Care Home: Potton House Nursing Home

What the care home does well People proposing to use the service were provided with comprehensive information about Potton House. The manager understood the need to ensure that people could be cared for appropriately before they moved in and carried out thorough pre-admission assessments. All of the residents had care plans that detailed the care they needed and ensured that there was a consistent approach to providing their care. Staff worked well with outside health professionals and ensured that robust medication systems were in place. Activities were provided as people wanted them and staff were `allowed` to spend time interacting with the people living at Potton House. Food was freshly cooked and people using the service were offered a choice at mealtimes. Hot and cold drinks and snacks were available throughout the day. A robust complaints procedure and staff awareness of safeguarding ensured people were kept safe at all times. The home was clean, tidy and nicely decorated. The communal areas of the home were warm and free of clutter, so as not to confuse those people with dementia. A variety of training was offered to all of staff to ensure that collectively, they had the skills and experience, to meet the needs of the people living at the home. Recruitment procedures were fully adhered to so that residents were protected. The manager was very experienced and had a clear understanding of the key principles and focus of the service and worked with the staff team to continually improve and evaluate the care that was provided. It is expected that if this is sustained it will become an excellent service. What has improved since the last inspection? The service had a new manager who had become the registered manager and had a wealth of experience working with older people, including those with mental health problems. The exact amount of medication, including variable dose prescriptions, given to people in this home, and any reasons for omissions were now clearly recorded. Different methods of offering service users with dementia a choice of meal had been considered and implemented. What the care home could do better: The service was offering a good standard of care to the people using it. This now needs to be consolidated and staff need feel confident that they are moving into a period of stability. CARE HOMES FOR OLDER PEOPLE Potton House Nursing Home Potton Road Biggleswade Bedfordshire SG18 0EL Lead Inspector Mrs Sally Snelson Unannounced Inspection 22nd December 2008 09:45 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 Potton House Nursing Home DS0000017688.V373556.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. Potton House Nursing Home DS0000017688.V373556.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Potton House Nursing Home Address Potton Road Biggleswade Bedfordshire SG18 0EL 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) 01767 314782 01767 314862 potton.house@craegmoor.co.uk Health & Care Services (NW) Limited Piwe Makanda Care Home 24 Category(ies) of Dementia - over 65 years of age (24), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (24) Potton House Nursing Home DS0000017688.V373556.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home can accommodate a maximum of 24 service users. The home can continue to accommodate the identified service user who is aged under 65 years. The home cannot admit any other service users aged under 65 years. Date of last inspection 20th February 2008 Brief Description of the Service: Potton House is a purpose built care home with nursing situated in the grounds of Biggleswade Hospital on the outskirts of Biggleswade, a rural village, in mid Bedfordshire. Biggleswade has good road access and there is a train station and a limited bus service. Potton House provides places for up to twenty-four older adults with mental health care needs and some physical problems. The home is single storey with accommodation separated into three wings. Each wing has eight bedrooms and its own living areas. There is also some additional communal space. The home has a large fenced garden and there is ample parking area at the front. All the beds at Potton House are block purchased by the Primary Care Trust. Potton House Nursing Home DS0000017688.V373556.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 stars. This means the people who use this service experience good quality outcomes. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which requires review of the key standards for the provision of a care home for older people that takes account of residents’ views and information received about the service since the last inspection. Sally Snelson undertook this inspection of Potton House. It was a key inspection, was unannounced, and took place from 09.45am on 22nd December 2008. Grace Makanda, the registered manager, was present throughout. Feedback was given throughout the inspection, and at the end. During the inspection the care of two people who use the service (residents) was case tracked in detail. This involved reading their records and comparing what was documented to what was provided. In addition to sampling files, people who lived at the home and staff were spoken to, and their opinions sought. Any comments received from staff or residents about their views of the home, plus all the information gathered on the day was used to form a judgement about the service. The inspector would like to thank all those involved in the inspection for their input and support. What the service does well: People proposing to use the service were provided with comprehensive information about Potton House. The manager understood the need to ensure that people could be cared for appropriately before they moved in and carried out thorough pre-admission assessments. All of the residents had care plans that detailed the care they needed and ensured that there was a consistent approach to providing their care. Potton House Nursing Home DS0000017688.V373556.R01.S.doc Version 5.2 Page 6 Staff worked well with outside health professionals and ensured that robust medication systems were in place. Activities were provided as people wanted them and staff were ‘allowed’ to spend time interacting with the people living at Potton House. Food was freshly cooked and people using the service were offered a choice at mealtimes. Hot and cold drinks and snacks were available throughout the day. A robust complaints procedure and staff awareness of safeguarding ensured people were kept safe at all times. The home was clean, tidy and nicely decorated. The communal areas of the home were warm and free of clutter, so as not to confuse those people with dementia. A variety of training was offered to all of staff to ensure that collectively, they had the skills and experience, to meet the needs of the people living at the home. Recruitment procedures were fully adhered to so that residents were protected. The manager was very experienced and had a clear understanding of the key principles and focus of the service and worked with the staff team to continually improve and evaluate the care that was provided. It is expected that if this is sustained it will become an excellent service. What has improved since the last inspection? The service had a new manager who had become the registered manager and had a wealth of experience working with older people, including those with mental health problems. The exact amount of medication, including variable dose prescriptions, given to people in this home, and any reasons for omissions were now clearly recorded. Different methods of offering service users with dementia a choice of meal had been considered and implemented. Potton House Nursing Home DS0000017688.V373556.R01.S.doc Version 5.2 Page 7 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. Potton House Nursing Home DS0000017688.V373556.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 Potton House Nursing Home DS0000017688.V373556.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): 1,2,3,4,6. People who use this service experience good quality outcomes in this area. The manager understood the need to ensure that people could be cared for appropriately at Potton House, before they move in. To this end she carried out a comprehensive assessment on all prospective residents to aid the decision process. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: As at the last inspection we noted that the ‘Statement of Purpose and Service User Guide documents have been reviewed and updated since the previous inspection, to reflect the present management of the home. Potton House Nursing Home DS0000017688.V373556.R01.S.doc Version 5.2 Page 10 The documents are displayed in the entrance to the home, and in individuals’ bedrooms, so that they are easily accessible to anyone entering the home. The Service User Guide is also impressively displayed in pictorial / sign format on laminates on the main notice board in the entrance hallway.’ This statement remains current. Each of the residents had a detailed contract that had been signed, usually on their behalf, and confirmed what was provided for them while residing at Potton House. We tracked the care of two people using the service as part of this inspection. One person had been admitted in the last six weeks. It was apparent that the manager had visited the resident and identified his needs before admission. Because of his risk of falls she had ordered a low bed and ensured that staff were familiar with the ways to identify, document and avoid possible risks. In addition to the managers assessment we saw information from other health professionals about this person’s needs and past medical history. The manager told of a recent assessment she had undertaken where it was necessary to refuse the admission as she considered the prospective residents needs could not be fully met at Potton House while ensuring the safety of the other residents. The staff team had the individual and collective skills to care for the residents. This will be discussed in detail in the staffing section of this report. At the time of the inspection the home did not provide an intermediate care service. Potton House Nursing Home DS0000017688.V373556.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 People who use this service experience good quality outcomes in this area. Care records were well written and ensured that staff had clear instructions as to how care should be provided. Medications records were fully completed and signed appropriately by staff. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Care plans had been written for all the activities of daily living. They were written in sufficient detail to ensure that staff had enough information about how to provide care. There was evidence that some of the relatives of the people using the service had been consulted about the plans. The care plans had been reviewed monthly and were updated as needs changed. Staff just needed to ensure that when they made changes to any documents they also altered any other documents that included the same information. It must be Potton House Nursing Home DS0000017688.V373556.R01.S.doc Version 5.2 Page 12 mentioned that the new manager had cleansed care files and ensured that wherever possible documentation was not duplicated. The manager had introduced a ‘whole staff’ approach to reviewing care plans as part of regular clinical meetings about individuals needs. The manager likened these meetings to a ‘ward round’, where the needs of each individual was discussed and the staff providing the care had the opportunity to update and challenge the care plans. All staff were to be offered the support to be part of the care planning process. Each care plan had any associated risk assessments and guides. For example we saw exactly how staff were to support a resident if he became agitated, aggressive or noisy. As a consequence staff provided a consistent approach to delivering care. The risk assessments also resulted in appropriate equipment being sought for people, such as pressure relieving mattresses and hoists. During the inspection we witnessed staff moving and handling people correctly and using the correct equipment to do so. We discussed with the manager the need to ensure that fluid charts were added up daily, so that it was clear that if a persons fluid intake/output was being monitored exactly what the amounts were taken in and passed out. This discussion resulted in it becoming apparent that fluid charts were not currently necessary for all the people who were using them. Since the last inspection there had been few admissions to the home and as a result the people using the service had become frailer, and had more physical needs. Staff were appropriately seeking the advice and support of other health professionals and making regular assessments to ensure needs were continually met and that any need for extra resources or equipment was identified. We noted that one resident who had shown signs of developing a pressure sore had been provided with the appropriate pressure relieving mattress and plan of care, to arrest this development. Chiropodists and opticians were regular visitors to the home. We checked the Medication Administration Record (MAR) sheets for the two residents we case tracked. Medications were appropriately stored in a locked trolley that was secured to the wall in a locked room. Monthly deliveries had been appropriately signed in and as a consequence it was possible to reconcile all of the medications (whether provided in a blister pack or not) for both people. We were pleased to see that staff used omission codes correctly and recorded the reason for any omissions on the reverse of the MAR chart. Controlled drugs (CD’s) were stored appropriately and all administrations had been recorded accurately with two signatures in the CD register. Throughout the inspection we saw resident’s being treated with respect and dignity at all times. Potton House Nursing Home DS0000017688.V373556.R01.S.doc Version 5.2 Page 13 End of life plans had been completed and included information about end of life wishes and relatives preferred time of contact in an emergency. We did not see supporting capacity documentation with the decisions for end of life care made by some relatives in respect of their loved ones. Any documentation of this type must conform to the Mental Capacity Act. At the last inspection we reported that ‘The Liverpool Care Pathway (LCP) was being used correctly to the benefit of a resident at the end of their life. Staff had been trained by the local PCT to use the LCP, which allows all those involved with a resident to plan the end stage of the residents’ life, and focuses on the physical, psychological and spiritual care of the resident’. Potton House Nursing Home DS0000017688.V373556.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People who use this service experience good quality outcomes in this area. Staff encouraged and supported socialisation by interacting appropriately with the residents. An activity co-ordination arranged a programme of activities that were flexible to the moods of the residents. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: An activity co-ordinator was employed to organise the activities but not to necessarily provide them all. The manager encouraged the care staff to participate in activities and to spend time with the people using the service. There was a plan of different activities including entertainers and trips out, but on the whole activities were arranged according to peoples moods and were arranged as people wanted them. We saw staff spending time with the residents that were in the communal areas but, on the day, we were unsure how much stimulation was provided for those people who spent time in their own bedrooms. Following an activity it was recorded in the activity plan that the resident had participated in the activity and how they had reacted to it. Potton House Nursing Home DS0000017688.V373556.R01.S.doc Version 5.2 Page 15 The home had built some links with the local community, and a choral society had provided a concert for Christmas. Visitors were encouraged to the home. The cook told us they were expecting one resident to have visitors for lunch on Christmas day and one to spend the day with family. On the day of the inspection residents were offered the choice of pork casserole or beef and onion pie. Both meals were served with a selection of freshly prepared vegetables and followed by apple sponge and custard. The manager told us that they had explored a variety of ways to offer residents choices at mealtimes. Photo cards were used for those people with communication problems, but the cook told us she knew what people liked and disliked and would keep offering alternatives if people did not appear to want their meal. The home employed two cooks who worked to cover seven days a week. They told us that ordered meat and vegetables locally and had the equipment to prepare the necessary food, including providing special diets and cake for midafternoon tea. They did tell us that their hot locker was 15 years old and the door was difficult to close. Potton House Nursing Home DS0000017688.V373556.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People who use this service experience good quality outcomes in this area. A robust complaints procedure and staff awareness of safeguarding ensured people were kept safe at all times. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: This homes’ complaints policy was displayed in the reception area and was easily accessible to residents and visitors to the home. It confirmed the expected timescales for responses, and advised people of the process if they were dissatisfied with the outcome. Staff were aware of the complaints policy and how they should respond if the manager was, and was not, available to take the complaints personally. There had been one complaint made to the home since the last inspection. The manager showed us the record she had made of the investigation process and how she had responded to the complainant. We were shown a training matrix that confirmed that all the staff had undertaken some training around safeguarding vulnerable adults (SOVA). A possible safeguarding scenario was given to the manager and to two other Potton House Nursing Home DS0000017688.V373556.R01.S.doc Version 5.2 Page 17 members of the care staff. All were able to correctly answer how they would respond to the situation. The manager had made a referral to the SOVA team as the result of a member of staff sharing concerns about the care practices of another member of staff. The information had resulted in a suspension for the alleged perpetrator and an investigation by the police on behalf of the multi-agency SOVA team. The incident had been satisfactorily concluded. Potton House Nursing Home DS0000017688.V373556.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, 23, 26 People who use this service experience good quality outcomes in this area. A continual programme of refurbishment had resulted in the home being a suitable and homely environment for people to live in. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home was clean, tidy and nicely decorated. The manager told us that relatives always praised the environment. The communal areas of the home were warm and free of clutter, so as not to confuse those people with dementia. The communal areas of the home were decorated in neutral colours with minimal photographs on the wall. These Potton House Nursing Home DS0000017688.V373556.R01.S.doc Version 5.2 Page 19 rooms had been tastefully decorated for Christmas with Christmas trees and Christmas ornaments. The home was designed for 24 residents, but at the time of the inspection there were only 14 people living there. The manager had plans for using the different wings of the home for people with different needs if more residents were admitted. During the inspection the handyman was upgrading the staff toilet and cloakroom. The handyman was also responsible for ensuring the building complied with fire regulations. Individual rooms had been decorated and furnished to meet with personal tastes. Photographs and ornaments on display in some of the rooms clearly reflected the family and personal history of the residents. The manager told us that she would ask the relatives of any new residents what colour they would like their bedroom to be decorated in before they were admitted. The home was all on one level and situated in well-tendered secure gardens that were enjoyed by residents and visitors when the weather allowed. There were plans to create a sensory garden for the home. A team of ancillary staff ensured that the home was kept clean and that laundry was kept up-to-date. People using the service were wearing their own clothes and looked neat and tidy. Potton House Nursing Home DS0000017688.V373556.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People who use this service experience good quality outcomes in this area. A variety of training was offered to all of staff to ensure that collectively, they had the skills and experience, to meet the needs of the people living at the home. Recruitment procedures were fully adhered to so that residents were protected. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home had entered a contractual agreement with the Primary Care Trust (PCT) who blocked book all the beds, that a registered general nurse and a mental health nurse would be on duty at all times. This had proved difficult on five occasions since the last inspection; we had been notified about these occasions, including the steps that had been taken to find the correct staff team and the way the problem had been managed. As a result of the staff problems, and because of the changing needs of the residents, management had consulted with the PCT and were hoping to lift this restriction. We felt confident that with the manager, who is dually quailed in general and mental health nursing, would be able to support qualified staff appropriately. All of the staff were working towards a NVQ level 2 or 3 qualification. Staff were confident and competent in their roles, and were able to talk in depth Potton House Nursing Home DS0000017688.V373556.R01.S.doc Version 5.2 Page 21 about individual residents needs and the care that they required. Training records indicated that staff attended a variety of mandatory and specialist training, which the manager ensured was kept updated. The manager had developed a training matrix that identified what training staff had undertaken and when training needed to be updated. The manager had recruited additional staff and was keen to offer staff flexibility and part-time contracts in order to persuade them to work at Potton House. The need to use agency staff was decreasing. We examined the personal files of two new members of staff. Both contained fully completed application forms, appropriate references, induction checklists and training records and certificates. Criminal Record Bureau (CRB) checks had been carried out on all staff, and home office paperwork was present where required. One of the new recruits had started with a pova first check before her Criminal Record Bureau had been returned. This person had been supervised at all times during that period. Potton House Nursing Home DS0000017688.V373556.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): 31,33,35,36,37,38 People who use this service experience good quality outcomes in this area. The manager had a clear understanding of the key principles and focus of the service and worked with the staff team to continually improve and evaluate the care that was provided. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager was appointed to the position in June 2008 and had successfully completed our registration process to become the registered manager. She was a registered nurse with a mental health qualification and many years Potton House Nursing Home DS0000017688.V373556.R01.S.doc Version 5.2 Page 23 experience working with older people at a management level. One member of staff said, “we have got a good manager, she has done nothing but good”, another said, “she is always polite, always kind and has been able to change the mind set of some staff”. As soon as the manager had been appointed she had produced an action plan for herself, which she shared with us. She had been able to achieve her plan in the timescale she gave herself and had made all the initial improvements she had planned. There were regular staff and relative meeting held, and these were documented. It was apparent that issues raised and discussed were acted upon to inform and improve the service. The area manager visited monthly and produced a comprehensive report of her visit and the manager audited procedures between times. Stakeholders were regularly asked for their opinions of the service. At the last inspection we reported ‘the personal expenditure accounts are managed by the company’s head office on the computer system. A small amount of petty cash is accessible seven days a week, however for larger amounts, it is only accessible Monday to Friday. The area manager is going to address this by displaying ‘banking hours’ and increasing the present petty cash facility’. Since then residents and/or their families had been made aware of when larger amounts of money were available and the petty cash had increased to £250.00. It was possible to check the balance of any residents account during the inspection. Staff supervision documentation was provided. The manager ensured that all staff, including the ancillary staff, were supervised and that everyone was on track to have had the required six sessions in 12 months. The manager had devolved some of the supervision to senior staff to achieve this. On the whole records were well kept. All staff needs to be vigilant that they record any changes in all the documentation in a timely way. We looked at health and safety documentation, including the fire log and maintenance book. There was evidence to indicate that fire call points and the emergency lighting were being tested on a regular basis, and that fire drills were carried out periodically. Maintenance issues and redecorations were being addressed in a timely fashion. Potton House Nursing Home DS0000017688.V373556.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 4 3 3 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 4 4 X X X 3 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 2 3 Potton House Nursing Home DS0000017688.V373556.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 2 3 Refer to Standard OP11 OP15 OP37 Good Practice Recommendations Any end of life directives/ decisions must conform to the Mental Capacity Act. Consideration should be given to replacing the ‘hot lock’ that was 15 years old, and the door was difficult to close. Staff should take care to record accurately and ensure that any changes in care are recorded in all areas of the care plan. Potton House Nursing Home DS0000017688.V373556.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Potton House Nursing Home DS0000017688.V373556.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!