Inspection on 07/02/07 for St Winifred`s Nursing Home

This inspection was carried out on 7th February 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.

Other inspections for this house

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

CARE HOMES FOR OLDER PEOPLE St Winifred`s Nursing Home 89 Crowtrees Lane Rastrick Brighouse West Yorkshire HD6 3LR Lead Inspector Paula McCloy Unannounced Inspection 7th February 2007 09:30 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 Winifred`s Nursing Home DS0000066904.V322467.R02.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 Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Winifred`s Nursing Home Address 89 Crowtrees Lane Rastrick Brighouse West Yorkshire HD6 3LR 01484 720100 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) Vishomil Limited Mrs Amanda Jane Bromley Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user under 65 years of age with a physical disability. This was the first inspection of the home since the new owners took over in June 2006. Date of last inspection Brief Description of the Service: St Winifreds is situated in Rastrick; there are shops, library, pub, hairdressers and pharmacy near by. St Winifreds is a care home with nursing. It is a stone built property, which has been extended to provide accommodation for 38 older people. The building is very well maintained, pleasantly decorated and comfortably furnished. There are four lounges, a dining room and small conservatory on the ground floor. There are televisions, a music system and video available for service users entertainment. One of the lounges also has a large fish tank. There are 30 single bedrooms, 14 of which have en suite toilet facilities. One single room has an en suite toilet, bath and separate shower. There are 4 double bedrooms, all with en suite toilets and two bedrooms with en suite toilet and shower. Bedrooms are well decorated and furnished to a high standard. There are four bathrooms all of which have assisted bathing facilities. There is an assisted shower room on the first floor. There are five separate toilets located around the building. There is a passenger lift, which serves both floors. There is a courtyard in the middle of the building where people can sit in the nice weather. The current weekly charges range from £323 to £742.50. Additional charges are made for Hairdressing, newspapers, chiropody, long distance telephone calls, personal toiletries, dentistry, individual physiotherapy, eye tests, alcohol and cigarettes. St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This was the first inspection of St Winifreds since the new owners took over the home in June 2006, because of the change of ownership the home is classed as a ‘new service’ by the Commission for Social Care Inspection. This means that the highest judgement about the service that can be given for this inspection is ‘good.’ One complaint has been received by the Commission for Social Care Inspection since the new owners took over. The complaint was about the home telling relatives that they could no longer meet the needs of a resident. (See section on Complaints and Protection). This inspection was carried out to assess the quality of care provided to residents living at the home. I carried out the inspection over a day and spent approximately 6.45 hours in the home. The methods used in this inspection included discussions with 6 residents, 1 relative, 10 staff, the manager and the owner, observation of care practice, examination of records, and a partial tour of the home. A pre-inspection questionnaire was sent to the home prior to this inspection visit asking for information. This questionnaire was returned to the Commission for Social Care Inspection and the information provided has been used in this report. St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 6 Comment cards were sent to 15 residents, 15 relatives and 3 GPs; these cards provide an opportunity for people to share their views of the service with the CSCI. Comments received in this way are shared with the provider without revealing the identity of those completing them. Eleven residents, eight relatives and three GP wrote to the inspectors with their comments. The comments received have been used in this report. What the service does well: St Winifreds is a well managed home that is run in the best interests of the residents. Anyone thinking of moving into St Winifreds can go and look around and get written information about the home, the service user guide. If they decide to move in staff from the home will carry out an assessment to make sure that they can meet that persons needs and arrange a day for admission. Residents get a contract/statement of terms and conditions document, this means that they are given information about their rights and obligations. Each resident has an individual care plan that sets out what care and support they require from staff. Staff are vigilant and care plans are updated as people’s needs change. Staff are also quick to involve doctors and other specialists for advice. One GP said ‘very well run nursing home with patient centred care’ and another said ‘the only home I would be entirely confident in placing one of my family. Residents look well cared for. All residents spoke well of staff and they felt that they were kind and caring. One relative said ‘My mother is able to make her own decisions but I am still consulted about her care.’ Activities are arranged on a regular basis to keep residents stimulated. Residents said ‘excellent activities.’ ‘We have games three afternoons a week. I join in everything.’ St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 7 Residents can follow their own routines and relatives and friends are welcome to visit at any time. Meals at the home are good. One resident said that ‘they are very nice cooks. I always enjoy the meals they do.’ If residents and/or relatives are not happy about the service they are getting the home has a complaints procedure. Residents and relatives were aware of the procedure and said that they would be able to raise any concerns and that they felt any problems would be resolved. The home is clean, tidy, comfortable and well maintained. One resident said ‘the standards of cleanliness and hygiene are very high,’ and another said ‘we have very able cleaners. Yes the home is clean and fresh.’ The staff are friendly and well trained. Staff enjoy working at the home and feel they work well as a team. All of the staff spoken to said that they would be happy for a relative of theirs to live in the home. What has improved since the last inspection? What they could do better: No requirements were identified during this visit. Please contact the provider for advice of actions taken in response to this St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 8 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 Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 9 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 Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 10 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. There is written information available for residents and prospective residents about services the home provides. The home’s admission procedures are good. Any prospective resident is fully assessed before they move into the home. This ensures that their care and support needs are planned for and can be met. Prospective residents and/or their families are encouraged to visit the home so they can make an informed decision about the suitability of the home. Residents are given a written contract/terms and conditions of residence document which gives them details of their rights and responsibilities. EVIDENCE: St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 11 The home’s statement of purpose and service user guide are available from the home. Both of these documents are on display in the reception area and are up to date. Residents are issued with a contract/terms and conditions of residence document and financial agreement about payment of fees. Eleven residents confirmed that they had received this document. Individual records are kept for each of the residents. The records for the two most recently admitted residents showed that staff from the home had completed a full assessment of their needs before they had been admitted to the home. This information had then been used to formulate the care plans to ensure that the residents’ identified needs were met. Staff said that they encourage prospective residents to come and have a look around the home, although it is more usual for relatives to do this. This gives people the opportunity to see the home for themselves and to decide if it is suitable for them. Two residents said that their families had been to look around the home before they moved in. The home does not provide intermediate care. St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 12 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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans are detailed and give staff the information they require to meet residents’ needs. The health care needs of residents are being met with health care professionals being involved as necessary. Residents’ medication is well managed which promotes good health. Personal support in this home is given in a way that promotes and protects resident’ privacy and dignity. EVIDENCE: Care plans are well organised and it is easy to find relevant information quickly. The care plans set out in detail what action needs to be taken by staff to ensure residents’ needs are met. Staff are vigilant and new care plans are developed as people’s needs change. Details of residents’ interests and preferred routines are also noted. Care plans are being reviewed on a monthly St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 13 basis and there was evidence of residents and relatives being involved in the planning process. Eleven residents confirmed that they get the care and support they need and that they get the medical support they need. Care plans are being reviewed on a monthly basis. On admission relatives are asked how frequently they want to be involved in their relative’s care plan reviews and their wishes are documented. Eight relatives said they were kept up to date about their relative’s well being and that they are consulted about their relative’s care. One relative said ‘my mother is able to make her own decisions but I am still consulted about her care.’ Residents’ health care needs are being identified and met. Staff are vigilant and GPs and other health care professionals are being involved as necessary. Details of any visits by health care professionals are clearly documented in the residents care plan, together with the advice that has been given. Three GPs said that staff understand the care needs of residents and that any advice they give is incorporated into the individual resident’s care plan. One GP said ‘very well run nursing home with patient centred care’ and another said ‘the only home I would be entirely confident in placing one of my family.’ One resident who moved into the home in January said how much his health had improved. He was spending most of his time in bed before he moved to St Winifreds. Staff at the home have involved the GP and a change in his medication and general good care has meant that he is now up and about and walking short distances with support from staff. He described the home as ‘champion!’ The medication system is well managed. Service users are receiving their medication at the prescribed times and records are well maintained. Service users looked smart and well cared for. All service users spoke well of staff and they all felt they were kind and caring. The staff induction programme covers treating service users with respect. St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 14 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. Service users’ preferences in relation to the routines of daily living are respected. Activities are provided to keep residents stimulated. Relatives and friends feel welcome to visit at any time. The meals at the home are good. EVIDENCE: Service users’ preferences in relation to the times they want to get up and go to bed are respected by staff. Care staff have documented service users’ preferences and these have been added to the care plans. One resident’s care plan stated that he liked a tot of whiskey at bedtime. The resident said that he has this every night. On admission residents are asked specifically about their religious and cultural needs. One resident confirmed that the priest comes to see her regularly and that she goes out to church. An activities organiser provides various activities on three afternoons per week. Outside entertainers are booked every month. There is a notice board in the St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 15 dining room and by one of the lounges that gives details of the activities on offer. Staff also record in residents’ care plans what activities they have been involved in. All of the residents said activities take place. Residents made these comments about the activities ‘the entertainer made me laugh.’ ‘Excellent activities.’ ‘We have games three afternoons a week. I join in everything.’ ‘I am still hoarse from singing the other day.’ One resident said that activities were on offer but that they preferred not to join in. One relative said ‘my mother cannot really take part in the activities, the staff try and encourage her to do so, if possible.’ Relatives confirmed that they can visit at any time and that they are made to feel welcome. Visits take place in the communal areas or in service users bedrooms if they want privacy. Every service user has a telephone in their room where they can make or receive calls in private. They can also telephone reception with any questions or queries they have. Service users stated that the food was good. Meals are served in a number of different rooms. There is a six week menu and the daily choices are displayed on the notice boards. At lunchtime there was a choice of scampi and chips or pork steak, chips, carrots and salad followed by bread and butter pudding. Meals were nicely presented. Residents are asked about the meals at the residents’ meetings and any suggestions they have are incorporated into the menus. Residents made the following comments about the meals ‘a little more variety of sandwiches at tea time would be appreciated as cheese and paste are quite often used.’ ‘They are very nice cooks. I always enjoy the meals they do.’ ‘Food could sometimes be better, not much to grumble about.’ ‘The food is very good. I have put on weight since I moved to the home.’ St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 16 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. The home’s complaints procedure is well publicised and residents are confident that that any concerns will be listened to, taken seriously and acted upon. Staff have a good understanding of adult protection issues which means service users are protected from any abuse. EVIDENCE: The complaints procedure is on display, detailed in the service user guide and in the terms and conditions of residence document. Complaints that have been received have been documented and resolved to the complainants’ satisfaction. Residents and relatives said that if they had any concerns they would feel able to raise these with the registered manager. They were also confident that they would be listened to and that any concerns would be resolved. One complaint was received by the Commission for Social Care Inspection in August 2006. The complaint was that when a resident was reassessed by the manager, following admission to hospital, she said that the home could no longer meet his needs. This was passed to the registered manager to investigate using the home’s complaints procedure. The Commission for Social Care Inspection were satisfied with her investigation and the response to the complainant. St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 17 Staff have attended adult protection training and the local adult protection procedures are available. All staff spoken to were able to detail exactly what they would do if they felt any practices in the home were not in the best interest of the service user. St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 18 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean, safe, comfortable, well maintained home. EVIDENCE: St Winifreds is situated in Rastrick; there are shops, library, pub, hairdressers and pharmacy near by. There is car parking to the front of the building. There is a courtyard, which provides a pleasant sitting area for residents in fine weather. Environmental Health last inspected the home in 2005 and all of their recommendations have been met. The home was very clean and there were no unpleasant odours. Residents and visitors confirmed that this was the norm. Residents said ‘the standards St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 19 of cleanliness and hygiene are very high.’ ‘We have very able cleaners. Yes the home is clean and fresh.’ One relative said ‘I have been visiting for 4 years the home is always immaculately clean.’ The laundry is well equipped and the required non-return valves are in place on the washing machines. There is a written infection control policy and an infection control information file. There have been no infection control issues at the home. St Winifred`s Nursing Home DS0000066904.V322467.R02.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. Staff morale is good and staff are working positively to improve the residents’ quality of life. Staff are receiving appropriate training to meet residents’ needs. Any new staff are thoroughly checked to ensure that they are suitable to work with older people. EVIDENCE: There is a qualified nurse on duty throughout the day and night. There are five care assistants on duty in the mornings and four care assistants in the evening. There are two or three care assistants on duty at night. The manager is in the process of recruiting care staff so that there will be three care staff on duty every night. The care staff team are well supported by cooks, domestics, laundry assistants, a receptionist, an activities organiser and maintenance person. St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 21 The home currently has vacancies for care staff. Agency staff are being used to cover shifts, these tend to be staff who are familiar with the home. All staff spoken to felt that they were working well as a team and that they enjoyed coming to work. Staff also said that the registered manager is very approachable and that they can talk to her about anything. The registered manager works supernumerary to the rota. She takes responsibility for the induction training of all new care staff. The induction programme for the two most recently appointed care staff was seen. This is comprehensive and meets the requirements of the ‘Skills for Care’ training. There are 50 of the care staff who are qualified to NVQ level 2 or 3 in caring for older people. Two more care staff are in the process of applying for this training. Care staff said that they are offered any relevant training courses and felt that they have been given more opportunities since the new owners took over the home. Recruitment procedures at the home are robust. Staff files confirmed that the necessary checks are being completed to ensure the suitability of new staff. All staff spoken to confirmed that they had received contracts of employment, since the new company had taken over the home. St Winifred`s Nursing Home DS0000066904.V322467.R02.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, 33, 35 & 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 well managed and run in the best interests of residents. Residents are involved in the running of the home and consulted about their care and support. Practices in the home promote the health, safety and welfare of the residents. EVIDENCE: The registered manager is a qualified nurse who has also completed the NVQ level 4 award in management. The manager works supernumerary to the rota and feels supported by the company who own the home. St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 23 Staff and residents all said that they were worried when the home was sold, because they thought that things might change. The change of ownership has not affected the running of the home. In fact staff said that they felt that they had benefited from the change. For example the manager now works totally supernumerary to the rota, staff see the new owners regularly and any problems with staff wages are sorted out quickly. The cook said that the owners were thinking of changing the meat supplier but when she explained that the current supplier was very good and provided good quality produce they listened to her views. Residents are consulted about the running of the home in residents’ meetings, through the 6 monthly quality assurance questionnaires and at the monthly reviews of their care plans. One resident had received a quality assurance questionnaire recently and was in the process of completing it. The manager said that the results of the survey will be published by the end of March 2007 and will be circulated to residents and relatives. Residents and relatives all said that if they had any problems they would speak to the manager and were confident that any issues would be resolved. Residents’ meetings are held every three months and the manager acts on any issues or suggestions they have. For example at one meeting residents thought a suggestion box would be helpful. There is now a suggestion box in the reception area. One of the suggestions put in was to have some folding chairs available for visitors. These are now in place and available in the dining room. The manager does not hold money on behalf of residents. On admission arrangements are made between residents and their relatives regarding the management of their finances. Residents or their relatives are then invoiced for any additional services they receive such as hairdressing and chiropody. There is a written Health and Safety policy. Staff receive moving and handling, food hygiene, fire safety, first aid and infection control training. The fire alarms are tested weekly and fire drills/practices are held. The service records for the hoists were seen and were up to date. St Winifred`s Nursing Home DS0000066904.V322467.R02.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 N/A 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 3 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X x 3 St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Winifred`s Nursing Home DS0000066904.V322467.R02.S.doc Version 5.2 Page 27 - 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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