Care Home: Greatwood House

What the care home does well A pre admission assessment of needs is carried out before a resident is admitted to the home to make sure that all their needs can be met. Visits to the home by prospective residents and/or their relatives are encouraged before a decision about admission is made. The majority of relatives` comment cards received indicated that they did receive enough information about the home prior to admission. From observations during this visit the relationships between residents and staff appeared to be very good. The activities programme is imaginative and stimulating and residents spoken to all commented on how much they enjoyed the activities provided. The residents and visitor spoken to were positive about staff attitudes. The majority of returned resident and relative comment cards sated that residents receive the care and support they need. Some comments included "all staff are helpful and cheerful to residents and visitors alike" and "they will go the extra mile to help make residents happy and comfortable". The visitor spoken to said that the staff are wonderful and very kind but there is not enough of them". From speaking to the people who live at the home and from the comments received in the comment cards privacy and dignity is respected. The home has an open visiting policy and the visitor spoken to said that they visit every day and staff always made them feel very welcome. Policies and procedures were in place to protect residents from abuse and staff had received appropriate awareness training. Staff are encouraged and supported to undertake training to ensure that they have the necessary skills to meet the needs of the residents living at the home. There are good recruitment procedures to ensure that the staff employed are safe to work with residents. What has improved since the last inspection? Since the last inspection visit the Service User Guide has been updated to ensure it contains up to date information. A monthly audit of the medication is now being undertaken to ensure that medication is given as prescribed by the GP. New conservatory furniture has been bought and there has been regular maintenance both inside and outside the home. What the care home could do better: No requirements have been made in this report, however two recommendations have been made. It is recommended that a copy of the GP`s original prescription is kept at the home and that some parts of the residents individual plan of care contains more detail to ensure that individual needs and personal preferences are met. CARE HOMES FOR OLDER PEOPLE Greatwood House Mancunian Road Denton Tameside M34 1GX Lead Inspector Geraldine Blow Unannounced Inspection 09:30 18 February 2008 th 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 Greatwood House DS0000005569.V351256.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. Greatwood House DS0000005569.V351256.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Greatwood House Address Mancunian Road Denton Tameside M34 1GX 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) 0161 336 5324 0161 320 3896 greatwood@tamesidecg.co.uk Meridian Healthcare Ltd Marie Mcpherson Care Home 60 Category(ies) of Dementia - over 65 years of age (60), Old age, registration, with number not falling within any other category (60), of places Physical disability over 65 years of age (60) Greatwood House DS0000005569.V351256.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 60 service users to include: *up to 60 service users in the category of OP (Old age not falling into any other category). *up to 60 service users in the category of PD(E) (Physical disability over 65 years of age). *up to 60 service users in the category of DE(E) (Dementia over 65 years of age). 21st November 2006 Date of last inspection Brief Description of the Service: Greatwood House is a purpose built, adapted and extended single storey building. The home is registered with the Commission for Social Care Inspection to provide personal care for 60 older people, some of whom may have a physical disability or dementia. All the accommodation is provided in single rooms, 37 of which have been extended to include en-suite facilities. The home is divided into 4 units each one having its own small kitchen, dining area and lounge. There is a separate day care centre within the building that is not subject to regulation. There are aids and adaptations throughout the home to meet the assessed needs of the people living there. A landscaped garden is situated in the centre of the building. It is secure and fully accessible from the home. Originally commissioned by the local authority, Greatwood House is now owned and managed by Meridian Healthcare Limited. The home is located within a large estate, close to community resources and transport networks. Fees for accommodation and care at the home range from £361.75 to £386.75. Additional charges are also made for hairdressing and chiropody services, newspapers and personal toiletries. There is also a voluntary weekly charge for social activities. The statement of purpose and service user guide are available in the main hallway. Greatwood House DS0000005569.V351256.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 3 star. This means the people who use this service experience excellent quality outcomes. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 21 November 2006 and supporting information received in the Annual Quality Assurance Assessment (AQAA) submitted by the manager prior to this visit. Residents, staff and relatives were sent comment cards. Thirteen resident comment cards, 8 staff comment cards, and 13 relative comment cards were received by CSCI. These gave good feedback and their comments are included in the body of the report. This visit was unannounced and forms part of the overall inspection process; it took place on Monday 18 February 2008. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS). This report is an overview of what the inspector found during the inspection. As part of the visit we (the commission) spent time examining relevant documents and files. We also spent time talking with one of the home’s senior care staff, several people living at the home, some members of staff, a visitor to the home and a tour of the building was undertaken. What the service does well: A pre admission assessment of needs is carried out before a resident is admitted to the home to make sure that all their needs can be met. Visits to the home by prospective residents and/or their relatives are encouraged before a decision about admission is made. The majority of relatives’ comment cards received indicated that they did receive enough information about the home prior to admission. From observations during this visit the relationships between residents and staff appeared to be very good. The activities programme is imaginative and stimulating and residents spoken to all commented on how much they enjoyed the activities provided. The residents and visitor spoken to were positive about staff attitudes. The majority of returned resident and relative comment cards sated that residents receive the care and support they need. Some comments included “all staff Greatwood House DS0000005569.V351256.R01.S.doc Version 5.2 Page 6 are helpful and cheerful to residents and visitors alike” and “they will go the extra mile to help make residents happy and comfortable”. The visitor spoken to said that the staff are wonderful and very kind but there is not enough of them”. From speaking to the people who live at the home and from the comments received in the comment cards privacy and dignity is respected. The home has an open visiting policy and the visitor spoken to said that they visit every day and staff always made them feel very welcome. Policies and procedures were in place to protect residents from abuse and staff had received appropriate awareness training. Staff are encouraged and supported to undertake training to ensure that they have the necessary skills to meet the needs of the residents living at the home. There are good recruitment procedures to ensure that the staff employed are safe to work with residents. What has improved since the last inspection? What they could do better: No requirements have been made in this report, however two recommendations have been made. It is recommended that a copy of the GP’s original prescription is kept at the home and that some parts of the residents individual plan of care contains more detail to ensure that individual needs and personal preferences are met. Greatwood House DS0000005569.V351256.R01.S.doc Version 5.2 Page 7 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. Greatwood House DS0000005569.V351256.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 Greatwood House DS0000005569.V351256.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): 2 & 3 (Standard 6 intermediate care is not provided at Greatwood House) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are given sufficient information to make a decision about where to live and their needs are assessed prior to them being admitted to the home to ensure that their needs can be met. EVIDENCE: The Statement of Purpose was available in the main reception for people to access. All returned resident comment cards stated that they had received enough information about the home before moving in. Individual service contracts, which contained details regarding the fees to be paid and the room occupied were seen on the care files examined as part of this visit. Greatwood House DS0000005569.V351256.R01.S.doc Version 5.2 Page 10 Individual care needs assessments were contained within the care files examined. The home also has a process of assessing potential residents’ needs before a decision about admission is made. Prospective residents and their relatives are encouraged to visit the home so that they can meet other people and see the accommodation for themselves. By completing such an assessment, the home can be sure that individual needs can be met. Greatwood House does not provide an intermediate care service. Greatwood House DS0000005569.V351256.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, social and personal care needs of residents were being met. EVIDENCE: Four residents were case tracked during this inspection visit and their care files were examined. Each resident had an individual plan of care, which had been reviewed on a monthly basis. Most areas of the care plans were person centred and included individual preferences and specific care needs. For example one care plan documented that the resident preferred a shower as she gets cramp in the bath and another had details of the resident’s preferred daily routine. Documenting these individual preferences is seen as good practice. However some other parts of the plans were quite vague and did not clearly set out the individualised actions which needed to be taken by staff to ensure that residents’ individual health and personal care needs or personal preferences are fully met. For example, entries included “requires slight assistance” and Greatwood House DS0000005569.V351256.R01.S.doc Version 5.2 Page 12 “requires assistance of 1 staff” but there was no details of what that assistance was. It is recommended that some parts of individual plans of care are further developed to include details of exactly what assistance is required, which includes residents personal preferences. Appropriate risk assessments had been included. Evidence was seen that where possible the plan of care had been drawn up with the involvement of the resident/representative. This is seen as good practice. Each resident was registered with a General Practitioner and evidence was seen of referral to other specialised services according to individual assessed needs, for example, District Nurses, Tissue Viability Nurse, Dentist, Dietician and Chiropodists. The senior staff are responsible for the administration of medication. There was evidence to show they had received training to correctly administer medications. There is a policy and procedure in place and a risk assessment for residents wishing to self medicate. The medication storage was satisfactory. As part of case tracking, evidence was seen that the Medication Administration Recording (MAR) sheets were recorded accurately, with the exception of one. A tablet count was undertaken for 3 boxed tablets for the same resident. Two of the counts were correct but one count identified that there were 2 tablets missing. It was day 4 of the MAR recordings. It was unclear if the original tablet count into the home was incorrect or if 2 tablets had been given without being signed for. The senior care staff gave assurances that she would inform the manager as soon as possible. It was seen that some residents apply their own creams and the senior care staff stated that a risk assessment is completed before any form of self medication is undertaken. However the care plans did not clearly identify that these residents were applying their own cream. A recommendation has already been made in relation to improving detail in the individual plans of care. The senior carer confirmed that the home does not have a copy of the GP’s prescription; this is kept at the dispensing pharmacy. To ensure that residents receive their medication as prescribed by the GP it is recommended that there is a copy of the GP’s original prescription in the home so that the medication received can be checked against medication prescribed. Based on observation during the visit and talking to residents, a visitor and staff working at the home it was apparent that the staff respected the Greatwood House DS0000005569.V351256.R01.S.doc Version 5.2 Page 13 residents’ privacy and dignity. Some comments received from relatives are “I am satisfied that my mother gets all the care she needs and is treated with respect” and “I am very impressed with the staff at Greatwood House they take very good care of my mother”. Greatwood House DS0000005569.V351256.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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Activities were provided and residents were able to maintain contact with family and friends. EVIDENCE: There is a comprehensive planned programme of activities, which is on display around the home and in some of the resident’s bedrooms. In addition to the planned and organised activities each unit has a variety of cards and board games and the staff on the unit facilitate their use. One the day of this visit 2 residents were seen enjoying a game of dominos. On the day of this visit there was a coffee and Baileys afternoon, which included a quiz. The residents, staff and a visitor were obviously enjoying the afternoon. Photographs around the home showed other social activities, including a boat trip, a visit to a Stockport air raid shelter, a cheese and wine tasting, a fruit and a chocolate fountain party and an ice cream parlour was planned for 2 days after this visit. The person responsible for organising the Greatwood House DS0000005569.V351256.R01.S.doc Version 5.2 Page 15 activities confirmed that all activities are planned around resident’s requests and personal interests. The majority of comment cards indicated that residents were happy with the activities provided. One comment was the activities are “varied and wonderful for residents. Residents and relatives are invited and staff do a wonderful job”. The visitor spoken to said that the home provides a lot of very good stimulating activities for the residents. One resident spoke to said that she particularly enjoyed the church services provided in the home on a regular basis. Based on direct observation, the residents benefit from relaxed informal contact with the staff. Residents, staff and the visitor spoken to confirmed that the home facilitated open visiting and visitors could be received in the resident’s own room or any of the communal areas of the home. The visitor said that she is always made to feel very welcome when she visits. The majority of relative comment cards indicated that they are kept op to date with issues affecting their relatives and one comment was that they are “always informed of treatment/medication etc.. However one comment card detailed that they were not informed following a couple of falls or the injuries that were sustained. From speaking to the visitors and staff it appeared that residents are encouraged to exercise choice and control over their lives and that residents are encouraged to bring personal possessions into the home. A daily menu is on display on each unit, however it had not been updated to reflect the menu on the day of this visit. The menus are based on a 3-week rota and included fresh vegetables on a daily basis. The main meal is served at lunchtime and breakfast is flexible, as and when the residents get up. It was encouraging that bowls of fresh fruit were available in the lounge areas. The menu has choices for breakfast and teatime but did not include an alternative to the main meal. However the senior carer and other staff spoken to did confirm that an alternative was available on request. Comments regarding the meals were varied. The visitor spoke to described the meals as “so,so” and said that the best meal of the day was at lunchtime but there was not much choice at tea time. One resident said the food was “ok but did get a bit boring”. Other comments included “I love breakfast but dislike the dinners and not keen on the teas – but I am not mad on food” and “I am on a soft diet and am satisfied”. The AQAA identified that the residents had assisted in developing the menus last year and they are currently in the process of reviewing the menus again via a quality monitoring customer feedback questionnaire which will go out in July. Staff confirmed that a new chef had very recently employed. Greatwood House DS0000005569.V351256.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are encouraged and supported to raise their concerns and complaints and there are policies, procedures and systems in place to protect residents from abuse. EVIDENCE: There is a complaint procedure, which was seen in the residents’ bedrooms that were looked at during this visit and is included in the Statement of Purpose, which is available in the main reception for people to access. The majority of returned resident comment cards identified that they knew how to make a complaint and one comment was “not needed to complain as yet”. All the returned relative comment cards indicated that they knew how to make a complaint and comments included, that they knew how to make a complaint “but there is nothing to complain about and that a complaint “has never been necessary”. The visitor spoken to confirmed that staff do listen to any concerns and act on them. The staff spoken to confirmed that the manager operates an open door policy and residents, relatives/visitors, staff and visiting professionals to the home are encouraged to raise any concerns or complaints they have. There is a complaint file which details the nature of complaints and the manager keeps Greatwood House DS0000005569.V351256.R01.S.doc Version 5.2 Page 17 copies of any investigation, including staff statements, copies of any correspondence and an outcome of the complaint. There were policies and procedures in relation to the protection of adults from abuse and leaflets were available in the main reception with include a free phone Protection of Vulnerable Adults Line. There was a copy of the ‘Safeguarding Adults in Tameside’ and staff spoken to confirmed that they had received awareness training in safeguarding adults from abuse. Greatwood House DS0000005569.V351256.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All areas of the home were clean, comfortable, well maintained and equipped to meet the needs of the residents. EVIDENCE: As part of this visit a tour of the building was undertaken which included all the communal areas and several bedrooms. The home was clean, tidy, well decorated and furnished to a high standard. There were no offensive odours and residents, staff and the visitor confirmed that the cleanliness of the home was always of a high standard. The received comment cards indicated that the home was clean and fresh and comments included “my room is immaculate” and the home is “always clean and inviting like a 5 star hotel”. Greatwood House DS0000005569.V351256.R01.S.doc Version 5.2 Page 19 The senior care staff confirmed that there is a rolling programme of decoration and refurbishment to maintain standards. As already mentioned in this report new conservatory furniture has been bought since the last inspection and there has been regular maintenance both internally and externally. The attractive landscaped garden area was well maintained, secure and fully accessible to residents. Greatwood House DS0000005569.V351256.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number and deployment of staff appeared sufficient to meet the residents’ assessed needs and the procedures for recruiting staff provided adequate safeguards to protect residents. EVIDENCE: At the time of the inspection visit the home was fully occupied and therefore accommodated 60 residents. On the day of this visit the numbers and skill mix of the staff appeared to be sufficient to meet the needs of the number of residents accommodated. Six returned resident comment cards stated that staff are always available when you need them and 7 said there usually is. However the visitor spoken to said that the staff were wonderful but there wasn’t enough of them. The majority of staff comment cards indicated that there was always or usually enough staff to meet the needs of the residents. We (the commission) were informed on the day of this visit that 72 of care staff have achieved NVQ Level 2 and a further 4 members of care staff are currently working towards NVQ Level 2. A small number of staff files were examined. They contained the required documentation as required by Schedule 2 of The Care Homes Regulations Greatwood House DS0000005569.V351256.R01.S.doc Version 5.2 Page 21 2001, with the exception of 1 file. This particular file contained only 1 character reference. This was rectified during the inspection visit as an e-mail was sent requesting the second reference and a phone call confirmed that the reference would be sent. The senior member of care staff on duty was reminded of the need to have 2 written references, 1 of which must be from the most recent/current employer before any person starts work at the home. Staff files contained photocopied documents, for example passports and certificates. However there was no evidence that the original documents had been seen. A recommendation has been made. All of the completed staff comment cards indicated that a CRB and references had been obtained prior to them commencing work. Evidence was seen of a structured induction, that all newly recruited staff must complete. The completed AQAA documented that both parts of the Skills for Care national minimum dataset for social care had been filled in. Evidence was seen of ongoing staff training which included Fire Safety, Mental Health Awareness, Moving People Safely, First Aid, Safe Handling of Medication, Basic Food Hygiene, The Six Social Care Values, NVQ Level 2, Abuse Awareness and POVA Training. Greatwood House DS0000005569.V351256.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, 33, 35, 36 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Systems and procedures were in place to safeguard and protect residents’ financial interests and the home was seen to promote the health, safety and welfare of the residents and staff. EVIDENCE: The manager successfully competed registration with CSCI in September 2007. Residents and staff benefit from a committed manager who operates an open management style and encourages residents, visitors and staff to make use of the ‘open door’ policy. At the heart of this style of management is a person centred approach where the focus is on how the individual resident wants their care needs to be met. The staff spoken to said they were happy with the way Greatwood House DS0000005569.V351256.R01.S.doc Version 5.2 Page 23 the home is managed and felt that they were very well supported by the manager and the residents receive excellent care. A system of annual satisfaction questionnaires is being used by the organisation to enable the residents and their relatives to improve or comment on their care. The results are made public in the form of a ‘Quality assurance monitoring residents/representatives satisfaction survey’ dated May 2007 is available in the main reception and a copy was sent to CSCI prior to this visit. The results were very encouraging. In addition resident/relative meetings are held every 3 months and minutes are taken. Evidence was seen that the systems in place safeguarded resident’s financial interests. Evidence was seen that staff are receiving regular supervision sessions and notes are made and held on file. The information provided in the AQAA demonstrated that the home’s maintenance certificates and records were up to date. Appropriate fire safety checks are carried out on a regular basis. Greatwood House DS0000005569.V351256.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 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 4 X 3 X 3 3 X 3 Greatwood House DS0000005569.V351256.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 OP7 Good Practice Recommendations It is recommended that some parts of individual plans of care are further developed to include details of exactly what assistance is required, which includes residents personal preferences. It is recommended that there is a copy of the GP’s original prescription so that the medication received can be checked against medication prescribed. It is recommended that all photocopied documents are signed to indicate that the original has been seen. 2. OP9 3. OP29 Greatwood House DS0000005569.V351256.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Greatwood House DS0000005569.V351256.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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