Inspection on 25/06/07 for Sydenhurst

This inspection was carried out on 25th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Sydenhurst 26/06/09

Sydenhurst 26/09/05

Sydenhurst 16/06/05

Sydenhurst 20/01/05

Sydenhurst 23/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Sydenhurst Sydenhurst Mill Lane Chiddingfold Surrey GU8 4SJ Lead Inspector Pauline Long Unannounced Inspection 25th June 2007 11:00 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 Sydenhurst DS0000013811.V343782.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. Sydenhurst DS0000013811.V343782.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sydenhurst Address Sydenhurst Mill Lane Chiddingfold Surrey GU8 4SJ 01428 683124 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) uksydenhurst@hotmail.com Association of Ukrainians in Great Britain David James White Care Home 32 Category(ies) of Dementia - over 65 years of age (16), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (14), Physical disability over 65 years of age (4) Sydenhurst DS0000013811.V343782.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Only 1 (one) named Service User in the category MD over the age of 60 years. Of the older people (OP) accommodated, up to 4 (four) may be in the category PD(E). Additional staff be allocated based upon the figures supplied by the Residential Forum. The Statement of purpose and Service Users Guide are required to be amended to include the change within the capacity of the home. 26th September 2005 Date of last inspection Brief Description of the Service: Sydenhurst is a large detached property set in its own enclosed grounds and located in the village of Chiddingfold. It is owned and managed by The Association of Ukrainians in Great Britain and provides care and accommodation to up to thirty-two older people, some of whom may also have a physical disability and/or dementia. The accommodation is arranged over three floors and has a number of communal sitting rooms, a spacious dining room and a large kitchen located on the ground floor. There is an adapted shower room on the ground floor and adapted bathrooms on the ground and first floor, with a standard bathroom on the second floor. The first and second floor can be reached by staircase or passenger lift. There are 23 single bedrooms, 11 of which have en-suite facilities, and 4 twin bedrooms, 1 of which has en-suite facilities. Those rooms without en-suite have toilet and bathing facilities located nearby. The home has its own mini-bus and people carrier to access activities and amenities in the local community. The fees at the home range from £400.00per week to £600.00 per week. Sydenhurst DS0000013811.V343782.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 11.00 and was in the service for 6 hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The CSCI would like to thank the residents, the acting home manager, staff and visitors for their hospitality, assistance and co-operation during the site visit. What the service does well: The home primarily provides for residents who are Ukrainian or have Ukrainian connections, and is able to meet their language, religious and cultural needs. The manager and staff demonstrated an open and inclusive approach to the residents care. The residents benefit from a long standing staff team, who have worked in the home for several years, and this was reflected in the level of knowledge and understanding of the needs and preferences of the residents. The home promotes and encourages contact with family/friends and the local community. Residents spoken with were complimentary about the care and services provided by the home. They commented that, that the care they received was good” and “that the staff were good at their jobs. Health care professionals commented that the staff were very knowledgeable and had a good understanding of the residents needs. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Sydenhurst DS0000013811.V343782.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sydenhurst DS0000013811.V343782.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 Sydenhurst DS0000013811.V343782.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): 3,6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents are only admitted to the home following an assessment of their needs. The home does not provide an intermediate care service. EVIDENCE: The home provides a care service for privately funded and local authority residents. The manager stated that following a referral the prospective resident would be visited at their home or in hospital, where a basic care needs assessment would be completed. Following this they would be invited to visit the home where a more in-depth assessment would be carried out. Following admission the care needs assessment would be fully completed over a period of weeks. The manager commented that the home was in the process of reviewing the care needs assessment format in order to simplify the process. Sydenhurst DS0000013811.V343782.R01.S.doc Version 5.2 Page 9 Four of the residents care needs assessments were sampled. Three had been fully completed and were found to provide a good overview of the residents care needs, for example all daily living activities and their preferences in respect of their names, health and social care needs, spiritual needs and their likes and dislikes around activities. The fourth care needs assessment was in respect of a new resident and was in the process of being completed, a local authority care management care needs assessment was on file in respect of this resident. The home does not provide for an intermediate care service. Sydenhurst DS0000013811.V343782.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): 7,8,9,10 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s health and social care needs are well met. They are treated with respect and their privacy and dignity is promoted. EVIDENCE: The care plans sampled were comprehensive, they reflected the care needs assessments and included all daily living activities and health needs, and gave the reader a good insight into a residents holistic needs. All of the care plans sampled had been signed, dated and regularly reviewed by staff, however none of them had been signed by a resident or their representative. Residents commented, that, “the care they received at the home was good” and that they had access to their care plan if they wished to see them, however none could confirm that they had been involved in drawing up their care plans. Whilst it was noted that the quality of the risk assessments within the care plans were good, there were no documented risk assessments in respect of the particular risks associated with Dementia care. Sydenhurst DS0000013811.V343782.R01.S.doc Version 5.2 Page 11 The home has recently secured the services of an NHS Chiropodist and Dentist, which makes it easier for the residents to access these services. Medication practices and procedures in respect of administration, recordkeeping and storage were sampled. Medication administration was observed and was found to be carried out in a sensitive and safe manner. None of the residents at the home were prescribed controlled medication. The storage of medication was found to be safe. Medication record sheets were sampled, and on the whole were found to be well documented, however some minor gaps in signatures were noted. This was discussed at the time with the manager, who stated that he had implemented a medication audit, and that when omissions in signatures were noted discussions were had with the staff responsible. Records in respect of these discussions were not sampled. Care staff confirmed that daily checks are carried on the medication record sheets and any issues noted would be addressed with the member of staff at the time. Discussions were had with the care staff about the homes medication policies and procedures. It was evident through these discussions, that the staff had a good understanding of the policies and procedures. The manager commented, that only staff, who had undertaken medication training and who were deemed competent were permitted to administer medications. Care staff confirmed this. Throughout the inspection process, staff, were observed carrying out various aspects of personal care for the residents, this support was offered in a respectful and sensitive manner. Staff, were observed knocking on doors and waiting to be invited in, before entering rooms. Bathroom doors were kept closed whilst staff, were attending to residents personal care needs. It was noted that several residents had keys to their bedroom doors and had chosen to lock them. Residents commented that, all of the staff were kind and treated them with respect. Care staff confirmed that the home operates a strict privacy and dignity policy. A requirement and a recommendation have been made in respect of theses standards. Please refer to page 25 of this report. Sydenhurst DS0000013811.V343782.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): 12,13,14,15 People who use the service experience excellent quality outcomes in this area. The residents are encouraged and enabled to maintain fulfilling lifestyles in the home and promotes contact with family, friends and the local community. Residents are encouraged and enabled to makes choices in their lives and meal times at the home are a positive and pleasant experience for the residents. EVIDENCE: The manager stated that, home is committed to ensuring that the residents maintain their relationships with their family and friends. Residents are also encouraged to maintain contact with their families living overseas via email and telephone. Residents commented that they received visits from their families and friends. Some relatives and visitors were observed visiting the home during the site visit. There was evidence of various flyers and photographs on the homes notice boards relating to activities and trips. All residents are encouraged to take part in all activities, outings, holidays and social events. The manager stated that the majority of residents went on holiday last year. Residents spoken with were happy with the activities provided in the home and could recall the holiday. One resident in particular Sydenhurst DS0000013811.V343782.R01.S.doc Version 5.2 Page 13 was looking forward to the good weather returning so he could get out to enjoy the sunshine. Some residents were observed reading the daily newspaper. Others were observed resting in their armchairs or watching the television. One resident was observed playing a harmonica and others hummed along to the tune. The home has recently opened their own day centre, and all residents are encouraged to use it, in order to have further opportunities to take part in activities outside the confines of the home. The manager commented that the home has strong social connections with the local village and that the residents regularly attend the weekly lunch club. The home actively encourages all of the residents to practice their faith. There is a small ecumenical church in the grounds, which is used for various faith services. One resident commented that he regularly receives communion. Residents were observed moving freely around the home, making choices as to how they would spend their day. The meals are freshly cooked in the home and it was positive to note, the choice of food on offer was good. The manager commented that there was a choice of seven main courses for the residents to choose. This was evidenced during the meal time activity as several residents were eating different meals. Discussions were had with the Chef in respect of resident’s likes and dislikes. He demonstrated a good understanding of each resident’s likes and dislikes, and specialist diets, for example diabetic, vegetarian and soft diets. Some of the residents required a soft diet, this was nicely presented in a way that looked appetizing and appealing. Residents commented that the food at the home was good. Some residents required support with their meals, this support was offered in a sensitive, dignified and unhurried manner. The home carries out meal surveys and as a result of feedback the last one, they have introduced a Residents Charter of Rights around meals and mealtimes. The charter covers various issues for example: choices, times of meals, the length of time given over to eating meals. The manager commented that the Charter was a reminder to all of the staff as to how important the meal times were to the residents. Sydenhurst DS0000013811.V343782.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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The residents are protected by the homes policies, procedures and practices around concerns, complaints and protection. EVIDENCE: Two complainants have contacted the Commission with information concerning a complaint made to the service since the last inspection. The complainants were advised to refer to the home in respect of these complaints. There was no evidence in the homes complaints log, to indicate the complainants had contacted the home. The manager stated that no one had spoken to him in this respect. One complaint has been made to the home in the last twelve months. This has been investigated under the homes complaints procedures and has been satisfactorily resolved. Residents and relatives commented, that if they any reason to complain, they would speak with the manager. The homes complaints procedure is provided in various languages and a copy is posted in every bedroom and various other prominent places throughout the home. No referrals have been made under the local authority multi agency Safeguarding Adults procedures since the last inspection. Discussions were had with the staff on duty and scenarios put to them in respect of the home’s safeguarding adults and complaints procedures. Staff interviewed Sydenhurst DS0000013811.V343782.R01.S.doc Version 5.2 Page 15 demonstrated a good understanding of the policies and procedures. All of the staff apart from the most recent recruits have, undertaken safeguarding adults training as evidenced in the training records. On the day several staff were undertaking an update in this training. Sydenhurst DS0000013811.V343782.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, 20, 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment is able to meet the changing needs of the resident’s, it is homely, clean safe and comfortable. Further improvements must be made to ensure that malodours are minimised. EVIDENCE: The home is an older property and presents the providers with challenges in respect of the constant need for updating and refurbishment. Considerable work has been undertaken in this respect since the last inspection providing a more pleasant environment for the residents. Improvements have made in the bathroom facilities, one assisted bath has been removed and is to be replaced with a more domestic style bath, which will provide a more dignified bathing experience for some residents. Most of the lavatories have been refurbished. Fifteen bedrooms have been redecorated. Two bedrooms have Sydenhurst DS0000013811.V343782.R01.S.doc Version 5.2 Page 17 been extended to provide en-suite facilities. Some of the communal areas in the home have been redecorated. Several new armchairs have been bought for the main sitting room. It was noted that the some of the carpets in the communal hallway on the first floor require attention. The manager stated that new carpets had been ordered. Major works are being undertaken in the main dining room in order to provide a more pleasant environment for the residents. Meals are being served in the homes conservatory until all of the work has been completed. Discussions were had with the residents and in respect of the building works and any disruption caused. They commented that the disruption was barley noticeable, and whilst there was some increase in dust and noise it was not a concern. They were looking forward to the completion of the project. They commented that the changes had been discussed with them and that they had, had input in to the design and choice of colours. This was evidenced in minutes of the last residents meeting. The area of the home where building works were taking place, were made inaccessible to the residents, ensuring their safety. A small section of the garden has been dedicated for the use of the residents who have Dementia, this area has been made secure in order to ensure that the residents can wander in safety. On the whole the home was clean and hygienic, however it was noted that there were some particular areas of malodour. Discussions were had with the manager in respect of this. The manager and staff commented that were some continence issues in the home, and that steps were being taken to eliminate the malodour. Otherwise there are good systems in place to prevent the spread of infection. Sydenhurst DS0000013811.V343782.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): 27,28,29,30 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service. EVIDENCE: Staff files sampled, and work based observations evidenced that the home employs a diverse staff group. The home specialises in providing a care service for residents who are Ukrainian and staff are recruited with this in mind. The home benefits from a long- standing, stable staff group and on the day the staffing levels were adequate for the dependency levels of the residents. Staff commented that the home was very seldom short staffed and that there was minimum agency usage. Resident’s and relatives commented that all of the staff were kind, helpful, knew what they were doing and good at their jobs. Health care professionals commented that staff were helpful, they communicate well and are very well informed about the residents needs, and that they manager many challenging situations well. One care manager commented that the home responds well to all of the residents needs regardless of age, disability gender and culture. The homes recruitment practices were sampled, and were found to be good. Three staff files were sampled and all had the required documentation in place, Sydenhurst DS0000013811.V343782.R01.S.doc Version 5.2 Page 19 with evidence of CRB (Criminal records) and POVA (Protection of Vulnerable Adults) checks. Discussions were had with staff, who, talked about their job roles and responsibilities. Work based observations evidenced competent and confident staff carrying out their various tasks. Staff training is given a high priority in the home and staff discussed some of the training they had undertaken. Training records demonstrated that statutory and various current good practice training had been undertaken since the last inspection for example: clinical observations, dementia care, manual handling, health and safety and adult protection. Some of the staff are undertaking English language courses at a local College and other classes are being held at the home at the weekends. The home is proactive in promoting NVQ (National Vocation Qualifications), and has achieved in excess of the National Minimum Standard recommendation of having at least 50 of care staff with NVQ2 or above for example 12 staff have achieved an NVQ 2 qualification and 18 staff are working towards an NVQ 2 qualification. The deputy managers have achieved an NVQ 3 qualification and are working towards an NVQ 4 qualification. The manager commented that training courses were arranged to ensure that all staff have an opportunity to attend, for example: training courses timed in the late evenings to enable the night staff and staff with carer responsibilities to attend. Sydenhurst DS0000013811.V343782.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): 31,32,33,35, 36,37,38 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The resident’s benefit from an open and inclusive management approach to the running of the home, their views are listened to and acted upon. Resident’s financial interests are safeguarded by the homes record keeping, policies and procedures. EVIDENCE: The registered manager has worked at the home for some years. He is social work qualified and has achieved the Registered Managers award and NVQ 4 in management. He has also undertaken statutory and good practice training courses and has keep abreast of changes in legislation as evidenced through discussions with him. All of the residents and staff spoken with, commented that, the manager has a “hands on” approach to the residents care, this was Sydenhurst DS0000013811.V343782.R01.S.doc Version 5.2 Page 21 evidenced on the day as the manager was helping out with carer responsibilities in order to enable some of the staff team to meet with the inspector and others to attend a training session. The manager was observed as being on first name terms with both residents and staff and they all appeared to be confident and relaxed in his company. The manager stated that home actively seeks the views of the residents. Residents meeting are held, where residents are encouraged to express their views and become involved in the day to day running of the home. This was evidenced in the minutes of the most recent residents meetings. Service users and stakeholders survey are sent out on a yearly basis, for example an admission process survey, a care service survey and a food survey. Some of the most recently returned surveys were sampled and evidenced positive responses. One survey evidenced a negative view of the service provided, and this was discussed with the manager, he stated that he had discussed this with the individual concerned. The manager was confident that resident’s views are actively sought on a daily basis as he spends time out on the floor. Residents spoken with commented that the manager was always around and always had time to listen to them. Discussions were had with the manager around resident’s personal monies. He stated that resident’s families/representatives had overall responsibility for resident’ finances. However the home holds small amounts of monies in resident’s personal accounts in order to meet the day-to-day needs for toiletries, reading materials and other consumables. The records in respect of these personal accounts were sampled and were found to be accurate and well documented. Discussions with the manager and care staff indicated that one to one staff supervision meetings are held. This was evidenced in the records of the dates of these meetings, most staff having a supervision meeting with a manager every 6 to 8 weeks. No supervision notes were sampled during this visit. The staff commented that they regularly work together with the manager and other senior staff and have regular discussions around residents needs. They also commented that if they wished to have a discussion with a manager, he operates an “open door” policy. The manager stated that staff are expected to attend quarterly staff meetings, the minutes of the most recent meeting could not be sampled as they were still in draft form on the IT system. Care staff confirmed that they attend regular staff meetings. The home has recently undertaken a review of all of the policies and procedures. Health and safety checks are routinely carried out at the home. Records evidenced that water temperatures, fire drills and fire bells and other safety equipment and checks had been regularly carried out and documented. All of the equipment in the home had been properly maintained and serviced. Sydenhurst DS0000013811.V343782.R01.S.doc Version 5.2 Page 22 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 3 3 4 3 3 Sydenhurst DS0000013811.V343782.R01.S.doc Version 5.2 Page 23 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. 1. Standard OP3 Regulation 12(1) 13(4) Requirement Assessments in respect of the particular risks associated with Dementia Care must be undertaken and documented on all residents who have Dementia. Timescale for action 25/08/07 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 could give consideration to encouraging a resident or their representative to sign their care plan in order to demonstrate their involvement in and agreement with the plan. Sydenhurst DS0000013811.V343782.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Sydenhurst DS0000013811.V343782.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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