Care Home: St Ann`s Rest Home

What the care home does well The service provides personal care to older people with mental health conditions of the older person. Residents appeared well cared for and happy within the home. Three residents spoken with said that they liked the staff and were well looked after. The home has recently changed ownership, some of the previous staff have remained and this has given the residents the benefit of being cared for by staff with whom they are familiar and who are aware of their individual characters and needs. The standard of catering is good with residents having the benefit of meals which are well presented and nutritious. All residents spoken with said that they enjoyed their meals. An activities co-ordinator is employed three afternoons a week and a variety of activities take place. Residents are able to enjoy the freedom of the home and a large garden and two residents attend a day centre at another home in the group. What has improved since the last inspection? A programme of complete refurbishment is in place. This is taking place with minimum disruption to the residents in the home. A new care planning system has been introduced and this contained long term needs assessments of the residents as well as comprehensive risk assessments. Staff are being encouraged to undertaken training, including training to attain the National Vocational Qualification level 2 or 3 in care and mandatory health and safety training is being updated. What the care home could do better: The new Service User Guide has not yet been completed in a format suitable for the use residents in the home. Care plans should include a care plan for all assessed needs, with clear instructions for the staff to enable the needs to be met. These should be reviewed on a regular basis, as directed by the National Minimum Standardsand show evidence that were possible, they were formed in consultation with the individual. There is scope to extend the range of activities available and the home should be aware that activities and appropriate mental stimulation form an important part of the holistic care of the older person with mental health needs. CARE HOMES FOR OLDER PEOPLE St Ann`s Rest Home 9 Stanford Avenue Brighton East Sussex BN1 6AD Lead Inspector Elizabeth Dudley Unannounced Inspection 09:30 5 August 2008 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 St Ann`s Rest Home DS0000071693.V369313.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. St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Ann`s Rest Home Address 9 Stanford Avenue Brighton East Sussex BN1 6AD 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) 01273 882626 birchgrcarehome@aol.com Birchgrove Healthcare (Sussex) Ltd Care Home 15 Category(ies) of Dementia (0) registration, with number of places St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Dementia (DE). The maximum number of service users to be accommodated is 15. Date of last inspection New service Brief Description of the Service: St Ann’s Residential Home is situated in Stanford Avenue, Brighton. This is central Brighton and therefore close to all main amenities, including the railway station, and local buses pass the home. There is restricted parking in the roads around the home but the home can provide car parking for approximately four cars. The home provides personal care for 15 older people with mental health problems, and is served by local General Practitioners. The home consists of both single and double rooms over two floors. There is no lift facility therefore the home is currently restricted to admitting people who do not have mobility problems. There is a large rear garden that is accessible to residents. The home was recently purchased by Birchgrove Health care (Sussex) Ltd and is undergoing total refurbishment at the present time. This is being carried out with minimum disruption to residents. The current fees as quoted on the 5th August 2008 range between £464 and £575 per week. The fees do not include extra services such as hairdressing and chiropody. Details of these charges are available from the home. St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This unannounced key inspection took place on the 5th August 2008 over a period of five hours and was facilitated by the responsible individual. There is no appointed manager in the home at present but one is in the process of being appointed. The person acting as manager was not present on the day of the inspection. This was the first inspection under the new ownership of the home. Methods used to collect information about the home included examination of documentation in the home, observation of staff working with residents, the serving of lunches and conversations with residents, staff and visitors to the home. All residents were spoken with during the inspection, and six residents were spoken with in depth and gave their views on life in the home. The inspector sat in on an activities session where a quiz was in progress and spoke to one visitor. Documentation examined included care plans, personnel files, staff training and supervision records, catering records and health and safety files. Prior to the inspection questionnaires were sent out to relatives and residents. Of these one was returned from a relatives and one from a resident. These gave information about the daily life in the home and helped to inform the judgements made in this report. Thanks are extended to those people who responded. The Annual Quality Assurance Assessment, required by the CSCI, which gives an overview of what has been achieved in the home and issues to be addressed, was received by the CSCI prior to the inspection but after the date required. A further visit lasting an hour was made to the home on the 8th August to assess some documentation that was unavailable due to the refurbishment works. What the service does well: St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 6 The service provides personal care to older people with mental health conditions of the older person. Residents appeared well cared for and happy within the home. Three residents spoken with said that they liked the staff and were well looked after. The home has recently changed ownership, some of the previous staff have remained and this has given the residents the benefit of being cared for by staff with whom they are familiar and who are aware of their individual characters and needs. The standard of catering is good with residents having the benefit of meals which are well presented and nutritious. All residents spoken with said that they enjoyed their meals. An activities co-ordinator is employed three afternoons a week and a variety of activities take place. Residents are able to enjoy the freedom of the home and a large garden and two residents attend a day centre at another home in the group. What has improved since the last inspection? What they could do better: The new Service User Guide has not yet been completed in a format suitable for the use residents in the home. Care plans should include a care plan for all assessed needs, with clear instructions for the staff to enable the needs to be met. These should be reviewed on a regular basis, as directed by the National Minimum Standards St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 7 and show evidence that were possible, they were formed in consultation with the individual. There is scope to extend the range of activities available and the home should be aware that activities and appropriate mental stimulation form an important part of the holistic care of the older person with mental health needs. 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. St Ann`s Rest Home DS0000071693.V369313.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 St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6. People who use the service experience adequate quality outcomes in this area. Prospective residents are invited to spend time at the home prior to making a decision over they wish to live there. The Statement of Purpose accurately reflects the current situation in the home. The Service User Guide is in the process of review and, once finalised, copies will be given to all residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 10 The Statement of Purpose has been reviewed and contains information which accurately reflects the situation in the home. No residents have an up to date copy of the Service User Guide, this is currently being reviewed to be in a format suitable for residents currently in the home. Similarly the contracts and terms and conditions are in the process of review. One resident has been given a copy of the new contract and terms and conditions but others are still awaiting this. There have been no admissions to the home since the home came under the present ownership, but one prospective resident has been assessed and invited to spend time at the home prior to deciding whether they wish to live there. The preadmission assessment was examined and included sufficient information to inform staff of the person’s initial needs and to enable a care plan to be formed. The home should ensure that prospective residents are informed in writing once a decision has been made over whether the home can admit them. All residents will be admitted for a month’s trial period. The home is able to admit residents for respite care but not for intermediate care. St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. People who use the service experience good quality outcomes in this area Residents appeared well cared for and stated that they were pleased with the standard of care given. Not all care planning was in place. Medication administration safeguards the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection five (50 ) of care plans were examined. These included a comprehensive long term needs assessment and various care documentation including nutrition charts and waterlow pressure score charts (nursing charts to determine whether an individual has a risk of skin damage). In some care plans residents’ long term needs were in place but there was no planning to show how the home would meet these needs. This should be completed for all St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 12 assessed needs including the mental health needs, which is the determining specialist care need for this home. They should include instructions of how these general needs are to be met, with clear instructions for the care staff, and include how the psychological health needs and any behavioural needs are to be met or minimised. Care plans identifying the care to be received during the night and continence care plans should be put in place. Good risk assessments, including bed rail assessments were in place. The manager should ensure that all parts of the care plans are reviewed on a monthly basis. Staff said that some residents had lost weight during the change of ownership, which may have been due to anxiety. This has been monitored and attention has been placed on dietary needs and the weight replaced. It was noted that many residents are now steadily putting on weight. There was evidence that residents receive care from district nurses, General Practitioners and other health care professionals as required. All residents appeared well cared for and those that were able to discuss their care said that ‘ I am well looked after’. ‘ The staff know us and how to look after us’, ‘ We see the doctor when we need to’. There was evidence that residents were being treated with respect and staff were seen conversing with residents and helping them in an empathetic manner. Only staff with the relevant training administer medication. Although the medication is not administered from a drug trolley, blister packs are used and the medication taken to individual residents with the carer waiting until the resident has swallowed the medication before moving away. New medication policies are in place, no residents self administer medication and there are no controlled drugs being used at present. Mar charts showed that as few medications as possible were prescribed for residents. Staff should ensure that handwritten prescriptions are signed by two people and that where PRN (as required medication) medication has been prescribed, that there are clear instructions in the MAR charts detailing the symptoms for which the medication is prescribed and regarding its administration. The home recently had a terminally ill resident. They were cared for by the home with nursing intervention provided by the district nurses. Staff showed a clear understanding of the care required and the required storage of the controlled drugs prescribed at this time. St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. People who use the service experience good quality outcomes in this area. Routines in the home are flexible to enable the residents to have choice in their daily lives. There is scope for more time to be afforded to the provision of activities and for the range of activities to be extended to enable residents to enjoy their quality of life. All residents said that they enjoyed the meals provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are able to walk around most areas of the home and have free access to a large garden. Routines in the home are flexible allowing residents to have choice in their activities of daily living including their times of rising and retiring. St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 14 An activities organiser works at the home three afternoons a week and residents enjoy a variety of activities, which include crafts, games and quizzes. Records are kept of activities which are taking place and which residents participate, care staff are responsible for other activities taking place which are identified on the weekly activities programme and must ensure that full records are kept of these. One resident stated in a survey that suitable activities were not offered. It was noted that there were few books, games or other activities around the home for residents although the home has purchased a new television and music centre for their entertainment. Two residents attend a day care facility at one of the other homes owned by the group. There is scope to extend the range of activities available and the home should be aware that activities and appropriate mental stimulation form an important part of the holistic care of the older person with mental health needs. Residents are able to have visitors at any time and a local church group visit the home on a monthly basis. Meals are provided from another of the homes in the group and brought to the home in a heated trolley. The menus seen showed that a good variety of food provided and staff said special diets could be catered for. There was a menu board on display in the home, but it did not identify choices of meals that could be available to the residents in this home. Staff said that they were aware of the resident’s likes and dislikes and that residents were asked if they wished to have the meal of the day, but some residents were not aware that there were choices available. Staff said that they had recently asked for the menus to be amended to ensure that they were suitable for the residents in this home. The lunch meal served on the day of the inspection was poached salmon, parsley sauce, green beans, broccoli and potatoes followed by bread and butter pudding. Supper menus include soup, sandwiches and a cooked option. Breakfasts are made in the home. The home keeps a variety of foodstuffs to make snacks for residents during the day and the night. Meals are served in a pleasant dining room and were well presented, with tables being set with tablecloths and napkins. Whilst generally staff were seen assisting residents with their meals in an empathetic and dignified manner, one member of staff was seen to be doing this whilst standing up. This may give the impression to residents that staff are too busy to spend time with them. St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 15 Staff must ensure that temperature checks of transported food as required by the Environmental Health Authority are done on a daily basis. The majority of staff employed at the home have the food handler’s course. St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18, People who use the service experience good quality outcomes in this area. Residents and their representatives are protected by the homes complaints policy, which ensures that complaints are addressed in an open and transparent manner. Staff are aware of their responsibilities in the safeguarding of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a complaints procedure, which meets the regulations and is displayed in the entrance hall. The home has received one minor concern in the past 6 months, which has been addressed and actions put in place to prevent reoccurrence. Records of concerns were seen. One survey from a relative identified that they are not sure who to report concerns to since the new provider has taken over the home. The majority of staff have received adult safeguarding training and this training has been booked for new staff. Adult safeguarding training takes place in house with a training consortium and it is recommended that the future manager and other senior staff attend the training provided by the local authority to ensure that they are fully conversant with the procedures. St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 17 The adult safeguarding policy requires a minor amendment to ensure that the reporting protocols are followed in line with the multi agency guidelines. There have been no adult safeguarding issues at the home. St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,25,26. People who use the service experience adequate outcomes in this area Refurbishment of the home is still ongoing but on completion the home will be a pleasant and comfortable environment for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is in the process of complete refurbishment. This is being done in a manner that causes the least disruption to residents in the home and risk assessments are in place to ensure resident’s safety. There is a large lounge and a separate dining room; external doors are fitted with keypads to ensure residents safety. Residents have access to a large rear garden; this is mostly laid to lawn with a small patio where residents can sit. St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 19 Residents are being encouraged to choose their own curtains and colours for their rooms and new carpets are being laid. However residents have been given the option for their rooms to remain as they were if they wish and one resident has declined to have the room redecorated. Window restrictors and radiator covers are in place and doors around the home have an automatic closing device that responds to the fire alarm. Water temperatures to resident’s outlets have been checked on a regular basis and records showed that these were within recommended parameters. All rooms have a lockable door, most rooms are kept locked but opened for residents as required, risk assessments have identified that no residents currently in the home are able to keep a key, this assessment must be ongoing for new residents coming to live at the home. Lockable drawers are provided in rooms, but at present these are kept unlocked, as current residents are not able to manage the keys. The home does not currently have either a shaft or a stair lift; therefore only residents who are mobile can be accommodated. There is currently only one bathroom that can be used due to the others being in the process of being refurbished and the provider is aware of the need to complete this as soon as possible. The bathroom in use has rust patches on the interior of the bath, which must be either resurfacing or replaced to negate the risk of infection. The underside of the bath hoist was in need of cleaning, this could pose an infection risk and staff must be vigilant in ensuring that this receives the same attention as rest of the hoist. One member of staff has attended an in-depth infection control training course and this should be extended to other staff. Staff were wearing disposable aprons and gloves as appropriate and there were soap dispensers and disposable towels in most rooms. Alcohol hand gel was available. The laundry has been fitted with new washing machines and tumble driers and red bags are used for soiled linen. St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,28,30. People who use the service experience good quality outcomes in this area. There are sufficient staff employed over the twenty-four hours to meet the assessed needs of the residents. Staff receive ongoing relevant training, which ensures that residents receive up to date and efficient care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The duty rota and discussion with staff showed that there are sufficient staff on duty over a twenty-four hour period to meet the assessed needs of the residents in the home. Either the acting manager or senior carer is on duty during daytime hours and a senior carer is on duty most nighttime hours. There are two members of staff, one waking and one sleeping, on duty overnight. New staff undertake a full induction course over a number of weeks, which is based on the recognised ‘ Skills for Care Induction’. Staff commence this on the day they start employment at the home. St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 21 Two (33 ) members of staff have National Vocational Qualification level 3 in care and two members of staff are studying for level 4. Staff are encouraged to undertake National Vocational Qualification level 2 & 3 in care. One member of staff has infection control training and three have training in dementia care. Only those members of staff who have undertaken medication training are involved in administration of medication. There is an ongoing programme of mandatory training which includes moving and handling and fire training and all staff have either updated or planning to update on these in the next month. Three personnel files were examined and these contained all documentation and checks as required by regulation. Two members of staff are currently working under supervision whilst waiting for the Criminal Records Bureau checks to be finalised and have the Protection of Vulnerable Adults check in place. Staff stated that the home was vigilant on ensuring that people are supervised prior to the Criminal Records Bureau check being in place. St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38. People who use the service experience good quality outcomes in this area. Although there is no permanent manager in the home at present, management systems in place ensure the safety and well being of service users and staff. A quality monitoring system is in place to gain the views of residents and their relatives to ensure that services offered by the home meet their expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 23 An acting manager and the responsible individual are currently managing the home, and a permanent manager is in the process of being appointed. Some of the staff previously employed at the home are currently employed which has ensured that continuity of care has taken place by staff that the residents are familiar with. It was evident that management has requested and listened to the opinions of these members of staff to ensure that routines and preferences of residents remained unchanged. The home has a homely friendly atmosphere The home has sent surveys to residents and their relatives as part of their quality monitoring initiative, comments received back were mainly positive. Staff meetings have taken place and existing staff have been able to ensure that any changes taking place would be in line with the preferences of the residents in the home. The Annual Quality Assurance Assessment which was formed part of the inspection was not received by the due date that it was required. Formal staff supervision has taken place at intervals directed by the National Minimum Standards and regulation 26 visits take place monthly (Provider visits to the home required by regulation on a monthly basis). Notifications of incidents have been received by the CSCI. Policies and procedures have been recently reviewed and reflect current practice within the home. The home does not hold any money for residents or become involved in any of the residents financial affairs. There was evidence that all utilities and equipment have been recently serviced. Curtains and furnishings are being replaced with fire retardant materials and doors have magnetic closures, which respond to the fire alarm. All alarms have been tested weekly and staff have received fire training and other mandatory training. The home must ensure that all food temperatures are recorded as required by the Environmental Health Authority. St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 2 2 x 2 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 x x 3 3 3 St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation Reg5 (1) Requirement That a service user guide is produced which is in a format suitable for the use of the service users in the home and is made available to each service user. Following an assessment of needs of the service user, a plan is put in place which gives clear guidance on how these needs are to be met and is formed in consultation with the service user. All parts of the care plan to be reviewed on a regular basis. Timescale for action 08/09/08 2 OP7 Reg15 30/08/08 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 That drugs prescribed to be given on an ‘as required’ basis include details of the symptoms requiring them to be administered. That hand written prescription in the MAR DS0000071693.V369313.R01.S.doc Version 5.2 Page 26 St Ann`s Rest Home 2 3 OP15 OP33 chart include two signatures. That service users receive a choice of menu at meal times. That stakeholders views are included in the quality monitoring process. St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone 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 St Ann`s Rest Home DS0000071693.V369313.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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