Care Home: Glen Heathers

What the care home does well What has improved since the last inspection? The home`s brochure has been updated and supplied to interested parties. A relative commented that there has been an improvement in the sharing of information about resident`s needs to their respective relative. Redecoration and refurbishment has taken place in a number of areas. There is an increase in the training opportunities available to staff including NVQ qualifications. A resident`s relative states the he/she has seen recent improvements in the home. What the care home could do better: Privacy could be improved by the installation of curtains on bedroom doors where there is a frosted a glass panel. Several people commented that the range of activities and stimulation for the residents could be improved. One to one supervision of staff needs to be improved. Residents` records need to be securely stored when not being used. Visits to the home by a representative of the owner are carried out each month but reports on the `conduct of the home` were not available which is required by the legislation. CARE HOMES FOR OLDER PEOPLE Glen Heathers 48 Milvil Road Lee-on-Solent Hampshire PO13 9LX Lead Inspector Ian Craig Unannounced Inspection 2nd January 2008 9:40 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 Glen Heathers DS0000069892.V355454.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. Glen Heathers DS0000069892.V355454.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glen Heathers Address 48 Milvil Road Lee-on-Solent Hampshire PO13 9LX 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) 07785 550783 Mr Amin Lakhani t/a Saffronland Homes Group Mr John Baden Perkins Care Home 53 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Glen Heathers DS0000069892.V355454.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing only - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) - maximum number of places (20) 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 53. Date of last inspection N/a Brief Description of the Service: The home provides nursing care for up to 53 older persons. It can accommodate up to 20 people whose primary need is dementia. There is a separate facility to accommodate up to 10 persons suffering from dementia who may be mobile sufficiently to be at risk from wandering outside the building unaccompanied. In addition to the care staff a registered nurse is on duty at any given time of the day. The service is located in a residential area of Lee on the Solent, close to the seafront promenade. Accommodation is provided over 2 floors. There are 11 double and 31 single bedrooms each with its own en suite toilet facility. Communal areas consist of dining rooms and lounges as well a sitting area in the entrance hall. A conservatory is to be built in the forthcoming months. There is parking for visitors. The weekly fees range from £500.00 to £700.00. Glen Heathers DS0000069892.V355454.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and lasted from 9.35 am to 3.35 pm. Records and policies and procedures were looked at. Discussions took place with the registered manager and 2 members of staff were interviewed about their work. Several residents and one resident’s relative were spoken to. Staff were observed working with the residents. Survey forms were sent to residents, their relatives, and to professionals who have an involvement with the home. These asked for views on the standard of service provided by the home. Surveys were returned as follows: • 1 from a general practitioner • 2 from social services staff • 1 from a community nurse • 14 from residents’ relatives • 11 from residents The service is also required by the Commission to complete an Annual Quality Assurance Assessment (AQAA). Information contained in this document has been used for this report. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. What the service does well: Comments from professionals, such as social services and community health staff, show that the service provided by the home is regarded as being of a very good standard. A general practitioner states that the home “provides a high level of service.” Health professionals state that the home works in partnership for assessing and reviewing needs, and for meeting people’s needs. Other comments from health and social services staff include the following: • ‘I have found that the standard of nursing care received by the residents is of a consistently high standard.’ • ‘Each resident is treated as an individual and the level of holistic care given is of a high standard.’ • ‘Glen Heathers has a close and in depth awareness of client’s needs and maintains accurate records.’ Glen Heathers DS0000069892.V355454.R01.S.doc Version 5.2 Page 6 Residents’ relatives also made many favourable remarks about the standard of care provided, including the following: • ‘I have found the nursing staff very dedicated and professional in the care of my mother.’ • ‘The staff at Glen Heathers have gone out of their way to ensure my mother is included in all activities.’ • ‘The staff provide a warm and clean environment. The residents are clean, well dressed. The food is of a good quality with plenty of variety. The staff are very competent and caring and make it as much like home as possible.’ • ‘Shows genuine care and friendliness to our mother/father and to the family as well.’ Potential residents’ needs are comprehensively assessed before it is agreed the person should be admitted to the home. Each person has a care plan. Records show that health care needs are addressed and that medication procedures meet current pharmaceutical guidelines. Residents have a nutritious diet and there is a choice available at each meal time. Residents and their relatives are supplied with a copy of the complaints procedure, which is also explained to them. The home was found to be clean and there is a programme of ongoing refurbishment. Staff are provided in adequate numbers to meet residents needs although comment was made that staff do not have time to talk to the residents. Checks are carried out when staff are recruited to work in the home. There is a process of induction for new staff and training courses are available including National Vocational Qualifications (NVQ) and dementia training. What has improved since the last inspection? The home’s brochure has been updated and supplied to interested parties. A relative commented that there has been an improvement in the sharing of information about resident’s needs to their respective relative. Glen Heathers DS0000069892.V355454.R01.S.doc Version 5.2 Page 7 Redecoration and refurbishment has taken place in a number of areas. There is an increase in the training opportunities available to staff including NVQ qualifications. A resident’s relative states the he/she has seen recent improvements in the home. 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. Glen Heathers DS0000069892.V355454.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 Glen Heathers DS0000069892.V355454.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 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential residents and their relatives are provided with information and are able to visit the home to help them decide if the service meets their needs. Comprehensive assessments are carried out before a service user moves into the home so that the home can determine whether or not the person’s needs can be met. EVIDENCE: Glen Heathers DS0000069892.V355454.R01.S.doc Version 5.2 Page 10 Documents relating to the assessment of people referred to the home for possible admission to the home were looked at and the process of residents moving into the home was discussed with the manager. The home’s pre admission assessments for residents recently admitted to the home includes the following areas of need: • Communication • Hearing • Sight • Breathing • Eating, drinking, diet and teeth • Elimination • Personal care, oral hygiene and foot care • Working and play • Family • Mobility/falls • Mental state • Pain • Sleep/rest Further assessments had been completed including a Waterlow pressure sore prevention assessment, barthel assessment and a nutrition screening. Where residents are referred by the local authority, the home obtains copies of the social services’ care manager’s assessment and care plan. Hospital discharge details are also obtained where appropriate. Records also show that the home reviews residents’ needs in conjunction with social services. A member of the community nursing team made the following comment: • ‘Pre assessment notes are always very thorough, so they know prior to admission that they will be able to meet the person’s needs.’ Records show that residents and/or their relatives have an opportunity to visit the home before making a decision about moving in. Residents’ relatives also confirmed that they are provided with information about the service provide by the home. A contract is agreed between the home and the resident, which outlines the terms and conditions of any stay at the home. Signed copies of these documents were available. For those residents funded by social services, copies of the local authority contract were available. Glen Heathers DS0000069892.V355454.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 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are met. Residents are treated with dignity. Privacy is promoted although there is scope to improve this. EVIDENCE: Each person has various documents which detail the assessed needs as well as care plans showing how those needs are to be met. Comments from community health and social services confirms that the home works alongside these services to meet people’s needs: Glen Heathers DS0000069892.V355454.R01.S.doc Version 5.2 Page 12 • • ‘Written records are of a good standard and the overall standard of nursing care is also good.’ ‘The staff deal well with complex mental health needs.’ Health and social services personnel also referred to their working relationship with the home: • • • ‘Comments and suggestions about care are always taken on board and discussed.’ ‘Trained nurses and notes are always available.’ ‘The home works in partnership.’ Care plans refer to the individual preferences of each person, such as times for getting up and going to bed, but it was highlighted that this could be developed further to include life history details, how the person likes to spend his or her day and greater detail on how staff should deal with mental health and communication needs. Care staff expressed the view that residents care needs are met. Records show evidence of liaison with health services for dental care, optical care from opticians, district nurse input and chiropody treatment. The home has developed policies and procedures for the palliative care of those with a terminal illness and works alongside specialist community health services to meet this need. The home’s medication procedures were looked at. Medication is only administered by one of the registered nurses on duty. Records of medication administered are maintained. Procedures for controlled medication also meet pharmaceutical guidelines. A general practitioner commented that medication is appropriately managed. Staff were observed administering medication. Residents’ relatives referred to the kindness and attentiveness of the staff. One relative stated that the home, ‘shows genuine care and friendliness to our mother and to the family as well.’ One relative states that the staff treat the residents in an adult manner whilst another relative said that the staff have ‘talked down’ to a resident and that this has been raised with the home’s management. Bedrooms are fitted with locks so that residents can lock the room for privacy when they are in the room. Keys to the locks are available so that they can be locked if the resident goes out, but the manager confirmed that the keys are not offered to residents. It was acknowledged that many residents would be unable to safely handle a key, but that this facility should be offered to Glen Heathers DS0000069892.V355454.R01.S.doc Version 5.2 Page 13 residents and may be wholly appropriate for some. A record of any decisions made by the resident or the home for this should be recorded. A number of bedroom doors have a frosted glass panel. Some of these are covered with a curtain for privacy but several are not, which compromises privacy. Screens are available for privacy in shared rooms. A member of the community nursing team commented, ‘If I need to speak to a resident I am given the opportunity to speak in privacy if appropriate.’ Glen Heathers DS0000069892.V355454.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to exercise choice in their daily lives. There are activities and stimulation for the residents but this could be improved. A nutritious diet is provided and there is a choice of food at each meal. EVIDENCE: Surveys from residents, their relatives and from professional show a mixed view regarding the provision of activities and stimulation for the residents. One of the 4 professionals who completed a survey refers to residents being provided with activities. Two other professionals comment that the level of activities and stimulation should be improved. One person stated: ‘Residents who sit in the lounge do not appear to be stimulated enough. Apart from the TV nothing much ever seems to happen, and all appear to be sleeping.’ Glen Heathers DS0000069892.V355454.R01.S.doc Version 5.2 Page 15 Residents’ relatives also gave mixed views on the level of activities and stimulation for the residents. Several make suggestions as to how this could be improved, such as the provision of arm chair exercises, meetings for relatives so that activities can be discussed, a notice board for information in residents’ bedrooms and some sort of occupational therapy. Four relatives state that the provision of activities and stimulation could be improved. Two relatives state that the staff do not have enough time to interact with the residents or to provide activities. One person commented: ‘The staff are very attentive and friendly. My relative appreciates their care, and they spend quite a lot of time chatting to her in her room, which makes up, to an extent, for the fairly low level of organised activities.’ Two relatives made positive references to the home providing activities, although one person stated this is mainly to the benefit of those have less complex needs. On the day of the inspection residents were observed sitting in the lounge areas. Some were watching television, some reading and some were asleep. There was a notice in the hall giving details of entertainment in the home for December 2007 and January 2008. This consists of 2 sessions in December and 3 in January. In addition to this, the manager states that bingo takes place most weeks. In the area of the home providing care for those with dementia, a notice displayed daily activities for the residents. A resident commented that she can go to the lounge if she wishes to socialise and that there are always a large number of books to read. This person also stated that he/she can attend the activities is he/she wishes to. Residents were observed reading daily newspapers. The provision of activities was discussed with the manager. It was suggested that this could be improved. For instance the frequency of activities for residents who are not in the area providing specialist care for those with dementia could be developed and the opportunity for outings could be improved. Currently outing are not organised for the more able residents, although families may arrange their own outings. Residents were observed receiving visitors on the day of the visit. Relatives commented how they are kept informed of any developments, and one person stated how the staff take the telephone to their mother /father when phoning. One relative stated, however, that he/she did not always receive information without asking. Residents confirmed that they are able to get up and go to bed at the times they wish. Residents are able to spend their time as they wish although a professional states that residents are not always supported to lead the life they Glen Heathers DS0000069892.V355454.R01.S.doc Version 5.2 Page 16 would choose due to the constraints on staff being able to spend time with the residents. Choice is available in the provision of food. This was confirmed by the residents and their relatives, who state that there is always a choice of 2 main courses. A record is made of each person’s food preferences including what the person likes for breakfast, which is recorded. A member of staff was observed asking residents what they would like to eat from a choice of 2 dishes for the forthcoming midday meal; a record was made of the response. Each person has a nutritional assessment. Staff were observed helping residents to eat where this was needed. The surveys contained only positive remarks about the quality of the food, although one person stated that the food was not always hot enough. Glen Heathers DS0000069892.V355454.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that each resident, and their relatives, are fully informed of the complaints procedure. Steps are taken by the home to ensure that residents are protected from abuse. EVIDENCE: Residents and relatives confirm that they are given a copy of the home’s complaints procedure. One person states: ‘The manager explained the complaints procedure prior to my mother entering the home and I was also given a written copy.’ The complaints procedure is displayed in the home. No complaints have been made to the home in the last 12 months. One of the surveys from the 4 professionals states that he/she has never received any complaints about the home. Information received in the surveys shows that Glen Heathers DS0000069892.V355454.R01.S.doc Version 5.2 Page 18 the home’s management engage residents and their relatives in dialogue about any concerns. The home has copies of the local authority adult protection procedures as well as Department of Health literature on protecting vulnerable persons. Staff confirmed that they have received training in adult protection procedures. Glen Heathers DS0000069892.V355454.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): 19, 20, 21, 22, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and well-maintained environment. EVIDENCE: The home has a programme for refurbishment and redecoration. Residents are able to choose a colour scheme if their room is redecorated. Bedrooms are personalised with belongings. Residents are able to have a telephone line in their bedroom which some have taken up. One resident stated that his/her room was a little Spartan when he/she moved in and so brought some of her own furniture to make it more homely. Glen Heathers DS0000069892.V355454.R01.S.doc Version 5.2 Page 20 Communal areas were seen and include lounges and dining rooms. Residents were watching programmes on a large television screen in the main lounge. There is also a sitting area in the entrance hall. The home is shortly to start work on creating a conservatory, which a resident and a relative said they are looking forward to using. One resident said that he/she uses the garden in the summer months. The home has a number of toilets and bathrooms with specialist facilities for those with mobility needs. It was noted that in one bathroom with a walk in shower facility that the floor tiling was cracked in a small area and should be repaired to reduce the risk of the spread of infection. The home was found to be clean. Staff receive training in infection control. Residents and their relatives, as well as professionals, made favourable remarks about the environment with the exception of one person who stated that a number of minor repairs are needed. Glen Heathers DS0000069892.V355454.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided in adequate numbers to meet the needs of the residents. Residents benefit from a well trained staff team. The home’s recruitment procedures ensure that the residents are protected. EVIDENCE: Residents and relatives made the following remarks about the staff: • ‘I have found the nursing staff very dedicated and professional in the care of my mother.’ • ‘The staff are always kind and cheerful.’ Care professionals also refer to the skill of the staff and the availability of trained nurses. Glen Heathers DS0000069892.V355454.R01.S.doc Version 5.2 Page 22 There were also comments that the staff are not supplied in numbers to provide sufficient activities for the residents. The staff rota showed that the following staff levels were provided at the time of the visit: • 7.30am to 1.30pm, 8 care staff and 2 registered nurses • 1.30pm to 7.30pm, 6 care staff and 2 registered nurses • 7.30pm to 7.30am the following day, 4 care staff and 1 registered nurse plus access to a ‘on call’ support staff member. These staffing levels can be adjusted according to the changing needs and numbers of residents. In addition to the above, cleaning, catering and laundry staff are employed. Newly appointed staff have an induction, which is based on nationally recognised guidelines. This was confirmed from the staff and from training records. Staff have access to a variety of training courses. At the time of the inspection 45 of care staff are trained to NVQ level 2 or above, or are undertaking this training. A further 5 staff are to start this training which will take the home past the national minimum standard of 50 trained to NVQ level 2 or above. Staff also receive training in moving and handling, first aid, challenging behaviour, fire safety and dementia. Care staff are supervised by the registered nurses. Staff described how they work as a team but also stated that regular staff meetings do not take place and that this might be beneficial for communication purposes. Records of supervision show that this is not taking place on a regular basis. This was confirmed from records for 3 staff, which showed no record of supervision for 2 staff and only an appraisal for the third person. This was also raised by one of the staff. Records and discussion with the staff and management show that staff only commence work in the home when the relevant checks have been carried out including the criminal record bureau (CRB) and protection of vulnerable adults (POVA) checks. Two written references are obtained for each new employee and that the staff member is assessed at an interview which is recorded. Glen Heathers DS0000069892.V355454.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, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in the best interests of the residents. Residents’ health and safety are promoted. EVIDENCE: The home’s manager has the Registered Manager’s Award and has been in post for 10 years. Glen Heathers DS0000069892.V355454.R01.S.doc Version 5.2 Page 24 The home has methods for monitoring its own performance including the use of surveys of residents and relatives. The views are compiled into a summary, which is used for devising an action plan. An action plan dated 28/08/06 and six monthly development plans were available. The registered manager is supported by the organisation’s management. This involves regular visits to the service. Monthly reports by the organisation should be prepared following these visits and must be left with the manager for the purpose monitoring and for future planning. These were not available and the manager was unsure if the reports had been produced for recent visits. Care and nursing staff describe the management as supportive and approachable. Relatives of residents also state that they are able to discuss any concerns with the home. Care records were left in a lounge area when not in use when they should be securely stored for confidentiality reasons. Support is given to residents in managing finances. Record are maintained of any transactions and amounts held on behalf of residents. Staff receive training in first aid, moving and handling, infection control and food hygiene. The home’s appliances and equipment are serviced by suitably qualified persons. Glen Heathers DS0000069892.V355454.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 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 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 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 2 3 Glen Heathers DS0000069892.V355454.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/a 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 OP12 Regulation 12 Requirement The home must review the provision of activities and stimulation for the residents with a view to improving the frequency of activities, taking account of the wishes of relatives and residents as well as the views of health and social care professionals. A written report must be provided to the manager by the representative of the organisation following monthly visits to the home. Timescale for action 28/04/08 2 OP33 26 (4)© (5) (b) 28/03/08 3 OP36 18 (2) Care and nursing staff must 28/03/08 receive regular formal one to one supervision. Residents’ records must be securely stored when not in use so that confidentiality is upheld and the Data Protection Act adhered to. 28/02/08 4 OP37 17 (1)(b) Glen Heathers DS0000069892.V355454.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. Refer to Standard Good Practice Recommendations Glen Heathers DS0000069892.V355454.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South East The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email:inspection.southeast@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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