Care Home: Hempton Field Nursing Home

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What the care home does well What has improved since the last inspection? This was the first inspection since the registration of the new provider in July 2007 therefore no improvements were required. What the care home could do better: CARE HOMES FOR OLDER PEOPLE Hempton Field Nursing Home 36 Lower Icknield Way Chinnor Oxfordshire OX39 4EB Lead Inspector Nancy Gates Unannounced Inspection 24th & 28th January 2008 1:00 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 Hempton Field Nursing Home DS0000070606.V357281.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. Hempton Field Nursing Home DS0000070606.V357281.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hempton Field Nursing Home Address 36 Lower Icknield Way Chinnor Oxfordshire OX39 4EB 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) 01270 882725 Ross Healthcare Limited Mrs Elizabeth Norris Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Hempton Field Nursing Home DS0000070606.V357281.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: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 33. Date of last inspection Brief Description of the Service: Hempton Field Nursing Home is owned and managed by Majesticare and is registered to provide nursing care for 33 individuals. It is located in a residential area on the outskirts of Chinnor village in Oxfordshire. The home is set in large gardens with an orchard and views over the countryside. Communal rooms are located on the ground floor, with bedrooms located on the ground and first floor. A passenger lift is provided. The company continues to voluntarily limited occupancy to 29 residents to reduce the number of double rooms in use. At present, there is one double room available. Fees for this home range from £575.00 to £950.00 per week. Hempton Field Nursing Home DS0000070606.V357281.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. The inspection of the service was a surprise visit and was a ‘key inspection’. The inspector arrived at the service at 13.30 p.m. on a weekday. The total number of hours spent at the home was 8 hours. The time spent at the home allowed for a thorough look at how well the service is doing. The inspection took into account detailed information from an Annual Quality Assurance Assessment, completed by the service manager and also took into account information that CSCI has received about the service since the registration of the new provider in July 2007. We asked for the views of all of the people who live at the home and also asked the views of others who support the needs of the people who use the service via a questionnaire/survey that we sent out. A total of six surveys were returned to us, two from the people who live at the home and four from relatives. All information received by the Commission for Social Care Inspection since registration, about this service was also taken into account when producing the key inspection report. The people who live in and home and all of the staff were very welcoming. Discussions with three staff members, the manager and the area manager took place within the site visit. We looked around the home including the bedrooms of individuals at their invitation. A number of records were viewed including individuals care plans, staff recruitment records, staffing rotas and maintenance/health and safety records. We looked at how well the service was meeting the standards set by the government. The report includes judgements about the standard of the service. What the service does well: Prospective residents are given information that will help them make an informed choice about whether to live at the home. There is a clear and detailed assessment process to ensure that all prospective residents nursing/care/support needs are assessed. The process ensures that the service is able to meet people needs before they move in. Hempton Field Nursing Home DS0000070606.V357281.R01.S.doc Version 5.2 Page 6 Care and support plans are based on detailed assessments of peoples needs and support the good quality care provided by staff. The people who live at the home are also enabled to take risks, in order that they are as independent as possible. People are offered a number of menu choices, in order that nutritional needs are met. Personal and healthcare needs are appropriately supported. Staff provide personal support in ways, which people prefer, in order that their needs are best met. Staff clearly promote individuals’ physical and emotional health, to keep them healthy and well. Access to additional support from health care professionals is consistent and meets health needs. Two people who live at the home responded to a survey and told us that they are happy with the support they receive, adding that they felt that staff know when they are unhappy. Feedback from relatives was also positive, “Wonderful, friendly and caring staff – it’s a genuine community”, “Staff have consideration and respect for residents”, “Generally the care is very good”, “Activities and outings are well organised and stimulating, also visits by people and organisations. Social evenings are also good fun”, “Hempton Field is first class…It is exemplary.” Needs arsing from equality and diversity are well met. From the evidence seen, we consider that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. The storage and administration of medication ensures the protection of individuals. Medication practice is well managed at the home, to ensure that health and well being are promoted. A clear complaints process is available to the people who live at the home and their representatives. Protection of the people who live at the home is assured by the availability of adult protection guidance, appropriate training and staff awareness. A pleasant and comfortable environment is provided for the people who live at Hempton Field Nursing Home. People’s bedrooms reflect individuality. The design and layout of the home, including adaptations and equipment meet individual need. The home is clean and hygienic, continuing to guard against the risks of infection and ill health. Staff are attentive and respectful promoting communication and independence in relation to need and abilities. Competent and qualified staff work at the home. Training provided to staff ensures that they qualified to meet individual needs. Staff records indicate that the recruitment process generally ensures the protection of the people who live in the home. Hempton Field Nursing Home DS0000070606.V357281.R01.S.doc Version 5.2 Page 7 The registered manager has remained at the home and continues to have extensive experience of managing care homes for older people and has a good understanding of the needs of the people who live in Hempton Field. She is a registered nurse and has obtained the NVQ Level 4 in Management, known as the Registered Manager’s Award. The award demonstrates that the manager has knowledge and skills to effectively manage the home. Staff described the manager as being very supportive and knowledgeable, defining clear boundaries of nursing and support offered at the home. There is regular monitoring by the provider, to ensure that the home is efficiently run and providing good standards of care. What has improved since the last inspection? 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. Hempton Field Nursing Home DS0000070606.V357281.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 Hempton Field Nursing Home DS0000070606.V357281.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, 3 & 6 Quality in this outcome area is good People who wish to move to the home are provided with information to help them make an informed choice about the service offered. The home has an assessment procedure, which ensures that prospective residents’ needs are assessed appropriately. The assessment determines whether the service can meet identified needs. Intermediate care (Standard 6) is not provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A statement of purpose and service user guide are available to inform prospective residents of what is offered at the home. Hempton Field Nursing Home DS0000070606.V357281.R01.S.doc Version 5.2 Page 10 The statement of purpose provides details of the registered provider and the manager including details of their qualifications and experience. It provides information about the organisation, information about the service on offer, admission to the home, the accommodation provided, how peoples’ views will be listened to, the staffing structure and details of the complaints procedure. The service users’ guide reflects the contents of the statement of purpose with the addition of information about agreements for residency. The manager confirmed that a copy of the inspection report would be made available to both the people who live at the home and their families/representatives. Admissions are not made to the home until a full needs assessment has been completed by the manager. We looked at the admission records for four people and they showed that a clear, standardised admissions process involving the individual and relevant professionals at all stages is undertaken. This ensures care needs are fully assessed before admission enabling the manager to decide whether the home can provide the care the person needs. Prospective residents are encouraged to visit the home before moving in to help them decide if it is somewhere they would like to live. Two people who live in the home returned CSCI questionnaires confirming they had received enough information about the home to help them decide if it was the right place for them. Hempton Field Nursing Home DS0000070606.V357281.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 The health needs of the people who live in the home are well met. The personal support offered promotes and protects the privacy, dignity and independence of the people who live in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Majesticare have introduced a new care planning system into the home to ensure consistency in recording about how to support people. A number of records were being transferred to the new recording system at the time of the inspection. We looked at the care plan files of six people who live in the home. The files contained a number of clear assessments and plans relating to peoples’ nursing and support needs, for example, ‘Nutritional assessment & weight’, Maintaining a safe environment’, Wound Care’, ‘Medication care plan’. Hempton Field Nursing Home DS0000070606.V357281.R01.S.doc Version 5.2 Page 12 Information focuses on issues identified by individuals and their family members/representatives to ensure that all aspects of the person’s health, personal, and social care needs are individually planned and agreed. All care and support needs are monitored by nurses to ensure that they remain realistic. We met with two people who confirmed to that they felt able to make decisions about many areas in their life and can ask for support when needed. Daily records show that staff are aware of the need to be non-judgemental, positive and respectful. Reviews are undertaken on a regular basis, confirmed not only by the people who live at the home but also within written information in individuals’ files. Appropriate risk assessments are in place. Any restrictions identified within the risk assessment process were considered reasonable and geared to ensure individuals safety and that the interests of all of the people who live in the home are best met. The health care needs of the people who live in the home continue to be managed by visits from local health care services. The two people who returned CSCI questionnaires said they receive the medical and nursing support they need and people spoken with during the inspection confirmed this. Medication administration and recording is of a good standard. Individuals’ agreement to take medication is recorded within care plans. Individuals receive medication on a singular basis; administration is conducted by nurses from a locked trolley. Medication is stored within room situated on the ground floor. Wall mounted cabinets and trolleys store medication safely and at the correct temperature. All medication entering and leaving the home is recorded to ensure the safety of the people who live at the home. Medication administration records are supplied by the pharmacist to support accurate administration and recording. Recording is accurate, no omissions were noted. Medication administration is only completed by qualified staff (nurses). Controlled drugs are stored and administered appropriately. A pharmacist representing the Primary Care Trust completed an audit in January 2008; recommendations made have been completed to ensure the continued safety of the people who receive medication. We received four questionnaires from relatives who relayed very positive views of the support offered at the Home, “Wonderful, friendly and caring staff – it’s Hempton Field Nursing Home DS0000070606.V357281.R01.S.doc Version 5.2 Page 13 a genuine community”, “Staff have consideration and respect for residents”, “Generally the care is very good. Hempton Field Nursing Home DS0000070606.V357281.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 good. There are opportunities for people to participate in social activities giving people full and flexible choice in how they spend their day. Meals are well managed and provide people with choice and variety, ensuring that their likes and dislikes are catered for. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two activity organisers are employed at the home to provide a variety of daily activities. Weekly activity planners show that people have the opportunity to join a number of activities, ‘music and movement’, ‘arts and crafts’, ‘pictionary’, ‘cookery (carrot cake, pancakes, Valentines biscuits), ‘film evenings’, quiz evening with cheese and wine, reminiscence group, needlecraft etc. One of the activity co-ordinators is an aroma therapist and is able to offer hand massage. During the inspection, a co-ordinator spent time individually and collectively with people, ensuring that individuals were able to join in with an activity if they wished. Hempton Field Nursing Home DS0000070606.V357281.R01.S.doc Version 5.2 Page 15 We received comments from two people who returned a questionnaire; they said that there were “always” activities they could take part in, referring to board games, films, and outings. A relative also returned a questionnaire stating, “Activities and outings are well organised and stimulating, also visits by people and organisations. Social evenings are also good fun.” Relatives said they could visit whenever they wished and always found staff to be cheerful and friendly. “Hempton Field is first class…It is exemplary.” Information received from the provider indicates that a number of people are supported to practice their faith, with the offer of communion from a local clergyman on a weekly basis. Majesticare have introduced a menu planning tool that states that each day’s menu should provide ‘At least’, 1 portion of starchy food at each meal, 2 portions of fruit, 3 portions of vegetables, 2 portions of protein foods, 2 portions of dairy food, a nourishing snack at supper and a milk drink, 8 cups of fluid each day and 1 portion of oily fish weekly. A sample of one weeks menus showed that people are offered a variety of options that provides a balanced diet and is in line with the menu-planning tool. Vegetarian options are offered each day. Nutrition/dietary assessments completed for each person highlights specific needs. Two people who live in the home told us they enjoyed the food, that there are two choices available at each meal and that “if you want something different they will get it for you.” The dining room provides a pleasant environment for people to have their meals, although people can have meals served in their room if they prefer. Hempton Field Nursing Home DS0000070606.V357281.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 A clear complaints process is available to listen to the views of individuals and their representatives. Protection of the people who live at the home is assured by the availability of adult protection guidance, appropriate training and staff awareness. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No formal complaints have been received at the home or at the CSCI since the registration of the service in July 2007. The home has a clear complaints procedure to help people raise concerns or complaints easily. The two people who live in the home and the four relatives/representatives who returned questionnaires to us said they know who to speak with if they wish to make a complaint. Responses to the CSCI questionnaires and comments made during the inspection showed that people felt confident to raise a concern. A number of people spoken with said the matron or the deputy matron are always available to speak with and they will listen to concerns or issues at any time. Hempton Field Nursing Home DS0000070606.V357281.R01.S.doc Version 5.2 Page 17 A whistle blowing and a Safeguarding/Protection of Vulnerable Adults policy and procedure are in place. Staff training records showed that the majority of staff have received training regarding the Protection of Vulnerable Adults. Staff spoken with were able to provide a good account of how to respond to allegations. The home has facilities for storing individuals’ money if required, but ‘money management’ is not provided. Small amounts of cash may be held on behalf of an individual, all transactions are recorded i.e. balance, money taken out, money returned. Hempton Field Nursing Home DS0000070606.V357281.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. A clean, safe and a reasonably well maintained environment has been created, providing people with a comfortable and homely place to live, suiting the needs of the people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well maintained and the standard of décor and furnishings remain good, particularly in the newer part of the home. Some areas in the older part of the building that would benefit from redecoration to improve appearance. Recorded visits to the home by a senior manager in October, November and December 2007have identified that there are a number of areas within the home that are ‘tired’ requiring some ‘minor décor and carpet replacement to uplift tired areas’. The manager confirmed that the new owners have indicated Hempton Field Nursing Home DS0000070606.V357281.R01.S.doc Version 5.2 Page 19 that refurbishment of areas of the home is being considered, but there is no timescale for redecoration. Bedrooms appeared comfortable and homely; people are encouraged to personalise their rooms. There remains a choice of communal areas both inside and outside of the home. This means that people living in the home have a choice of places to sit quietly, meet with family and friends or be actively engaged with other people. There is good access from the home into the garden, with a number of bedrooms having direct access into the garden and courtyard areas. All hot water outlets used by the people who live in the home are checked periodically to ensure thermostatic mixing valves are working correctly, keeping water at a safe temperature level. All areas seen within the main areas of the home were clean and comfortable, providing living areas, which are light, well heated whilst also providing good ventilation. Cleanliness remains at an exceptionally good standard throughout the home. Hempton Field Nursing Home DS0000070606.V357281.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. Staff in the home are trained, skilled and in sufficient numbers to support the people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Job descriptions are in place for all staff defining clear roles and responsibilities to support the people who live at the home. There were 27 people living in the home and at the time of the inspection, the staff on duty consisted of the manager (matron), 2 registered nurses, 6 carers, the activity organiser, 2 domestic staff, the cook/chef and a kitchen assistant. The inspector considers this level of staffing to be sufficient for the current needs of people living in the home. Staff spoken with were clearly knowledgeable regarding the needs of people who live in the home describing the importance of good care plans alongside getting to know people well to be able to support them as they wish. The people who live in the home told us that staff are helpful and friendly, “they know how to help me, they ask me if I feel alright and whether I need Hempton Field Nursing Home DS0000070606.V357281.R01.S.doc Version 5.2 Page 21 anything”. People confirmed that they thought there were sufficient members of staff on duty to provide care when they needed it. Relatives who returned a questionnaire to us also confirmed that there are enough staff on duty and that staff have the right skills and experience to look after people properly. We looked at seven staff files, of which the majority contained the information required for recruitment and for the protection of the people who live and work at the home. The manager confirmed that two written references are obtained before the commencement of employment. Criminal Record Bureau checks, including POVA first are completed centrally within the organisation, appointments confirmed following the receipt of acceptable references and CRB check. Two of the seven files did not contain confirmation of a CRB check. The manager confirmed that the checks had been undertaken and a record would be held within the individuals files. All new employees undertake a induction programme, inclusive of the required courses to ensure the safety of household members i.e. first aid, fire safety, health and safety, food handling and hygiene, protection of vulnerable adults. Information received from the provider shows that of the 21 permanent and 7 bank staff 14 staff are qualified to NVQ level 2 or above, indicating that 50 have achieved the required standard of qualification, exceeding the 50 stated within the standard. This indicates a clear commitment from both the care staff and the provider to ensure that standards of care are consistent. Internal and external training opportunities are offered to employees, relating to the identified needs of the people who live at the home. Training records confirmed that the staff group have a mix of skills and knowledge to support individuals’ needs. Hempton Field Nursing Home DS0000070606.V357281.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 & 38 Quality in this outcome area is good The home is well managed and is run in the best interests of the people who live in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Majesticare was registered as the new provider organisation for Hempton Field Nursing Home in July 2007. The registered manager has remained at the home and continues to have extensive experience of managing care homes for older people. She is a registered nurse and has obtained the NVQ Level 4 in Management, known as Hempton Field Nursing Home DS0000070606.V357281.R01.S.doc Version 5.2 Page 23 the Registered Manager’s Award. The award demonstrates that the manager has knowledge and skills to effectively manage the home. The people who live in the home and their relatives provide extremely positive accounts of the manager’s commitment to maintaining good standards of care. Meetings are held with the people who live at the home and their relatives on a 2-3 month basis and are used as an opportunity for people to raise issues and provide an opportunity for discussion. Staff feel the manager supports them and were able to discuss any concerns they had with her. Staff meetings are held regularly to provide opportunities for staff to raise and discuss issues. The home employs a maintenance person to carry out minor repairs, with external contractors with specialist knowledge brought in as and when needed. Weekly fire alarm tests are carried out and the outcome recorded, ensuring the fire system is in good working order. A fire risk assessment had been completed in November 2007 to ensure fire alarm system and fire safety information is up to date. Health and safety is promoted; training is provided to staff in induction and it is proposed that all staff will have regular training/updates. Records held in relation to health and safety viewed at the site visit are accurate and up to date, promoting the safety of all household members. The manager confirmed that all staff had attended fire training during the past 12-months. The provider undertakes formal monthly unannounced visits and prepares a written report on the conduct of the care home. Copies of the reports are available at the home for inspection at any time. The new provider has provided a year plan of when an monthly audit of how the home is operating will be conducted, for example June 2008 will determine that the Statement of Purpose and Service User Guide will be reviewed, a ‘Living in the hone survey’ will be conducted, a review of maintenance records will be completed etc. This should ensure that a consistent service is offered to the people who live in the home. The procedure for recording and reporting of incidents and accidents is satisfactory. Policies and procedures relevant to the conduct of the home are available. Hempton Field Nursing Home DS0000070606.V357281.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 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hempton Field Nursing Home DS0000070606.V357281.R01.S.doc Version 5.2 Page 25 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. 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. Refer to Standard Good Practice Recommendations Hempton Field Nursing Home DS0000070606.V357281.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office 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: 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 Hempton Field Nursing Home DS0000070606.V357281.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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