Inspection on 07/06/05 for St Ronans Nursing and Residential Care Home

This inspection was carried out on 7th June 2005.

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.

Other inspections for this house

St Ronans Nursing and... 12/11/08

St Ronans Nursing and... 13/11/06

St Ronans Nursing and... 15/12/05

St Ronans Nursing and... 05/01/05

St Ronans Nursing and... 13/07/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE St Ronans Nursing & Residential Care Home 23 - 27 St Ronans Road Southsea PO4 OPP Lead Inspector Jan Everitt Unannounced 7 June 2005 9:30 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 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 Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Ronans St Ronan‘s Nursing & Residential Care Home 23 - 27 St Ronan‘s Road, Southsea PO4 0PP Address Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) (023) 92 733359 (023) 92 817738 Mr John PattisonMs Jane Helliwell Ms Amanda Jayne Brett Care Home 33 Category(ies) of Dementia - over 65 years of age (33), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (33), Old age, not falling within any other category (33), Terminally ill (33), Terminally ill over 65 years of age (33) St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: .1. Service users in the TI category can not be admitted under the age of 55 years. 3 - Staffing levels apply. Date of last inspection 5/1/05 Brief Description of the Service: St Ronans is a care home providing nursing and personal care for 33 older people in the categories of terminally ill, mental disorder, excluding learning disabilities and those with mental frailty associated with old age. There is a condition of registration that no person under the age of 55 years can be admitted with terminal illness. The home is owned by a partnership of two people and is the only home owned by them in the area. The home is three large, four-story victorian houses that were converted to a care home a number of years ago. The home is located in a residential area of Southsea in close proximity to the seafront and local shops and is in easy access to Portsmouth city and the local hospitals. The current providers are in the process of negotiating and planning extensive alterations to the home to provide level access to all parts of the home and the general refurbishment of the home. This work is anticipated to span over the next two years and is due to commence in July 05. The home is commited to staff training an development to enhance working practices and maintain a good standard of care. St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of St Ronan’s Nursing and Residential Care Home took place on the 7 June 2005 by one inspector over a period of 6.5 hours. The deputy manager Mrs. Sandra Healey, assisted the inspector throughout the process. The providers, Mr. John Pattison and Ms. Jane Helliwell attended the home during the day. A tour of the premises took place that included visiting service users’ rooms and all the communal areas. At the time of the inspection the home was accommodating 32 service users and one service user was in hospital. A number of the service users were spoken with and one visiting relative. Owing to the nature of some of the service users physical and mental frailty the inspector was not always able to gain a balanced view of service users’ experience living in the home. Service users able to give opinion and comment were positive about their home life. Care plans and staff records were viewed and 14 of the 20 key standards to be assessed over the 2005/6-inspection programme were examined. 15 standards in all were inspected. The inspection concluded that the overall standard of the services delivered in this home was good with requirements and recommendations discussed in the main body of the report. What the service does well: The visitor spoken with said the home always’ welcoming and he is able to visit at any time’. The home provides a good standard of care and promotes the independence of the service users within their own abilities. The inspectors observed that staff demonstrated respect for service users individual privacy and strive to give them choices throughout their activities of daily living. Staff demonstrated that they work well together and interact well with service users. Staff were observed to be sensitive and tolerant to the service users’ frailty and to meeting their physical and psychological needs. Service users are offered a well- balanced wholesome diet and their likes and dislikes are taken into consideration and respected within the cook’s menu planning. The home is homely in appearance and the proprietors are striving to extend and improve the fabric of the building to enable service users easy access to all areas of the home. The home demonstrated that records and systems are in operation to maintain the health and safety of the home. St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 6 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 Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 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 standard(s) 3 Service users are comprehensively assessed prior to moving into the home to ensure the home can meet their needs. EVIDENCE: All prospective service users are assessed by a senior nurse prior to admission to the home. The pre-admission assessment documentation forms part of the care planning process and is maintained in the care plan documentation. The assessments viewed by the inspector evidenced that information collected from service users, relatives and social workers included the physical, emotional and health needs of prospective service users. Owing to many of the service user’s mental and physical frailty, those spoken with reported that it was their relatives that had visited and chosen the home for them and that they considered that it had been a ‘good choice’. St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 9 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 standard(s) 7, 8, 9, 10 &11 The care plans clearly set out the service users nursing and personal needs. Systems and procedures are in place to meet the health needs of the service users. The medication policies, procedures and records in place demonstrate that medication is ordered, stored and administered through safe practices. The home’s practices demonstrate that the core values of care are upheld. The care of the service user and their family are treated with respect and sensitivity at the time of death. EVIDENCE: All service users have individual care plans in place. A sample of three service user’s care plans was tracked during the inspection. The care plans are formulated from a comprehensive assessment of service user’s individual personal and nursing needs. Risk assessments were identified in the care plans and a dependency-scoring tool. The dependency score for the records examined indicated a high dependency level but another record indicated a low dependency. The information was misleading and the assessment contrary to the assessment score. This was discussed with the deputy manager and proprietor and a recommendation will be made There was evidence that care plans are reviewed monthly. Service users, who are able and wiling, do sign their care plans as evidence of their participation. St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 10 The inspector evidenced one service user’s plan signed to demonstrate their participation and agreement with the plans. The deputy manager reported that the other service users were unable to participate in the care planning process owing to their frailty and inability to participate. There was no evidence of relatives signing care plans as a representative of the service user. The home could not demonstrate that risk assessments for the use of bedrails is consistently recorded and the inspector could not evidence records to demonstrate that agreement for their use had been sought from the service user or their representative/relative. This is further discussed in Standard 18 Service users health needs are met fully and a visiting continence assessment nurse was reviewing files at the time of the inspection. She reported that she gained information from the records of care plans and also talking to the staff. Service users spoken with told the inspector that they see their GP and other healthcare professionals if they are needed. A newly admitted service user who had no verbal communication was in need of an optician for which a visit had been requested. The home reported that no service users were choosing to administer their own medication at the time of the inspection. A service user spoken with at length confirmed that their medication is receive appropriately and administered by the trained nurse. Medication charts evidenced that medication is signed for at the time of administration. All other medication records examined were recorded correctly. Cupboards containing the medication and stock were found to be well organised. Observation by the inspector that screens were present in shared rooms, staff knocking on doors before entering and generally the interaction between staff and service users confirmed that service users choices and privacy are respected. The inspector enquired of a service user sharing a room, if she had been consulted about sharing the room and she reported that she was ‘quite happy’ with her roommate who was ‘very quiet’. One service who needs supervision whilst smoking confirmed that she had chosen to get up late that morning and that her request for a cigarette is promptly met. This was supported when the service user visited the nurses’ office to request a smoke and was responded to immediately. It was observed by the inspector that a number of service users remained in bed until quite late in the morning. This was discussed with the deputy manager who reported that the dependency level at the current time was high and that many of the service users needed two carers to get them up and dressed and so delayed their getting up. One service user was asked if he chose to stay in bed late, he was unable to verbalise a reply but indicated that ‘ no but that he did not mind being there’. The staff reported that if dependency levels are high, the more dependant service users take it in turn to be got up later. Further discussion on this issue is discussed in the standard 27. Service users appearance was clean and well presented. One lady spoken with said she enjoyed putting her make-up on each day and wearing her jewellery. A service user and her relative were spoken with and both told the inspector that they were very satisfied with the services and care provided in the home. St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 11 The visitor reported that he visits from away and he considered that his relative looked well and happy. The service user had recently been moved to a downstairs room and confirmed to the inspector that this had been undertaken with consultation and agreement from her. The inspector observed that all rooms have locks fitted and each bedside draw provides lockable storage space for the service users. The inspector discussed the high number of deaths over the previous twelve months that had been reported to the CSCI via Reg 37 reports. The deputy manager reported that service users are being admitted from hospital in a more frail state and that the home has the terminally ill category to its registration and therefore more terminally sick people are being referred to the home. Service users wishes and needs during their terminal illness are documented if they are able to and wish to discuss this with the nurses and carers. Staff have received training to care for those with terminal illnesses. St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 &15 The meals served in the home are well balanced presenting both choice and variety and are enjoyed by the service users. Service users are able to maintain their contact with their families and friends and are able to go out into the community if they so wish. EVIDENCE: Service users are encouraged to maintain contact with their families and friends. Visitors are welcome to the home at any time of the day and the visitors’ book records support the home is visited regularly. The visitor spoken with confirmed that he is always made welcome to the home and that he stays for most of the day when he does visit. A carer employed by the sitting service visits the home once or twice a week to take service users out for walks to the seafront or around the local area. The lunchtime meal was served during the inspection. The food was wholesome and well presented. The service users praised the standard of food and reported it to be ‘very good, excellent and plentiful’. The visiting relative also reported that he considered the food to be of a high standard and that when he was visiting he could also have a meal. The inspector spoke with the cook who was in the process of making the cakes that are baked daily for the service users to have with their afternoon tea. She reported that she devises the menus and changes them with the seasons. The menus are recorded in the diary and the inspector, who also observed that the daily menu is displayed in the dining room area, saw this. Should service users not like what is on the St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 13 menu alternatives are provided but that the cook is aware of the service users’ food likes and dislikes, which are recorded on admission to the home. The inspector observed a large bowl of fresh fruit in the lounge from which service users may help themselves and also large jugs of fruit drinks available throughout the home. A number of service users need assistance with their eating and this was done in a sensitive manner on a one to one basis with the care staff. Meals are eaten in the two dining areas that seat about 20 service users. Service users confirmed that they may choose where they eat their meals and some choose to eat in their rooms. St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 14 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 standard(s) 16 & 18 The complaints procedure is set out and forms part of the Statement of Purpose to assure service users and relatives that their complaints will be listened to and investigated appropriately. The home’s protocols and staff training are in place to protect service users from abuse. EVIDENCE: The home has a complaints procedure in place, a copy of which is part of the Statement of Purpose. The policy states that in the first instance will investigate complaints and timescales within which they will be responded to. A complaints log is maintained and this was viewed by the inspector, which evidenced that no complaints have been received by the home. The CSCI address and contact number is documented in the policy. The home has an adult protection procedure which is underpinned by the DOH document ‘No Secrets, which guides the whistle blowing policy. The home has not received any allegations of abuse. Restraint is used in the home in the form of bedrails and the inspector could not evidence that all those in use had been risk assessed and permission sought for their use with either the service user or relative/representative. A requirement will be made from these findings. Those service users who were able to communicate reported they understood why the bedrails were in place.’ St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 15 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 standard(s) 19 & 26 Service users live in a safe environment, however the plans for the forthcoming extensive alterations has resulted in areas of the home, in need of redecoration and refurbishment, being delayed until all the building works are completed in that area of the home. Good standards of hygiene are maintained throughout the home and infection control policies adhered to. EVIDENCE: The home is homely in appearance and is maintained on a day-to-day basis by a full-time maintenance man. The home was found to be clean and tidy with no detection of offensive odours. There are areas of the home that are in need of redecoration and refurbishment but these will be addressed during the forthcoming extensive alterations to the home over the next two years, which is to create level access to all areas of the home. This will enable service users access to all parts of the home with a new shaft lift being installed to reach all floors. A new stair lift that reaches all floors without interruption has been installed since the last inspection. This gives service users, who are mobile and able, access to all floors. St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 16 The provider and manager are aware of the health and safety implications of such major alterations taking place whilst the home is occupied and strategy plans are in place to address the risks. The providers reported that the service users and relatives would be consulted and informed about the work as it is to take place but most have been informed of this. Service users spoken with found it difficult to understand and discuss the forthcoming building works and alterations and their experience of this will be assessed whilst work is in progress. Service users in general reported that they considered their environment to be comfortable and adequate for their needs. The relative spoken with reported that he felt that his relative was very comfortable and was being cared for admirably. Rooms are well furnished and have been personalised with pictures and photographs and some service users had chosen to bring some items of personal furniture with them. There is a pleasant area of garden at the rear of the home that service users may enjoy in the finer weather The home has an infection control policy in place. All members of staff have undergone infection control training and this forms part of the induction programme. Gloves and aprons were observed to being worn by two carers who were attending a service user. Hand-washing facilities in toilets and bathrooms were available. The laundry is situated in the basement of the home and has access to the outside for ventilation. The situation of the laundry does not lend itself to easy cleaning. The provider informed the inspector that the laundry is to be moved from its present allocation and a new laundry is being created as part of the alterations and refurbishment. All bed linen is contracted out to a laundry and only personal clothes and towels are laundered at the home. The inspector observed personal clothing to be laundered well and stored in service users rooms neatly. The home has a key-worker system and part of their role is to ensure service users clothes are well maintained and stored properly. A service user invited the inspector to look in her wardrobe at her clothes, of which she was obviously proud, which appeared well kept and neatly stored. St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 & 29 Staffing levels are maintained and care is delivered by trained nurses and care staff who are trained to NVQ level 2 and 3. However, staffing levels do not consistently meet the growing dependency needs of the service users. The recruitment practices of the home strive to maintain support and protection for the service users. However, the recruitment records do not always evidence that all the required documentation is in place and that POVA first checks are obtained before employment is commenced. EVIDENCE: On the day of the inspection the deputy manager was taken out of the numbers of staff to enable her to assist with the inspection. The staffing levels are maintained and the deputy reports that the manager will request more staff if the dependency levels are high. Dependency levels were discussed and the level of dependency did not correlate with the dependency level stated in the care plans. The deputy manager reported that two service users wander at night and the night staff were finding this difficult to manage The inspector observed that a number of service users were still in bed at 11.00 and on the tour around the home observed that carers were working in pairs and that they were very busy right through the morning period leaving little time to spend with the service users once they were in the lounge. One service user spoken with, although unable to communicate verbally, indicated that he did not mind still being in bed at 11.30 although he wanted to get up. The staff reported that this gentleman would not always be the last person to be got up. The evidence indicates that staffing levels are insufficient for the dependency of the service users in residence at the time of the inspection. This was discussed with the proprietors who reported that the registered manager is able to call in St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 18 more staff if she feels necessary. A requirement will be made a round this finding. Agency staff are used sometimes but permanent staff are willing to undertake extra hours if requested. The home has a separate housekeeping staff rota and care assistants undertake the personal laundry. The home is committed to NVQ training and of the 17 care staff employed only 5 have not achieved the NVQ level 2. A large majority of the carers have achieved NVQ level 3 training. The home employs 10 registered nurses. The manager and proprietor recruit staff. Four staff personnel files were viewed. Information to be maintained and stated on Schedule 2/4 of the Care Home Regulations was not present in some of the files. A professional reference was not obtained from the previous employer for a trained nurse, although other satisfactory references were present. Copies of birth certificates could not be evidenced in three of the four files. The administrator has a list of CRB and POVA checks that have been sent off and some have not been received, she reports there is a delay because the checks all go through an umbrella body. The inspector discussed the POVA first check that can be obtained through the CRB on line. The inspector reiterated that all staff must have a clear POVA first check along with two references before commencing employment. Requirements will be made around these findings. The administrator reported that some new recruitment documentation was being reviewed to ensure the interview process is more robust with record keeping. St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 & 38 The home does not handle the management of service users financial affairs. The health and safety of the service users and staff are promoted and protected by staff training, regular testing and servicing of systems and equipment. EVIDENCE: The home does not manage any of the service users financial affairs. The home appeared to be safe and the inspector viewed the fire logbook, which demonstrated regular and thorough testing of the homes fire detection equipment at appropriate times. The inspector evidenced a fire risk assessment and an assessment of the environment. All senior staff have undertaken a risk assessment training. Staff are trained in appropriate health and safety issues and a training matrix evidenced that this takes place. The inspector observed two fire doors being wedged open. The fire officer had been consulted about this situation. They have advised that automatic fire closure be fitted to these two doors that St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 20 access a service user’s room. A risk assessment of this has been undertaken and was seen by the inspector. A sample of servicing certificates for equipment and systems was seen by the inspector and found to be current. The fire officer report was viewed and the recommendation has been activated. The kitchen was not inspected on this occasion but appeared tidy and clean and well organised. The dry good store was toured and found to be clean and not over stocked. The inspector observed some out of date lemon curd, which the cook was instructed to dispose of immediately. Doors are secured appropriately at night. During the day the front door can be opened from the inside only, and the deputy manager reported that a risk assessment would be undertaken if there was a safety risk to a service user who was unable to go out alone. St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x 3 x x 3 St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 22 no Are there any outstanding requirements from the last inspection? 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 18 Regulation Reg 13(7)(8) Requirement Timescale for action 31/8/05 2. 27 3. 29 Risk assessments for the use of bedrails must be doucmented and agreement from the service user or their representative/relative documented in the care plan. Reg The number of staff on duty 18(1)(a) must reflect the dependancy and needs of the service users in residence and must remain under constant review with the service users changing needs. Reg All documentation stated on 19(1)(b)(c Schedule 2 of the Care Home ) Regulations must be obtained and maintained in all personnel files at the time of recruitment. 30/9/05 4. 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. Refer to Standard 7 Good Practice Recommendations It is strongly recommended that theservice users dependancy scoring reflect the result of thorough assessment within the context of the care home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 23 St Ronans Nursing & Residential Care Home 2. 38 environment. It is recommended that dry goods must be checked for out of date items and those identified disposed of immediately. St Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 24 Commission for Social Care Inspection 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Ronans Nursing & Residential Care Home H55-H03 S11505 St Ronans V218553 070605.doc Version 1.30 Page 25 - 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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