Care Home: Shandon House

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What the care home does well The well being of the residents is at the heart of this home, and is viewed as the most important aspect of the ethos of the home. Residents` needs and wishes come first, and their viewpoints are always taken into account and met wherever possible. There are very good systems in place to enable residents to make a clear choice about moving into the home. This includes providing good documentation, and encouraging prospective residents to visit for at least half a day before making a decision. Residents are enabled to live their lives as they choose. This includes promoting their independence, ensuring that they can go out as they please and can join in with activities as they please, so long as it is assessed as being safe for them to do so. There is a stable staff team; who are committed to caring for the residents, and who carry out their duties efficiently, gently, and respectfully. The home provides a good choice of in-house activities, and the management are constantly looking at ways to improve residents` lifestyles. What has improved since the last inspection? The management have made a number of changes as a result of listening to residents. These include: Reviewing the activities and the times these take place. Reviewing the menus, and ensuring that food temperatures are hot enough. Introducing a named key worker scheme, so that residents have a specific person to relate to, and to assist them with day to day living. Improving the information on the activities notice board. Commencing Internet shopping on residents` behalf. They have also made some refurbishment changes to the home, which include redecorating some bedrooms and other areas; renewing carpets; and completely refurbishing 2 bathroom facilities. One of these has been altered into a shower room. What the care home could do better: The provider and manager have already identified some areas of weakness, and are taking action to address these. Not all one to one staff supervision is up to date, and some staff training updates are due. As they are already taking action on these issues, there is no need to issues requirements or recommendations. Medication administration charts had several handwritten entries which had not been signed. It is important that these are signed and checked by 2 staff together prior to any administration. CARE HOMES FOR OLDER PEOPLE Shandon House 3 Mill Road Eastbourne East Sussex BN21 2LY Lead Inspector Mrs Susan Hall Key Unannounced Inspection 13th February 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 Shandon House DS0000021211.V359057.R02.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. Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shandon House Address 3 Mill Road Eastbourne East Sussex BN21 2LY 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) 01323 723333 01323 410129 breel990@aol.com Mrs Lindsey Bree Mrs S Bree Nicola Louise Moss Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That a maximum number of service users to be accommodated must not exceed (25) twenty-five. That service users must be aged (65) sixty-five years or over on admission. That only older people, not falling into any other category be accommodated. 15th January 2007 Date of last inspection Brief Description of the Service: Shandon House is a large, detached, three-storey house situated in the pleasant Ocklynge area of Eastbourne. It is owned by Mrs. Bree, who also owns another care home close by. She has many years experience of providing care for older people, and works alongside the manager overseeing the day to day running of the home. Shandon House is registered to provide care and accommodation for up to 25 residents. Most rooms are for single use, and 12 rooms have en-suite toilet facilities. A passenger lift provides easy access for residents to all floors. However, only the ground floor is used for residents who need wheelchair access. The home has a large lounge and a conservatory at the rear of the premises; a separate dining room, and a well maintained garden. There are parking spaces at the front of the house. There are good toilet and bathroom facilities, including a shower room on the ground floor. The provider is continually funding updates and improvements within the home. Regular social activities are arranged within the home, as well as outings to places of interest, the cost of which is subsidised by the home. The range of fees is currently from £332.40 to £387 per week. Self funding residents are not charged above the rates of social services. Additional charges are made for hairdressing, chiropody, newspapers and dry cleaning. Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection, which takes into account all information gained about the service since the previous inspection, and covers all the key national minimum standards. Most other standards were also assessed, so as to give a comprehensive view of how the home is running. The manager completed an Annual Quality Assurance Assessment (“AQAA”) shortly before the inspection visit, and this contained clear details about improvements made during the past year, and ideas for changes in the future. This is a legal self assessment document which all services are required to complete each year. We (the Commission) sent out survey forms for residents, relatives, health professionals and staff just before the visit, and these had not yet been returned. They will enable CSCI to corroborate the findings of the inspector. A visit to the home by one inspector took place over four and a half hours. This included a tour of the premises; chatting with 8 residents and briefly meeting another 6 residents; talking with the provider and the manager and another 5 staff; and reading documentation such as care plans, staff files, medication charts and staff training records. The home was clean and well presented in all areas. Residents were relaxed and looked well cared for. Several made very positive comments such as “I like living here”; “the staff are very helpful”; “the staff are wonderful”; and “I couldn’t ask for anything better”. What the service does well: The well being of the residents is at the heart of this home, and is viewed as the most important aspect of the ethos of the home. Residents’ needs and wishes come first, and their viewpoints are always taken into account and met wherever possible. There are very good systems in place to enable residents to make a clear choice about moving into the home. This includes providing good documentation, and encouraging prospective residents to visit for at least half a day before making a decision. Residents are enabled to live their lives as they choose. This includes promoting their independence, ensuring that they can go out as they please and can join in with activities as they please, so long as it is assessed as being safe for them to do so. Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 6 There is a stable staff team; who are committed to caring for the residents, and who carry out their duties efficiently, gently, and respectfully. The home provides a good choice of in-house activities, and the management are constantly looking at ways to improve residents’ lifestyles. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 7 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 Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 8 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): 1-5 (Standard 6 does not apply to this home). Quality in this outcome area is excellent. The provider ensures that detailed information is available to enable residents to make a choice about moving into the home. The admission process is very well managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The statement of purpose contains all the necessary information and is in the process of being reviewed and updated. The service users’ guide is well produced in a large print format, and has a photo of the home on the front cover, and further photos and a map on the back. It includes clear details about the staffing and management of the home, the terms and conditions of residency, the admission process and the complaints procedure. Prospective residents are provided with a copy of the home’s contract. They are encouraged to take away a copy of the service Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 9 user’s guide to read prior to admission, so that they are familiar with how the home is run, and can ask any questions before making a decision. The manager or deputy carry out a pre-admission assessment in the person’s own home or in hospital, and obtain as much information as possible to enable them to check that they can meet the needs of each individual person. Three pre-admission assessments were viewed, and contained comprehensive information. These included details such as mobility, relevant medical history, vision, hearing and speech, emotional and mental state, and social and spiritual interests. The manager ensures that people are informed that wheelchair use is only considered suitable for the ground floor, as corridors are fairly narrow on the first and second floors, and wheelchairs could block corridors. It is suggested that prospective residents visit the home for half a day for lunch, the afternoon, and tea prior to admission. This gives them plenty of time to look round, try the food, meet staff and other residents, and see how they fit in with others. If more than one room is vacant they are able to choose their room, providing it will meet their needs in terms of space and equipment. Fee levels are kept at the same rates for people who are self funding, as those paid for by Social Services, and this is commendable. Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 10 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): 7-11 Quality in this outcome area is good. The ethos of the home is centred on ensuring that residents are well cared for, and that all their health needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are discussed with residents prior to and during the admission process, and then on a monthly basis. A signed statement confirms that they understand and agree to their care plan being shared with other authorised people who are involved in their care. The manager and assistant manager carry out a monthly audit of care plans, ensuring that the information is up to date, and agreeing any changes with the resident and/or next of kin as appropriate. Care plans are kept in 2 folders that are stored confidentially, but kept available for care staff to refer to. 6 care plans were viewed, including 2 for residents who had been recently admitted. The plans are set out in a Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 11 straightforward format that is easy to follow and to find the relevant information. A “care plan action” sheet, enables care staff to quickly refer to specific data such as moving and handling details, and any changes in care agreed at the latest review. Care plans include a property list, ensuring that each resident’s own items are clearly documented. The plans include all aspects of daily living, such as assistance needed with personal care, skin care, diet, continence, medication, sleeping pattern, and social preferences. Information is suitably detailed, with comments like “uses the lift with assistance, and walks with the aid of a stick”; “likes to have feet soaked once per week”; “ needs assistance with soaking dentures”; and “ self administers own medication”. Risk assessments are written so as to reflect individual risk hazards, and include checking that residents are safe to walk outside unsupervised; can understand and hear what is said; and are checked for risks such as slipping and falling; use of hot water, opening windows, and needing assistance with bathing/showering. A record of daily care delivery shows when staff have assisted residents with tasks such as shaving, cutting fingernails, bathing, shower, cleaning teeth and having their hair washed. Daily records include good quality information, and are signed and dated. The manager contacts other health professionals as needed, and there are good records to show input from these, such as GPs, Physiotherapist, Occupational Therapist, District Nurses etc. Residents are escorted by care staff to hospital appointments, and at no extra cost. Medication storage is satisfactorily maintained. Most medication is administered via the Boots monitored dosage system. There was no overstocking, and no drugs out of date. Good systems are in place for checking receipt of medication into the home and for management of waste medication. Homely remedies are only given in agreement with the residents’ GPs. All medication administration records (MAR charts) were viewed and were well completed except that handwritten entries had not been signed. All care staff attend a half day training course about medication, and are then supervised and checked for competency and confidence before being allowed to administer medication. Residents have a detailed competency check if they wish to manage their own medication, and this is then checked on a monthly basis. The home has good policies in respect of death and dying, trying to ensure that individual viewpoints are discussed and recorded as soon after admission as possible. The manager ensures that additional health professionals such as hospice nurse, GP are contacted as needed. Residents are enabled to have family or friends to stay with them as they wish; and spiritual comfort and their religious preferences will be met with in accordance with their wishes. Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 12 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 –15 Quality in this outcome area is good. There is good provision in place for a variety of activities. Food is well managed in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides a variety of activities on a daily basis, as well as planned entertainment from outside entertainers. Daily activities are usually carried out in the mornings, as it has been noticed that many residents like a rest after lunch, and do not feel like group activities then. In-house activities are mostly carried out by the care staff, and include things like general knowledge quizzes, music and movement, bingo, floor board games, arts and crafts, and reminiscence. An activities plan for the week is kept on the notice board in the front entrance hall. Care staff spend more time with residents on a one to one basis in the afternoons, and will take residents out to do shopping/ buy clothes etc. as arranged with the manager. There are nice touches for different days in the Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 13 week, like having sherry before lunch on a Sunday; and a full English breakfast offered especially on a Friday. The home has a large conservatory as well as a lounge, and a half finished jigsaw was in place there. The staff said there is often one that is ongoing and everyone helps with it. A new computer with Internet access has just been added to the conservatory, and one of the relatives has offered to help residents to understand how to use this. The home has also had sky television installed recently. There are 2 payphones for use, and residents can have their own phones fitted if they wish. The management have also started to do Internet shopping for residents. Outside entertainment includes pantomime and theatre groups as well as singing. Residents are enabled to visit their own churches. Family and friends can visit whenever they wish, and can stay for meals – even at short notice. There is a small room adjoining the dining room, which is set up to enable residents to have meals quietly on their own, or separately with family/friends. Relatives said that they are always made welcome in the home whenever they visit, and it really has a “homely” atmosphere. Residents said that the food is very good, and there is always sufficient choice. One said “there is always plenty to choose from and if you still don’t feel like what’s on the menu, they will make something else for you”. Another two residents said that they are “very well fed” and enjoy the food. The kitchen was seen to be generally clean and well organised. Some of the units look “tired”, and the provider said she is already implementing plans to fit new ones. The floor is also going to be replaced. There is a separate dry food store room, and another room for fridge and freezer storage. There is a programme in place for daily and weekly cleaning, and fridge and freezer temperatures are checked daily. Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 14 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. Residents are confident that any concerns they raise will be properly addressed. Residents are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is on display in the entrance hall, and is included in the service users’ guide. It is clearly written, and includes the necessary information. It does not include local Social Services details, and the manager said that she would include these as a reminder that this is another avenue for anyone wishing to complain. The home has only had one complaint during the past year, and the records showed that this had been dealt with appropriately and sensitively. CSCI have not received any complaints about the home, and there have been no safeguarding adults’ referrals during the past year. Residents said that they have “never had to make a complaint” and that the manager and staff always “sort anything out”. The manager has a very proactive approach, by checking with residents every month when care plans are reviewed as to how they feel about their care. This gives them the opportunity to share anything they feel could be done better or differently. Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 15 Staff training records showed that all staff are trained in the recognition and prevention of different types of abuse, and that there is a rolling programme to ensure that staff training is updated. Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 16 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 –22 and 24-26 Quality in this outcome area is good. The home is well maintained, and provides a pleasant environment for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All areas of the home were viewed, and it was seen to be generally well maintained, and clean throughout. There is a variety of communal space, with a large lounge at the rear of the building, a large conservatory leading into a pleasant garden, a dining room and a small separate quiet/dining room. The garden has different seating areas, and has spacious lawns and flowerbeds. There is also a small lounge area on the second floor. The dining room looked particularly attractive with colour matching tablecloths and décor. The residents were involved in the Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 17 choice of colour for the dining room carpet. Furniture and soft furnishings are of satisfactory quality throughout the home. Bedrooms are personalised with residents’ own possessions. When bedrooms need redecorating, residents are included in the decision-making process about the change of décor whenever possible. Some of the bedrooms have small ensuite toilet areas as well as wash hand basins. Most bedrooms are for single use. The home has bathing and/or shower facilities on each floor. Two of the baths have an integral hoisting facility. One of the bathrooms on the first floor has been refurbished during the last year, and looks very pleasant; and one of the bathing facilities on the ground floor has been altered into a shower room, with a large shower cubicle and shower chair. This work has been carried out to a high standard. The home has other equipment to assist residents, such as grab rails, raised toilet seats, toilet surrounds, and commodes. There is a call bell system with a point in each room, and items such as a pressure mats are obtained if staff need to be alerted to a resident (who is unsteady on their feet), getting out of bed in the night. The home is equipped with a hoist in the event of anyone falling, so that they can safely be lifted from the floor. All radiators are provided with radiator guards. The laundry room is sited on the first floor and was seen to be spotlessly clean. There is one washing machine and one tumble dryer. Care staff and housekeeping staff work together to keep up to date with the washing and ironing. Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 18 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): 27-30 Quality in this outcome area is good. There are suitable numbers of competent staff, and the provider ensures that they have ongoing training to keep up to date with requirements This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has 3 care staff on duty throughout the day time (morning, afternoon and evening), and the manager and/or assistant manager are on duty most days as well. There is one waking night staff and one sleeping night staff, so that a second person is always available. The care staff work together to take part in all aspects of the life of the home – assisting with laundry and in the kitchen, and keeping the rooms tidy and clean when the housekeeping staff are off duty. They have additional responsibilities as key workers, checking that drawers and wardrobes are kept tidy, dusting and polishing residents’ rooms, helping them with shopping, and other duties such as cutting finger nails and liaising with families. There is a cook on duty each day. The housekeeper also helps with the gardening. Day to day maintenance is carried out by the provider’s son, and professional maintenance is brought in for items such as plumbing and electrical work. Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 19 7 out of 12 care staff have completed NVQ 2 or 3, (58.3 ) and others are now commencing NVQ 2, 3 or 4. Residents said that “the staff are always there for them”, “the staff are wonderful” and staff are “very helpful”. They were seen to show caring attitudes, friendship and concern, and to carry out their duties efficiently and sensitively. They talked gently and did not rush people. 2 staff files were viewed and were well compiled, and had all the required information – e.g. POVA First and Criminal Record Bureau checks; 2 written references from professional referees; proof of identity; full employment history since leaving education (with gaps explored); health declaration; and training records. A staff training matrix was in the process of being updated, but showed that staff training is carried out for mandatory subjects, and is updated as necessary. Most training is carried out with external training companies, and updates are carried out in-house. Staff go through a 12 week induction course when initial training is carried out. Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 20 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): 31,32,33,35,36,38 Quality in this outcome area is good. The home is efficiently run by an experienced manager. Good procedures are in place to ensure the health and safety of residents and staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has many years of experience in caring for older people, and is appropriately trained for this role. She keeps up to date with her own training requirements. She is supported by an Assistant Manager, and a Trainee Manager, who cover the home in her absence. The provider is also experienced as a care provider. Both were present during the course of the inspection. Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 21 The manager has a good rapport with staff, and they respect her commitment to good care, her knowledge, and her hands on approach. Several staff are related to each other/and to the provider – (this really is a family run business) – and this seems to enhance the communication and staff working together, rather than causing any problems. Quality assurance is mostly assessed by ongoing daily feedback from residents and relatives. The system of asking residents each month about how they feel their care is being delivered is a very good way of ensuring that any concerns are dealt with quickly. The home has residents and relatives meetings every 6 months, and there is clear evidence that their views and decisions have influenced the changes in the home during the past year (e.g. installing Sky TV; installing a computer, choosing colour of dining room carpet, etc.). The home does not deal with residents’ personal money. If they cannot manage their own finances, this is arranged with their authorised family member, or advocacy is arranged. Any additional items purchased on residents’ behalf (hairdressing, clothes etc.) are invoiced to the relevant people on a monthly basis. The manager has a good format in place for staff supervision. The aim is for all staff to have one to one supervision every 2 months, but some were not currently up to date with supervision, and the manager is addressing this. Safe working practices include a daily reminder on a printed handover sheet about good management of infection control. COSHH items (e.g. cleaning substances) are stored in a locked cupboard. Servicing of equipment is kept up to date – e.g. a hoist check is carried out twice yearly, and PAT testing has been done for all electrical items. The fire risk assessment has been checked and amended during the past year, to ensure that all fire regulations are complied with. Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 22 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 3 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 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 3 4 X 3 2 X 3 Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 23 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 OP9 Good Practice Recommendations To ensure that any handwritten entries on medication administration records are signed by 2 staff. Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Shandon House DS0000021211.V359057.R02.S.doc Version 5.2 Page 25 - 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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