Inspection on 20/08/07 for Stanshawes

This inspection was carried out on 20th August 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

Stanshawes 21/05/08

Stanshawes 06/10/06

Stanshawes 19/04/06

Stanshawes 03/11/05

Stanshawes 22/06/05

Stanshawes 22/03/05

Stanshawes 16/11/04

Stanshawes 23/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Stanshawes 11 Stanshawes Drive Yate South Glos BS37 4ET Lead Inspector Melanie Edwards Key Unannounced Inspection 20th and 21st August 2007 9:50 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 Stanshawes DS0000020253.V340378.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. Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Stanshawes Address 11 Stanshawes Drive Yate South Glos BS37 4ET 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) 01454 850005 01454 850006 stanshawes@fshc.co.uk www.fshc.co.uk Laudcare Ltd (a wholly owned subsidiary of Four Seasons Health Care Ltd) Mrs Jeen Mary Davis Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate up to 48 persons aged 50 years and over who are receiving nursing care. Staffing Notice dated 04/06/1999 applies Manager must be a RN on parts 1 or 12 of the NMC register Date of last inspection 6th October 2006 Brief Description of the Service: Stanshawes is a Company owned Home, situated on the outskirts of Yate, in a residential location close to local shops, amenities and social venues. It is a purpose built Home designed to accommodate a maximum of forty-eight residents requiring nursing care over the age of 50 years. The Home provides accommodation over two floors. There are 36 single and 6 double bedrooms. Whilst none of the rooms have separate en-suite facilities, all rooms have a wash hand basin. There is a lounge and dining room on each floor. All areas of the Home are accessible via a lift. The Home is set in its own grounds. Car parking is available for several cars. Visitors are welcome to the Home at any time. In house activities and entertainments are provided. Mrs Jeen Davis is the registered manager of Stanshawes. Fees range between £505- £600. Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection lasted nine and a half hours and was carried out over two days. The inspector met nineteen of the forty-five residents living at the Home. A number of visitors were also consulted. The inspector joined a small group of residents for lunch. The deputy manager, four care assistants and a cook were consulted about their roles and responsibilities, their training needs, and how they assist and support residents. The registered manager Mrs Davis was on annual leave at the time of the inspection. The deputy manager assisted the inspector on both days of the inspection. Residents were observed being assisted with their needs by staff. A selection of records relating to the day-to-day running and management of the Home were inspected. A range of care records and care plans were also reviewed. The majority of the environment was seen. The only areas that were not viewed were a small number of bedrooms. The ‘AQAA’ (an annual quality assessment document that all Homes are required to complete) has been used to help form the judgments in the report. Sue Fuller the Commission Pharmacist Inspector for the South West region carried out an inspection of medication standards in the Home. A copy of the report following her visit is available on request to the Commission. The Home was operating within the required conditions of registration set down by The Commission. The conditions of registration set out the type of care and the needs of residents as well as the numbers of residents who may stay at the Home . What the service does well: Staff treat residents with respect and are warm and friendly to them. Staff were observed to treat residents in a kind and considerate way when supporting them to meet their needs. Residents made a range of comments including, ‘ the staff look after me well ’, ` they are caring and they do their very best ’, and, ` the staff are very nice and very helpful ’. Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 6 Residents’ meals are of a good quality, nutritionally well balanced and satisfactorily presented. The menus offer residents choices of what they would like to eat. Residents can take part in a range of social and therapeutic activities. This helps residents to be able to enjoy a better quality of live at the Home. Residents ’ bedrooms and communal areas are decorated to a good standard that enhances the environment for residents. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6. Quality in this outcome area is good. Residents’ needs are satisfactorily assessed by the Home. Prospective residents and their representatives have the information they need to make an informed choice about living at the Home. Prospective residents can ` test drive ’ the Home before they move in to see if it is suitable for them. The Home does not provide residents with intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: To find out how prospective residents and their representatives are helped to find out about the Home a copy of the service users guide was reviewed. Residents’ representatives, or the residents themselves are given their own copy of the guide so they have access to helpful information about life in the Home. There is information about the service provided, the qualifications of the staff employed, and the accommodation. The philosophy of the Home and how the service aim to meet residents needs is included. The complaints procedure is in the document so residents know how to complain about the service. Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 9 There is also a brochure with photographs of the Home as well as a website for Four Seasons, (the company who run the Home) that contains a range of helpful information about the service. Five nursing assessment records were checked in detail to see how well residents’ needs are assessed. The assessment records were reasonably informative, and showed residents physical, mental and social needs had been assessed. An assessment of each resident’s level of dependency had been carried out. There was an assessment of each residents skin vulnerability and the risk of their skin `breaking down’ and getting sore. The actions that should be taken to keep the persons skin healthy had also been recorded. There was an assessment of each residents nutritional needs, and how best to support them to maintain their health. However while assessment records were generally detailed and informative there was information written in them relating to residents needs that were not included in the care plans. This is written about in more detail in the next section of the report. The assessment records had been reviewed and updated on a regular basis. This demonstrates the Home make sure they can continue to meet residents’ needs. Several residents and relatives said they had visited the Home before deciding to move in. The service users guide says it is the policy that prospective residents visit first wherever possible. This helps to confirm residents can visit and check out the service first to see if it is suitable for them. The Home does not provide intermediate care for residents. Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8. Quality in this outcome area is adequate. Residents are treated with respect by staff at the Home. Residents’ care needs are met. However care plans do not always show how to support residents with their range of needs. One resident’s needs are not being consistently met by all of the registered nurses. This judgement has been made using available evidence including a visit to this service. EVIDENCE: To find out how residents are supported to meet their range of needs five care plans were read. The care plans were reasonably informative and detailed how to meet some of the care needs of the residents. The staff were familiar with the content of care plans and knew what actions they must take to meet needs. Care plans had been reviewed and updated regularly by registered nurses. This is to demonstrate residents’ health needs are being monitored and the Home knows they can still meet these needs. However the overall standard and content of the care plans was patchy and variable in the detail they contained. Specifically four of the five care plans did not include up to date information showing how to support the residents with all of their range of needs. Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 11 There were nursing needs identified in the assessments records of four residents that were not included in the residents care plans. For example one resident had been assessed as having very vulnerable skin that may break down and get sore if not properly looked after However the care plan did not include clear guidance on how to prevent this happening. The staff were observed to be helping residents with their range of needs in a calm, friendly and professional manner. It was also observed that a senior care assistant reported to a registered nurse that a resident was in pain. The registered nurse did not assess the resident until prompted by the Inspector, who overheard the conversation. This failure to assess the resident’s pain levels is a serious matter. Action must be taken so that nurses assess residents and do what is required to make sure they are free from pain. Residents are registered with local GP surgeries. They are also supported with their health needs by community nurses who review residents’ health care needs when needed. This is to further assist and support residents with their health care needs. There is a health record maintained for each resident. This records when residents see a doctor, optician, dentist and chiropodist and the reasons for the referral, and what treatment may be required. There was information in the daily records that demonstrated staff monitor and observe residents and call a doctor if concerned. Staff were observed knocking on residents bedroom doors before entering them and assisting residents in a polite and respectful manner. This demonstrates that staff treats residents respectfully. Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15. Quality in this outcome area is good. The Home encourages residents’ social, religious and recreational interests. Residents are supported to maintain contact with family and friends and be part of the local community. Residents are offered a choice of appealing, nutritional meals in relaxed surroundings. However some residents are not being assisted with their meals in a dignified and respectful manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Home employs two activities co-ordinators who work part time, over five days a week to run a range of social and therapeutic activities. The residents who were consulted said there was a range of activities offered at the Home, including day trips. On the first day of the inspection there was a Marx Brothers video being shown for a small group of residents, who looked as if they were enjoying the film. There is a weekly timetable including a range of activities like exercises, bingo, and arts and crafts sessions. Two residents said they really enjoyed playing bingo. There are also regular visits by representatives from the local church. This helps residents to meet spiritual needs. Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 13 There is a hairdresser who comes to the Home regularly for residents to have their hair done. Residents said that they are encouraged to have regular contact from their family and friends. One visitor said that the staff team are very welcoming to them. Relatives also said that they are invited to have lunch at the Home if they want to. Residents were observed entertaining friends and relatives in the communal areas of the Home. The facilities provided in residents ’ rooms and the communal lounges offer people a comfortable environment to receive guests. The Home consults with residents to offer them a selection of choices about their meals. The menu choices showed residents are provided with satisfactory, well-balanced and well-presented food. The inspector had lunch with a small group of residents. The meal was roast beef, roast potatoes, Yorkshire pudding, and two cooked fresh vegetables. There were also alternative meal options being served for residents. A number of residents seemed to enjoy their meal times and were seen talking among themselves. Meals were served to residents in an unhurried and relaxed way. On one floor of the Home staff were sitting down with residents and talking to them when they were helping them to eat their lunch. However on the other floor three staff members were observed assisting residents with their meals by standing up next to them instead of sitting down in a chair by the person. This is important practise for staff to follow so that residents who need extra help with their meals are assisted in a way that is respectful and maintains their dignity. Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Quality in this outcome area is good. Residents can be confident that complaints about the service are listened to and acted upon wherever possible. There is training and systems in place to help to protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a copy of the complaints procedure on display in the reception area. This includes the name of the Commission for Social Care Inspection, for anyone who wishes to contact us. The contact details of Four Seasons and the senior manager are in the complaints guide, if people wish to contact the owners directly to make a complaint. Residents who were consulted during the inspection said that they would feel confident to make a complaint to the manager or staff. They said they felt Mrs Davis was supportive and interested in their suggestions, concerns and complaints. This helps to demonstrate the Home welcomes and responds positively to complaints. The complaints record was looked at to find out how well complaints are dealt with. There had been two complaints received since before the last inspection. One complaint concerned a nurse’s failure to pick up a prescription that the GP had prescribed. The second complaint concerned care practise and is currently being investigated by a senior manager of Four Seasons. Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 15 Staff are provided with training to ensure they are up to date in their understanding of the principle of the protection of vulnerable adults from abuse. The company have their own in house training booklet on the subject of how to protect residents from abuse .The information in the booklet is particularly relevant to helping staff in the work they do. There is an up to date policy in place relating to the issue of protection of vulnerable adults from abuse. Staff were aware of the policy and the actions they must take to protect residents. Stanshawes DS0000020253.V340378.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): 19,22,24,26. Quality in this outcome area is adequate. Residents live in an environment that is mostly suitable to meet residents’ needs. However the Home is not adequately clean in all parts as there is a strong unpleasant odour in two areas. This makes the environment a less pleasant and enjoyable place for residents to live in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Stanshawes Care Home is a large property built in the suburb of Yate, near Bristol. The Home is built over two floors, which can be accessed by stairs or lift. The building is about a twenty-five minute car ride away from Bristol City Centre. There are local shops a library, a church, pub and Frenchay Hospital is also nearby. Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 17 The Home environment was clean and tidy in the majority of areas. However on the first day of the inspection there was only one domestic assistant on duty as there was a shortfall in the numbers of one domestic staff. This meant the person on duty had to work very hard to try and keep the Home clean. There was also a strong offensive odour present in two parts of the Home. Prompt action was taken by the deputy manager to address this matter. However action must still be taken to make sure in the long term so that residents live in a Home that remains free from strong and unpleasant odour. There is a range of specialist equipment and adaptations in place throughout the Home to assist people who may have reduced mobility. There are two open plan lounges, one on each floor of the Home. This means residents on both floors have easy access to a lounge area if they so wish. Communal living areas were light, spacious and looked welcoming. Residents were observed sitting in communal areas looking relaxed and comfortable in the environment. There is a range of specialist equipment and adaptations in place throughout the Home, to assist people who may have reduced mobility. The majority of bedrooms and all the communal areas were viewed. The majority of bedrooms are for single occupancy, however there are two double rooms. Rooms have been decorated light colours and there are light pastel curtains at the windows. This makes the rooms look more homely for residents to enjoy. Stanshawes DS0000020253.V340378.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): 27,29,30. Quality in this outcome area is good. Residents are generally supported by skilled and trained staff, who are encouraged by the organisation to undertake regular training Residents can be confident there is regularly enough staff on duty to meet their needs. The Home’s recruitment practices are robust, ensuring staff suitability to work with vulnerable adults. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff duty record for August 2007 for nursing and care staff was reviewed to find out if residents benefit from a sufficient number of staff to meet their needs. There is a minimum of two registered nurses on duty at all times and eight care assistants in the morning, as well as an extra care assistant who works a `floating’ shift every morning and helps out where needed. There are six care assistants and two registered nurses in the afternoon. At night there is one registered nurse and five care assistants on duty, including a senior care assistant. Mrs Davis works nine to five hours and a full time deputy manager supports her in her role. Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 19 There is also catering, domestic, and laundry staff employed, although the numbers of these staff were not reviewed. Based on the evidence from the inspection residents’ needs are generally being met. However the comments that have been written about a shortfall in the numbers of domestic staff, on the first day of the inspection, in the environment section of the report are also relevant here. The training records of one registered nurse and two care assistants were reviewed to see if registered nurses are keeping up to date with their clinical knowledge and practice. There was evidence that demonstrated registered nurses had attended clinical training sessions, and updating over the last twelve months. The care staff have also attended relevant training in the Home. A number of care staff are either undertaking or have just completed the National Vocational Qualification in care award. Four Seasons have their own National Vocational Qualification trainers, who assess care staff at work. To find out if the Home operates safe recruitment practises a sample of staff files were inspected. There are two written professional references taken up for all new staff prior to offering work at the Home. In addition, all staff will complete a Criminal Records Bureau check before commencing employment. These checks are a further safeguard for vulnerable residents. Stanshawes DS0000020253.V340378.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): 31,33,36,37,38. Quality in this outcome area is good. Residents’ benefit from having an experienced manager who runs the Home efficiently and in their best interests. Residents and their family and friends are supported to raise concerns to the management of the Home. Staff are regularly supervised in relation to the work they carry out in the home. This makes staff more skilled and knowledgeable in the work they do caring for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Mrs Davis is a first level registered nurse with many years of experience caring for people with a range of nursing needs. Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 21 The staff reported that staff meeting are held regularly and that they can make their views known to Mrs Davis about how the Home is run. A number of residents said that they see Mrs Davis regularly .She will walk around the Home and she asks if they are all right. Several residents also said that Mrs Davis was, `very nice’, and, very kind’, and she would always make time for them. Staff are provided with regular structured supervision sessions to assist them in their work and in better understanding the needs of residents. A sample of supervision records were inspected and these showed staff are monitored and the quality of their work is reviewed with them on a regular basis. Four Seasons have introduced a format for monitoring the quality of the care and the overall service. Mrs Davis and the team have audited different areas of the service. An action plan has been devised to address any weaknesses in the Home. Mrs Davis and the team have worked hard to review and audit the care. The team are implementing the actions that were set in the Homes action plan. The monthly monitoring visits of the Home that must be carried out by a representative of the owners are being undertaken as required by law. There are detailed and informative records of these visits being sent to the Commission. The records demonstrate that the designated individual responsible for the visits spends time with residents and their representatives and observing staff carrying out their duties. Residents’ rights are protected by records that are satisfactorily maintained, up to date, legible and in order. The environment looked safe and satisfactorily maintained throughout. The maintenance man carries out a health and safety audit of the whole environment on a regular basis. A copy of the document that is used to carry out the audit was inspected, and was detailed and aimed to address health and safety areas through the Home. The fire logbook records showed fire alarm tests are being carried out. There are also fire drills carried out on a regular basis to help protect the health and safety of residents and staff. There is an up to date fire safety risk assessment in place for the home that sets out how to minimise fire risks and maintain the safety of residents staff and visitors. The Home won a five star award from the local council environmental health inspectors in May 2007.This helps demonstrate staff follow good health and safety practises in the kitchen when preparing food. Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 22 The kitchen was tidy and organised when viewed. There were up to date daily records being kept of the fridges and freezer temperatures. This information is necessary to demonstrate the fridges and freezer is working properly and foods are being kept at a safe temperature. The cooks check the temperatures of all high-risk foods before serving the food to residents. This is necessary to ensure the food has been cooked to a safe temperature for residents to eat. There were also dairy products, cooked meats, and cooked food stored in the fridge that had covered and dated. This is done for these foods so they are used within a safe timescale. Staff who are directly involved in personal care were observed serving food to residents and going into the kitchen wearing suitable protective clothing over their uniforms to minimise the risks of cross infection from their uniforms onto food or surfaces in the kitchen. Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 23 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X 3 X 2 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 3 3 Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 24 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 Home s Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15. (1) Requirement Care plans must clearly state in detail what actions must be taken to support residents to meet all of their identified needs. All parts of the Home must be free from strong offensive odour. This requirement is for health and safety reasons as well as to make sure residents live in attractive and hygienic environment. Residents must be assisted with their needs in a manner that respects their dignity. Timescale for action 19/09/07 2. OP26 16.2 (k) 21/08/07 3. OP15 12.4(a) 20/09/07 4 OP7 12.1 This requirement refers to staff helping residents to eat their meals by standing up next to them. All registered nurses must assess 19/09/07 residents’ pain levels and take necessary action when it is reported that a person is in pain. This requirement refers to the registered nurse on duty at the inspection. Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 25 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 Stanshawes DS0000020253.V340378.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Regional Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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