Inspection on 16/08/06 for The Heathers Nursing Home

This inspection was carried out on 16th August 2006.

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

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

Other inspections for this house

The Heathers Nursing Home 06/02/08

The Heathers Nursing Home 29/08/07

The Heathers Nursing Home 13/12/05

The Heathers Nursing Home 24/05/05

The Heathers Nursing Home 22/12/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Heathers Nursing Home Bowling Hill Chipping Sodbury South Glos BS37 6AX Lead Inspector Grace Agu Key Unannounced Inspection 16th August 2006 09:15 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 The Heathers Nursing Home DS0000062576.V307981.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. The Heathers Nursing Home DS0000062576.V307981.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Heathers Nursing Home Address Bowling Hill Chipping Sodbury South Glos BS37 6AX Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01454 312726 01454 312726 Mr Hitan A Patel Mr Roger Tippings Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places The Heathers Nursing Home DS0000062576.V307981.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. May accommodate up to 4 persons aged 50 years and over who are receiving nursing care May accommodate up to 3 persons (aged 65 years and over) who are receiving personal care Manager must be a RN on parts 1 or 12 of the NMC Register Staffing notice dated 10/06/99 applies. Date of last inspection 13th December 2005 Brief Description of the Service: The Heathers is a Grade II listed Georgian manor house situated in Chipping Sodbury close to the town centre of Yate. There is access to public transport for surrounding areas and the centre of Bristol and the home is close to the Avon Ring Road and motorway system. It is a care home with nursing and offers accommodation in single and shared rooms. The accommodation for residents is on two levels and there is a passenger lift between floors. There are several lounges and a small courtyard to the front of the building for use in good weather. The home operates a No Smoking Policy, staff and service users who smoke must do so outside of the building. Fees start from £490 per week. The Heathers Nursing Home DS0000062576.V307981.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which was undertaken over nine hours to review the requirements made at the last inspection and also to review the care practice to ensure that it is in line with the legislation and that best practice is followed at the home. At the last inspection two requirements were made in relation to different areas of service provision at the home. It was noted that the home had met one of the requirements and one was partially met. Generally the home was found clean, warm and free from unpleasant odour. Staff were noted working as a team and interacting with residents in a positive, dignified and sensitive manner, residents were found to be relaxed and looked well cared for in this homely environment. A tour of the building was undertaken and a number of records were viewed. Nine residents and twelve staff members were spoken with on the day. What the service does well: The home continues to provide high quality and effective care by ensuring that prospective residents are appropriately assessed before admission and are informed about options available to them in order to make an informed choice about staying at the home. The home provides meaningful activities for all the residents based on individual capabilities and ensures that individual interaction is provided if necessary. In order to ensure adequate nutrition, good meals are provided and are not hurried; those who are unable to feed themselves are fed in a respectful and sensitive manner. Residents are protected and enabled to complain through a robust complaints procedure and the home would ensure that all complaints are thoroughly investigated and all required action (if any) implemented. In addition, to ensure that residents are adequately protected, ongoing training courses are provided for staff and stringent recruitment procedures are followed for all persons that are employed at the home. The home ensures that there are adequate numbers of staff to meet the residents’ needs. The home ensures that aids and equipment are provided in sufficient quantity to assist staff with meeting the needs of residents. The Heathers Nursing Home DS0000062576.V307981.R01.S.doc Version 5.2 Page 6 At a discussion, the manager stated there is good communication between the residents staff, relatives and visitors and that the residents are involved in the decision making process of the home. The home promotes a non-institutionalised environment and encourages the residents to maintain independence as much as practicably possible. 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 Heathers Nursing Home DS0000062576.V307981.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 The Heathers Nursing Home DS0000062576.V307981.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3,4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that residents are assessed before admission to ensure that their needs will be met. EVIDENCE: The care records of two recently admitted residents were viewed. There was detailed assessment from Social Services as well as the home to include physical, mental and social needs. This assessment was undertaken to ensure that the needs of the resident would be met at the home. Also seen in the files were confirmation letters from the home of its ability to meet the residents’ needs. One of the residents whose care file was viewed confirmed that they visited and were assessed at home before admission. Terms and conditions of their stay was also noted in the care files viewed. The Heathers Nursing Home DS0000062576.V307981.R01.S.doc Version 5.2 Page 9 The Heathers Nursing Home DS0000062576.V307981.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed and respected. Doctors and other health professionals are involved in their care. However there was evidence that care plans were not being updated and there were errors in the administration of medication. EVIDENCE: Three care files were reviewed. There was evidence of pre-assessment of residents before admission to the Home to ensure that their needs are adequately met. There were individualised care plans to match the needs, these care plans described in details how the needs were met through the entries noted in the daily report. Residents spoken with stated that they are well cared for and that “staff are excellent, they know my needs”, “they provide me with privacy and respect The Heathers Nursing Home DS0000062576.V307981.R01.S.doc Version 5.2 Page 11 me”, “I get up and retire when I like” and “staff help me when I ask them”. One relative’s comment card stated “I have always been pleased with the way my mother is being cared for and especially now, when my mother is ill”. One of the care files reviewed had no care plan for communication following the need identified in the pre-admission assessment. The record states, “ Support her with her communication need”. Furthermore, It was also noted that an individual that attended recent surgery and subsequent restriction on the affected area had no care plans on how staff were meeting the increased need including pain management. Another care file viewed noted that another resident with a medical condition had no care plan on how this identified need was being met. These are detrimental to the residents’ well-being, it was agreed that the care plans must be in place to ensure that the needs are being met. Evidence that this has been implemented was noted at the home before this inspection was completed. Other care plans seen were satisfactory and were regularly reviewed. An inappropriate and hazardous piece of equipment was noted on a resident’s bed, this was brought to the attention of the manager and the deputy and this was replaced before the completion of the inspection. The accident book confirmed that all accidents were well documented and were regularly reviewed. This is fully discussed in standard 38. Evidence from the care files and discussions with residents and staff showed that residents have visits from their GPs, physiotherapists, dentist, opticians and other health professionals. Minor shortfalls in relation to medication administration noted on the day were remedied before the inspection was completed. All other medication administration practices were satisfactory. Evidence of residents’ wishes in the event of death was noted in the care files viewed. The home also had a death and dying policy. Staff interviewed were aware of the importance of ensuring that all information about residents are kept confidential. Staff are also aware of the policies and procedures and where to access them if needed. The Heathers Nursing Home DS0000062576.V307981.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 at least once during a 12 month period. 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 Home enables the residents to maintain contact with families, friends and the local community. It provides meaningful activities and choice in respect of meals and meal times. EVIDENCE: Evidence of discussion with residents and staff along with entries in the visitors’ book showed that the Home actively supports the residents to maintain contact with families, friends and advocates. One resident spoken with stated that her family visits very regularly and that the Home would contact her family anytime she wanted them to. Another resident spoken with on the day stated that there are no restrictions to time of visiting and that her friends live locally and visit regularly, sometimes twice a day if they have to. One relative’s comment card stated that they are satisfied with the home and the services provided, “staff are very welcoming”, “they treat us like family”. The Heathers Nursing Home DS0000062576.V307981.R01.S.doc Version 5.2 Page 13 The home continues to provide meaningful activities for the residents. The manager stated that the home has a new activities person that has been allocated six hours a week to provide activities for the residents. This individual is a care worker, however is not expected to provide care during this period. Residents are assessed on an individual basis to enable the home to plan suitable activities after consultation with the resident/relatives on admission. Information on the activities preferences is regularly reviewed to ensure it is still appropriate. Whilst walking round the building it was noted that the activities programme was displayed in the lounges and the hallway. The manager stated that a form had been devised to record activities that the residents had participated in. This is to enable the home to monitor participation and to plan other ways to encourage those who are reluctant to participate in any activity. Activities noted planned include trips to Harry Ramsden’s for musical entertainment, picnic in the park when the weather is good, bingo and Six weekly aromatherapy. One staff member stated that staff see the residents every morning with the menu and to inform them of the activities for the day and also provide the residents with personal interaction. The manager stated that the residents benefit from the services of the local church. The church provided a Holy Communion service to the residents monthly. The residents always look forward to that service. There was evidence of personal possessions in the rooms viewed, one resident stated that she enjoys being in her room because she enjoys the privacy and more importantly the loving memories it provides whilst looking at her family photographs and other personal possessions. Staff were noted knocking on doors before entering the resident’s room to ensure privacy. Noted on the table in the small lounge on the ground floor was a file, which included copies of most recent ‘appreciation’ letters and e-mails and other relevant information, including a newsletter to ensure that the residents and relatives are updated with information about the home. On the day of inspection there were two choices of meals in the menu, to include Lasagne and salad and Quiche and salad. Residents spoken with in the dining room at lunchtime stated that they enjoyed their lunch. Staff were noted with aprons whilst serving residents and those unable to feed themselves were seen being fed in a sensitive and dignified manner. The Heathers Nursing Home DS0000062576.V307981.R01.S.doc Version 5.2 Page 14 The kitchen was found to be clean; there was a cleaning schedule in place. The home was inspected by the South Gloucestershire Council Environmental Services and was provided with a food safety award. There was a kitchen risk assessment in place, however it was noted that there were missing tiles around the sink area. The kitchen assistant stated that they were aware of this and are waiting for it to be replaced. A requirement has been issued to speed up this process to ensure food safety and infection control. The Heathers Nursing Home DS0000062576.V307981.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are enabled to complain and are confident that their complaint will be listened to. Practices at the Home ensure the protection of residents from harm and abuse. EVIDENCE: The Home has appropriate procedures in place for the management of complaints. The complaints procedure was noted displayed in the hallway at the entrance. This document contains information about the Commission for Social Care Inspection to enable individuals to contact the Commission if they were not satisfied with the outcome of their complaint to the organisation. There had been no recorded complaints since the last inspection. The Manager stated that the home has an open door policy and would usually resolve any concerns before it became a complaint. The manager stated that he as well as the Deputy manager sees the residents on a daily basis to provide them the opportunity to discuss any concerns that they may have. Staff are also readily available at the home to talk to relatives and to respond to any concerns that may be raised. The Heathers Nursing Home DS0000062576.V307981.R01.S.doc Version 5.2 Page 16 Residents spoken with stated that they are aware of whom to complain to, however, have no reason to complain. One resident stated that they are aware of their rights and were enabled to vote using the postal voting system. Staff are aware of the Whistle Blowing policy and would report any bad practices to the Manager without fear of reprisal. One staff member spoken with stated, “It does not matter if it is my friend, I will still report it”. There is evidence of staff training in relation to Protection of Vulnerable Adults from Abuse. There is a copy of the South Gloucestershire Council policy on The Protection of Vulnerable Adults from Abuse at the home to ensure that the home is aware of the protocol to be followed if incidents of abuse occur. Records of recently employed staff members contained statutory information to include two satisfactory references, record of previous employment, personal details and satisfactory Criminal Record Bureau disclosures. The Home ensures that all Personal Identification Numbers of Registered Nurses are checked with the Nursing and Midwifery Council before commencement of employment and periodically. Residents spoken with stated that they felt safe at the home. The home does not handle residents’ money. The Heathers Nursing Home DS0000062576.V307981.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents enjoy a pleasant, safe and homely environment however one resident’s room fails to meet good standard of hygiene. EVIDENCE: No changes had occurred in relation to the home’s suitability for its stated purpose on the provision of care for the residents. The residents were found sitting in the communal areas and appeared relaxed in their homely environment. The home was found clean, warm, well lit and free from unpleasant odours. Whilst the home was found to be generally clean it was noted that one room’s flooring on the first floor was heavily stained and needed to be deep cleaned or The Heathers Nursing Home DS0000062576.V307981.R01.S.doc Version 5.2 Page 18 replaced. The manager stated that the flooring is new and had been deep cleaned regularly. The home would consider alternative flooring. A requirement was made to deal with this issue to ensure that the resident is provided with a comfortable environment. The clinical waste is correctly disposed of to prevent the spread of infections. There is an infection control policy in place. One resident spoken with stated, “The Home is lovely”. Residents spoken with stated that they felt safe at the home. The home’s maintenance book was up to date and a handy person had recently been employed to ensure that the home remains in a state of good repair. The handy man was noted undertaking a cleaning task on the first floor however whilst this individual was called away, the cleaning liquids were left unattended in the corridor. This is hazardous and compromises the health and safety of the residents who are confused or suffering with a medical condition affecting their memory. This was discussed with the manager and the chemicals were safely stored away immediately. The manager stated that the home would ensure that this incident does not reoccur. The laundry area was found clean and tidy. Housekeeping staff have attended courses on Control of Substances Hazardous to Health (COSHH). The Heathers Nursing Home DS0000062576.V307981.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents enjoy a good, warm relationship with competent staff. The Home’s recruitment procedure offers protection to residents. There are adequate numbers of staff to meet the needs of the residents. EVIDENCE: On the day of the inspection there were twenty-eight residents at the Home. The rota showed that there were two registered nurses and five care assistants in the morning. There also two registered nurses and four care assistants in the evening. One registered nurse two care assistants work at night. The Manager stated that this is regularly monitored to ensure that residents’ needs are adequately met. Residents spoken with stated that staff attended to them promptly when they rang the bell and provided time for them to talk. The Home operates a key working system to enhance the resident/staff relationship. Staff training records showed that the home invests in the training of its staff to ensure that staff are aware of their roles and responsibilities and that a high standard of care is maintained. Records showed that staff have attended training on Health & Safety, fire safety updates and other relevant courses. The Heathers Nursing Home DS0000062576.V307981.R01.S.doc Version 5.2 Page 20 Records of the newly employed staff showed that they have received comprehensive induction training prior to attending to residents’ personal care independently. Staff spoken with stated that the training provided is very valuable. Staff have also received various training to include in house training on Protection of Vulnerable Adults from Abuse using a package developed by Mulberry House Limited. Five staff members attended an activities training day organised by specialists in older people activities base in Gloucestershire. This training will enable the staff to engage the residents more in activities and make the home more homely. A pre-inspection questionnaire received from the home evidenced that one staff member has completed an assessors course in order to assess staff members undertaking National Vocational Vocation at level 2. Recent staff recruitment showed that all statutory requirements in relation to the protection of residents were met. The Home’s recruitment procedure is detailed and robust. All staff working at the Home had satisfactory Criminal Records Bureau disclosures. The Heathers Nursing Home DS0000062576.V307981.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home benefits from good leadership and management; its practices offer protection to the health and safety of residents. EVIDENCE: The Heathers Nursing home residents continue to enjoy the services and dedication of an experienced and well-qualified manager. Roger Toppings has attended various training courses to enable him to lead his team competently and provide quality care for the residents. On the day of inspection there was a friendly and interactive atmosphere in the home. Residents looked well cared for and were seen talking to staff in an informal way. The Heathers Nursing Home DS0000062576.V307981.R01.S.doc Version 5.2 Page 22 This is evidence of the Manager’s leadership and management style. Staff spoken with were very complimentary of the Manager’s ability to manage the home. The manager stated that he had been well supported by the deputy manager, staff and management (Mr Hitan Patel) to carry out his leadership responsibilities. Evidence from staff records and discussion with two staff members showed that staff have received regular supervision. The staff stated that it afforded them the opportunity to express their opinion about the services provided at the home and to discuss areas of concern in relation to residents’ care. The Home has a comprehensive general risk assessment to cover all areas of the Home. A new call bell system was being installed on the day of inspection to provide residents with better security and assistance. Quality assurance for the Home was reviewed. The Manager stated that the Home audits its service through regular questionnaires to residents and relatives and health professionals. Questions were centred on Health care needs, communication, medication, meals and atmosphere. The manager stated the information is collated and the result enables the home to make changes if necessary. Other tools used include care plan reviews; resident and staff meetings; daily visit to residents by the Manager and deputy; comment cards from visitors, home newsletter. In addition there are ‘back to work’ interviews with staff after illness, a health and safety indicator tool for work related stress and reports of regulation 26 visits. The fire logbook was viewed and is well maintained. Staff have attended fire lectures, evidence also showed that fire alarm systems are tested and evidence showed that staff have attended regular fire drills to ensure awareness of measures to be taken in actual fire emergency both day or night. The home employs the services of a maintenance person who has a schedule for work that needs doing and when it has been completed. Servicing of hoists, lifts and electrical appliances were all in date. The accident book confirmed that all accidents were well documented and were regularly reviewed. The Manager undertakes a monthly ‘accident audit’ to ensure that measures are in place to prevent reoccurrence. All residents have risk assessments including tools for assessing falls and falls prevention The number of accidents to residents and staff noted in the book was discussed with the manager and deputy and the manager stated that the home has appropriate moving and handling equipment and that staff have attended The Heathers Nursing Home DS0000062576.V307981.R01.S.doc Version 5.2 Page 23 updates on handling residents, however, the home would investigate the causes of the accidents. The inspector provided the home a ‘Falls Risk Assessment Tool’ developed by a Primary Care Trust based on the government’s guidelines on falls prevention in older people to assist with updating risk assessments. The Home has policies and procedures to include complaints, missing persons, risk assessment, whistle blowing, Protection of Vulnerable Adults and Health and Safety. The Heathers Nursing Home DS0000062576.V307981.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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 3 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 3 18 3 2 X X X X 2 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 3 3 X 3 3 3 2 The Heathers Nursing Home DS0000062576.V307981.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. 1 2 4 3 Standard OP19 OP8 OP24 OP38 Regulation 23 15 23 13 Requirement Repair or replace the dropping tiles underneath the kitchen sink. Provide a care plan for identified resident’s specific needs and. Deep Clean or replace the flooring in identified residents room. Ensure that cleaning liquids are not left unattended. Timescale for action 16/09/06 16/08/06 16/12/06 16/08/06 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 The Heathers Nursing Home DS0000062576.V307981.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Heathers Nursing Home DS0000062576.V307981.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!