Care Home: Bourne House Nursing Home

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What the care home does well The feedback we received, in 10 of the questionnaires we circulated, say that "Bourne House gives the very best care..."; I have been very pleased with level of support and care they have been giving"; "Bourne House is doing well and is giving quality care". This confirms that manager`s position that she is building a reputation for providing a good service to client group with complex and sometimes challenging care needs (that is, older people with advanced dementia). This is clearly a very good care home and like its sister homes in the LRH group is moving towards excellence. What has improved since the last inspection? We discussed with the manager her contact with agencies that support care homes caring for people with dementia and note the work already done and more planned to improve the environment for residents; particularly the use of colour to signal different areas and facilities, such as toilets, within the home. No requirements were issued at the previous inspection. Several recommendations were made during our last site visit in 2006 and these have been addressed. In particular the staff are now much clearer about reporting matters of alleged abuse to the local Social Services before initiating internal investigations. There were no complaints about the laundry service on this occasion. The home is also piloting a `dementia support group` for relatives of residents in Bourne House. These meetings will include speakers from the Alzheimer Society and a Pharmacist. The manager herself is undertaking a Diploma in Dementia and this is a commendable approach to maintaining quality care. What the care home could do better: CARE HOMES FOR OLDER PEOPLE Bourne House Nursing Home 45 Langley Avenue Surbiton Surrey KT6 6QR Lead Inspector Michael Williams Key Unannounced Inspection 16th September 2008 2:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bourne House Nursing Home DS0000026244.V371276.R02.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. Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bourne House Nursing Home Address 45 Langley Avenue Surbiton Surrey KT6 6QR 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) 0208 399 6022 020 8399 9690 info@lrh/homes.com www.lrh-homes.com London Residential Healthcare Limited Paula Gratton Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (40), of places Physical disability over 65 years of age (40) Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing Levels as follows: Registered Nurses (RN) Nursing Assistants (NA) No. of Residents 8am-2pm 16-20 1 RN 3 NA 21-25 1 RN 4 NA 26-30 2 RN 4 NA 31-35 2 RN 5 NA 36-40 2 RN 6 NA 2pm-8pm 1 RN 2 NA 1 RN 3 NA 2 RN 3 NA 2 RN 4 NA 2 RN 5 NA 8pm-8am 1 RN 2 NA 1 RN 2 NA 1 RN 2 NA 2 RN 2 NA 2 RN 2 NA 2. 3. The home manager is to be supernumery to the above numbers and work full time. There is to be adequate and sufficient staff and/or contract arrangements in place at all times to ensure a good quality catering, domestic, cleaning, laundry, maintenance and administrative service for all users. A maximum of three service users aged between 55 and 65 years of age in the Dementia and Physical disability categories. A variation has been granted to allow one specified service user in the Mental Disorder - over 65 MD(E) category to be accommodated. This variation remains in force until such time as the needs of the person can no longer be met or until such time as the placement ceases. 6th June 2006 Date of last inspection Brief Description of the Service: Bourne House is a registered care home providing nursing care for up to 40 people who have dementia or a physical disability. It is a large detached property situated in a residential area of Surbiton, with access to public transport systems, with local shops and leisure facilities. The home is owned and managed by London Residential Healthcare Limited. Accommodation is provided over three floors. Passenger lifts are available in the home. There is a large, well maintained garden to the rear of the premises and parking to the front. Fees as at June 2006 were from £649 to £1,000 and extras for additional care would be by negotiation with the authorities funding care; residents pay for personal requisites, usually by invoice. We manager advises us that there have been no changes to ownership of the company LRH – Homes. Bourne House Nursing Home DS0000026244.V371276.R02.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 key unannounced inspection took place on the afternoon and evening of 16th September 2008 when we visited the home; we met with people who use the service (in this home they prefer to be called residents and this is the term used in this report); we met with their visitors and with staff and management. We also toured the premises, checked residents’ case files and staff files and records and documents to cross-check information. We also took account of information we have received since our previous inspection and we noted the contents of the homes AQAA [Annual Quality Assurance Assessment form that each home is required to supply]. What the service does well: What has improved since the last inspection? We discussed with the manager her contact with agencies that support care homes caring for people with dementia and note the work already done and more planned to improve the environment for residents; particularly the use of colour to signal different areas and facilities, such as toilets, within the home. No requirements were issued at the previous inspection. Several recommendations were made during our last site visit in 2006 and these have been addressed. In particular the staff are now much clearer about reporting matters of alleged abuse to the local Social Services before initiating internal investigations. There were no complaints about the laundry service on this occasion. The home is also piloting a ‘dementia support group’ for relatives of residents in Bourne House. These meetings will include speakers from the Alzheimer Society and a Pharmacist. The manager herself is undertaking a Diploma in Dementia and this is a commendable approach to maintaining quality care. Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 6 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. Bourne House Nursing Home DS0000026244.V371276.R02.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 Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 1 and 3: People using this service experience excellent quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be assured their needs will be assessed and they will be given comprehensive information so that their decision to reside in Bourne House will be well supported. EVIDENCE: Bourne House, with the support of the company LRH Homes, has introduced a new version of the Statement of Purpose that incorporates the resident guide and additional information sheets, such as the initial agreement and fees required to be given to each resident upon admission. The delightful picture on the front cover of the new guide offers a glimpse of the happy atmosphere visitors tell us they experience when they call in. This guide is their latest version and offers a comprehensive statement of purpose combined with a resident guide, which is very specific to the resident group and considers the different styles of accommodation, support, treatment, philosophies and specialist services required to meet the needs of residents. The information is provided at different levels, about the company, the specific home and information particular to the resident and is in a format suitable for their and Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 9 their families’ need. The company can provide the information various ‘community languages’, pictures or Braille if this is needed. This new version is ‘person centred’ that is, the documents put the resident as the focus of the information and describes what is being offered to them individually. The inserts to be enclosed in each ‘handbook’ will be not only specific to the home but to the individual resident so as to give specific information – about fees, contracts, catering arrangements and so forth All new residents receive a comprehensive needs assessment before admission. This is carried out by staff with skill and sensitivity. Bourne House is highly efficient in obtaining a summary of any assessment undertaken through care management arrangements, and insists on receiving a copy of the care plan before admission. For residents who are self funding, the assessment is undertaken by qualified members of staff, Nurses. Individuals are supported and encouraged to be involved in the assessment process. Information is gathered from a range of sources including other relevant professionals, and with the resident’s agreement where possible, carer’s interests are taken into account by asking relatives to provide information that the resident may have forgotten or overlooked. The assessment focuses on achieving positive outcomes for people and this includes ensuring that the facilities, staffing and specialist services provided by the home meet the ethnic and diversity needs of the individual including the six strands of diversity are: gender, age, sexual orientation, race, religion or belief, and disability. This means that before agreeing admission the Bourne House staff carefully consider the needs assessment of each individual prospective resident and the capacity of the home to meet that person’s needs. Prospective residents are given the opportunity to spend time in the home. An individual member of staff is allocated to give them information and special attention to help them to feel comfortable in their surroundings and enable them to ask any questions about life in the home. Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7 to 10: People using this service experience excellent quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. Health and social care appears to be exemplary in this care home and so residents can be assured that their care needs will be met to very high standard. EVIDENCE: Visitors describe this home as “giving quality care” and “we are very pleased with the level of support and care they have been given”. The commission strives to ensure that residents, and their families feel they are getting the care they need and in Bourne House this seems to be the case. Relatives are of course very much aware that the needs of the resident, their mother, father or spouse can be complex as their memory deteriorates but Bourne House is evidently building a reputation for quality care and is to be commended for this. Like the other homes in this group [LRH Homes] the residents receive effective personal and healthcare support using a ‘person centred’, that is, a very individualised approach to care that respects residents’ expectations to be treated with dignity, equality, fairness, autonomy and respect. The new statement of purpose sets out the competencies and specialist services the home offers and delivers this effectively through a skilled, trained and Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 11 knowledgeable staff group that work in this person centred way. Staff are very much aware that the way in which support is given is a key issue for older people. Individual plans clearly record people’s personal and health care needs and detail how they will be delivered. Staff in this home respect people’s preferences and have expert knowledge about individual personal needs when providing support, including intimate care. The staff group is balanced to enable choice of male, female and age related preferences when delivering personal care. We confirmed this by checking one of the home’s AQAA forms [their Annual Quality Assurance Assessment], which provides details about the balance of male and female staff and their age range and background. This enables the home to give choice; so as an example a resident made appoint of commenting how kind and gentle the male carers were. As we toured the Bourne House we were able to observe that staff respond appropriately and sensitively in all situations involving personal care, ensuring that it is conducted in private and at a time and pace directed by the person receiving the care. Aids and equipment are provided to encourage maximum independence for people using services; these are regularly reviewed and replaced to accommodate changing needs. Specialist advice is sought by the home to ensure effective use of equipment such as raisable beds, alternatingair mattresses, hoists and similar equipment. Since most residents are very frail the home arranges for health professionals to visit residents at home. The home fully respects the rights of people in the area of health care and medication. They recognise and work with the decisions made by the individual regarding any refusal to take medication, or any specific requests about how their healthcare is managed. We received a total of 13 questionnaires fro residents, their families or staff. All were very positive and highlight the good care being provided in this home. We are impressed that the manager is undertaking a Diploma in dementia care and that she has researched ways of improving care - for example by contacting agencies that give advice on modifying the environment to assist residents with failing memories. The use of colour and layout and cues such as picture and large signs to guide residents are very commendable and warrant an excellent rating since the manager is not just meeting standard but seeking to excel. Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 12 to 15: People using this service experience good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be assured that Bourne House offers choices about the lifestyle residents would expect including respect for their background, contact with their family and friends and the home offers a range of meals that are well balanced. EVIDENCE: Many of the residents are quite unable to communicate their wishes or their opinion as to the care they get. So we observed staff going about their duties and we asked visitors about life in Bourne House. We also received several forms in reply to our written questions. As the afternoon unfolded we found residents to be variously disperse about the home, some in the lounge, some wandering the corridors and others in their room. As we might expect some seem a little restless but not ill at ease whilst others were contentedly dozing in their armchairs. The afternoon sing-along brought a sense of fun and laughter to the main lounge and one or two residents were recalling, and singing their favourite songs. We see from the activities programme that Birthdays are regularly celebrated in Bourne House and an entertainer is also brought at regular intervals; two were invited to entertain residents in September. Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 13 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): NMS 16 and 18: People using this service experience good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems are in place for the effective handling of complaints and protection issues and service users and their relatives are encouraged to raise any concerns they have. So residents know that their concerns will be acted upon. EVIDENCE: To assess this standard the record of complaints was checked; relatives offered their opinions about the quality of the service; residents were given the opportunity to express any concerns -usually in a non-verbal manner. A robust complaints procedure is in place and is clearly being used when the need arises. Two procedures are in place to guide staff when dealing with allegation of abuse, one is the in-house version and the other is the local authority’s. Staff now seem clearer about the need to refer suspicions of abuse rather than initiate investigations within the home. But not all staff were clear about the meaning of ‘whistle-blowing’ they confused it with the need to maintain confidentiality - so quite the opposite meaning since reporting a suspected abuse means disclosing confidential information to protect the resident. Areas of strength are the positive approach to complaints and the clear documentation to support practice and a matter requiring improvement is the need for staff to be sure they know they must act without delay in referring allegation of abuse, if necessary by ‘blowing the whistle’ reporting to a suitable professional agency such as the Social Services or to the Commission. This section, about complaints, is assessed as good but a requirement is made about policies and procedures designed to protect residents. Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 14 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): NMS 19 and 26: People using this service experience good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is decorated and furnished to a good standard and facilities are accessible and clean. This ensures that service users live in a safe, pleasant, homely and comfortable environment. EVIDENCE: The manager is aware that for a group of 40 residents with dementia it would be ‘best practice’ to offer group-living accommodation but this is not seem possible in Bourne House which is an older building of domestic style and not purpose built for group living. So the manager is seeking to make changes that will improve matters, for example by using colour, lighting, signs and the like to help residents orient themselves. Already toilet doors are yellow so the benefit is obvious since most other doors are white. The home was free of malodour and this is commended. The home was clean and tidy. Like other homes in the LRH group of care homes the décor is to a high standard and the communal rooms such as the dining room are well presented and show respect for the client group. Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 15 As we toured the building with the manager we noted one or two anomalies such as the window restrictors – they are in place but can be easily disengaged so need to be risk-assessed for security and safety. We also noted a shortage of storage space so a linen trolley is left on the landing during the day (this would impede escape in an emergency). We also observed that two doors had wedges; one in the form a fire extinguisher holding open the door to a lounge area and the other, though not in use, was clearly intended to hold open the hairdressing room door. Both doors need to have functioning magnetic door holders if residents want them held open. Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 16 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): NMS 27 to 30: People using this service experience good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff recruitment, the number of staff employed and their skill mix are appropriate to the assessed needs of the current service users in this home – so this will ensure that their needs are being met. EVIDENCE: To evaluate this staffing we interviewed a range of staff including, the manager, nurses and carers. In addition to this head-office staff, now based in new building near by, were most helpful in making staff files and other records available for inspection and the training officer was also briefly available to confirm the training arrangements for the home. The Manager stated and office staff confirmed that all staff have a police check [a CRB] in place and no staff are being employed without such checks in place as required by regulation. Staff recruitment is very thorough so all staff are checked and assessed prior to employment including reference checks, nursing qualification checks (P.I.N. checks), health checks, work permits and so forth are confirmed to be in place. Induction and on going training is in place for all grades of staff. The staff interview were well informed about the duties. The residents and their visitors thought the staff were kind and caring people and were complimented in many ways; for example, “staff provide very personalised care” – the staff can be very proud of such a commendation but as with many other care homes in the region, this home’s AQAA [Annual Quality Assurance Assessment form] shows that the majority of staff do not share a common culture and background with residents. Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 17 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): NMS 31, 33, 35 and 38: People using this service experience good quality outcome in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be assured that Bourne House is well managed, staff receive good guidance and leadership and the management team are running this service so as to serve the best interests of the residents. EVIDENCE: That the manager is undertaking a Diploma in dementia care tells us how very much committed she is to the care of her clients. The manager, Paula Gratton, is of course already well qualified to run Bourne House and is registered with the Commission to do so. Paula Gratton communicates a clear sense of direction, constantly strives to achieve ‘best practice’ particularly in relation to continuous improvement in customer care; in this client group she needs to anticipate their needs since most residents are quite unable to articulate their needs. Equality and diversity, human rights and ‘person centred’ thinking are given priority by the manager and the way the home is run shows an understanding Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 18 of people’s needs in respect of the six strands of diversity: gender, age, sexual orientation, race, belief, and disability. The manager was able to demonstrate through formal qualification, robust operational systems and or professional experience and ability that they are knowledgeable and highly competent in a range of areas. These can include service-specific good practice areas, understanding current legislation and proposed developments, and the importance and purpose of having effective quality assurance systems and in this the manager is supported by a management and administrative team who, as we have noted in other homes run by LRH Homes, all exude the same enthusiasm and regard for the residents. The manager should at all times provide an excellent role model for other employees and this appears to be the case. Other professionals see the manager as an imaginative and effective leader who consistently provides high quality services and this is reflected in the feedback we get. Staff practice and performance is being discussed during supervision, staff training and team meetings and we have spoken to staff and checked records to confirm this. Spot checks and quality monitoring systems provide management evidence that practice reflects the home’s and organisation’s policies and procedures. The company’s Responsible Individual [RI] plays an important role here in visiting all home in the company regularly to monitor services on behalf of the owners. There is strong evidence that the ethos of the home is open and transparent. The views of both residents and staff are listened to, and valued. The AQAA, Annual Quality Assurance Assessment forms we ask for each year, contains detailed information as required. It includes a high level of understanding about the importance of equality and diversity and a wide range of evidence showing how they have listened to residents. The home has efficient systems to ensure effective safeguarding and management of residents’ money and valuables, including record keeping. Residents are supported to manage their own money where possible. They have access to their records whenever they wish. Record keeping is of a consistently high standard. Records are kept securely and staff are aware of the requirements of the Data Protection Act. Residents can gain access to their records and contribute to them. They are always told when a significant new entry has been made and what it says. All the working practices in the home are safe and there are no preventable accidents, or there are clear trends indicating a steady reduction in the number of preventable accidents, evidenced by good monitoring and record keeping systems. The home has a comprehensive range of policies and procedures to promote and protect residents’ and employees’ health and safety. Staff are trained, understand, and consistently follow these. There is full and clearly written recording of all safety checks and accidents, and there is no evidence of a failure to comply with statutory reporting requirements and other relevant legislation. The home proactively monitors its health and safety performance and this again is monitored by the Responsible Individual [RI]. Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 19 Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 20 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 4 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 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 Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP18 Regulation 13(6) Requirement Protection: must receive regular refresher training in the policies and procedures, including the whistle-blowing procedures so as to ensure residents are protected from abuse. Timescale for action 30/11/08 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 Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 22 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Bourne House Nursing Home DS0000026244.V371276.R02.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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