Care Home: Southdown Nursing & Residential Home

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What the care home does well The service provided by the home has improved since coming under new ownership in January 2007. People living in the home appear to receive the personal support and health care that they require and they are able to maintain links with family and friends. The level of social activities continues to improve, with more opportunities to get out of the home. People were happy with the meals provided. As noted at the previous inspection, there is an overall improvement in the management of the home with the manager demonstrating an increased awareness of her responsibility to meet statutory requirements. What has improved since the last inspection? Care planning has improved and plans are in place that reflect peoples care needs. Care assistants are now more aware of how to refer to care plans to ensure the care and support they give is correct. People who have problems taking in adequate nutrition are now being regularly weighed and assessed. Nurses are now following follow recommended procedures when recording and administering medication. Quality assurance systems have been introduced to ensure that people`s views about the home are heard and there is now regular auditing of care practices and the environment. A formal staff supervision system has been fully introduced and staff training has improved. Further improvement to the decoration of the home and the provision of new bedding, curtains and corridor carpet has improved the environment. What the care home could do better: Care plans are not all being regularly reviewed to ensure that they are up to date and some plans do not have the person`s (or their relatives) signed agreement. When a person has been assessed as being at risk from pressure damage, a care plan should be in place in order to direct and record care. Where a person is assessed at risk from inadequate hydration or pressure damage, their fluid input and output, and positional changes, need to be accurately recorded and monitored. The home needs to make sure that the number staff on duty is sufficient to meet the needs of the service users at all times. CARE HOMES FOR OLDER PEOPLE Southdown Nursing & Residential Home The Old Vicarage 17 Church Road Wanborough Swindon Wiltshire SN4 0BZ Lead Inspector Steve Cousins Unannounced Inspection 09:30 16 – 17 October 2007 th th 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 DS0000068647.V339477.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. DS0000068647.V339477.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southdown Nursing & Residential Home Address The Old Vicarage 17 Church Road Wanborough Swindon Wiltshire SN4 0BZ 01793 790727 F/P 01793 790727 southdowncare@aol.com 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) Southdown Care Limited Miss Deborah McHugh Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places DS0000068647.V339477.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. From time to time service users aged between 60 and 65 years may be accommodated. No more than 24 persons in receipt of nursing care at any one time. Date of last inspection 13th March 2007 Brief Description of the Service: Southdown Care Home is registered to provide nursing and residential care for up to thirty older people. The home is located within the village of Wanborough with local pubs, post office and bus stop nearby. It is approximately four miles from Swindon and the M4 motorway. The home is a converted listed building with a purpose built annexe. Accommodation is provided on three floors and there is access to a secluded courtyard and gardens. Carevale Ltd owns the home and Deborah McHugh is the registered manager. A registered nurse is on duty at all times, supported by care assistants. Catering, laundry, housekeeping and maintenance services are also provided. The current range of fees is £400 to £575 per week. DS0000068647.V339477.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days on the 16th and 17th October 2007 in order to inspect all of the key minimum standards relating to care homes for elderly people. We visited the home between 9.30 a.m. and 4.00 p.m. on the first day, and 9.15 a.m. and 3.00 p.m. on the second day, making a total of 12.25 inspection hours. The lead inspector then met with Mrs McHugh, the registered manager, in order to discuss the outcome of the visit. The findings from this inspection are based on a tour of the premises, speaking to people living in the home, their relatives, the manager and staff, and visiting frail residents. A number of records were inspected, including care plans, medication records and staff records. We reviewed the care of four people in detail. They had varying physical, social and mental health needs. Three were new to the home and one had been at Southdown for some time. The care of other people living at the home was reviewed in less detail. Consideration was given to issues of ethnicity and diversity. Comment cards were received from two relatives prior to the inspection and their views are incorporated in this report. Other information was obtained from the home’s Annual Quality Assurance Assessment (AQAA), which had been completed by the manager and sent to the Commission prior to the inspection. The judgements contained in this report have been made from evidence gathered during the inspection and take into account the views and experiences of people using the service. What the service does well: What has improved since the last inspection? DS0000068647.V339477.R01.S.doc Version 5.2 Page 6 Care planning has improved and plans are in place that reflect peoples care needs. Care assistants are now more aware of how to refer to care plans to ensure the care and support they give is correct. People who have problems taking in adequate nutrition are now being regularly weighed and assessed. Nurses are now following follow recommended procedures when recording and administering medication. Quality assurance systems have been introduced to ensure that people’s views about the home are heard and there is now regular auditing of care practices and the environment. A formal staff supervision system has been fully introduced and staff training has improved. Further improvement to the decoration of the home and the provision of new bedding, curtains and corridor carpet has improved the environment. 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. DS0000068647.V339477.R01.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 DS0000068647.V339477.R01.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): 3. Standard 6 does not apply to this service Quality in this outcome area is good. Where possible, people are assessed before they move into Southdown to ensure that their needs can be met. When people are moved into the home as a matter of urgency, the home ensures adequate supporting information is obtained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The records of three people admitted to the home since the previous inspection were reviewed. They had all been admitted under the crisis care scheme whereby people are admitted to the home at short notice due to a risk to their health and welfare. Their records contained supporting information regarding their needs from professionals such as care managers, community nurses and hospital doctors. This information had been used to aid completion of care plans. Other people’s records that were reviewed contained satisfactory preadmission assessment forms that had been completed by the manager. DS0000068647.V339477.R01.S.doc Version 5.2 Page 9 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 and 10. Quality in this outcome area is good. The standard of care planning has improved. Peoples health care needs appear to be addressed and they are supported to access health care professionals as required. People were happy with the support they receive and their privacy and dignity appears to be respected. People are protected by the home’s procedures relating to medication. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There had been an improvement in the standard of care planning since the previous inspection. Plans were clearer and more detailed and generally appeared to be an accurate reflection of the person’s needs and were based on appropriate assessment. Some care plans contained information that reflected people’s wishes as to how they wanted to be cared for when they reached the end of their lives. DS0000068647.V339477.R01.S.doc Version 5.2 Page 10 Care needs to be taken to ensure that all plans are regularly reviewed (at least monthly) as one person’s plan had not been reviewed since August 2007. Also, one person had been assessed as being at risk from developing pressure damage, but a care plan was not in place to direct the care required (although appropriate pressure relief equipment had been provided). Where possible staff should ensure that care plans are agreed and signed by the resident where capable or by their representative, as this was not always the case. Care assistants spoken to appear more aware of how to use a care plan to direct the care that they gave, which is an improvement on the previous inspection. We visited the people whose care we reviewed and found that interventions were in place to meet their assessed needs, such as pressure relief equipment, continence aids and manual handling equipment. Positional changes and fluid intake were being recorded, but not always consistently. Records indicated an improvement in how those people who are assessed as nutritionally at risk are monitored. Care plans relating to nutrition were in place and people were regularly weighed. As found at the previous inspection, nurses were prompt in referring people to their General Practitioner (GP) and to other health care professionals when required. All people living in the home have an allocated GP and one visits the home weekly to see any people with health care problems. People spoken to indicated satisfaction with the care given. Their comments included “They are so good, they come quickly when you call the bell, day or night” and “Staff are very nice, we have a laugh, they help me when I need it, sometimes you have to wait a little but you have to expect it as they can’t be everywhere”. One comment received from a relative was ‘During the short time my mother has been in the home, the care and attention she has received has been exemplary’. There was evidence to suggest that people’s privacy and dignity was respected. Personal care was being given behind closed doors and staff knocked on doors before entering a room. People appeared to be having their personal hygiene needs met and those who were unable to dress themselves were dressed in clothing that maintained their dignity. There were no concerns voiced about how the staff treated people. The arrangements regarding administration of medication were reviewed. Registered nurses are responsible for the administration of medicines in the home. Medications were safely and securely stored and records of receipts, administration and disposals are maintained. Due to their needs, there were no people currently living in the home who self-administer their medication. DS0000068647.V339477.R01.S.doc Version 5.2 Page 11 Some medication administration record (MAR) sheets contained unsigned handwritten additions. It is best practice to ensure that any handwritten additions or amendments to MAR sheets are signed by the person making the amendment/addition and witnessed by another person, who should also sign. DS0000068647.V339477.R01.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, 13, 14 and 15 Quality in this outcome area is good. Social activities are provided and there opportunities for people to get out of the home. Contact with friends and relatives is maintained and as far as possible, people are supported to live their lives as they wish. People were complimentary about the food provided, but the system employed to offer them a choice of meal needs to be more consistent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Social activities are provided both in and out of the home and the manager reported that more staff hours have been allocated to activities. The home has a designated activities coordinator and records are kept in care plans that relate to social activity. Records indicated, along with the comments of the people living in the home, that there had been an improvement in the provision of social activity since the last inspection, particularly in relation to opportunities for people to access the community. One person told us “I have been out three times and only been here a short while” and another “I’m now going out a lot more, it’s improved”. DS0000068647.V339477.R01.S.doc Version 5.2 Page 13 Relatives and visitors were around the home at different times during the day, both in the communal areas and in people’s rooms. There were no restrictions on visiting, several people confirming that they were able to receive visitors at any time. Many of the people living at Southdown are very dependant on staff to meet their needs however some of their comments during the inspection indicated that they had some control over how they lived their lives. One person said that they did not like to join in any group activities and stated that they were happier staying in their room and watching T.V. They confirmed that the staff respected this. Another person told the inspector “I am able to have a lie-in if I want, but I’m normally up early and they give me a hand”. Some people had brought in personal items and furniture for their rooms. People were complimentary about the meals provided. One stating “It’s (the food) very good” and another “The food’s ok”. Comments from staff, allied to records available in the kitchen, indicate that people are not always consulted about what they would like to choose from the menu. This appeared to depend on what catering staff member was on duty at the time. The inspector observed part of the lunchtime meal over two days. People receiving assistance with their meals were provided with support from staff in a discreet and sensitive manner. People are able to eat in the dining room, in the lounges or in their own rooms if they want to. DS0000068647.V339477.R01.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 and 18 Quality in this outcome area is good. Complaints are taken seriously and records are maintained. As far as possible, people living in the home are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaint procedure, which is contained in the service users guide. The complaints record book was reviewed. Complaints had been logged and the action taken to resolve them had been recorded, although as noted in the previous inspection the complaints procedure also states that the complainant will be asked to read and sign the book in order to confirm that it is a an accurate record of the complaint. This was not evident during this inspection. The Commission have not received any complaints about the home since the previous inspection. One person living in the home who said that they had had a concern told us “the manager sorted things out when my daughter asked”. A ‘whistle blowing’ policy is in place along with a protection of vulnerable adults policy that also relates to the local ‘no secrets’ guidelines for reporting suspected abuse. Staff training relating to protection of vulnerable adults is held and records indicated that the majority of staff had received this. Staff DS0000068647.V339477.R01.S.doc Version 5.2 Page 15 spoken too demonstrated an awareness of the reporting procedure relating to alleged abuse. A review of staff employment documentation indicated that procedures for the protection of people living in the home had been carried out, including Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks. DS0000068647.V339477.R01.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, 20, 21, 22, 23, 24, 25 and 26 The overall standard of accommodation has improved. The home was clean and appears well maintained. People have access to sufficient toilet and bathroom facilities and there are suitable adaptations to support people and maintain their independence where possible. There are suitable internal and external communal areas that are accessible to the people living in the home. Further improvements could be made in relation to the lighting in some bedrooms. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been a noticeable improvement to the environment. A tour of the building was made and all bedrooms and communal living areas were seen. DS0000068647.V339477.R01.S.doc Version 5.2 Page 17 Since the previous inspection, the parts of the home that needed decorating have been attended to; corridors have been carpeted and the courtyard area had been improved. The majority of the bedrooms offer single occupancy and some en suite facilities. Where people shared a bedroom, screens to respect their privacy have been provided. New bed linen and curtains had been purchased. Adjustable beds are provided throughout the home, as is pressure relief equipment where required. The lighting in the top floor bedrooms was weak and in the two double rooms, consists of one central light fitting. No alternative lighting was available, meaning should a person require attention during the night, the other person may be wakened by the light being switched on. Provision of alternative lighting should be considered. There are three separate communal lounges where comfortable seating is provided. In one communal lounge there is a small dining area where a maximum of eight residents can eat their meals. This is the only dining area in the home and means others have to eat their meal either in their room or in one of the communal lounges. As previously reported, while this currently meets the requirements for care homes registered before the 31st March 2002 consideration should be given to providing additional dining facilities. If additional dining facilities were to be provided this would offer people living in the home more choice and provide an area where all could enjoy a meal together. Toilet and bathing facilities are situated on all three floors of the home close to communal living areas and people’s bedrooms. Sluice areas were clean and some new waste bins had been provided. The accommodation is split over three floors, which can be accessed by two passenger lifts. One of the lifts continues to be unreliable due to frequent breakdowns, however the manager stated that this lift is to be replaced. In addition, a chair lift has been fitted to ensure residents can access the top floor area should the passenger lift fail. Aids and adaptations are in place at the home, such as hoists, bath hoists and handrails. The home was generally clean and free from unpleasant odours apart from one bedroom. The manager was aware of this and was considering what action to take. A bath hoist on the second floor had lime scale on the underneath surface of the seat and this was reported to the manager. Supplies of disposable gloves and hand rub were available throughout the home. The laundry room is situated on the first floor well away from any food preparation or food storage areas. The walls and floors are readily cleanable. DS0000068647.V339477.R01.S.doc Version 5.2 Page 18 Appropriate infection control procedures were in place in relation to the handling of soiled linen. The kitchen was clean and food safety checks are carried out and recorded. However as reported in the previous inspection, the kitchen floor covering was cracked and worn in places and it is recommended that it be replaced. DS0000068647.V339477.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. Staff numbers and skill mix appear to meet the needs of the people living at Southdown, but there are times when reduced numbers of staff compromise this. The level of care assistants with an NVQ is high and recruitment procedures were satisfactory. Staff training has improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had 30 people living there at the time of the inspection. The manager stated that she aims to ensure that one nurse and five care assistants are on duty in the morning until 2:00 p.m. when the level drops to one nurse and four care assistants until 5:00 p.m. The number of care assistants rises again at 5:00 pm to five. There are two care assistants and one nurse on night duty. The number of care staff over the two days of this unannounced inspection appeared enough to meet peoples’ needs and call bells were answered without any delay. Review of the homes duty rota indicated that there were several occasions when the staffing levels dropped to one nurse and three care assistants, either in the evening or at weekends. Staff members spoken to confirmed this and indicated that when this occurs, then they have problems meeting the needs of people in the home. One person living in the home remarked about staff levels DS0000068647.V339477.R01.S.doc Version 5.2 Page 20 saying, “They are sometimes short staffed at weekends so you have to wait a bit longer”. One relative commented that they felt the home could improve by having ‘More staff’. The manager stated that she was aware of this issue and was currently trying to recruit staff specifically for weekend work. The findings of this inspection would indicate that the current level of domestic and catering staff is appropriate. The recruitment records of three staff members were reviewed. Criminal Record Bureau (CRB) checks had been obtained or applied for and references and Protection of Vulnerable Adults (POVA) checks had been obtained prior to the person starting employment in all cases. Other documentation required was in place. The home has an equal opportunities recruitment policy. We reviewed the arrangements relating to staff induction training. Induction training relating to Skills for Care standards had commenced. Records indicated that newly appointed staff had received induction training along with mandatory training. One staff member confirmed the training she had received and stated that for the induction training was “good” and indicated that they had received good support and supervision. The level of staff receiving mandatory training had improved, as had records documenting the training. Records indicated that staff’s training needs were being addressed during regular supervision sessions. The Annual Quality Assurance Audit (AQAA) supplied by the home indicated that 60 of the care assistants had an NVQ level 2 or above, with a further four staff who having commenced NVQ level 2. Four staff spoken to confirmed their NVQ status. DS0000068647.V339477.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33,35, 36 and 38 Quality in this outcome area is good. The home is well managed. Quality assurance systems have improved. A formal staff supervision system has been fully introduced. As far as possible, the management of health and safety in the home protects the people living there, and it’s staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Deborah McHugh is the homes registered manager and has been employed at Southdown since 1990. She is a first level trained nurse and an NVQ Assessor. Mrs McHugh has also obtained the Registered Managers Award. DS0000068647.V339477.R01.S.doc Version 5.2 Page 22 The findings of this inspection would indicate that the improvements in the management of the home noted at the last inspection in March 2007 have been maintained and Mrs McHugh has demonstrated a continued commitment to meet the responsibilities of a registered manager. A new deputy manager, who started employment in April 2007, has provided additional support. Southdown changed ownership in January 2007 and it is evident that the new owners have made genuine efforts to improve the home and support the manager in her role. Comments received from staff were positive towards the owners, manager and deputy, one stated: “Management is much improved, things are talked about now and solved, where as before people would just leave” and another said “Morale is better, we’re more of a team”. The quality assurance arrangements were reviewed. The home has an annual questionnaire that had been sent to people living in the home and their relatives. The manager stated that action had been taken in response to issues raised, such as the introduction of residents’ meetings. Records showed that issues had also been discussed at staff meetings. The manager had held ‘open evening’ for residents’ relatives and had carried out audits relating to environmental and practice issues. The registered provider had carried out monthly regulatory visits to the home and had reduced a report for the manager. Records indicated that regular formal supervision sessions with staff had been held and staff members were able to confirm this. The manager reported that the home does not handle any personal money on behalf of people living there and no member of staff is involved with any persons’ finances The health and safety arrangements in the home were reviewed. Accidents are recorded correctly and audited in order to monitor any patterns or trends. The fire safety log indicated that checks were being undertaken at the recommended intervals and the home has a fire risk assessment. Radiators are protected and hot water temperatures are controlled. Environmental risk assessments were carried out in September 2007. Risk assessments relating to the safety of bedrails has been carried out. Moving and handling equipment is available and staff are trained in its use. Staff have also received health and safety training. Records sent to the Commission following the inspection indicate that lifting equipment is regularly serviced. DS0000068647.V339477.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 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 3 3 3 3 3 2 3 STAFFING Standard No Score 27 2 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 X 3 DS0000068647.V339477.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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. 1. Standard OP7 Regulation 12 (1,b) Requirement Timescale for action 01/11/07 2. OP7 15 (1) 3 OP8 12 (1,a) 4 OP27 18 (1,a) The registered manager must ensure that, when a person has been assessed as being at risk from pressure damage, a care plan is in place in order to direct and record care. The registered manager must 01/11/07 ensure that residents care plans are reviewed at least once a month, updated to reflect changing needs and current objectives for health and personal care, and actioned. (Requirement issued at previous inspection 13/03/07. Met in part) The registered manager is 18/10/07 required to ensure that where a person is assessed at risk from inadequate hydration or pressure damage, their fluid input and output, and positional changes, are accurately recorded and monitored. The registered manager is 18/10/07 required to ensure that the number staff on duty is sufficient to meet the needs of the service users at all times. DS0000068647.V339477.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP7 OP9 Good Practice Recommendations The registered manager should ensure that care plans be agreed and signed by the resident whenever capable and/or their representative (if any) The registered manager should ensure that any handwritten amendments/additions to medicine administration records are signed be the person making the amendment/addition and witnessed and signed by another person. The registered person should ensure the record of meals served is kept up-to-date and any alternative provided is clearly recorded. The registered person should replace the kitchen floor covering. The registered person should consider providing additional dining room facilities. The registered person should ensure that the lighting in service users accommodation on the top floor meets the recognised standards (lux150) and should consider providing separate lighting for those accommodated in shared rooms. 3 4 5 6 OP15 OP19 OP20 OP25 DS0000068647.V339477.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 DS0000068647.V339477.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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