Care Home: Redcot

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What the care home does well The home continues to provide a good service to the residents living at the home. Contact with family and friends are encouraged and residents are able to entertain their visitors in the privacy of their bedroom if they so wish. The manager complies with given requirements under the Care Homes Regulations 2001 within the given timescales. The documentation of individual care plans is easy to read, gives the reader a full picture of the residents` likes and dislikes, communication needs and risk assessments and care needs. Observations of care staff interaction with residents indicated that residents are treated with dignity and respect. It was also observed that great care was taken in respect of the residents` personal belongings and standard of cleanliness in bedrooms ensured residents lived in a well-maintained environment. The home has demonstrated its preparation to cater for residents from ethnic minority by ensuring each member of staff gets the opportunity to attend the Equality and Diversity course when it is commenced at the home. What has improved since the last inspection? All requirements issued on the last inspection have been actioned within the given timescales The home continues to be proactive in meeting the training needs of the care workers in order that seamless care can be offered to the residents. The home continues to refurbish bedrooms and replace worn carpets as per their annual refurbishment plan. The home has developed a Re admission assessment form which they use when a resident has been discharged from hospital back into the home. We were told that this reassessment would enable the carers to give up to date care to the residents. What the care home could do better: The home continues to offer a good standard of care to the residents. The reviewed care plans contained a heading "Nursing Actions". A recommendation of good practice was made to change this to "Care Actions" as this home does not provide nursing care. CARE HOMES FOR OLDER PEOPLE Redcot Redcot Three Gates Lane Haslemere Surrey GU27 2LL Lead Inspector Mavis Clahar Unannounced Inspection 23rd October 2007 09:25 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 Redcot DS0000013756.V347097.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. Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Redcot Address Redcot Three Gates Lane Haslemere Surrey GU27 2LL 01428 644637 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) www.fote.org.uk Friends of the Elderly ****Post Vacant**** Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th September 2006 Brief Description of the Service: Redcot is situated in a rural location a short distance from Haslemere town, which offers a good range of small shops a library and a museum. Redcot is a large detached property set in its own substantial grounds. There are limited parking facilities at the front and at the side of the building. Service users’ bedrooms are provided at ground, first and second floor levels and all have en-suite facilities. The home has a wide variety of communal spaces including outdoor areas to enjoy views across to the South Downs. The home has a terrace with plenty of seating and shade from the sun and very extensive landscaped gardens designed by Gertrude Jekyll. Fees range from £535 - £680 per week. This fee does not include newspapers, hairdressing, chiropody, transport, and personal physiotherapy or arranged outings. Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit, which forms part of the key inspection undertaken by the Commission for Social Care Inspection, (CSCI) was completed by Mrs Mavis Clahar on 23rd October 2007 and lasted for six hours and twenty minutes, commencing at 09:40 hours and concluding at 14:50 hours. Both the new manager of the home and the deputy manager assisted in the inspection. The new manager has only been in post three weeks on the day of the visit. The first part of the visit was spent with the new manager and deputy manager of the home, discussing and agreeing how the inspection process would be conducted. This was followed by discussion about the Annual Quality Assurance Assessment (AQAA) she submitted to CSCI, the training needs of the care workers and how these needs were being identified and met, and employment and induction of new care staff. A review of the requirements given at the last inspection was undertaken and these were all completed within the agreed time scale. A review of residents’ files and care workers records was undertaken and all found to be in good order. The second part of the visit was spent reviewing selected residents care plans, which were up to date and sampling selected policies and procedures. It was noted that care plans contained “Nursing Actions” as a heading and a recommendation of good practice was made to change this to “Care Actions”. The information contained in this report is gathered from residents’ notes and records kept by the home, from information contained in the AQAA, from relatives and residents feedback in the pre inspection questionnaires and from discussions with residents. Information was also gathered from direct observation by the inspector, along with discussions with care workers. The third part of the inspection was spent visiting and discussing with residents and observing lunchtime activities. Residents were enthusiastic about their home and the service they receive. Residents spoken to said they enjoyed their lunch, which was prepared freshly in the home’s kitchen. Time was spent observing the presentation of the meal, care workers and residents’ interactions and to obtain feedback on the meal, its suitability, taste, texture and amount. The inspector observed that portions were varied to suit the appetite of the residents and that they all ate their meal in a very social gathering, all sitting at tables which were laid for four, with a small vase of flowers and condiments. Residents commented positively on their meal, and the food served at the home in general. A tour of the home was undertaken and it was observed that residents’ bedrooms were kept in very good condition, both decorative and clean and Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 6 tidy. The bedrooms are attractively presented. Generally, the home presents as clean and tidy. The inspector would like to thank all the residents and care staff who made the visit so productive and pleasant on the day. The final part of the visit was spent giving feedback to the manager and deputy manager about the findings of the visit. What the service does well: What has improved since the last inspection? All requirements issued on the last inspection have been actioned within the given timescales The home continues to be proactive in meeting the training needs of the care workers in order that seamless care can be offered to the residents. The home continues to refurbish bedrooms and replace worn carpets as per their annual refurbishment plan. The home has developed a Re admission assessment form which they use when a resident has been discharged from hospital back into the home. We Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 7 were told that this reassessment would enable the carers to give up to date care to the residents. 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. Redcot DS0000013756.V347097.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 Redcot DS0000013756.V347097.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): 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users and their relatives have the information needed to choose a home, which will meet their needs. EVIDENCE: A selection of service users files were reviewed and it was noted that residents received a needs assessment prior to moving into the home to ensure the home is able to meet the identified needs of the prospective resident. Furthermore, the first four weeks is used as a trial period for both new resident and the older residents, to ensure the new resident is comfortable on all counts in the home. It was also noted that residents are given a contract of residency, and this contract is signed either by the resident or their representative. Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 10 This was verified in discussion with the residents. The manager told us that a more comprehensive assessment as reviewed in resident’s file is obtained, once the resident has settled in the home. The manager, who is skilled in the art of assessing residents care needs usually, carries out this assessment. Standard 6 does not apply to this home. Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good and clear care plan in place for residents, which also includes appropriate risks assessments. This forms the basis for care based on the agreed care needs of the service users and demonstrated that health and personal care needs were met. Care staff receives training to meet the assessed care needs of the residents ensuring that competent staff supports residents and their health and care needs are met. The home’s medication policy on receiving, storing and administering and return of medication was in place and being adhered to thereby ensuring the safety and protection of the residents. Residents are treated with respect and are encouraged to maintain their dignity and privacy when receiving personal care. Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 12 EVIDENCE: The randomly selected care plans were clear and easy to read, identifying potential and actual risks to residents with risk assessments completed as required. It was stated in the Annual Quality Assurance Assessment (AQAA) that care plans are reviewed on a regular basis and residents and or their families’ sign the care plans to demonstrate their participation and agreement with the plan of care. This was supported by the review of the care plans, in discussion with care workers and with the deputy manager. Review of the daily work sheet along with discussion with residents demonstrated that residents’ care needs are fully met. Care Plans reviewed demonstrated that residents care needs are identified and are being met. Residents spoken to, rated the personal care they receive at the home as very good; they said they were contented, they had contact with their General Practitioner (GP) once a fortnight and more often if required. They also have the District Nurses come to see them and the chiropodist on a regular basis. Opticians and Dental care are also available for them to use in the home or for those who wish still keep their own Optician and Dentist. A number of residents at the time of inspection were responsible for his or her medication; and the manager produced a sample of risk assessment for residents who wish to self-administer. It was noted that both the resident and their General Practitioner signed these risk assessments. The manager told us that any resident who wish to self-administer their medication can change their mind at any time and the staff will administer their medication to them. Good clear records are kept of medication receipts, storage, and administration and returned. There is a list of staff trained and assessed as competent to administer medication and this is kept on the medication trolley at the front of the medication charts. In discussion with care workers assessed as competent to administer medication it was evident they were working within the home’s policy and procedure on administration of medicines, which include using the Medication Administration Record (MAR) Sheet Residents said the staff treated them very well. One resident said, “the staff are so kind. They will come to you at the drop of a hat”. Care workers were observed interacting with residents in a friendly but respectful manner. One resident told us they go out at least three times per week either using a taxi or the bus on Fridays or their relative collects them and bring them back. Residents told us about the new computer room opened for their use and that they are now able to keep in touch with their families by emails. Some residents also told us they were not really interested in this new technology and so they do not book themselves on to the course. Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 13 Redcot DS0000013756.V347097.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. This judgement has been made using available evidence including a visit to this service. Service users lifestyles matched their needs and preferences and where possible they are able to maintain contact with family, friends and the local community. Service users are able to make choices in accordance with their abilities and were provided with a balanced diet in pleasant surroundings and in an unhurried way. EVIDENCE: Residents spoken to say they were able to go to bed and get up when they choose, take part in activities as they wished and consulted on how they would like to spend their time. This statement was supported by the deputy manager in discussion and from comments made to us in the pre Inspection Questionnaires residents completed prior to the inspection of the home. The Annual Quality Assurance Assessment (AQAA) stated “Social activities are ongoing and for the past fifteen months we have had an Activities Co-ordinator working twenty four hours per week. Having initially ascertained the interests Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 15 and preferences of male and female residents, an extensive programme of regular weekly activities of broad appeal (topical quizzes and competitions and games for mental stimulation, billiards, garden games for gentle exercise.” During the tour of the home we were shown the computer room, the wide screen ‘cinema’ for film shows. Random review of residents’ activities records supported these statements and also revealed other outings undertaken by residents on a regular basis. The home has its own Chapel that is intra-denominational and both the C/E Vicar and the R/C Priest hold religious services there on a fortnightly basis for the Residents and staff are welcome to join in the service. We found the chapel very peaceful and restive and one care worker told us she often spends part of her break in the Chapel for the peace she feels after being in there. We were told Residents who wish to continue to worship at their previous place of worship are encouraged and enabled to do so and Residents who are not of the Christian faith are provided with opportunities to practice their faith both inside and outside of the home. Pre inspection questionnaire received by CSCI indicated that both residents and relatives are contented with the care offered by the home. No visitor to the home on the day of the inspection wished to speak with the Inspector. Residents said their relatives and friends are able to visit when they wished, and the number of visitors to the home evidenced this on the day of the inspection as seen in the visitors’ book. They further told us they are treated with respect and they have their privacy respected and maintained at all times. One resident wrote, “I was aware of Redcot’s excellent reputation many years before I thought about coming here. It has lived up to its reputation”. In discussion with residents Ten in total, it was abundantly clear that these residents were involved in the running of the home, they had choices which they exercised, they were highly motivated and were in control of their lives. We randomly chose these residents on the day of the visit. On the day of inspection residents were observed enjoying their food. The menu is four weeks rotating, and review of residents’ personal folders revealed monthly nutrition screening is carried out with appropriate actions taken. Catering facilities are managed and carried out by a private company. In discussion with residents we were told that since the change over to the new company the food is much better, and in discussion with the Chef, it was apparent she had a good knowledge of the dietary needs of the residents. The inspector did not sample the meals, but the residents spoken to all said the food is good, the texture just right and the amount was what they ordered. We noted that the vegetables were served in covered dishes, which helped to keep them hot, and residents were able to help themselves. We also noted that residents were offered second helpings and that helpings were served in portions requested by the residents. Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 16 Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints policy and procedure and training in place that evidenced that residents and relatives concerns are listened to and acted upon. Robust Safeguarding adults’ policies are in place to protect the service users from abuse. EVIDENCE: The home has a complaint policy, which outlines the processes the home undertakes to respond to complaints received. There was no complaint logged in the complaints book since the last key inspection. CSCI have not received any complaints about the home. The deputy manager told us issues raised are dealt with instantly before they spiral into a complaint Both residents and their relatives in their reply to the complaints question in the pre inspection questionnaire said they knew how to complain but have not had any reason to do so. There are a number of thank you notes and letters of appreciation from grateful relatives to the whole staff team praising their work with their relatives. Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 18 All staff as evidenced in the training record and substantiated in discussion with care staff, have completed the Safeguarding Adults Course which is based on the local authority (Surrey multi-agency Policy). In discussion with care workers they were knowledgeable about whistle blowing procedures of the home, how to report an accident or incident occurring in the home. Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables service users to live in a safe, well- maintained and comfortable environment, which encourages independence, and protect their privacy and dignity. EVIDENCE: The management and staff encourage service users to see the home as their own home. It presents as a comfortable, attractive home, which has all the specialist adaptations, needed to meet the service users needs. It was noted that call bells were left within reach of each service user and service users said the bells are answered promptly. The home has attractive gardens, which are well maintained and there is good access to the gardens from various parts of the home. Some service users told Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 20 the inspectors that they try to go out daily weather permitting to enjoy the gardens. The inspector noted that adverse weather would not stop service users enjoying the garden, as the windows are low enough to allow service users to view the gardens from their armchairs. It was noted that service users were able to personalise their bedrooms with small items of furniture, paintings on the wall and many family photographs. Generally, the home presents as clean, safe, pleasant, hygienic and tidy and free from offensive odours. Random review of care workers training record demonstrated they have had training in infection control and this was evident in the storage of waste. The AQAA stated, “Two Pantries are situated on each floor for the use of the service users”. In discussion with residents we were told that they regularly use the pantries to make their breakfast and to make drinks for their visitors. We also noted laundry facilities situated on the ground floor, and residents who wish to do their own laundry are enabled to do so. Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to fulfil the aims of the home and meet the changing needs of the service users. EVIDENCE: The staff rota demonstrated the number and grade of staff on duty to provide care and attention to service users for any twenty-four period was adequate to meet the assessed care needs of the service users. Review of training records indicated all staff have undertaken the medicine training as required from the last inspection. Care workers have undertaken training and updating in Manual Handling, Dementia care, principles of care and all staff files sampled contained record of having undertaken a period of induction during the first three months of appointment. Random review of care workers files indicated that the home complied with the regulation regarding employment of staff to work in the care home. The records contained evidence that care workers attended all training offered. Recruitment to the home is through a process of equal opportunity and in accordance with the code of conduct and practice set by the General Social Care Council (GSCC). All staff has Criminal Record Bureau (CRB) and Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 22 Protection of Vulnerable Adults (POVA) checked prior to commencing employment, and they are in receipt of terms and condition of employment as evidenced in their randomly selected files. During discussion with the deputy manager it was stated that staff are regularly supervised. This was supported in discussion with care staff spoken to on the day and by records kept by the home. There was evidence that newly appointed staff undertook a programme of induction and care workers in discussion supported this. Documented evidence indicated that the home ensures that care workers undertake the mandatory training with yearly updates as necessary to maintain their competency to fulfil their duties. This was evidenced through discussion with the deputy manager and care workers. Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the experience to run the home and works to continuously improve services and provide an increased quality of life for the service users. There is a strong ethos of being transparent and open in all areas of running the home. The views of service users and their relatives are actively sought in the running of the home Service users financial interests are safeguarded. The service provides training on health and safety issues for all staff and service users are involved in the running of the home. Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager is new to the home and has only been in post three weeks on the day of the inspection. However, she has been a registered manager for a number of years is registered with CSCI for that home. Both the new manager and the deputy manager participated in the inspection process. The manager has demonstrated that she has kept herself updated on issues relating to care of the service users and staff in her charge. She has attained the Registered Managers Award and is a registered nurse currently live on the Nursing and Midwifery Council register. In discussion with the manager it was evident she was knowledgeable about the care needs of the service users and the training needs of the care workers to meet these identified needs. There are clear lines of accountability within the home, each member of staff spoken to on the day of inspection aware of their role and responsibilities. Regular residents meetings are arranged and minutes of the meetings are passed to the owners who will action requests as soon as possible. The Charity/owners are in attendance on twenty-four hourly basis, and are able to monitor the running of the home through interaction with service users, relatives and care workers. The home does not become involved in service users finance. The home does not become involved with residents finance, except for small amounts of spending money for which records are kept of all expenditures. Review of documented records demonstrated that health and safety checks are routinely carried out at the home. All equipment examined on the day was properly maintained. Records indicated that fire drills, fire alarm, water temperature fridge and freezer recordings were regularly checked. Random sample of care workers’ training files demonstrated that up to date and relevant training were carried out by care workers to protect service users’ health, welfare and safety. In discussion with care workers they discussed their understanding and implementation of appropriate procedures to safeguard service users. Further more they spoke about their understanding of promoting safe working practices based on their health and safety training. Throughout the service there is a highly evolved understanding of the equality and diversity needs of the individual service users. Care workers are confident in delivering high quality outcomes for service users in the areas of age, sexuality, gender, disability and belief. Although the care workers are knowledgeable about issues relating to race and equality and diversity, they are not able at the moment to put this knowledge into practice, with the current service users are all Caucasians. However, the staff rota demonstrated Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 25 a good mix of ethnicity and the new manager told us this is one area she plans to develop through discussion with the care workers. Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 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 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 Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Replace “Nursing Actions” with “Care Actions” in residents’ care plans. Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Redcot DS0000013756.V347097.R01.S.doc Version 5.2 Page 29 - 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. 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