Inspection on 22/11/06 for Tatchbury Manor Nursing Home

This inspection was carried out on 22nd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Tatchbury Manor Nursing Home 09/10/07

Tatchbury Manor Nursing Home 15/11/05

Tatchbury Manor Nursing Home 13/07/05

Tatchbury Manor Nursing Home 30/11/04

Tatchbury Manor Nursing Home 24/06/04

Tatchbury Manor Nursing Home 05/03/04

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

CARE HOMES FOR OLDER PEOPLE Tatchbury Manor Nursing Home Tatchbury Lane Netley Marsh Southampton Hampshire SO40 2HA Lead Inspector Mr Roy Bega Unannounced Inspection 22nd November 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 Tatchbury Manor Nursing Home DS0000011447.V315962.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. Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Tatchbury Manor Nursing Home Address Tatchbury Lane Netley Marsh Southampton Hampshire SO40 2HA 02380 812352 02380 814779 tatchmanor@btconnect.com 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) Mr Sewah Singh Adkar Mrs Helen Diane Woodman Care Home 38 Category(ies) of Dementia (7), Dementia - over 65 years of age registration, with number (38) of places Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users must be at least 50 years of age. Date of last inspection 15th November 2005 Brief Description of the Service: Tatchbury Manor Nursing Home is situated close to the village of Netley Marsh in the New Forest. The old wing of the building is of historic interest being over 1000 years old. The building has been extended and renovated over the years and now provides accommodation for 38 residents with dementia. The home stands in extensive grounds and the rear garden has a large pergola and patio area. Separate buildings in the grounds house the laundry and training room. Current weekly fees range from £440 to £600 per week with additional costs being made for hairdressing, and chiropody. Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is an assessment of how the National Minimum Key Standards for Care Homes for Older Persons were being met. Evidence has been collated from the service’s history file a returned pre inspection questionnaire and this site visit. This visit took place on 22 November 2006 between the hours of 9-30 a.m. and 5 p.m., a total of seven and a half hours. Opportunity was taken to look around the home view records, observe the working environment and speak with management, staff, residents and relatives. Due to the high level of residents’ mental capacity, meaningful conversation was not possible. The inspector did however spend time with several residents and visitors in open discussion. Also throughout the day observed the interaction between staff and residents and care being provided. The ten requirements raised resulting from the previous inspection have been assessed as being met. There were no requirements raised resulting from this visit. What the service does well: Care plans are detailed and personal to each resident. They are written in plain language, easy to understand and consider all areas of individual’s lives including health, personal and social care needs. Residents are able to enjoy a full and stimulating life style with a variety of options to choose from. The home employs a full time activities co-ordinator (who is also a Registered Mental Nurse) and two activities assistants. They are responsible for creating meaningful activities and experiences both in the home and the wider community. Food is considered to be highly important and meal times considered a social occasion. Mealtimes are relaxed enabling residents’ time they need to finish their meal at their own pace. Staff were seen to give assistance in a discrete and sensitive manner to those residents who need help to eat. Cooks and kitchen assistants valued as members of the staff team an are in the process of completing National Vocational Qualifications. Discussions and records show the manager works continuously to improve services and provide an increased quality of life for residents. There is a strong ethos of being open in all areas of running the home which is resident focused. Tatchbury Manor Nursing Home DS0000011447.V315962.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 Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Tatchbury Manor Nursing Home DS0000011447.V315962.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 Tatchbury Manor Nursing Home DS0000011447.V315962.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): Key Standard 3 was assessed on this occasion. This service does not provide intermediate care as defined by key standard 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information they need to make an informed choice with regards to moving into the home. EVIDENCE: A sample of two comprehensive assessment records was seen for most recently admitted residents. Admissions are not made to the home until a full needs assessment has been undertaken. Detailed documentation was seen for example which included residents needs with regards to dependencies, moving and handling, psychological, mobility, falls, personal hygiene and activities. Written evidence and discussions with management and relatives indicated that the assessment is conducted professionally and sensitively and has involved the family or representative of the resident. Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 10 Relatives spoken with stated they were fully involved in the assessment process and management and staff were so kind and helpful before, during and after the move. They were provided with an information pack which included the service’s statement of purpose; objectives and philosophy of the service; a detailed account of the quality of the accommodation, qualifications and experience of staff, how to make a complaint and recent inspection findings of the Commission. They were also given a statement of terms and conditions prior to moving to the home, which sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the resident. Before making a decision they had opportunities to visit the home. Staff spoken with informed the inspector that they are made aware of prospective new residents and their needs prior to them moving into the home. Tatchbury Manor Nursing Home DS0000011447.V315962.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): Key Standards 7, 8, 9 and 10 were assessed on this occasion. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are detailed and personal to each resident. They are written in plain language, easy to understand and consider all areas of individual’s lives including health, personal and social care needs. Personal support within the home is offered in such a way as to promote and protect residents’ privacy and dignity. Residents are supported by appropriately trained staff, who follow the homes policies and procedures for the management of medicines. EVIDENCE: A sample of three resident care plans was seen. Information recorded was detailed and personal to each resident. They are written in plain language, easy to understand and considers all areas of individual’s lives including health, personal and social care needs. For example, in the area of providing personal care the “What is needed” and “How to carry it out” are clearly documented. Documentation seen and discussions with staff indicated the management of Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 12 risk takes into account the needs of residents and their rights for independence and choice. Seen documentation and discussions with staff and relatives indicated residents’ health care forms an integral part of their care plans. Records give a comprehensive overview of their general health and acts as an indicator to changing health needs. Residents are also encouraged to have the choice to shower or bath when they wish, and are supported and facilitated to be independent in their personal hygiene. Observations, discussions and available training records indicate staff have the skills and experience to deliver care effectively. Members of staff spoken with regard care plans as working tools. The need to respect residents’ privacy and dignity when delivering health and personal care is a key principle of the service’s aims and objectives. Staff were observed to inform residents what they were going to do with regards to care before carrying it out ensuring dignity was maintained. Relatives spoken with informed the inspector staff are very patient and understanding. Comments included, “Staff are reliable”, They know what they are doing”, “They are super” and “Staff treat my brother with respect”. Training records seen showed the induction for new staff covers the management of privacy and dignity. The service ensures that each resident’s plan is reviewed regularly and involves the resident and family/representative if agreed and they choose to. Records seen showed plans are updated at a minimum monthly and the necessary action taken to respond to any changes. The wishes of individual residents about dying and terminal care, and the arrangements they want after death are openly and sensitively discussed with both the residents and their family during the development of the care plan. These are clearly recorded, respected and known to the staff delivering the care. The home has a detailed policy, procedure and practice guidance to help staff when handling terminal care and death. All staff receive in house training and practical advice in caring for these residents, and have continuous support and opportunities to discuss any areas of anxiety and concern. (See also the section on Staffing of this report.) Medication within the home is administered primarily through a monitored dosage system. The inspector was informed that any resident who has the capacity are encouraged to keep and take their own medication but currently there are not any who have been assessed as able to. Evidence was seen that staff who administer medication have completed appropriate training. Records seen were well maintained an up to date. Procedures for medication to be taken as required were in place. The staff member who assisted the inspector Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 13 with the auditing of this standard was able to demonstrate an understanding of the medication currently being used and appropriate storage. Since the previous inspection the home has taken the following action with regards to enhancing residents privacy. Suitable screening has been provided in all double bedrooms. Suitable locks have been fitted on the doors of communal bathrooms. Where appropriate residents have been provided with individual lockable storage space and suitable locks have been fitted onto bedroom doors. Risk assessments have been carried out to assess residents’ ability/wish to have a lock on their bedroom door. Where assessed a resident does not to have the mental capacity to make a decision, a written declaration has been obtained form their relative/power of attorney. The inspector was assured that if any new resident wished to have a lock fitted on their bedroom door their request would be honoured. Management was provided with guidance that having single action locks fitted on bedroom doors at the same time would enable them to be “suited” which permits the provision of one master key for all. Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key Standards 12, 13, 14 and 15 were assessed on this occasion. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to enjoy a full and stimulating life style with a variety of options to choose from. Visitors are made to feel welcome and know they can visit the home at any time. The home is conducted to maximise residents’ capacity to exercise personal autonomy and choice. Residents receive a healthy, varied diet according to their assessed requirements and choice. EVIDENCE: Residents are able to enjoy a full and stimulating life style with a variety of options to choose from. The home employs a full time activities co-ordinator ( Who is also a Registered Mental Nurse) and two activities assistants. They are responsible for creating meaningful activities and experiences both in the home and the wider community. A varied programme of activities both for groups and individuals is in place. For example, on the day of the visit an activities assistant spent time with residents on a one to one basis providing stimulation through talking and pursuance of individual interests. During the Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 15 afternoon residents readily participated in arts and crafts. The programme seen and discussions indicated other activities include; visits from external entertainers; outings; local dramatic society; monthly visit of pet therapy; local churches and a three monthly visit of a mobile farm. Observations and discussions with relatives and staff indicated the routines of the home are planned around residents’ needs and wishes. Systems enable the service to be flexible and changed to meet individual wishes. For example, at 9-30 a.m. when the inspector arrived, residents were arriving for breakfast. Staff were observed to assist residents in moving around the home when residents wanted to and at their pace. Comments made by visitors included, “It is so relaxed here”, “Always lots going on”, “They motivate people”, “Dad is free to move around” and “Staff spend quality time with mum”. Visitors informed the inspector that they feel welcome and know they can visit the home at any time. Observations and discussions indicated staff always make time to talk with visitors. The layout of the home provides areas where residents can entertain their visitors, in addition to the privacy of their own room. Comments received from visitors included, “We are always made to feel welcome”, “Management and staff are so obliging”, and “They explain if their any concerns about dad”. Food is considered to be highly important and meal times considered a social occasion. The home employs two cooks and two kitchen assistants. Kitchen staff are viewed as important members of the care team. Records seen and discussions with management and the cook on duty showed that the home is providing appropriate training for all kitchen staff. Discussions and records seen showed the dietary and cultural needs of each resident are being met. The menu is varied, balanced and nutritious. Choices include a healthy option, with a variety of dishes that encourage residents to try new and sometimes unfamiliar food. Observations showed food is served to meet the need of all residents including those who have swallowing or chewing difficulty. Staff were seen to give assistance in a discrete and sensitive manner to those residents who need help to eat. The mealtimes witnessed by the inspector were relaxed. Staff were patient and helpful, enabling residents the time they needed to finish their meal whilst encouraging them to serve themselves. Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Key Standards 16 and 18 were assessed on this occasion. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents and their representatives have access to an effective complaints procedure. Staff have good awareness policies and procedures to protect residents from abuse. EVIDENCE: The service has developed a clear complaints procedure that highlights the importance of complaining or making suggestions for improvement. The complaints procedure is provided to residents and relatives. Visitors informed the inspector they have been provided with a copy of the home’s complaints procedure, know what action to take but have not had the need to do so. The Commission has not received any concerns in respect of the service in the preceding year. Policies and procedures are in a place with regards to the protection of vulnerable adults. Staff spoken with portrayed a good knowledge and understanding of what action to take if they had any concern. Evidence was seen to show staff have completed an adult protection course as part of the service’s training programme. Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 17 Discussion with management indicated through training and supervision, care staff are supported to comply with the policies and procedures in relation to protecting and safeguarding the rights of residents. Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key Standards 19 and 26 were assessed on this occasion. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is accessible, safe, clean and well maintained. It meets residents’ individual and collective needs in a comfortable and homely way. EVIDENCE: To ensure good management of routine problems, the service employs a maintenance contractor for sixteen hours per week and has an on call agreement for an average of twelve hours per week. Two new cleaning staff have been appointed subsequent to the previous inspection. The inspector toured the building with the home’s manager. It was noted subsequent to the previous inspection visit, two lounges have been redecorated the laundry room refurbished to provide permeable walls and floor and a wash hand basin. Damaged paintwork in bedrooms has been made good Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 19 and damaged bed rails and commodes have been replaced. An order form and invoice was seen for the replacement of the entrance hall and lounge carpets. Where rooms are shared it is only by agreement, and screens provided for privacy. Discussions with relatives and records seen indicated residents are always given the choice to move into a single room when one becomes vacant. Residents have the choice to bring small personal items of furniture into the home. As well as a good selection of general aids such as hoists and variable height beds, the service also ensures equipment is individualised for each resident and all staff members are trained in its safe use. At the time of the visit the service was well lit, warm, clean, tidy and free off offensive odours. The management has a good infection control policy. They seek advice from external specialists, e.g. infection control, and encourage their own staff to work to the service’s policy to reduce the risk of infection. Staff spoken with told the inspector they are provided with appropriate protective clothing and were seen to wear it during the visit. Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key Standards 27, 28, 29 and 30 were assessed on this occasion. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The service is staffed efficiently, with particular attention given to busy times of the day and changing needs of the residents. The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of residents. Staff are well trained, skilled and in sufficient numbers to meet the aims of the service and changing needs of residents. EVIDENCE: Rotas show the service is staffed efficiently, with particular attention given to busy times of the day and changing needs of the residents. For example four Registered Nurses and six Care Staff cover a typical morning shift. The service also employs a full time activities co-ordinator (Registered Mental Nurse) and two part time activity assistants, two cooks, two kitchen assistants, a part time administrator and two domestics. A good recruitment procedure is in place that clearly defines the process to be followed. Records seen and discussions indicated this procedure is followed in practice. The service views induction and probationary period as being an extension of recruitment. There is little use of any agency or temporary staff Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 21 but where they are used systems are in place for their induction and support. A senior Registered General Nurses has the responsibility for supporting new staff through the induction process by means of observation one to one supervision and completion of the “Skills for Care” programme. A sample of two records was seen for the most recently appointed staff. They included all the required information and completed “Skills for Care” induction-training programmes. Members of staff spoken with told the inspector they have been fully supported by management on joining the team, have completed a rigorous and informative induction programme and hope to progress to more formal training such as the National Vocational Qualification (NVQ). Management and a senior member of staff are qualified trainers in the areas of infection control, health and safety and manual handling. The service also uses external providers to deliver training if they do not have the appropriate skills within the organisation. This training can be small scale and individualised if necessary or professional advancement. For example records and discussions showed, nurses from overseas are supported to complete the three-month conversion course at a university and mentored by qualified mentors within the service. Discussions with staff indicated they are encouraged to complete the NVQ in care level two and above. At the time of this visit records and discussions showed that seven have completed level two and three are in the process of doing so. It was noted cooks; kitchen staff and domestics are completing NVQ courses appropriate to their positions. Records seen and discussion showed the following specific training has been provided. – First aid, manual handling, infection control, dementia care, care of substances hazardous to health, health and safety, fire safety, management of medication, optical awareness, falls and the elderly and adult protection. Comments received from visitors included, “Staff are skilled in their jobs”, “They are very proficient”, “They are professional people” , “They meet my brother’s needs” and “Residents are kept motivated”. Discussions were held with regards to management to consider incorporating “The Mental Capacity Act 2005” within the service’s 2007 training programme. Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Key Standards 31, 33, 35, and 38 were assessed on this occasion. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is experience and competent to run the home. Management and administration of the home is based on openness and respect. An effective quality assurance system is in place. Safeguards are in place to protect the interests of the residents. As is reasonably practicable the health, safety and welfare of residents and staff are promoted. EVIDENCE: The Manager has the required qualifications and experience and is competent to run the home. Discussions and records show she works continuously to improve services and provide an increased quality of life for residents. Staff informed the inspector management has a strong ethos of being open in all Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 23 areas of running the home and is resident focused. Relatives spoken with commented management are always approachable and available. Records and observations showed management leads and supports a strong staff team who have been recruited and trained to a good standard. Discussions indicated management is aware of current developments both nationally and by the Commission and plans the service accordingly. The service has sound policies and procedures, which the manager effectively reviews and updates, in line with current thinking and practice. Efficient systems are in place to monitor staff adherence to policies and procedures during their practice. A quality assurance and monitoring system based on seeking the views of residents, relatives, staff and professional is in place. As well as completing questionnaires, monthly resident and staff meetings respectively are held and considered as another source in obtaining views in monitoring the service. Copies of letters responding to relatives’ comments were seen. The service works to a clear health and safety policy, all staff are given a copy, and regular random checks take place to ensure they are working to it. The service has a good record of meeting relevant health and safety requirements and legislation. Records are of a good standard and are routinely completed. Service records for systems and equipment were seen and are up to date. Records seen and discussions showed the service has very efficient systems to ensure effective safeguarding and management of resident’s money. Invoices/receipts were seen where the home had purchased goods on behalf of residents and requested the money from relatives/representatives. Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 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 X 3 X 3 X X 3 Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 25 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. Refer to Standard Good Practice Recommendations Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Tatchbury Manor Nursing Home DS0000011447.V315962.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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