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Inspection on 11/12/06 for Summerhill Nursing & Residential Home

Also see our care home review for Summerhill Nursing & Residential Home for more information

This inspection was carried out on 11th December 2006.

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

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

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

What the care home does well

Residents spoken to like living in the home and spoke highly of the staff and the care and support they receive from them. Residents commented on how friendly the home is and the kindness of the staff. One resident said, "I don`t think you could do much more than the staff already do for us". Relatives survey responses were positive with one saying, "They could not compliment the home enough". Throughout the day the inspectors saw that staff and residents get on well together, that staff know the residents well and interact with them sensitively and as individuals. The home is furnished and maintained to a high standard and the atmosphere is relaxed and homely. Attention is paid to detail in resident`s private rooms and in their decoration. The bedrooms are clean and well furnished and all are en suite and communal areas are attractive and well used for a variety of activities and social gatherings. The home has a well supported staff team and staff morale is good with staff saying what a good working environment they have. There is a stable and competent management team displaying a clear focus on providing the kind of services resident`s want. The home has good working relationships with the local doctors and district nursing service and access to them is prompt. The home maintains a high standard of catering with the majority of food home made, reflecting residents preferences and choice. Efforts are made to ensure residents are offered a varied and nutritious menu with fresh fruit and vegetables available each day.The home provides a comfortable and homely atmosphere for residents and many of the residents say they especially enjoy the home`s gardens. The home is kept very clean and well maintained and all furnishings are of an attractive and high standard. The management responds positively to the inspection process and keeps the Commission for Social Care Inspection (CSCI) informed of problems and changes and seeks advice in a timely way. Training, professional and personal development are given a high priority by the management team the manager is open to advice in looking for ways to improve the home for residents.

What has improved since the last inspection?

CARE HOMES FOR OLDER PEOPLE Summerhill Nursing & Residential Home East View Kendal Cumbria LA9 4JY Lead Inspector Marian Whittam Unannounced Inspection 11th December 2006 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 Summerhill Nursing & Residential Home DS0000006157.V316218.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. Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Summerhill Nursing & Residential Home Address East View Kendal Cumbria LA9 4JY 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) 01539 726000 01539 727254 askinsh@bupa.com www.bupa.co.uk BUPA Care Homes (CFCHomes) Limited Mrs Helen Elizabeth Askins Care Home 71 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (31), Old age, not falling within any other of places category (37), Physical disability (2) Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 71 service users to include: up to 39 service users receiving nursing care in the categories of OP(22) and DE(E)(17) up to 31 service users in the category DE(E) (Dementia over 65 years of age) up to 37 service users in the category of OP (Older people not falling within any other category) up to 1 service user in the category DE (Dementia under 65 years of age) up to 2 service users in the category PD (Physical disabilities under 65 years of age) Date of last inspection 6th February 2006 Brief Description of the Service: Summerhill is a care home with nursing registered to provide nursing and residential care for up to 71 residents. The home is divided into 4 suites as follows: Buttermere for general nursing care, Windermere for nursing care of residents with dementia, Grasmere for high dependency personal care with mental health needs and Thirlmere for those with personal care needs only. The home is in a residential area of the market town of Kendal and close to the shopping areas, banks, libraries and general amenities. The home has mature and well-tended gardens, including a secure walled garden for Windermere suite. It has patio and seating areas for service users that overlook the town. There is a large car park to the front of the building. The home is on two floors these can be reached by a passenger lift or by stairs. There are attractive dining and communal areas for residents on each suite and all residents have single bedrooms with en suite facilities. The home has its own kitchen and laundry facilities on site. Fees payable at the home are £430.00 to £763.00 a week as at 11th December 2006. There are additional charges for personal newspapers and magazines, hairdressing and private chiropody. The home makes information about its services available through its Service User Guide and Statement of Purpose. There is an information file containing useful information on the home and all the services provided in every resident bedroom. Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place on 11th December 2006. Two inspectors carried out the inspection, looked around the home and spoke with the manager, residents and with staff members. Staff recruitment records, training records, medication handling records and care plans were examined and a selection of records required by regulation. Information about the home and its services, asked for by the Commission for Social Care Inspection (CSCI), before the inspection took place, was provided in good time by the home manager. Before the visit information was also gathered on the service from records of previous visits, notifications and other regulatory activity. Questionnaires from residents and relatives about the service, provided by CSCI, were returned before the inspection took place and also provided information about their experiences of the home. What the service does well: Residents spoken to like living in the home and spoke highly of the staff and the care and support they receive from them. Residents commented on how friendly the home is and the kindness of the staff. One resident said, “I don’t think you could do much more than the staff already do for us”. Relatives survey responses were positive with one saying, “They could not compliment the home enough”. Throughout the day the inspectors saw that staff and residents get on well together, that staff know the residents well and interact with them sensitively and as individuals. The home is furnished and maintained to a high standard and the atmosphere is relaxed and homely. Attention is paid to detail in resident’s private rooms and in their decoration. The bedrooms are clean and well furnished and all are en suite and communal areas are attractive and well used for a variety of activities and social gatherings. The home has a well supported staff team and staff morale is good with staff saying what a good working environment they have. There is a stable and competent management team displaying a clear focus on providing the kind of services resident’s want. The home has good working relationships with the local doctors and district nursing service and access to them is prompt. The home maintains a high standard of catering with the majority of food home made, reflecting residents preferences and choice. Efforts are made to ensure residents are offered a varied and nutritious menu with fresh fruit and vegetables available each day. Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 6 The home provides a comfortable and homely atmosphere for residents and many of the residents say they especially enjoy the home’s gardens. The home is kept very clean and well maintained and all furnishings are of an attractive and high standard. The management responds positively to the inspection process and keeps the Commission for Social Care Inspection (CSCI) informed of problems and changes and seeks advice in a timely way. Training, professional and personal development are given a high priority by the management team the manager is open to advice in looking for ways to improve the home for residents. What has improved since the last inspection? What they could do better: The home has its own systems in place for monitoring quality that work well in identifying areas for improvement and change. However as a good practice suggestion the home could consider extending its use of surveys to nursing and medical professionals who come into contact with the home to see if they have any opinions and ideas about the service. Following from the observations of the inspector on the dementia unit the manager should, for good practice, consider providing tactile objects for people Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 7 with dementia to help them relate to their environment more by touching and exploring familiar objects. 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. Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 1, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The pre admission assessments done by the home are detailed to ensure individual needs will be met on admission. EVIDENCE: Information is available about the home for prospective residents and their families in the statement of purpose and service users guide so they know what the home can provide. The Statement of purpose has been updated to include the services the home offers in respect of Palliative Care. An information/welcome pack is provided for all residents in their bedrooms with useful information about the home, the services on offer and about settling into their new home. All residents have an individual plan of care and resident’s needs have been assessed in detail before and following admission and their individual care Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 10 plans developed from this. The home manager or senior nursing staff do an individual assessment of needs to ensure that the home could meet the needs before residents came to live there. The assessments seen are detailed and clear. Where appropriate families, specialised care agencies and professionals are being involved in providing information on the health and personal care needs to be met for residents. All prospective residents and/or their families are invited and encouraged to visit the home prior to admission. This gives them an opportunity to assess the quality and suitability of the home. Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7, 8, 9, 10 and 11. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There is a comprehensive care planning and assessment system in place to provide information for staff to meet resident’s individual health, personal and social care needs. EVIDENCE: All residents have an individual plan of care, based on initial assessments and these individual plans set out their health, personal and social care needs and personal and clinical risk assessments. All plans and assessments are evaluated, reviewed, updated and audited regularly to make sure procedures are being followed. Changes identified at evaluation are incorporated into care plans and needs assessments and the plans are resident focused. The manager periodically makes spot checks within the home to monitor practices. One inspector spent a period of close observation on the units where residents with dementia live. The observation exercise shows that residents are being cared for in accordance with their individual plan of care. For example, where Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 12 a care plan stated a resident needed certain help with eating, this was seen being done. Care plans are well laid out to a set format, and include the detailed information the staff need to provide appropriate care to each individual. The information in the care plans is kept updated to reflect changing needs. However, during the observation period residents did not have access to any objects or everyday items to hold or handle, except for cups and cutlery. Research indicates that it is important for people with dementia to relate to their environment by touching and exploring familiar objects. Residents spoken with are happy with their care and survey responses supported that view. One resident said “I like it here very much, I came in for 2 weeks and decided to stay, I have everything I want”. Another said “I am just happy to be here and be so cared for” and that “there is always a lot of laughter here”. The home has also been involved in the development of a new care planning system across the organisation that is based on person centred care and assessment so that care planning approaches will be further improved for residents. Senior staff have been trained in this and all staff are due for the training to implement this fully in February 2007. This should further improve an already good care planning system. There is evidence of timely referral to health care services and working with other agencies and the actions taken following their involvement. Resident’s health care needs and reviews are being promptly attended to and the home works well with other agencies and health professionals to meet identified needs. Residents spoken with said their privacy was respected and felt their dignity upheld. Observation during the inspection, including moving and handling and assistance with eating and drinking suggests that resident’s dignity is being promoted and independence promoted. One resident said that, “the carers are very cheerful and kind, remarkable really when you consider all they have to do”. There is evidence from speaking with residents and from their care plans that residents are involved in making choices about their care. Residents confirmed that their opinions are sought about their personal care and life in the home generally. Surveys received from residents and relatives also support this. Medication practices, the storage of medicines and their handling is of a good standard and subject to audit to make sure procedures are being followed. Audits have revealed where improvements are needed and when problems have been found the manager is properly addressing them. The home keeps records of medicines it receives and returns and has arrangements in place for disposal through a licensed contractor. Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12, 13, 14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A full and varied programme of well organised activities is provided that take into account residents individual preferences, capabilities and cultural and religious expectations. EVIDENCE: The home now has 3 activities coordinators who provide a range of advertised group and one to one activities and entertainments including outings, holistic therapies, origami, quizzes, bingo, art sessions, discussion groups and social and religious events. Each unit has an activities programme and this is provided at weekends as well. There is a clothes show and sale scheduled for the following day. Care staff were helping to make paper Christmas decorations with residents on one of the suites. Resident’s former hobbies and current interests and ‘life maps’ are recorded in detail and individual abilities and capabilities are given consideration in planning and carrying out activities. The pictures provided by the social assessments are clear and give a person centred background to residents as Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 14 individuals and to what is important to them and what has or has had significance in their lives. An activity record shows what people have enjoyed doing and valued. Resident’s surveys confirm that there are a variety of activities on offer but that residents do not have to join in if they do not want to. One resident said that they especially liked the quizzes but not the bingo. One resident spoken with said, “they pull out all the stops when its an occasion, the Halloween party was excellent and Christmas is always very good”. Relative’s comments indicate that they feel involved in the life of the home and one said “there is always a warm welcome on arrival”. A resident told the inspector that families may stay for meals with them and that some were going to do that at Christmas. . Several of those spoken with thought the quality of the food provided was “ very good”, some others thought it was “fair” and “adequate”. There is always a choice of food each day and that there are drinks provided throughout the day. The menus, displayed in the foyer, showed a nutritious diet. Residents said that they could have alternatives to the choices on the menu and mealtimes were flexible. The lunchtime meal was observed on the nursing and on the residential suites and these were relaxed and sociable with residents chatting and taking their time. Staff assisted residents in the dining room and in their bedrooms if that is where they wanted to eat. Staff are friendly and discreet in offering assistance and offering second helpings to residents, which some accepted. Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has an effective complaints system and procedures to promote residents safety that both residents and staff are aware of. EVIDENCE: The home has a clear complaint procedure and a whistle blowing procedure that is displayed and available throughout the home. Additionally the complaints procedure is in the information files in resident’s rooms. Surveys received from residents and relatives indicate that they are aware of the complaints systems and that they felt confident that they would be properly dealt with. There is a complaints logging system that records all complaints and the details of the investigation and the actions taken to prevent it happening again. Complaints monitoring is linked to the home’s quality assurance system. Two complaints have been made to the home since the last inspection and records show these have been investigated and resolved using the home’s procedures. Information on advocacy is provided for residents in the home and the service obtained on request. Nursing and care staff have had training on abuse and adult protection and the Deputy Manager is the home’s lead practitioner on POVA and trains other staff Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 16 on this. Training records show that staff are trained on managing violence and aggression and the home also has its own in house trainer on this to act as a resource. Senior care staff also take the POVA training course to be able to teach other staff and to act as a resource. The home has policies and procedures in place for adult protection; identifying and reporting abuse and whistle blowing. Systems are in place to safeguard residents financial interests and the home invoices residents for any bills and keeps receipts individually. Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 17 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): NMS 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is of a consistently high standard providing residents with a well maintained, well equipped, clean, attractive and homely place to live. EVIDENCE: The home is well maintained with a high standard of decoration throughout that provides a clean, tidy and homely environment for residents. Attention is paid to detail and making the environment welcoming and homely, lounges are arranged in a way that promotes groups rather than being institutional. The lounge and dining areas are spacious, comfortable and well furnished with good lighting and seating. New carpets and chairs have been provided on both nursing and residential units to further improve the environment for residents. Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 18 The home has a rolling programme of redecoration and upgrading of bedrooms and communal areas. The homes own maintenance person does small daily maintenance jobs promptly. One relative who visits the home regularly commented that the home is always “ clean and fresh” and that “the gardens are excellently maintained and are a delight to sit in”. The gardens are well kept and do have appropriate seating for the residents. Several residents said that they had enjoyed the garden during the warm summer months and during the home’s fete. Resident’s bedrooms seen by the inspector had a high standard of décor, and furnishings with en suite toilets and showers. Many residents had brought some of their own possessions in with them and this made their bedrooms more personal and homely. Bedrooms are all single occupancy, are light and naturally ventilated with domestic type lighting. One resident said that the reason they decided to stay permanently was because they liked their room and the view from it so much. There are clear infection control procedures and staff observed to be using gloves and aprons during care and using appropriate clinical waste disposal. Staff have been given training on infection control and this is recorded in their training records. Records of water testing for prevention of risks from Legionnaires Disease and temperature testing to prevent risks of scalds to residents are kept. There is a range of equipment, nursing beds and adaptations in the home to help residents make the most of their independence and to get about the home. Staff have been trained in the use of such equipment and residents are assessed for its safe use. Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 19 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): NMS 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has robust recruitment processes and sufficient nursing and care staff on duty to be able to provide consistent care and meet resident’s needs. EVIDENCE: Staff rotas and observation during the visit indicate the home has sufficient staff on duty to provide care and that there is now a more stable staff group. This provides continuity for residents during the day and night. Staff spoken with enjoyed their work and morale was good in the home. Residents said that staff and management were “friendly” and “cheerful”. One relative survey response said that, “staff are always so cheerful and polite, it’s a joy to visit”. The home has a good percentage of care staff with NVQ Level 2 in care or above and encourages and offers incentives for staff to undertake training. The home has a specific training programme for care staff as they move up to senior carer level so they are properly prepared for that role. Staff training and development for nursing and care staff is promoted, with a range of training including palliative care. There is an annual training plan covering mandatory training and training specific to the resident groups, individual training files identifying staff training needs and induction records are kept for all staff. Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 20 . Robust recruitment procedures and practices are in place and are being observed. Records of recent staff recruitment show that all necessary checks to safeguard residents are being done prior to staff starting work there. Staff have clear job descriptions and terms and conditions of employment. Registered nurses personal identification numbers are checked on recruitment and periodically to make sure no changes have taken place to further protect resident’s interests. Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 21 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): NMS 31, 32, 33 35, 36, 37 and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Procedures are in place to safeguard resident’s interests and promote their health and safety. EVIDENCE: The registered manager is appropriately qualified and experienced for their role and is well supported by an enthusiastic and highly effective deputy to provide a well run service. The management team has a clear vision for the home of continued improvement. Staff morale was observed to be good and staff confirm that formal and daily supervision is being done and regular staff meetings are held with staff contributing to the agenda. This allows staff Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 22 feedback as well as internal reviews of policies and procedures, audits and information sharing. Record keeping is in good order with clear up to date documentation that is kept securely. The home has clear development plans outlining annual objectives. The home has effective quality assurance and quality monitoring systems to measure performance through a process of clear planning as in the case of the new person centred planning process. The home evaluates and assesses and then takes any actions needed. There are regular residents meeting and the changes to the care planning were taken to the last one for resident’s views. The activities coordinator and cook also attend these meetings. Audits are done across all aspects of the home’s systems, medication, maintenance, care planning, skin care, complaints, accident, incidents and results are fed back into the quality monitoring system to identify areas needing improvement, monitoring or change. Satisfaction surveys are in use for residents and relatives with the results collated and published. It is recommended that the home extend this to include other stakeholders such as nursing and medical professionals who come into regular contact with the home. Records and servicing contracts indicate that the home has systems in operation and training to promote resident health and safety. There is evidence that appropriate testing and cleaning being carried out to reduce the risk Legionella and water temperature testing to reduce the risk of scalds to residents. Records showed that servicing and maintenance of equipment is being done. Summerhill Nursing & Residential Home DS0000006157.V316218.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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 3 3 3 Summerhill Nursing & Residential Home DS0000006157.V316218.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 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. 1. Refer to Standard OP7 Good Practice Recommendations The manager should consider providing tactile objects for people with dementia to help them relate to their environment by touching and exploring familiar objects. The home should consider extending its use of surveys to nursing and medical professionals who come into contact with the home. 2. OP33 Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 Summerhill Nursing & Residential Home DS0000006157.V316218.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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