Care Home: Dane House

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What the care home does well The home provides nursing care for older people in a pleasant and relaxed environment. The interaction between staff and residents was open and friendly and it was apparent that residents are treated with dignity and their choices respected. Visitors spoken with said ` There is always a friendly atmosphere in the home`. ` Staff are very friendly and they always tell you what`s happening`. Staff were aware of the needs and preferences of individual residents. The standard of care appeared good; with care plans identifying the current and changing needs of the residents, and nursing intervention charts completed and identifying the daily care that was being given. The standard of medication administration reflected current legislation and guidelines and was administered in a safe manner. The home makes a great effort with the presentation of meals; all meals including pureed meals were well presented. Residents can take these in the dining room, the conservatory or their rooms. Visitors may join them for meals and dining tables and trays were sent out with flowers, condiments, table linen and individual menus. Residents have a choice of two options at each meal, with other options available at each meal. One resident, who was a vegan, said that special meals were prepared for him and his tastes were ` well catered for`. Homemade cakes are offered at teatime. A ` snack box` is also prepared for the night hours with a selection of snacks and easy to prepare meals available for any resident who wishes for these. There is a good range of activities, which include outings and crafts, and residents were very complimentary about the activities provided. Staff take residents into the garden in clement weather and residents were having their afternoon tea in the garden on the day of the inspection. What has improved since the last inspection? The home has complied with all the requirements made at the last inspection. The standard of care planning has improved and regular medication audits take place. The manager and staff said that they are vigilant in ensuring that resident`s medication is always available. Staff said that they feel well supported, listened to and valued and that they enjoy working at the home. The home is now recruiting staff to make up for the turnover of staff and although agency staff is still being used, they have had success in recruiting permanent staff. What the care home could do better: No requirements have been made following this inspection. Issues that were apparent, including broken window restrictors and variation in water temperatures in resident`s rooms, were discussed with the manager and a means to rectify this was commenced on the day. The manager must ensure that regular checks of window restrictors take place and that variation in water temperatures in resident`s rooms is addressed immediately. Staff supervision should take place at intervals directed by the National Minimum Standards and the manager gave assurances that this would take place. A recommendation has been made around this. A recommendation has also been made around quality monitoring. The manager should ensure that the views of stakeholders form part of the quality monitoring process. CARE HOMES FOR OLDER PEOPLE Dane House 52 Dyke Road Avenue Brighton East Sussex BN1 5LE Lead Inspector Elizabeth Dudley Unannounced Inspection 24th June 2008 10:00 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 Dane House DS0000013976.V365307.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. Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dane House Address 52 Dyke Road Avenue Brighton East Sussex BN1 5LE 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) 01273-564851 01273 507161 dane.house@fshc.co.uk www.fshc.co.uk Ringdane Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability (5) of places Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is twenty-five (25). That service users should be aged sixty-five (65) or over on admission. That a maximum of five (5) service users may have a physical disability and be aged between forty-five (45) years and sixty-five (65) years on admission. 16th July 2007 Date of last inspection Brief Description of the Service: Dane House is a converted family house situated in a residential area of Hove. The home is registered to provide nursing care for twenty-five service users in the category of old age. A variation to the category has enabled the home to provide care for up to five service users with a physical disability. Intermediate care is not provided at Dane House. Dane House is a large detached property, with a conservatory to the rear of the house leading to a pleasant rear garden with an attractive pond and quality garden furniture. The accommodation offered consists of nineteen single bedrooms, ten with en suite facilities and three double bedrooms, and two with en suite bathrooms. There are ample communal bathrooms with adaptations for the disabled. The lounge area is large with comfortable furniture, which leads into a conservatory, which is used as a dining and seating area. There are other quiet areas on the ground floor with comfortable chairs, which can be used by the residents. Fees as told to the CSCI on the 24th June 2008 range from £700 to £820 per week depending on the room to be occupied. Additional charges are made for hairdressing, individual toiletries, chiropody, newspapers and outside activities such as visits to the theatre. Within the homes philosophy of care it identifies one of its main aims is to ‘care for every individual in a holistic humane and sensitive way’. Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced key inspection took place on the 24th June 2008 over a period of six hours and was facilitated by Ms M Barber, appointed manager and Ms A Cleave, Care Services Director. During the course of the inspection a tour of the home took place, documentation which supports the services offered by the home was examined, including care plans, medication charts, health and safety records and menus and personnel files. Four care plans were examined in depth and the residents had their care tracked from admission onwards with discussions held with them to ensure that the care written in the care plans and delivered to them met their needs and expectations. All residents were spoken with on the day and in depth conversations were held with six residents, which included the four residents that were being ‘ case tracked’. Staff on duty were spoken with and their training and personnel files examined. The Annual Quality Assurance Assessment (an annual assessment required by regulation which identifies what the home has achieved and future plans for the home) was received when we asked for it and accurately reflected the situation in the home. Prior to the inspection surveys were sent out to CSCI to ten residents and ten relatives. Eight of these were returned from residents and five from relatives. Following the inspection two representatives of residents were contacted by phone and one health care professional contacted. Positive comments about the home were made. Comments received from surveys were varied and included ‘ It’s a lovely home’. ‘The activity lady makes a huge effort to provide creative activities’. ‘Staff do not always listen to what I say’. ‘ Home is always very clean’. ‘Staff are very helpful’. Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The home has complied with all the requirements made at the last inspection. The standard of care planning has improved and regular medication audits take place. The manager and staff said that they are vigilant in ensuring that resident’s medication is always available. Staff said that they feel well supported, listened to and valued and that they enjoy working at the home. Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 7 The home is now recruiting staff to make up for the turnover of staff and although agency staff is still being used, they have had success in recruiting permanent staff. 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. Dane House DS0000013976.V365307.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 Dane House DS0000013976.V365307.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): 1,2,3,4,5,6. People who use the service experience good quality outcomes in this area. Prospective residents receive sufficient information to enable them to make a decision over whether they wish to live at the home. The manager assesses all prospective residents to ensure that the home is able to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service User Guide have been amended to reflect the current situation in the home. All residents have a copy of the service user guide. The manager assesses prospective residents prior to their admission to ensure that the home can meet their needs; this is then confirmed in writing. Three Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 10 preadmission assessments were examined, these contained sufficient information to inform the care plans. Prospective residents and their representatives are encouraged to visit the home prior to making a decision over whether the home is suitable. All residents are initially admitted for a month’s trial period. Residents are provided with a Contract and Terms and Conditions of Residence on admission. The format of these meets the National Minimum Standards and regulations. Recently admitted residents said that either they or their representatives had received sufficient information about the home before they commenced living there. The home accepts people for respite care but not for intermediate care. Dane House DS0000013976.V365307.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): 7,8,9,10,11 People who use the service experience good quality outcomes in this area. The standard of care planning ensures that the current and changing care needs of the residents are addressed. Medication administration safeguards the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the course of the inspection four care plans were examined. Care plans contained the relevant information including nutritional, wound and continence care plans. The Malnutrition Universal Screening Tool is used to assess resident’s nutritional needs and residents are weighed on a regular basis. Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 12 Staff must ensure that all relevant information detailed in the daily record forms a care plan i.e. one resident’s fluid intake had deteriorated but no care plan formed to identify this. Night care plans should be put in place. Personal risk assessments in the care plan showed actions to minimise the risks to residents. Staff should ensure that all parts of the care plan including nursing tools are reviewed on a monthly basis and that there is evidence that residents or their representatives have been involved in the care planning process. Residents spoken with said that their care had been discussed with them. Residents spoken with said the care was good: ‘They look after us very well and always get the doctor when I need him’. ‘ The sisters are excellent, they are really on the ball, can’t fault them’. Records such as fluid and turn charts had been filled in regularly and identified the care received and there was evidence of involvement with the Specialist Wound Care Nurse, Physiotherapist, Speech and Language therapist and Community Psychiatric nurses. There was good interaction between residents and staff, and residents said that the daily routine was sufficiently flexible to enable them to make choices in their activities of daily living such as rising and retiring. They said that the majority of the staff treated them with courtesy and respect and were polite. A relative spoken with said that she was very pleased with the care being given to her recently admitted father. Call bells were answered promptly and residents confirmed that this was generally the case both night and day. The standard of medication administration safeguards the residents. Medication had been signed and recorded on receipt, disposal and administration and medicines were being administered in a safe manner. The administration and storage of controlled drugs meet the regulations. The clinic room was clean and showed evidence of checking of equipment and recording of drug fridge temperatures. The manager and staff said that medications are audited monthly; the manager checks on stocks of drugs and looks at what is needed. Measures have been taken as far as possible to ensure that resident’s medication is in stock. Staff have not commenced studying the Liverpool care pathway or the National Gold Standards Framework (a nursing tool for ensuring that terminally ill Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 13 residents receive sufficient pain relief and appropriate care) and it is recommended that this be commenced. Registered nurses have had clinical updating on the use of syringe drivers and are proficient with PEG feeds (tube feeding through a gastrostomy site) and some have had palliative care training in the past. Residents being nursed in bed appeared comfortable and there was evidence of appropriate nursing intervention taking place. Notes of thanks from relatives of deceased residents were seen and these showed satisfaction with the care that had taken place. Dane House DS0000013976.V365307.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): 12,13,14,15, People who use the service experience good quality outcomes in this area The home provides suitable leisure activities to provide stimulation and interest for the residents. The home provides a well-balanced nutritious diet which is attractively presented and which most of the residents find enjoyable and to their satisfaction. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides an activities person for 15 hours per week and the activities programme shows that activities such as arts and crafts, quizzes and outings take place. Entertainers are brought in and a barbecue took place during a weekend. The home has a small ‘shop on a trolley’, which sells toiletries and confectionary at cost to residents and staff. On the day of the Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 15 inspection many residents were asking to go into the garden and staff were helping them to achieve this. Social care plans are in place and records are kept of those residents who participate in activities. The home should try and endeavour to provide some recreational time for those residents who are nursed in bed or who do not leave their rooms. Residents said that they have choice in the times of rising and retiring and other activities of daily living. Some residents saying they did not go to bed until 11pm and could sit in the lounge and watch television or talk to other residents and staff. Residents said that they are served breakfast in bed and do not have to get up at any specific time. Visitors can come into the home at any time and visitors spoken with said that they were made welcome. The Brighton Mission (a local Christian group) visits the home for religious services and other ministers of religion are accessed as residents wish. Menus are displayed in the corridors and on tables in the dining room. There are two choices of menu at each meal and extra choices available if required. Residents can have a cooked breakfast if required. Tables for lunch were attractively set out, with flowers, table linen, condiments and menus. Residents are able to take their meals in the dining room, the conservatory or in their rooms. All meals, including the soft diets were well presented. There were bowls of fresh fruit in the lounge and dining areas and fruit is also sent to the rooms of those residents who wish to have it. There is system in place for the provision of snacks at night ‘The Snack Box’ whereby a range of provisions is left for the night staff to provide snacks during the night for the residents. The kitchen was clean and there were adequate supplies of fresh, frozen and dried food. Cakes and puddings are homemade and special diets can be catered for. The chef manager has undertaken training in the dietary needs of the older person, but this has not yet been extended to the assistant cook. The majority of residents said that they enjoyed the food ‘I like the food, its usually very good’. ‘ The food is very nice, we have a lovely selection’. ‘ The food is generally okay’. Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People who use the service experience good quality outcomes in this area Residents were confident that any complaints they make would be dealt with in an open, transparent and timely manner. Staff were aware of their responsibilities in the safeguarding of those in their care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is keeping records of complaints and minor concerns and how they address these. The complaints policy is displayed but some residents were not aware of this or how to make a complaint. The manager will address this at the next residents meeting. Whilst most residents said that they felt comfortable with making a complaint to the manager or the company, some said that they would be wary of making a complaint about members of staff because of confidentiality reasons, the manager was made aware of, and will address this. There have been nine complaints since the last inspection, five of which were substantiated; there have been no adult protection issues Staff have attended adult protection and the manager has arranged to go on this training with the local safeguarding team. Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 17 The safeguarding policy requires amending to include verbal abuse, and this is in progress. Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22, 24, 25,26. People who use the service experience good quality outcomes in this area The home provides a homely, clean and attractive environment for residents. Residents are encouraged to personalise their own rooms with their own possessions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Dane House is a converted premise that has retained a home like environment. Accommodation for residents is provided on the ground and first floor with disabled access being provided via a passenger shaft lift. A tour of the home confirmed that a good standard of decoration is maintained throughout along with a satisfactory standard of cleanliness. Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 19 The garden is very attractive and well maintained and provides alternative seating areas and includes a selection of water features. The home provides attractive and versatile communal areas, which include a lounge and large conservatory that is used as a dining and provides additional seating. Blinds have been fitted to the conservatory although it still becomes very hot. One resident said that the temperature of the water to his room was cool. Water temperature records showed that the water temperature in this room was below the recommended parameters, whilst the water in a few other rooms was above. The maintenance person said that he was waiting for the head office to address this. This was commenced on the day of inspection. Some window restrictors were not operational. This was addressed on the day of the inspection and the manager has arranged for these to be checked weekly. Residents are encouraged to bring in their own possessions to make their rooms personalise their rooms and all residents have a lockable drawer facility. All rooms have variable height beds in place to facilitate the nursing care of the residents. The home is planning to extend the laundry facilities. Staff were seen to have knowledge of and to be practising good infection control techniques but it was noted that whilst care staff put on protective aprons to enter the kitchen, this was not extended to other staff. The manager gave assurances that this would be addressed. Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People who use the service experience good quality outcomes in this area There are sufficient staff with suitable training to ensure that residents needs can be met. Staff recruitment systems safeguard the residents living at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rota showed and staff and residents said that there were sufficient staff on duty over a twenty-four hour period to meet the needs of the residents. The manager, an administrator, a maintenance person and housekeeping and catering staff support care staff. Currently there are fourteen care staff employed at the home and six of these have the National Vocational Qualification level 2 or 3 in care (44 ). The training matrix showed that staff have received updating in mandatory training such as moving and handling and fire training. Fourteen of the staff have first aid training and infection control training. Care staff receive training relating to the care of the residents and registered nurses are encouraged to update their skills. Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 21 Catering staff stated that they would benefit from attending training relating to nutritional needs of the older person. On commencement of employment staff receive a handbook, which includes the General Social Care Code of Conduct, and care staff commence an induction course, which is linked to the recognised ‘Skills for Care’ induction training. All staff complete the home’s local induction course. Personnel files of three recently recruited staff were examined. These contained all documentation as required by the National Minimum Standards and associated regulations including Criminal Records Bureau check and Protection of Vulnerable Adults checks. One member of staff was working under supervision whilst waiting for the completion of the Criminal Records Bureau check but a Protection of Vulnerable Adults check was in place. Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 People who use the service experience good quality outcomes in this area. . Management systems in place safeguard the residents and ensure the home meets the expectations of the residents and their representatives. Formal supervision of staff does not always take place within the timescales recommended by the National Minimum Standards and this could have implications on the care of the residents and smooth running of the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 23 The manager has been in post since October 2007, is a Registered General Nurse and has experience in managing other care homes with nursing. She has attained the Registered Managers Award and is in the process of being registered with CSCI. Residents said that they liked living at the home and comments made about the staff and management were generally good. ‘ Can’t fault the home’. ‘ Staff fall over backward to help you’. Staff appeared to be unhurried and had time to talk to residents and help them and bells were not ringing for an undue amount of time. Staff said that they feel supported following the recent management changes. The Annual Quality Assurance Assessment (required by regulation to show what is happening in the home and the homes achievements and plans for the future) was received within the timescale required and correctly identified what was currently taking place in the home. Questionnaires are also sent out by head office who in turn audit the results from these and provide a report to the home. The manager stated that these results are shared with the staff and intends to share them with the residents at the next residents meeting. The home should ensure that stakeholders such as health and social care professionals are asked for their views on the home. The manager does not act as appointee for resident’s money, but small amounts of money are kept in the home for safekeeping. Records of these showed that they were well monitored. Formal supervision of staff is taking place but not always at intervals directed by the National Minimum Standards. The manager gave assurances that this would be addressed. Regulation 26 visits (visits by the provider in accordance with the regulations) were taking place at regular intervals and reports of these were seen. There were some health and safety issues including water temperatures and faulty window restrictors found. The manager gave assurances that these would be addressed, immediately put risk assessments in place and has since confirmed that repairs have been completed. Therefore no requirements have been made. However regular checks must take place and actions taken to rectify any faults found immediately. All staff have undertaken mandatory training and utilities and equipment has been serviced as required by relevant regulation. Dane House DS0000013976.V365307.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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 x 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 3 3 Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP33 Good Practice Recommendations That questionnaires are provided to staff and visiting professionals as part of the quality assurance monitoring programme. That formal supervision of staff takes place at intervals as directed by the National Minimum Standards. That the manager ensures that regular checks take place of window restrictors and water temperatures and that any discrepancies are reported to her to address immediately 2 2 OP36 OP38 Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Dane House DS0000013976.V365307.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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