Inspection on 03/11/05 for Stanshawes

This inspection was carried out on 3rd November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Stanshawes 21/05/08

Stanshawes 20/08/07

Stanshawes 06/10/06

Stanshawes 19/04/06

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 Grace Agu Unannounced Inspection 3rd November 2005 09:00 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.V261835.R01.S.doc Version 5.0 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.V261835.R01.S.doc Version 5.0 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 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.V261835.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Manager must be a RN on parts 1 or 12 of the NMC register May accommodate up to 48 persons aged 50 years and over who are receiving nursing care. Staffing Notice dated 04/06/1999 applies Date of last inspection 22nd June 2005 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 and amenities and social venues. It is a purpose built home designed to accommodate a maximum of forty-eight service users 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. Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken over nine hours to review the requirements made at the last inspection and also to review the care practice to ensure that it is in line with the legislation and that current and best practice is followed at the Home. The inspection was also undertaken in response to a telephone message received from a concerned social worker in relation to a lack of appropriate handling equipment, which led to two falls, by a resident at the Home. The Commission for Social Care Inspection was satisfied with actions taken by the Home to ensure that the resident was safe and was protected from further injuries after the falls. The Commission was kept updated about the resident’s progress, however, the resident sadly passed away before this inspection was undertaken. Furthermore, the inspection was undertaken to review the staff shortages at the Home. The Commission was concerned about the frequency of notification of staff shortages sent to the Commission by the Home. At the last inspection, 21 requirements were made and eleven requirements were met; the Home is making efforts to ensure that those outstanding requirements are met. A tour of the building was undertaken and a number of records were reviewed; seven residents, five relatives and three staff members were spoken with on the day. What the service does well: What has improved since the last inspection? The Home recently installed a new call bell system to ensure that residents felt safe at the Home and are able to summon assistance when needed. Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 Page 6 The Home purchased an external lockable storage for all unwanted items and spare equipment to ensure that facilities for residents are not used for storage at the Home. 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. Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 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.V261835.R01.S.doc Version 5.0 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 the following standard(s): 1,2,3,4,5 The process of admission is well planned with clear information to enable the resident or their representatives to make decisions about the services provided at the Home EVIDENCE: The Home’s Statement of Purpose and Service User’s Guide remains in place and provides information to prospective residents in relation to services provided to enable them to make a decision about the Home. Evidence from two newly admitted residents showed that one resident was assessed on the phone due to emergency admission and another resident was assessed at the hospital before admission. One resident interviewed who was admitted two months ago stated that he/she was assessed by the Manager at home, he also visited to view the Home and chose his room before moving in to the Home. Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 Page 9 The Manager stated at a discussion that the Home has Terms and Conditions for Local Authority residents and self-funding residents. The Terms and Conditions has information in relation to services provided, fees to be paid and other relevant information. This document is given to the resident or relatives on admission with an acceptance form to be signed and returned to the Home. The home is to confirm in writing of its ability to meet the assessed needs of the residents on or before admission. The requirement, made at the last inspection, remains. Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 The Home offers care and support to residents throughout their lives and towards the end; however, it fails to protect the residents by lack of care plans and review of healthcare needs. EVIDENCE: Five of the residents’ care files were reviewed. One care file showed a follow up of the last inspection requirement in relation to poor fluid intake and poor care, it was noted that action plans drawn up by the Home in order to meet the requirement had been fully implemented. Three of the care files also gave clear and detailed information to staff to enable them to deliver appropriate care according to the residents’ assessed needs. These care plans were regularly reviewed and updated. However, it was noted that a resident who was admitted on 25th October 2005 had no care plan in relation to three identified health care problems and how these were being met. There were no risk assessments and handling profiles to enable staff to assist the resident to ensure that the resident is safe. An immediate requirement was issued for the home to draw up a plan of care in relation to the identified needs. Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 Page 11 The care file of one resident who had several falls was reviewed. The resident had three previous falls between April and September 2005 with no serious injuries and the risk assessment was reviewed. There were entries in the progress notes of encouraging the resident to use the call bell to summon assistance. The resident had recent falls on 14th October 2005 (twice) and 15th October 2005 which resulted in a fracture of the left hip that were satisfactorily managed by the Home in terms of liaison with the GP and subsequent visits to the Accident and Emergency Department. However, the Manager stated that the resident suffered from depression. It was also noted that there were entries in the progress note, which evidenced that the resident had shown signs of challenging behaviour towards staff and had refused care. There were no care plans in relation to the depression and behaviour that challenges to enable staff to provide appropriate care to the resident. This concern was discussed with the Manager and an immediate requirement was issued to ensure that the above concerns are rectified. The Commission for Social Care Inspection received an action plan which met the requirements within the time scale given. It was also agreed that the Home provides a weekly up-date on the recovery progress of the resident. Residents interviewed stated that they receive good care, staff showed respect and dignity. One resident stated “I get up when I want and go to bed when I want to”. One resident also was on respite care and was going home on the day of the inspection stated that “staff are good here”, she had used the Home several times for respite care and had always been satisfied with the care provided at the Home. One Health Professional met on the day commented positively on the efforts being made by the staff to provide good care for the residents. The Health Professional stated that her/his role is to work with the Doctors to improve the quality of care for the residents in order to prevent hospital admissions. She/he also stated that the role is to empower the nurses to make good assessments of the residents’ conditions without taking away their Clinical Skills. Staff spoken with were aware of their role and responsibilities in relation to death and dying of a resident. Staff is also aware of the importance of ensuring that information about residents is kept confidential. Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 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 the following standard(s): 12,13,14,15 The Home enables the residents to maintain contacts with families, friends and representatives. It also provides them with meaningful activities; however, it fails to provide the residents with a choice of meals. EVIDENCE: Residents, staff and relatives interviewed on the day of the inspection confirmed that the Home enables and supports the residents to maintain contact with their families and friends. The residents are also encouraged and supported to maintain links with the local community as they wish. One resident spoken with stated that she/he had two grandchildren and they take it in turns to visit regularly. Another resident stated that his/her two children live locally and they visit on alternate days. Five relatives met on the day stated that they visit regularly to see their loved ones and that there are no restrictions. On the day of inspection a relative opened the door for the Inspector, the relative stated that he visits his relatives daily and that he knows the code to get in to the Home. This demonstrates the relaxed atmosphere at the Home and a sense of trust between the Home and the relatives. This is commendable. Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 Page 13 Staff are aware and are mindful of the residents’ wishes in regard to the timing for care provisions and also residents wishes for getting up and retiring for bed. The Home employs an Activities Co-ordinator. This person is supported by an Activities Volunteer to provide activities for the residents as far as is practicable, and on two days a week. The Activities Co-ordinator stated that the activities are adapted to suit all types of residents and that she is aware of the residents’ needs. Activities for the week and beyond were noted displayed around the Home. These activities included, a trip to the Garden Centre on 30th November 2005, Harry Ramsden’s on 7th December 2005. Other activities included skittles on a different day and different floors there is also a little trolley that goes round the Home on Thursday mornings with different items of interest for residents to purchase. The Activities Co-ordinator also stated that she visits some residents in their bedrooms for a one-to-one interaction. Residents were noted on the ground floor enjoying a game of skittles. Residents spoken with after the game stated that they enjoyed the game. The menu was reviewed and it was noted that there was no choice at lunch times to enable the residents to decide what they would wish to eat. Furthermore, the menu for the day was changed without involving or informing the residents. The Chef stated that it was the responsibility of the care staff to ensure that residents were aware of the change. The Manager stated that she was not aware of the change, however, she would ensure that adequate provision is made in future to avoid this from happening. The Manager stated that she would review the menu with a new chef who is due to commence shortly. Three relatives met in the dining room and assisting residents with their meals stated, “The residents could do with more fresh vegetables”. The Manager also stated that there is a meeting organised by the Home to discuss activities, food and entertainments for the residents. The meeting comprises of two residents, some relatives and some staff members. The last meeting was on 26th October 2005. A requirement was made for the Home to provide nutritious wholesome meals and to ensure that more residents are involved in choosing the menu. The kitchen was found fairly clean; the Manager stated that the kitchen floor is to be repaired on Monday 7th November 2005. Confirmation that the floor had been repaired was received at the Commission on 15/11/05 A new dishwasher had been installed to ensure better hygiene and protection of the residents in relation to infection control. Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 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 the following standard(s): 16,17,18 Residents are enabled to complain, however, the home fails to offer them adequate protection through lack of training of some staff members. EVIDENCE: The home has appropriate procedures in place for the management of any complaint. The Manager stated that there have been no complaints since the last inspection. The concerns raised by a Health Professional in relation to a resident who slipped out of handling equipment twice were followed up. The concern was satisfactorily dealt with by the Manager in terms of regular review of the resident’s risk assessment and care plans, involvement of the Occupational Therapist and GP, regularly updating the Commission, meetings with the resident and her/his relatives and liaison with the Social Services Department. The resident passed away before this inspection was undertaken. The Home has a copy of the South Gloucestershire Council’s document for the Protection of Vulnerable Adults. The Manager stated that fourteen staff members have attended formal training on Protection of Vulnerable Adults. The home employs forty-eight staff members. At the last inspection, a requirement was made for the Home to ensure that staff members undertake training on Protection of Vulnerable Adults. The action plan sent to the Commission before this inspection stated that “structured training is now in place for vulnerable adults”, however, the Manager stated that there is “no Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 Page 15 structured training”, and that she has no budget for training for staff on Protection of Vulnerable Adults. The Manager intends to have training sessions with staff members and provide their Protection of Vulnerable Adults training pack and a workbook from Four Seasons Health Care. The staff members would complete the workbook and hand it in for the Manager to sign them off. The Manager also stated that she intends to send some staff members on the South Gloucestershire training session on Protection of Vulnerable Adults as soon as there are available spaces. A requirement for this training remains in place. The Home is reminded that failure to comply with this requirement may lead to an enforcement action. Residents spoken with at the Home stated that they feel safe at the Home and that they are aware of their legal rights and are enabled to vote using the posting voting system. The Registered Manager regularly checks and updates the Personal Identification Numbers of the Registered Nurses to ensure that residents are adequately protected. Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,22,26 The Home is a safe, clean well-maintained environment. Specialist equipment suitable for residents is provided. EVIDENCE: The Home was found clean, tidy and free from offensive odours. Residents were found sitting in the communal areas, relaxed in their homely environment. During a walk about, and a follow up of the requirement made at the last inspection, it was noted that the bathrooms used as storage had been cleared. The Home Manager stated that the Home recently purchased a mobile shed for storage of unwanted items previously stored in the ground floor bathrooms. One of the ground floor bathrooms is to be converted to a shower room to Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 Page 17 ensure that adequate facilities are in place and especially for residents who may prefer to have a shower. There is appropriate specialist equipment at the Home to meet the resident’s needs. The Home continues to involve the Community Physiotherapist and Occupational Therapist to assess the residents for any equipment that they may need. Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The Home’s recruitment process offers safety to the residents; however, the Home fails to ensure adequate protection through lack of training and adequate numbers of staff. EVIDENCE: The Home has a recruitment procedure to ensure that suitable staff are recruited to meet residents’ needs. The record of one recently employed staff member contained required information to include personal details, three satisfactory references and Criminal Records Bureau disclosure. It was also noted that one staff member recruited from outside the UK had satisfactory Police Checks from his/her country and appropriate work permit and other documentation from the Home Office. The Manager stated that staff have attended various training up-dates, however, it was noted that a recently recruited and some other staff members have not attended training on Protection of Vulnerable Adults. In addition the Manager stated that eight staff members have attained National Vocational Qualifications in Care at Level 2, one staff member has achieved NVQ Level 3, three staff members are to commence NVQ Level 2 as soon as possible. The Manager stated at the discussion about the above, that Four Season’s Health Care have appointed NVQ assessors to ensure that care staff are trained to achieve the qualification and meet the required 50 by the end of 2005. An Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 Page 19 immediate requirement was issued for the Home to provide training staff for staff in the protection of vulnerable adults. Whilst the Home had adequate numbers of staff on the day of inspection the Commission was concerned about the number of notifications of shortage of staff received from the Home since the last inspection. It was disappointing to note that most of the shortage happened on weekends. The Manager explained that the Home is making efforts to recruit more staff to ensure that the residents needs are met at all times. The Manager stated that the Organisation has been supportive and that she would usually contact a Care Agency to supply the Home with staff to cover shortages, however, the Agencies have not been able to supply the Home with staff members in most cases. A requirement had been made for the Home to ensure that adequate numbers of care staff are available at the Home at all times to ensure that the residents’ needs are met at all times. The Home is reminded that failure to comply with this requirement may lead to enforcement action. Two residents spoken with state that “staff are kind” and “staff answer the bell when it rings”. One staff member interviewed demonstrated awareness of her role and responsibilities in relation to care of the residents. Another staff member stated that she was given a job description and that she had three months induction period. Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38 The Home benefits from good leadership and management; however, health and safety practices do not fully protect the resident’s staff and visitors. EVIDENCE: Mrs Jeen Davis is a Registered Nurse (First Level) and has many years experience of managing a Home and also has the overall responsibility of managing Stanshawes Nursing Home. Mrs Davis has attended various training courses to enable her to lead her team effectively. Residents and staff interviewed commented positively on her ability to manage the Home. One resident stated that the Manager comes to see her/him and that she would listen if she/he had any concerns. Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 Page 21 One staff member stated that she would approach the Manager if she was unhappy about services provided at the Home and that she was confident that the Manager would listen. There was a good atmosphere at the Home on the day of this inspection, however, it was disappointing to note that there was lack of communication between the kitchen and care staff in relation to the menu for residents’ lunch. The residents were not informed about the change in menu and the kitchen staff insisted that the care staff were aware and that it was the responsibility of the care staff to pass this information to the residents. The Manager was unaware of these changes in menu. The Manager stated that she would ensure that communication is improved at the Home to ensure that residents are well informed. Evidence from the records reviewed showed that staff have received regular supervision to enable them to meet residents’ needs appropriately. The Fire Log Book was reviewed and was well maintained. Staff have attended fire lectures, however, fire drills have not been regularly undertaken by the Home to ensure that all staff are aware of actions to be taken in the event of actual fire outbreak. An immediate requirement was made for the Home to ensure that all staff attend fire drills within a given time scale. The Home had recently installed a new call bell system to ensure that the safety of residents is maintained and especially in emergencies. However, while touring the building, it was noted that call bells were not within easy reach of some residents. The manager stated that she would ensure that staff are aware of this concern. The Manager also stated that she would ensure that staff received an update on infection control to ensure that the residents are adequately protected. The Accident Book was reviewed and it was noted that accidents were regularly recorded and were reviewed in the care files. The Manager stated that the Home does not have an account for self-funded residents, the Local Authority send pocket money for their residents to the Home, these amounts are received and the money is securely locked. A recent visit from the South Gloucestershire Audit Department was noted and the Manager provided the report. The Home has policies and procedures, which are accessible to all staff. At the last inspection a requirement was made for the Home to implement a quality assurance system that includes the views of the residents, relatives and other visitors to the home. The Home is making efforts to ensure that the requirement is met. The Manager stated that the Home is in the process of implementing structured questionnaires for residents and relatives to complete in order to obtain their views in relation to care and services provided. Other Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 Page 22 ways used by the Home include, Care Plan reviews, Provider’s monthly visits to the home, residents’ meetings, staff meetings and Care home monthly audit by the Manager. Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 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 3 3 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X 3 3 X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 2 Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? YES 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 2 3 4 5 6 7 8 9 Standard 38 38 38 30 30 27 15 8 4 Regulation 13 13 23 13 18 (1) C (i) 18 (1) (a) 16 15 14 Timescale for action Ensure fire doors are not wedged 10/11/05 open. Ensure call bells are within easy 10/11/05 reach of residents. Ensure staff attend regular fire 10/11/05 drills. Ensure staff receive training on 10/11/05 Protection of Vulnerable Adults. Ensure that staff are trained on 03/12/05 communication. Ensure adequate numbers of 06/12/05 staff are working at the home at all times. Provide varied nutritional meals 03/12/05 for the residents and inform them when menu is changed. Ensure care plans are in place 10/11/05 for assessed need of residents. Confirm in writing that home is 03/12/05 able to meet residents’ needs. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 Page 25 No. Refer to Standard Good Practice Recommendations Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Stanshawes DS0000020253.V261835.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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