Care Home: Rectory House Nursing Home

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What has improved since the last inspection? Improvements have been made to the assessment and care planning process and care plans are now comprehensive, have clear instructions for the staff team to follow and daily records and nutrition and fluid charts are current and in good order. People have improved standards of care and this includes pressure area care with good equipment in place and clear monitoring and recording procedures being followed. Risk assessments are in place and people have the equipment and support they need to keep them safe. There has been an increased programme of activities and outings and people have a choice of fresh, home cooked meals with the support they need at meal times. There have been major changes to the quality of the environment, with redecoration, new furniture and carpets and the addition of a large specialist bathroom. Complaints and concerns are recorded and acted upon and the staff team have an awareness of safeguarding people from risk of abuse or harm. There are robust recruitment processes in place and the staff team have the support, training and monitoring they need to make then effective and efficient.Rectory House Nursing HomeDS0000052037.V375665.R01.S.doc Version 5.2 Page 7The new manager ensures that the home`s records are current and in good order, that Service Users and families have the opportunity to give feedback on the services being provided and health and safety issues are now being identified and addressed. There have been improved monitoring systems put in place by the Registered Providers. What the care home could do better: The home should continue to build on the large number of improvements made since the last inspection visit. In light of feedback from Service Users and some staff members, consideration should be given to reviewing the staffing numbers at peak times and to further discussing with Service Users the choice of menus and the number of outings on offer. Key inspection report CARE HOMES FOR OLDER PEOPLE Rectory House Nursing Home West Street Sompting West Sussex BN15 0DA Lead Inspector Annie Taggart Key Unannounced Inspection 1st June 2009 12:12 DS0000052037.V375665.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Rectory House Nursing Home Address West Street Sompting West Sussex BN15 0DA 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) 01903 750026 01903 751921 rectory@caringhomes.org Rectory House (Sompting) Ltd Manager post vacant Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - N to service users of the following gender: Either whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category - OP The maximum number of service users who can be accommodated is: 48 1st December 2008 Date of last inspection Brief Description of the Service: Rectory House is a care establishment registered to provide nursing care for forty-eight service users. The home is a detached property arranged on three floors and situated in Sompting village within easy travelling distance of Lancing and Worthing town centres with their shops and other amenities. The accommodation includes two lounge/dining room areas, one on the ground and another on the first floor. Building work has been completed to increase the number of bedrooms and communal space. There are thirty-eight single and five double rooms. There is a large garden to the front, side and rear of the house. Car parking is available at the front. The fees are currently between £565 and £900 per week. Rectory House Nursing Home DS0000052037.V375665.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 two star. This means the people who use this service experience Good quality outcomes. In preparation for this visit we looked at the last inspection report and the reports from two Random visits carried out since the last key inspection. An Annual Quality Assurance Assessment (AQAA) was sent to the manager for completion; this was returned in the given timescales and gave very comprehensive information about the services being offered in the home. Ten Service User and four staff surveys were returned and all made positive comments about the care being provided. The unannounced inspection visit was carried out by Annie Taggart at 10.30am on 1st June 2009 and the visit lasted for four and a half hours. During the visit we tracked the care plans and all supporting documentation such as daily records for four of the service users currently living in the home and we looked at the system for administering and recording medication. We looked at evidence of activities and outings for people and saw menus and food records. Records for the running of the business including complaints, incidents and accidents, Regulation 26, Registered Provider’s visits and Regulation 37 reports, maintenance and fire records were also seen. The recruitment records for four new members of staff were tracked and all of the required documentation was in place. We spent time with the service users currently living in the home, either in their private bedrooms or in communal areas and they were very positive about the changes in the home. We also spoke to the staff on duty and a family member who was visiting their relative. The Registered Manager was not in the home but the Operations Director (South) Julie Mason came into the home for part of the visit and for feedback and feedback was also given to the deputy manager. Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 6 What the service does well: Rectory House is providing good quality care to the people who live there. People have their needs and wishes assessed and recorded in a comprehensive plan of care that is kept under regular review. There are a range of activities and outings on offer and people have a choice of fresh home cooked meals. The home is working well with other professionals and people are receiving good physical and mental healthcare support. Service Users and family members tell us that the staff team are very competent, kind and caring and that the home is being well managed by the new manager. What has improved since the last inspection? Improvements have been made to the assessment and care planning process and care plans are now comprehensive, have clear instructions for the staff team to follow and daily records and nutrition and fluid charts are current and in good order. People have improved standards of care and this includes pressure area care with good equipment in place and clear monitoring and recording procedures being followed. Risk assessments are in place and people have the equipment and support they need to keep them safe. There has been an increased programme of activities and outings and people have a choice of fresh, home cooked meals with the support they need at meal times. There have been major changes to the quality of the environment, with redecoration, new furniture and carpets and the addition of a large specialist bathroom. Complaints and concerns are recorded and acted upon and the staff team have an awareness of safeguarding people from risk of abuse or harm. There are robust recruitment processes in place and the staff team have the support, training and monitoring they need to make then effective and efficient. Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 7 The new manager ensures that the home’s records are current and in good order, that Service Users and families have the opportunity to give feedback on the services being provided and health and safety issues are now being identified and addressed. There have been improved monitoring systems put in place by the Registered Providers. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Rectory House Nursing Home DS0000052037.V375665.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 Rectory House Nursing Home DS0000052037.V375665.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 3 5 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective Service Users and their families have the information they need about the services on offer in the home, people have their needs and wishes assessed and recorded and can make visits to the home and contracts of terms and conditions of residency are agreed. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place and both documents have been recently reviewed and updated. Each person living in the home has a copy of the guides and other information about the services on offer in their private bedrooms. From following records and speaking to a family member we saw that there is a clear and comprehensive process in place for people being assessed and admitted to the home. From looking at the records of one recently admitted Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 10 person we saw that a detailed assessment of need was carried out and recorded and this included a past life history and addressed the person’s physical, emotional and social needs and wishes. There was evidence that the Service User, their family and other professionals were in involved in the process. Contracts of terms and conditions of residency are agreed and the samples that we saw had been signed by the Service User of their representative. Rectory House does not provide intermediate care. Rectory House Nursing Home DS0000052037.V375665.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is clear and current information in care plans to guide the staff team to the needs and wishes of the people they are supporting. The home works well with other healthcare professionals and medication is being well managed. EVIDENCE: For each person living in the home there is a clear and detailed plan of care in place that guides the staff team to the individual needs and wishes of the people they are supporting. Care plans covered areas such as personal care preferences, physical and mental healthcare needs, nutritional assessments, risk assessments, pressure area care, medication management and end of life care. We tracked the care plans for four people and saw that they also contained a life history that had been compiled with information from Service Users and their families, the plans had recently been reviewed and updated and the staff on duty showed a good knowledge of the people they were supporting. Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 12 Where people were being cared for in bed we saw that there were clear guidelines in place for the use of pressure relieving equipment such as the settings for pressure mattresses and the home carries out a monthly wound care and body chart monitoring process that is audited by the Area Manager. Signed agreements are in place for the use of photographs of pressure wounds and for the use of bed rails. Risk assessments are in place for people who have poor mobility and we saw that several people had fall alert pads in place on the floor of their bedrooms, people also had call bells in place and where they had difficulty using them, regular staff checks were recorded. From looking at records we saw that the home is working with a variety of healthcare professionals and this included local surgeries, mental healthcare teams and the local Palliative Care team. All records of outcomes of doctors visits and visits from other professionals are recorded and we saw that they are then passed on to the staff team at shift handovers and outcomes are recorded in daily records. We saw that a clear and concise nutritional screening tool is in use and where people are being cared for in bed there are charts in place for food and fluid intake and also for when people are turned and offered care. In all of the bedrooms that we visited the charts were current, they had been signed and contained clear information. A family member visiting the home at the time of the inspection visit told us, ‘ when my relative came here from hospital we thought that they were at the end of their life but the staff here have been wonderful, attentive and very caring, they have managed to clear up his pressure areas, which was very difficult and he is now much better’. The home has clear policies and procedures in place for the management of medication, only trained nurses administer medication and we saw that there was a current list of medication handlers in the file. We looked at the system for recording and administering medication and saw that this was well managed with Medication Recording Sheets (MAR) being current with no gaps in signing. We also checked on the management of three controlled medications and found these to be current and in good order. Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are offered and range of activities and outings, they can see their families and friends at any time and they have a choice of fresh, home cooked meals. EVIDENCE: In order to offer the people living in the home stimulation and interest, there are a range of activities and outings on offer. Each person has an individual pictorial record of the activities they enjoy in their rooms and we saw that this included arts and crafts sessions, music and exercise, bingo, games and quizzes, cooking and make up and beauty. The activities person told us that there are now two other people who come to the home to assist with activities two days a week and a driver takes people for outings every other week. From talking to Service Users we found that they enjoy the outings, for example shopping and to garden centres for tea and they said that they would like this to happen more often. People said that they had especially enjoyed a recent visit from a birds of prey sanctuary, when they told us they were able to hold the birds. Where people are being cared for in bed, one to one sessions are Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 14 carried out and this might include hand massage, reading the newspaper or just sitting and spending time with people. We saw that a weekly programme of activities is given to each person and that social occasions, church services and outing are discussed at resident’s meetings. For one person the home had contacted a speech and language therapist who had helped to compile a communication booklet. When another person with speech difficulties had been admitted to the home the activities person copied the pictorial communication book to see if it would help also this person to communicate and we saw that this was very successful. A visitor to the home told us that they can visit at any time; they said that they were made welcome and were contacted if there was any concern about their relative. Menus and food records showed us that people are offered a range of fresh, home cooked meals including a cooked breakfast and that specialist diets are catered for. We saw lunch, the main meal of the day being prepared and served and it was freshly cooked, looked nutritious and was attractively served. There was also a large home baked cake being made for tea and we were told that this happened every day. People told us that there was always a choice available , one person said, ‘I told the cook that I liked pilchards and salad for lunch and it is always freshly made for me and I also have a fresh fruit basket with strawberries, kiwi fruit, grapes and bananas’. Two people told us that they would like more variety in sweets and vegetables but said that they were consulted by the cook and the staff on their choices of meals. Where people are receiving their meals and nutritional supplements in bed, there are clear records in place, an example of this was that after lunch one staff member had written, ‘ate only five to six spoonfuls of lunch but all of a bowl of pudding’. As it was a hot day we saw the staff on duty regularly offer cool drinks to people and this was being recorded. Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints and concerns are recorded and acted upon and the staff team receive training in protecting Service Users form risk of abuse or harm. EVIDENCE: There is a clear complaints procedure in place, a copy of which forms part of the Service User Guide and is also displayed in the home. We looked at the complaints book and saw that complaints are recorded and acted upon within the home’s given timescales and the outcomes fed back to complainants. There is also a monthly audit of complaints and concerns carried out by the Area Manager. Service Users and a family member told us that they would feel confident in making a complaint and said that they thought that it would be taken seriously and acted upon. From looking at staff training records we saw that the staff team attend training in protecting people from risk of abuse or harm and six of the staff on duty that we asked were aware of their responsibilities and told us that they would report any suspected abuse straight away. Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 16 In the AQAA we are told that there have been two Safeguarding referrals made and investigated by West Sussex Safeguarding team. One has been resolved with no further action and one is still to be completed. Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 21 22 24 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home offers a comfortable homely and attractive environment, people have the aids and adaptations they need and infection control issues are addressed EVIDENCE: There has recently been a programme of refurbishment and redecoration carried out in the home and this has included communal lounges being redecorated with new furniture, new carpets fitted to communal areas and some bedrooms, the addition of a large specialist bathroom and the purchase of new pressure relieving equipment. The environment was bright, airy and attractive with many the bedrooms overlooking the communal gardens and Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 18 sensory garden and people had personalised their private bedrooms with their own belongings and sometimes with their own furniture. People have the aids and adaptations they need to support their independence and care and this includes accessible bathrooms and showers, pressure relieving beds, fall alert pads and hoists and care plans are clear and guide the staff team to the use of equipment for each person. On the ground floor there is a large conservatory type family lounge and an activities area. We are told that the activities area is to be turned into an accessible hairdressing room and a larger dining room that will be easier for people to access with the activities room moved to a quieter area. From looking at records we saw that regular maintenance is carried out and this included water temperature checks, fire safety checks and staff fire training. We also saw that environmental and health and safety spot checks form part of the monthly audit of the home by the Registered Providers. Service Users told us that they were very pleased with the improvements to the environment and we saw that the home was clean and hygienic throughout, with protective aprons and gloves in use by the staff on duty and antiseptic hand gels and hand washes located in each room. Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in the home are supported by a well trained and competent staff team and recruitment practices are designed to protect people from risk of abuse or harm EVIDENCE: From looking staff records we saw that the staff on duty reflected the rota. For the thirty five people in residence on the day of the visit there were two Registered Nurses, six carers, and six ancillary staff on duty on the early shift and there is one trained nurse and two carers at night. The manager, who was not in the home at the time of the visit, is extra to the staffing rota and the home was being managed by an experienced deputy who is also a Registered Nurse. We looked at the records for four members of staff and found them to be complete with all of the required documentation in place including a current Criminal Bureau Check (CRB) and two references. New staff undertake an inhouse induction and then complete a formal induction in line with the Common Induction Standards and they sign up to the General Social Care Council code Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 20 of practice, During this time new staff complete mandatory training such as moving and handling, first aid and health and safety awareness. From looking at training records and talking to the staff on duty we saw that there is a programme of training in place and people attend courses such as dementia awareness, customer care and safeguarding people from risk of abuse. In the AQAA we are told that 80 of the staff team have the NVQ award at Level 2 and that three people have begun level three. Service Users and a family member were very complimentary about the staff team describing them as ‘very kind and patient’, ‘friendly and polite’ and ‘really helpful’. In three returned surveys and from four people during the day we heard that although the staff are very kind, people feel they sometimes have to wait a long time to get up in the morning as the staff are always so busy. Four returned staff surveys also said that higher staffing levels would be beneficial to Service Users. From looking at staffing records we saw that staff meetings are held and that regular supervision and support sessions are recorded. Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 36 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is being well managed and is monitored by the Providers. There are processes in place for service users and their families to give feedback on the service being provided and health and safety issues are being addressed EVIDENCE: The manager of the home is a Registered Nurse with many years experience of managing care homes and she also hold the Registered Manager’s Award. We are told that the manager is undergoing the interview to be registered with the Commission on Wednesday 3rd June 2009. Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 22 Service Users, the staff on duty and a family member were very complimentary about the new manager describing her as ‘very open and accessible’, ‘has made lots of positive changes to the home’ and ‘completely on the ball and aware of everything that is going on and she works on the floor to monitor the practice of the staff team’. Service Users told us that the manager came round to see them on most days to ask how they were and if they were satisfied and we saw that the manager had also facilitated the latest resident meetings. There is a quality assurance process in place and we saw evidence that surveys have been recently sent to service users, families and other people involved with the home. From looking at the results of last year’s process we saw that outcomes are collated and used to inform the future development of the home. Processes are in place for the management of service user’s monies, with all transactions being recorded and receipts sent to families or legal representatives. We checked the records against cash for three people and found them to be correct. We looked at evidence of Regulation 26, Provider’s visits and saw that there is a comprehensive system in place to monitor the home. The manager of the home produces, weekly and monthly ‘ Clinical Governance’ reports regarding the running of the home and this includes, monitoring accidents and incidents, the number of people with pressure wounds, Regulation 37 reports and any complaints or concerns. Monthly visits are then carried out by the Area Manager where spot checks are made on all standards of care in the home and a report is then completed. The samples that we saw were very detailed with an action plan produced to address areas of improvement. From looking at records and observation on the day of the visit we saw that the home is well maintained, that fire training is up to date, the staff team receive regular supervision and support and health and safety issues are identified and addressed. Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A 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 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 24 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. Refer to Standard Good Practice Recommendations Rectory House Nursing Home DS0000052037.V375665.R01.S.doc Version 5.2 Page 25 Care Quality Commission North West PO BOX 1255 Newcastle upon Tyne NE99 5AF National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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