Inspection on 13/02/08 for Thames Side

This inspection was carried out on 13th February 2008.

CSCI found this care home to be providing an Good service.

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

Thames Side 16/10/08

Thames Side 11/09/07

Thames Side 16/03/07

Thames Side 25/05/06

Thames Side 07/11/05

Thames Side 17/05/05

Thames Side 01/02/05

Thames Side 01/06/04

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 Thames Side Thames Side Beldham Gardens West Molesey Surrey KT8 1TF Lead Inspector Vera Bulbeck Key Unannounced Inspection 13th February 2008 09:45 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 Thames Side DS0000013813.V357936.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. Thames Side DS0000013813.V357936.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Thames Side Address Thames Side Beldham Gardens West Molesey Surrey KT8 1TF 020 8939 3850 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) tracey.kavanagh@anchor.org.uk sharon.blackwell@anchor.org Anchor Trust Vacant post Care Home 60 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (60), of places Physical disability over 65 years of age (8) Thames Side DS0000013813.V357936.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the residents accommodated in the home up to 26 may fall within the category DE(E) and up to 8 may fall within the category PD(E) The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE 11th September 2007 Date of last inspection Brief Description of the Service: Thames Side is a purpose built residential care home to accommodate older people. It was opened January 2003 and the home is sited in its own grounds with good size, well-maintained gardens that are accessible to the residents. Car parking facilities are available at the front of the building. The home is well presented, providing accommodation for up to 60 residents over the age of 65 years. All bedrooms are for single occupancy and have en-suite facilities. The home has five separate units, each with its own sitting room, dining room and kitchen. Stairs or passenger lift accesses the upstairs accommodation. At the time of this site visit the fees were from £457.52 to 741.60 per week. This does not include hairdressing, some chiropody, papers, toiletries and transport for trips. The cost to hire a vehicle for outings is £25.00 the cost is divided between the numbers of residents using the transport. Thames Side DS0000013813.V357936.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced visit was the second ‘key’ inspection and was carried out by Vera Bulbeck, Regulation Inspector. An Expert by Experience was involved with the inspection and spoke with a considerable number of residents. The Registered Manager was present as the representative for the establishment. This second key inspection was to follow up on the previous inspection at how well and if the service has met all the previous requirements. It took into account detailed information provided by the manager and any information that CSCI has received about the service since the last inspection. A tour of the premises took place. On the day of this visit the inspector spoke with a number of the residents and all staff on-duty. The home completed an annual quality assurance assessment (AQAA) prior to the previous inspection and client’s’ care plans, staff recruitment and training records, menus, health and safety check lists, activity records, policies, procedures, medication records and storage were all sampled on the day of this visit. The inspector would like to thank the residents and staff for their time, assistance and hospitality during this visit. What the service does well: The staff team have worked hard to ensure that residents’ needs are appropriately assessed and that their care is planned to ensure that these needs are met, whilst encouraging and enabling residents to maintain their independence where possible. The Expert by Experience spoke with fifteen residents and the majority expressed their satisfaction with their quality of life at the home. Two relatives were spoken with and both stated they were satisfied with the home and one stated the home had improved. Comments received from some of the residents included: One resident commented, she has three favourite carers, the food was good and liked having her hair done every other Wednesday and commented that another male carer was very kind. Thames Side DS0000013813.V357936.R01.S.doc Version 5.2 Page 6 Another resident stated her budgie had died and the staff bought her a new budgerigar, which she has in her room, she also stated the domestic staff cleans the cage. Another comment from a resident said a carer, “was lovely and had played a game of chess” which was very much enjoyed and another carer, was ‘ace’. The food was excellent. A resident stated the food was good but prefers food of own choice, which is regularly cooked by the chef and different to the menu. The resident stated he likes to walk once a day and said the carers were good. Another resident said it was reasonable in the home, but the food was not exciting; not enough vegetarian choices and that there are not enough skilled carers, likes the carers, but thought that one was lovely and kind, and that another two were good. One resident made a point of saying the food was horrible, and would like more milk puddings and also said “you wouldn’t recognise a casserole”. A relative commented “thing’s at the home are changing for the better”. Another resident commented the food was OK but they are often short of staff. All interactions observed between the management, staff and residents evidenced that the home has a caring staff team. One member of staff commented “ the best thing about working in here is having a good working relationship with the staff and manager, being friendly and caring for residents in the best way”. What has improved since the last inspection? What they could do better: Further comments made by residents to the Expert by Experience: One resident found the mattress uncomfortable and has a fleece blanket on order to put on top of the mattress. A comment was also made regarding would like a key to the bedroom occupied by the resident, and would like it to be recorded that previously had not had a key, as the person didn’t want anyone to think the key had been lost. Thames Side DS0000013813.V357936.R01.S.doc Version 5.2 Page 7 Another resident commented that according to health needs was not able to eat fat and claimed that staff did not give biscuits and cakes. However, when the carer was asked, she said that the residents are given biscuits including the resident who made the comment. A resident stated she would like to go for a drive in the country in the summer months and thought the carers were good. The Expert by Experience noticed that a resident was lying down on the bed eating; a plate of food was on her legs. She didn’t look or sound very comfortable. This was discussed with the manager on the day of the visit, the manager stated that she would deal with the situation immediately. Another relative commented that she would like to be informed when her mother’s medication is changed by the G.P. However the relative did comment that she was generally satisfied with the home. 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. Thames Side DS0000013813.V357936.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 Thames Side DS0000013813.V357936.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): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident is only admitted to the home following a comprehensive needs assessment to ensure that the home can meet the resident’s identified needs. The home does not offer intermediate care. EVIDENCE: The inspector was advised that, on the first enquiry from a prospective resident or their representative, the resident or their representative would be invited to visit the home. Following the initial visit to the home, and if the resident wishes to continue. The manager and team leader will visit the resident and carry out a pre-admission assessment to ensure that the home can meet the resident’s needs and wishes. Four care plans were sampled during this visit. In each case comprehensive pre-admission assessments had been carried out to ensure that the home could meet the residents’ identified needs. Thames Side DS0000013813.V357936.R01.S.doc Version 5.2 Page 10 Data provided in the homes AQAA identifies some residents who may have specific religious, racial or cultural needs at this time. From the evidence seen and observation 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. In the AQAA, to demonstrate what the home does well, the document states that the home is not fully occupied with social services and privately funded residents, at the moment. It is very rare that a resident needs to move to another home because the home cannot meet their needs Residents spoken to commented that they felt they had, or their relative had received enough information prior to moving to the home. Thames Side DS0000013813.V357936.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): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support is planned and was seen to be provided, where needed, in a respectful and sensitive manner. Policies, procedures and practices are in place to ensure the safe administration of medication. EVIDENCE: The home has a dedicated care team and the staff demonstrated an in depth knowledge of each individual residents’ needs, abilities and preferences in how they wish their care to be delivered, resulting in all the residents spoken to stating that they always receive the care and support they need. One resident commented “I am very well looked after” and another stated, “I have every thing I need” The care plans sampled during this visit were all based on pre-admission assessments and had been drawn up shortly after each resident’s admission to the home and included appropriate risk assessments. The care plans are detailed and set out the actions, which need to be taken by care staff to meet the health, personal and social care needs of the residents. Care plans are reviewed on a monthly basis and daily notes are kept that reflect the care Thames Side DS0000013813.V357936.R01.S.doc Version 5.2 Page 12 given. These daily notes demonstrated that any changes or new concerns are promptly acted upon. The care plans have been updated to be person centred and two members of staff have completed this task. In the AQAA, to demonstrate what the home does well, the document states that each resident has an individual plan, these are reviewed and updated monthly by the care staff, and then six monthly reviews take place. The district nurses visit during the week provides any specialist support help and advise on equipment that is required. Dental, chiropody and hairdressing facilities are provided in the home, chiropody, opticians, and dental treatment is provided in the residents own room, and all recorded in their care plan. The lunchtime medication round was observed and the medication administration records, medication storage, policies and procedures were all sampled and found to be in order. The AQAA states medication training has been undertaken for all levels of administration, and individual drugs are stored for all residents. Controlled drugs are stored in line with national legislation. Staff training on specific areas of health care takes place according to resident’s needs, for example palliative care, nutrition, activities, medication and infection control. Policies and procedures instruct staff of the rights of the individual, the values of training for all staff and BTEC induction. During the tour of the home staff were observed to always knock before entering the residents’ bedrooms and all interactions observed between staff and residents were seen to be caring and respectful. The residents who were able to communicate well stated that they felt their privacy was always respected. Thames Side DS0000013813.V357936.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): 12,13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities provided by the home are individualised to each resident and include contact with the local community both within and outside the home. Contacts with family and friends are encouraged. Meals are well balanced and varied with individual choices and preferences catered for. EVIDENCE: The routines of daily living are arranged to suit individual resident’s preferences and choices. Some residents spoken with by the Expert by Experience confirmed this. There are two activity organisers and the activity programme covers seven days a week and is displayed on the notice boards around the home. All the residents have been provided with a programme of trips out and are able to choose the trips they would enjoy going on. The management of the home hire a mini bus and the cost is divided between the residents. We (the Commission) talked to the activity organisers and several residents who confirmed they enjoyed the activities provided. Some of the entertainment includes: flower arranging, arts and craft a music afternoon. Trips out only started in January 2008 and on the day of the site visit four residents were Thames Side DS0000013813.V357936.R01.S.doc Version 5.2 Page 14 going to Kingston shopping with two members of staff. One resident informed the inspector that she had not been out for such a long time she was feeling very nervous. The inspector asked her how she had enjoyed her day out on her return and was informed she was very pleased she had gone and had made some purchases in one of the big stores. Residents are able to choose which activities they attend or participate in and their individual rooms were all seen to contain many personal possessions, which were arranged to suit their individual wishes. There are no restrictions to visiting times and staff support and encourage residents to maintain family links and friendships inside and outside the home. Menus sampled showed that the home offers a varied and well-balanced menu, with residents able to choose alternatives if they do not want the dish that is on the menu on the day. The lunchtime meal was taking place during this visit, the food was well presented, the atmosphere in the dining rooms was pleasant and relaxed and there were two members of staff available to serve the meals and offer help and assistance as needed. On one of the units the fish looked dry and not appetising. The manager stated that she is going to review the menus and will discuss with the residents at the next meeting. Of the fifteen people who were spoken to stated, eleven said that they always liked the meals at the home. Three said the meals were not good, one resident commented on how much she enjoyed the fish pie and another added ‘I am very happy here and enjoy all the meals.’ Thames Side DS0000013813.V357936.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): 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 a simple, clear and accessible complaints procedure, which includes timescales for the process. All the staff have received training to ensure the residents are protected from potential harm or abuse. EVIDENCE: The home has a complaint’s procedure in place that is available to all residents and their relatives and is also included in the service users’ guide. No complainant has contacted the Commission with information regarding a complaint or allegation made to the service since the last inspection. All residents said that they always knew who to talk to if they were not happy, with one resident adding that: ‘the staff are very helpful.’ There is a whistle blowing policy in place and the home have a copy of the latest Surrey Multi-agency Procedure for the Protection of Vulnerable Adults. Training in safeguarding adults is included in the home’s staff induction and all staff confirmed that they had received the training and were aware of the whistle blowing procedures. All residents spoken with said that they felt safe at the home with one resident adding ‘very’ and another commenting ‘I feel very happy and safe here.’ Thames Side DS0000013813.V357936.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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the home and gardens are suitable for the residents. An ongoing maintenance and redecoration programme provides the residents with clean, pleasant and homely surroundings in which to live. EVIDENCE: Residents spoken with expressed their satisfaction with the accommodation provided at the home. Residents spoken to say that the home was always fresh and clean. However one resident’s bedroom was noted to have a very strong malodour. The manager stated that a new carpet is on order and within the next week this will be laid. Also she has contacted the continence nurse for guidance and assistance. A tour of the premises was undertaken and all areas of the home are nicely decorated and pleasant for the residents to enjoy. The maintenance and redecoration programme for the home was seen to be ongoing. Since the last Thames Side DS0000013813.V357936.R01.S.doc Version 5.2 Page 17 inspection there have been many improvements to the home in the communal and individual areas of the home. The management and staff to be congratulated on the amount of work they have undertaken to improve the home since the last inspection. Laundry facilities are sited on the ground floor with washing machines and dryers suitable for the changing needs of the residents. There is a full time laundry person Monday to Friday who stated that she is able to keep up with the volume of work during the week. However, at weekends the staff currently undertake the laundry duties therefore on Mondays there is normally a backlog of washing and ironing. This was discussed with the manager who stated she would take action immediately to ensure the work is covered from next weekend. In the AQAA, to demonstrate what the home does well states that redecoration for the home includes, new curtains for entrance hall and lounges, more chairs and carpets for entrance hall. Refurbishment of ground floor bathrooms, toilets and kitchens is to be undertaken this year. On the day of this visit the home was found to be warm and bright with a homely atmosphere and a high standard of housekeeping apparent. Thames Side DS0000013813.V357936.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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of the staff meets resident’s needs. The home has a comprehensive staff recruitment and training programme which incorporates all areas, to ensure, as far as reasonably possible, that residents are in safe hands at all times. EVIDENCE: The staffing rota evidenced that staff are provided in sufficient numbers to meet the needs of the residents at the home. The staffing levels have been raised and eleven care staff covers each shift for the five units during the waking day, and a team leader. The night staff consists of three waking care workers and one team leader. There are a number of housekeeping staff, two administration staff and two activity organisers. Positive comments from residents about the staff, and one stated that staff are always available when needed and one answered ‘usually’. One resident commented that: ‘Staff are very supportive and nice.’ A few staff holds a National Vocational Qualification (NVQ) level 2 in care. The manager informed the inspector that she has an action plan in place for staff to undertake NVQ training. The manager was very clear about the future training programme for staff to attend. She has produced a training plan, which was displayed on the office Thames Side DS0000013813.V357936.R01.S.doc Version 5.2 Page 19 wall notice board and a number of courses have been booked throughout the year. Staff induction is in line with the new, mandatory Skills for Care common induction standards and the inspector was advised that staff are supervised until they have completed their induction. Staff are booked on additional training and updates as the courses become available. During this visit the files of two recently recruited members of staff were sampled, and another member of staff who had been working in the home for a number of years. All files were seen to contain proof of identity, two references, a completed application form and enhanced Criminal Record Bureau (CRB) and Protection of Vulnerable Adult (POVA) list checks had been obtained. It was pleasing to note that staff has a sound knowledge and experience of equality and diversity. There are some residents from a range of different backgrounds and cultures living in the home. Some staff are able to communicate by speaking in the preferred language of the resident. A member of staff commented that if staff has a problem communicating with a resident she is always willing to speak on the telephone to the resident to translate even if she is off duty. All staff spoken to confirmed they had been supplied with a copy of the General Social Care Council (GSCC) code of conduct and practice. In the AQAA, to demonstrate what the home does well, the document states robust recruitment procedures are in place. Clear job profiles and a formal interview process. Appropriate staffing levels and no agency staff are used. Excellent training programs include Anchors generic courses and specific courses run by Surrey County Council and PCT such as POVA and Fire training. All new staff now completes BTEC Induction training. Monthly staff and senior meetings are held and staff supervision and personal development plans are in place. One member of staff commented that she was ‘very happy with the level of training’ provided by the home. Thames Side DS0000013813.V357936.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from the clear management approach at the home providing an open, positive and inclusive atmosphere. The home has an effective quality assurance and monitoring system in place that is based on seeking the views of the residents. EVIDENCE: The manager is currently undertaking her Registered Manager’s Award and expects this to be completed by the end of April 2008. Her management style is inclusive and the residents benefit from the ethos, leadership and clear management approach of the home. The majority of staff on duty was spoken to and all confirmed they were satisfied with the overall management of the home. Most of the staff was complimentary regarding the manager and some stated they felt supported but Thames Side DS0000013813.V357936.R01.S.doc Version 5.2 Page 21 the manager made it clear of her expectations of the staff team. To ensure the residents are living in a home that is fit for purpose. The home has an effective quality assurance and monitoring system in place that is based on seeking the views of the residents and their relatives. The inspector was advised that the home carry out yearly resident and relative surveys, correlate the responses and then formulate an action plan to address any issues that are raised. Policies and procedures are in place to protect residents’ financial interests. There is also a person who deals with the finances and the records were checked and found to be well documented. The manager stated that a number of relatives manage the financial affairs for residents. Health and safety monitoring check sheets were sampled and found to be well maintained and up to date. All staff have received required safe working practice training and updates. Staff was observed to be following appropriate health and safety practices as they went about their work. The manager was advised by the inspector to contact the Fire safety officer and the Environmental health officer (EHO) for advice. This is to ensure the home is fully up to date with the changes regarding evacuation and the kitchen has not had a visit from the EHO for some considerable time. The inspector advised the management of the home to ensure all dried foods including cereals are stored in a sealed container. In the AQAA, to demonstrate what the home does well, Anchor has been awarded with the Investors in People award; also Anchor has been re-awarded Hospitality Assured Status. Thames Side DS0000013813.V357936.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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 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 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Thames Side DS0000013813.V357936.R01.S.doc Version 5.2 Page 23 No Are there any outstanding requirements from the last inspection? 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 2 3 4 5 Refer to Standard OP27 OP31 OP38 OP38 OP38 Good Practice Recommendations Staffing arrangements in the laundry to be reviewed to ensure adequate cover during the weekend period. The homes terms and conditions need up dating. All dried foods should be stored in a sealed container. Management to contact the fire officer for advise. Management to contact the Environmental Health Officer for advise. Thames Side DS0000013813.V357936.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Thames Side DS0000013813.V357936.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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