Standards. Documentary evidence confirmed a continuing adherence to the quality of staff selection, recruitment effort and practice, which remains impressive. The management have established a comprehensive procedure for interview, selection and appointment of staff. This involves a standard application form to assess and profile, two references taken and CRB (enhanced) checks being returned before a contract is offered to successful candidates. No staff would be employed prior to a POVA check. The required checks were evidenced from the records. The thoroughness of staff selection has a significant effect upon the provision of care to ensure protection of residents. However, residents were not fully supported and protected by these practices, as not all new staff undergoes a thorough induction process. The two most recent members of staff recruited had not been subject to an induction programme. This is a requirement of the report. Staff induction programmes need to be well established, well designed as they form the base upon which in-service supervision and training are planned and achieved. All staff receive training in care issues within the home from registered nurses and external trainers. There is currently 59 of care staff with NVQ II and/or III working in the home. It was pleasing to see a continued commitment to the educational process. St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is supported well by senior staff and provides clear leadership throughout the home. All staff demonstrate a broad awareness of their roles and responsibilities. The majority of health and safety standards had been met. The arrangements for the supervision of care staff are poor. EVIDENCE: The management systems in place are good with both clear and consistent leadership and direction. The administration of the home is efficient and sensitive to the needs of the residents. St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 21 The home system for staff training was generally good and the staff do receive the necessary mandatory training of fire safety, food hygiene, health and safety and moving and handling. The home had risk assessments in place for safe working practices. Not all care staff have received two monthly supervision as outlined in the National Minimum Standards. This is a requirement of the report. Standards are discussed at staff meetings, daily handovers, direct observation and involvement and one to one staff meetings. However, staff meetings need to be undertaken more frequently to ensure that their views and opinions are listened to and acted upon. The home had procedures in place for the testing of fire prevention systems and the fire alarm and the emergency lighting was being tested appropriately. There were regular fire drills taking place for day staff to ensure staff are alert to procedures so protecting the service users. However, not all night staff have received four fire drills a year in line with the Fire Authorities requirements. This is a requirement of the report. The home had procedures in place for the safe storage and use of hazardous substances. Radiators were protected. The accident books for staff and residents were checked and found to be accurate and current. These issues and routines promoted the health, safety and welfare of residents and staff. Information provided from the home in the pre inspection information confirmed that all other maintenance standards required had been met. St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 3 X 3 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 2 X 2 St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP25 Regulation 13(4)(a) 23(2)(j) Requirement The registered person must ensure that hot water is available to all residents rooms at all times, to meet their personal hygiene needs. Staff must not transport hot water around the building, as this is potentially dangerous. Hot water outlets must have hot water available as near to 43.C as possible. The registered person must ensure that • Doors, which are badly marked and scratched, are made good. External windows that are showing signs of wood rot are replaced or made good. 04/03/07 Timescale for action 04/02/07 2 OP19 23(2)(b) 04/03/07 • 3 OP19 16(2)(c) The registered person must ensure that the carpets in the home, which are badly stained, are either deep cleaned or replaced. St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 24 4 OP30 18(1)(c) (i) 18(2) 5 OP36 6 OP38 23(4)(e) 7 OP18 18(1)(c) (i) The registered person must ensure that all new staff complete a full induction programme. The registered person must ensure that all care staff receive two monthly supervision, which is documented. The registered person must ensure that all night staff undergo four fire drills a year, in line with the Fire Authorities requirements The registered person must ensure that all staff receive training in relation to POVA. 04/01/07 04/02/07 15/01/07 04/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP27 OP33 Good Practice Recommendations It was recommended that domestic cover be provided at weekends. It was recommended that staff meetings be undertaken more frequently to ensure that their views and opinions are listened to and acted upon. St Quentin Nursing Home DS0000026964.V317321.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Quentin Nursing Home DS0000026964.V317321.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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