Inspection on 16/07/07 for The Herons Care Home

This inspection was carried out on 16th July 2007.

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 Herons Care Home 26/07/06

The Herons Care Home 08/11/05

The Herons Care Home 20/07/05

The Herons Care Home 08/03/05

The Herons Care Home 06/07/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Herons Care Home Swiney Way Toton Nottinghamshire NG9 6GY Lead Inspector Stephen Benson Unannounced Inspection 16th July 2007 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 The Herons Care Home DS0000008691.V341016.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 Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Herons Care Home Address Swiney Way Toton Nottinghamshire NG9 6GY 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) 0115 946 0007 0115 946 1363 jennyc@derwentliving.com www.derwentliving.com Derwent Housing Association Limited (Supported Housing Section) Jennifer Cooper Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2006 Brief Description of the Service: The Herons, part of the Derwent Housing complex, is a purpose built home in a residential area of Toton, close to the Tesco superstore and opposite the Chetwynd Army Barracks. The home provides care for up to 38 older people, with rooms on two floors with a passenger lift between the levels. All the rooms are single and en-suite. The home is well maintained, pleasantly decorated and clean. The gardens are well maintained and are regularly used by the service users and there is a gate to the adjacent school where community links have been formed. The manager said on 16th July 2007 that there is one fixed rate fee of £366.79 per week. There are additional charges for hairdressing and chiropody. Further information about the home is available in the brochure and service user guide or from the website: www.derwentliving.com. The manager welcomes any telephone enquiries and a copy of the latest inspection report is available in the entrance foyer. The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first visit to the home since 1st April 2007 by The Commission for Social Care Inspection. Prior to the visit an analysis of the home was undertaken from information gathered over the last year. The site visit lasted for 5 ½ hours and the main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the manager, staff on duty and care practices were observed. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. The registration certificate was checked and found to be incorrect and a replacement has been requested. What the service does well: Prospective new residents are assessed either during a visit to the home, or in their current surroundings to make sure that the home is able to meet their needs. Residents’ health is monitored through observation and regular health checks and staff are told how to respect residents’ privacy and dignity which ensures that residents are cared for in a way that respects their privacy and dignity. Residents are kept informed about what is happening in the home including any forthcoming entertainment. There are regular opportunities for residents to take part in activities and trips out of the home are organised. Visitors are welcome at any time and can join in activities and trips. Residents are involved with the local community, who join in some of the home’s entertainment. This means residents have opportunities to do things they find meaningful and enjoyable and maintain relationships with people outside of the home. Routines in the home are flexible to take into account the wishes of the residents, including how and where they spend their time so residents retain control over their lives. There is a varied menu providing a choice of main meal and residents can have a cooked breakfast. The dining rooms were well presented. This means that residents have a nutritious and balanced diet. The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 6 The home is spacious and suitable for people using a wheelchair. Everywhere is kept clean and tidy, suitably decorated, appropriately furnished and kept in a good state of repair, as a result residents live in a safe and well maintained environment. The home provides a minimum of 5 staff on duty during the day and two staff at night. There are staff who work in the kitchen and keep the home clean. New staff can only start work when the required checks have been carried out, including a satisfactory Criminal Records Bureau or Protection of Vulnerable Adults check. The majority of care staff have either completed or are working towards National Vocational Qualifications, which means that residents are cared for by staff who have a qualification in their work. There is a suitably experienced manager in post who is working towards a recognised qualification. Residents are able to express their views on how the home is run through meetings and completing questionnaires, which ensures the home is properly run and in the best interest of residents. The home will hold money for residents so they can make any purchases they want to. All transactions are signed for and witnessed to safeguard residents’ financial interests. Regular checks and tests are carried out on the building and equipment, including the fire alarm and water storage system to protect the health and safety of residents. What has improved since the last inspection? The home has a complaints procedure, which is available for residents to use. This has been used by residents to raise things they are not happy about, which are then resolved. The home has policies and procedures for staff to follow if they suspect anyone is not being properly treated which makes sure that residents are protected from any form of abuse. There are sufficient aids and adaptations and these are kept in full working order. Regular training is provided, which means that residents are cared for by people trained to meet their needs. The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Herons Care Home DS0000008691.V341016.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 The Herons Care Home DS0000008691.V341016.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. New residents are fully assessed prior to moving into the home to ensure that their needs can be met. The home does not offer an intermediate care service. EVIDENCE: The home has their own assessment form to complete to help assess the needs of any prospective resident and one was seen completed for the most recently admitted resident which was dated before they were admitted to the home. Assessments included details of any specialist assistance a resident requires. The manager said that someone from the home will asses all new residents prior to admission, even if they have had an assessment completed by Social The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 10 Services. Residents are invited to visit the home, however if this is not possible someone will go to visit them. A senior member of staff said she had been to assess a resident in hospital to make sure their needs could be met. Another member of staff said assessments are available for them to read before the resident moves in. A resident said she had been to visit the home before moving in and another said she had been visited in hospital. The manager said that anyone is welcome to apply for a place providing they fall within the registration category for the home and that there are male and female residents all whom are of white British origin with the exception of one who is of Chinese origin. There is no arrangement made for the home to provide an intermediate care service. The Herons Care Home DS0000008691.V341016.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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ health, personal and social needs are met by care practices in the home, but these are not clearly laid out in the care plan. EVIDENCE: A sample of four care plans were looked at and these were completed to differing standards, but overall they did not include enough detail. For example comments included ‘maintain level of independence’ and ‘monitor anxiety’. The care plan system used has limited space to record details of care plans and staff were completing them in different ways because of this. The manager said they can have these changed. There were some needs identified for residents who were case tracked that did not have care plans. These included using a hearing aid and being assessed as being at risk of falls. The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 12 There were risk assessments for a variety of activities including mental and physical health, moving and handling, personal care, behaviour, tissue viability, nutritional screening and falls. The manager said that staff have been provided with training on completing these, however more work is needed to get these to the required standard. Staff said that some of the care plan system is good, particularly the risk assessments but they are limited to what they can write due to space restrictions. Residents had signed care plans to show they were in agreement with them. A resident said, “Staff may have discussed my care plan with me, I can’t remember”. There is a form in the care plans for recording any healthcare received by residents, however this is not being completed, so staff have to look through the daily notes when checking on what healthcare a resident has received. The manager said that all routine healthcare appointments take place and doctors come and hold medication reviews. The manager said they receive good support from local healthcare services. Staff said that residents see opticians, chiropodists, dentists, audiologists as well as doctors and district nurses. Staff said that they note any changes in resident’s routines to see if they are not feeing well. A resident said, “My health is looked after very well. They have given me lots of encouragement to get me walking again”. Medication is stored in a designated room and there is a trolley for taking medication to residents. Medicine Administration Records were correctly completed, although when a medication had to be handwritten this had not been signed by the person doing so or checked by a second person to make sure it is correct. The controlled drugs register was correctly completed. A tablet was seen left unattended in a medicine pot on a table in the dining room. This had been signed as taken in the Medicine Administration Record. Staff said that they have risk assessed a number of residents as being able to take medication unsupervised once dispensed, and showed the risk assessment for the resident concerned. The manager said she would review the current administration procedures in light of this and ensure that their practices reflect the guidance from The Royal Pharmaceutical Society. The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 13 A resident said, “staff give me my medication, they watch me take it. They have never run out”. Only one of the care plans seen referred to promoting residents’ privacy and dignity. The manager said that promoting privacy and dignity is incorporated in the home’s vision and values and is included in the induction of new staff. Staff said that having all single bedrooms with their own ensuites helps promote their privacy and that they encourage residents to be as independent as possible, which helps them to maintain their dignity. A resident said, “Staff do their best, the help they give me is excellent, all of them”. The Herons Care Home DS0000008691.V341016.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): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents have opportunities to satisfy their social, cultural, religious and recreational interests and needs through opportunities provided within the home, the local community and being able to maintain relationships. Residents are helped to exercise choice and control over their lives and receive a wholesome and balanced diet. EVIDENCE: The manger said a regular newsletter is sent out to residents telling them about things happening in the home, including any change of staff or activities arranged. A memo was seen on the notice board informing residents the lounge would be out of action whilst it is being decorated. The manager said she is currently organising some movement to music sessions Staff said that one of the team leaders is responsible for coordinating any activities and there is a committee to plan events. A local resident comes to The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 15 call bingo numbers. Staff said they offer residents opportunities to try new things and when they have they are normally glad they took the opportunity. Residents had made some crafts which, were sold at the recent summer fayre, Staff said there are regular musical evenings and a monthly church service is held. A resident said, “I sometimes play the piano and I played the organ at the monthly church service yesterday which I really enjoyed and would love to do again. The manger said that visitors are welcome at anytime and can take residents out. They often go to the local supermarket, which has a café. Staff said they also take residents to the café and that some residents are able to go on their own. Staff said there is a good relationship with others living in the local area and they join in some of the activities, including attending coffee mornings in the home. There is also a good relationship with the local junior school next door and some residents are involved in helping and the children put on entertainment at the home. A resident said, “I go out with my family and I think there are some outings here in the pipeline. A trip on the river would be nice”. The manager said that residents are asked what they want to do and the home is flexible to their wishes. Staff said some residents have requested not to be checked on by night staff during the night and there is a lot of flexibility in the routines of the home, giving examples including that residents can have breakfast in their own room or in one of the dining rooms, and being able to get up and go to bed when they want. I was asked not to go into the dining room during mealtimes as residents had requested not to have visitors when they were having meals. This was recorded in the minutes of a residents’ meeting. A resident said, “I don’t feel rushed, I can do things at my pace. I go to bed when I want and am able to spend a lot of time in my room”. The home has three dining rooms where residents can eat their meals. A cooked breakfast is available in one of these each morning. The dining rooms were well laid out with linen tablecloths and serviettes. The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 16 The main meal is at lunchtime and dishes include gammon, stews, sausages and pies. There is a different type of fish on Fridays and a roast dinner on Sundays. A lighter meal is had at tea time with such things as quiche and salad, pork pie, cheese on toast and pate. A pudding is provided at lunch and teatime. The manager said mealtimes can be flexible to suit residents wishes. A resident was seen collecting her own milk from the kitchen, as she preferred skimmed and discussing with the cook about having a different egg custard made to suit her preferences. A resident said, “The food is excellent, we were asked for ideas for the new menu”. The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 17 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents feel able to complain if something is not to their liking and staff would respond to any allegation of abuse. EVIDENCE: The home has a complaints procedure and a book to record any complaints in for smaller complaints, which can be resolved internally. There were 17 complaints recorded since September 2006, all of which were about catering except one, which was about a noisy delivery driver. Complaints about catering mostly concerned individual preferences, for example preferring to have potatoes peeled rather than with their skins on. Records of complaints made included action taken to resolve the complaint. There was another system to record more serious complaint in which is done electronically and sent to head office. There have not been any complaints made using this system. Staff were aware of the complaints procedure and how to respond to any complaint made. The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 18 A resident said, “I would take any complaint to the manager, but I haven’t had one”. There was a copy of the Adult Protection Procedures in the office and the manager said she will be visiting the adult protection website to get the updated version. The manager said that some staff have had safeguarding adults training and this is covered in National Vocational Qualification training. Staff said that fire doors are alarmed so they know if a resident is trying to leave the building and that residents who are able to go out are asked to sign in and out so staff know where they are. A resident said “no” very forcefully when asked if she had seen any mistreatment in the home. The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 19 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): People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents live in a safe, well-maintained environment, which is clean, pleasant and hygienic. EVIDENCE: The home is well laid out and has wide corridors and everywhere is accessible to wheelchair users. There is a choice of communal areas and the main lounge has recently been refurbished. There are handrails on both sides of the corridors and grab rails in toilets and bathrooms. The garden has been further developed with more raised flowerbeds and was officially opened recently. A local newspaper has arranged to come and do a feature on this. Residents were seen using various areas of the garden and one resident showed a flowerbed she had planted out. The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 20 There were no outstanding repairs seen and staff said any maintenance is dealt with very quickly. Staff said they thought the building was suitable for its purpose and that there is good access to bathrooms and toilets. A resident said, “It’s a lovely building, I don’t think enough use is made of the big lounge”. Staff have had training in infection control and this is being updated. The manager said infection control nurses had praised how the home had responded to and contained an infection that was bought into the home. The manager said that they are waiting for new infection control guidelines to be issued to them. Staff said that the home is kept very clean and there is plenty of protective clothing available. There is a system for washing soiled laundry and there are arrangements for waste disposal. The manager said they have ordered a macerator for disposing of continence wear. The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 21 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are sufficient and suitably trained staff employed at the home, ensuring that residents needs can be met. Residents are supported and protected by the home’s recruitment policy and practices. EVIDENCE: The home has assessed their minimum staffing levels to be 5 care staff and 2 team leaders in the morning, 4 care staff and 1 team leader in the afternoon and 2 care staff and a team leader on call overnight. In addition the home employs an administrator, kitchen staff and housekeepers. The home employs staff of varying ages, the majority being over 40 years old. All care staff are currently female and from differing ethnic backgrounds. The manager said they are in the process of recruiting a deputy manager to share in the management of the home. Staff said that staffing levels are varied according to needs and recently an extra member of staff had been on duty to stay with a resident who was very poorly. There was an additional member of staff on duty today to support The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 22 another member of staff who had just returned to work after a period of longterm sickness. A resident said, “Occasionally staff are under pressure when someone is off, but normally there are enough staff on duty”. The manager said that the majority of staff, including domestic and catering staff, have completed National Vocational Qualification level 2 or higher and there are 5 care staff left to start this training. An National Vocational Qualification assessor was seen discussing the course with the cook. A resident said, “Staff seem properly trained”. The manager said the correct recruitment practices are followed, but staff files seen did not included all the required information. The manager said that most of the information is held at head office and arrangements can be made for this to be seen. The home follows their equal opportunities policy in the recruitment of new staff. A member of staff said she had an interview before being offered the job and did not start until a Criminal Records Bureau check and references had been obtained. The manager said a new appraisal system has been introduced which includes identifying staff training needs. The manager said that recent training provided included fire safety, and administration of medicines and that manual handling and 1st aid are planned for in the near future. Night staff have had training on the safe handling and administration of medicines. The manager also said that training on equity and diversity is included in the induction of new staff. The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 23 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are suitable management systems in place for the smooth running of the home and to protect residents. Residents are empowered to express their views on how the home is run. EVIDENCE: The manager has been registered for over 6 years and prior to that worked as the deputy manager. The manager has completed the Registered Managers Award and is waiting for this to be verified. Staff said that they think the home is well run and offers an efficient service. The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 24 A resident said, “The manager is excellent, the home is the best you could find”. There are suggestion boxes for residents, visitors and staff to make any suggestions about the home. The manager asks residents complete questionnaires about the home and a sample seen included comments about food and a suggestion to have a notice stating who the duty manager is. The manager said a board is to be put up listing all staff on duty. Minutes of residents’ meetings were seen and these showed that residents raise a variety of issues. One comment stated that residents had been willing to complete a beetle drive to help a member of staff with her National Vocational Qualification, but had not really enjoyed it and don’t want to have one again. A resident said, “We have residents’ meetings, we can be forthright and open. We are asked what we think about things”. The manager said the home had recently been audited and finances were found to be in order. Staff said that only senior staff have access to residents’ money and that a record is made of all money received and taken out of residents accounts. There were two signatures with each transaction and a sample of balances checked were found to be correct. The manager said that all the required health and safety checks are carried out at the required frequency and there are service contracts in place for servicing all the equipment. Dates of tests were recorded in the Annual Quality Assurance Assessment showing they are regularly carried out. The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 25 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 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 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 The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 26 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. 1 Standard OP7 Regulation 15 (1) Requirement Care plans must clearly describe how resident needs are to be met and where a need is identified a care plan must be written for this, so that staff know how to meet residents’ needs. When it is necessary to handwrite a Medicine Administration Record this must be signed by the person doing so and by another person to confirm they have checked it has been copied correctly. This is to make sure residents are given the correct medication. The practices for administering medication to residents must be reviewed so residents are not at risk of not taking, or taking the wrong medication. Timescale for action 01/08/07 2 OP9 13(2) 01/08/07 3 OP9 13(2) 26/07/07 The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP8 Good Practice Recommendations A clear and easy to refer to record should be made of all healthcare received by residents so that staff can make sure that resident receive the healthcare they need. The Herons Care Home DS0000008691.V341016.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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. 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