Care Home: St Lukes Nursing Home

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What the care home does well The manager provides good information to residents and relatives to help them make informed choices, and they are assured that the home can meet their needs through a comprehensive assessment process. Residents benefit from comprehensive care plans and access to a range of healthcare professionals. They enjoy a balanced diet based on their likes, dislikes and choices and benefit from a comfortable and hygienic environment that meets their individual needs. A senior carer stated that the home is well run and the manager is very supportive and approachable. Comments received by the expert by experience on a previous visit from residents were that, they liked the home, were happy and the staff were `lovely.` All felt their needs were met and they could go to bed and get up when they wished. Showers/baths were taken regularly, and staff are `ever so good.` Her observations were that, `residents were treated with care as friends, and I did not hear any resident spoken to in a patronising manner`. What has improved since the last inspection? The manager stated that most of the requirements made in the last visit had been addressed and care plans are continuing to be improved, incorporating the Mental Capacity Act and its outcomes for residents. The administrator has now undertaken an audit of all administration issues and updating where necessary. She also commented that training programmes are ongoing for all members of staff working at this establishment. Decoration of the home is ongoing, with plans for an extension that will be built in the near future. Residents are consulted about the meals, with their likes and dislikes recorded and choices are available. CARE HOMES FOR OLDER PEOPLE St Lukes Nursing Home 35 Main Street Scothern Lincoln Lincolnshire LN2 2UJ Lead Inspector Doug Tunmore Unannounced Inspection 19th May 2008 09:30 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 Lukes Nursing Home DS0000054407.V364674.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 Lukes Nursing Home DS0000054407.V364674.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Lukes Nursing Home Address 35 Main Street Scothern Lincoln Lincolnshire LN2 2UJ 01673 862264 F/P 01673 862264 nursingstlukes@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) Carecall Limited Paula Willows Care Home 30 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (30) St Lukes Nursing Home DS0000054407.V364674.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only:Care home with nursing - Code N To people of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP Physical Disability, over the age of 65 years - Code PD(E) Dementia, over the age of 65 years - Code DE(E) The maximum number of people who can be accommodated is: 30 2. Date of last inspection 28th November 2007 Brief Description of the Service: St Lukes Nursing Home is situated four miles north of Lincoln in the rural village of Scothern. The village has a pub and a church. The home is registered as a care home, with nursing, and accommodates 30 older people. The home is a converted two-storey building with a single storey extension to the rear. There are 26 single rooms and 2 shared rooms. There are enclosed gardens to the rear of the property laid to lawns and flowerbeds. These have been made accessible to service users by means of ramps and handrails. There is also an enclosed courtyard furnished with garden furniture and a containing a water feature. The home has a registered Manager who is responsible for the management of care. The responsible individual for the company is responsible for the administrative aspects of the homes management. The fees at the inspection visit on the 19/05/08 ranged from £379:00 to £585:00 each week. Extras are for hairdressing which range from £6:65 upwards, chiropody £8:50, personal newspapers and magazines. The provider makes no charge for escorting residents to hospital. Information about the home can be obtained from the manager of the home. The service users guide is available from the manager and is kept in the office. All residents have a copy of the service users guide in their rooms. St Lukes Nursing Home DS0000054407.V364674.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star. This means that people who use this service experience good quality outcomes. One inspector undertook this visit to the home. However, information gained during a previous visit with an expert by experience, on the 26/11/07, will also be used throughout this report. This formed part of an unannounced key inspection. This visit took into account any previous information held by The Commission for Social Care Inspection (commission) including the homes previous inspection reports and the homes Annual Quality Assurance Assessment form, hereafter in this report referred to as AQAA. ‘Have Your Say’ surveys were sent to the home by the commission and six were returned by residents, seven from relatives and three from carers. The site inspection consisted of case tracking a sample of two residents records and assessing their care. The inspector joined three residents for lunch and spoke to other residents during the meal. The inspector spent time with two residents, the registered manager, business administrator and a senior carer. A full tour of the home and a review of a sample of the records were also included. What the service does well: The manager provides good information to residents and relatives to help them make informed choices, and they are assured that the home can meet their needs through a comprehensive assessment process. Residents benefit from comprehensive care plans and access to a range of healthcare professionals. They enjoy a balanced diet based on their likes, dislikes and choices and benefit from a comfortable and hygienic environment that meets their individual needs. A senior carer stated that the home is well run and the manager is very supportive and approachable. Comments received by the expert by experience on a previous visit from residents were that, they liked the home, were happy and the staff were ‘lovely.’ All felt their needs were met and they could go to bed and get up when they wished. Showers/baths were taken regularly, and staff are ‘ever so good.’ Her observations were that, ‘residents were treated with care as friends, and I did not hear any resident spoken to in a patronising manner’. St Lukes Nursing Home DS0000054407.V364674.R01.S.doc Version 5.2 Page 6 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. St Lukes Nursing Home DS0000054407.V364674.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 St Lukes Nursing Home DS0000054407.V364674.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): Standards 1, 2, 3,4 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive good information about the home, which helps them to make an informed decision about where to live. The clear assessment process assures residents that their needs can be met within the home. EVIDENCE: The providers AQAA showed that; ‘prior to admission an initial assessment by our registered manager, or her deputy, is carried out, followed by a letter, confirming our ability to meet their individual needs. Further liaison with other multi-disciplinary professionals ensures that any other requirements are in place. New service users are welcomed to a pre-arranged room at St Luke’s, which they will have viewed beforehand. Our Service User Guide and St Lukes Nursing Home DS0000054407.V364674.R01.S.doc Version 5.2 Page 9 Statement of Purpose provide them with further information concerning the service they can expect and useful data regarding the staff who will be caring for them’. A review of all information available prior to this inspection and evidence seen at this inspection in residents files and care plans showed that the home does not admit residents without a care assessment being undertaken. Prospective residents are also written to by the home confirming whether they can meet the residents care needs or not. Six residents surveys returned to the commission showed that four felt that they received a contract from the home, one was not sure and one resident felt that he had not received a contract. All six residents stated that they had enough information about the home prior to admission. Seven relatives surveys indicate that they or their relative received enough information about the home to help them to make a decision about coming to live in St Luke’s. The provider undertakes intermediate care, having two beds at the present time. Full care need assessments are undertaken and on a previous visit the intermediate care nurse and physiotherapist were reviewing the care of their patients. We looked at two files of people who were being case tracked which contained a contract detailing the care that they were to receive. St Lukes Nursing Home DS0000054407.V364674.R01.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): Standards 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from comprehensive care plans, which accurately reflect their assessed needs. Their personal and healthcare needs are met in a manner that promotes and maintains their privacy and dignity. An accurate record is made of medication given to people so as to ensure their safety. EVIDENCE: The providers AQAA states that;‘ all service users are vigorously assessed by a trained member of staff so that all their individual care needs are identified and met. St Luke’s has a professional relationship with the continence nurse who comes when needed. Exercise and physical activity is provided when appropriate to service users who are able. A physiotherapist also comes in St Lukes Nursing Home DS0000054407.V364674.R01.S.doc Version 5.2 Page 11 twice a week privately. All service users have a choice of retaining their own GP, or to transfer to one of two of our local GP services’. Surveys returned from residents confirmed that five felt that they always received the medical support they needed and one usually did. Specific comments received from relatives surveys were; ‘the staff are all very good and very helpful’. ‘Whenever I visit, 4-5 times a week, Dad is always comfortable and his needs appear to be met. He is always clean, shaved and neatly dressed’ One survey reflected the view that, ‘some of the carers/nurses do not understand the needs of my mother who has severe dementia’. All other surveys indicated that the staff have the right skills and experience to look after people. Two people seen stated that they see the GP when they want to and felt that their health and care needs were met at the home. A specific comment made by one resident was, ‘my privacy and dignity is quite private and staff wrap towels around me’. Another resident confirmed that she was aware of her care plan and got on well with staff who were ‘very nice and friendly’ and had lots of contact with them. We looked at two files of residents who were being case tracked. It was found that care plans had a blanket approach to all residents privacy and dignity. The manager stated that she would ask all the people in the home how their individual privacy and dignity needs should be maintained. A previous visit in 2007 evidenced that monthly reviews were available on each file and that residents have access to McMillan nurses, District Nurses and GP’s where they require such. During that visit the intermediate care nurse and the manager of the home were conducting a review of a residents needs. We looked at residents medication sheets and an accurate record was kept. One resident who self medicates had a risk assessment showing the potential risks from administering her own medication. This resident told the inspector that she was aware of the risk assessment and that she had a lockable facility in her room. She also said that staff keep a friendly eye on her to ensure that medication is taken and checked. A tour of the home found that all residents have a lockable facility. St Lukes Nursing Home DS0000054407.V364674.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. This judgement has been made using available evidence including a visit to this service. Residents enjoy a varied and appropriate activity programme, which enables them to maintain an active social life. They are able to choose from a range of foods within a balanced diet. EVIDENCE: The providers AQAA evidences that ‘Nutritional assessment and screening is carried out on admission and carried out monthly, including weight gain/loss, and appropriate action taken accordingly. St Luke’s provides opportunities for all service users to: Reminisce – our Care Plans include a personal history to enable staff to interact and talk to individuals about their interests. Share conversation in our comfortable communal areas. Enjoy the peace and privacy of their own room if preferred’. St Lukes Nursing Home DS0000054407.V364674.R01.S.doc Version 5.2 Page 13 There was a list of activities for the information of residents and outings had been planned for the coming months. The residents notice board showed that residents undertake music for health, reminiscences, aroma therapy/reflexology and monthly gardening. Religious holidays are also celebrated in the home and relatives are also invited to these events. One resident said that she does cooking with three other residents and everybody had enjoyed that the scones they had baked. She also said ‘we play bingo and sing hymns on a Sunday and if its nice weather we sing outside’. She also commented that gardening club has just started and she is looking forward to it. She confirmed that her son visited regularly and was made welcome at the home. A second resident said ‘the foods good here’ and that he goes to his daughters twice a week. The majority of relatives surveys indicated that people are supported to live the life they choose as much as possible. At a previous visit on the 26/11/07 residents informed the expert by experience that they have ball-playing activities using light balls. They said that they enjoyed dominoes, cards, bingo and weekly visits by a hairdresser. When craftwork is in progress, a large table is used in the lounge, and a glass of sherry enjoyed. The expert by experience noted, at that visit, that there is no choice of lunch, but the usual choice at tea time i.e. soup, sandwiches, beans on toast etc. The meal of gammon, mashed potato and vegetables, with white sauce, was served on small plates and was hot and well cooked. Residents were not ‘over faced’ by huge amounts of food, but no ‘seconds’ were offered. The hot desert looked equally good. The inspector joined three resident for lunch and found the food to be hot, well presented and nutritious. Residents made favourable comments about the food and staff were observed supporting residents to eat, being mindful of their dignity. St Lukes Nursing Home DS0000054407.V364674.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): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures for addressing and monitoring complaints and concerns are in place to protect residents who are vulnerable. Adult protection issues are taken seriously and the manager would seek advice if she had concerns. EVIDENCE: The providers AQAA confirms that ‘staff are fully aware of the need for the protection and the well being of our residents and that of each other, they are fully aware of the adult abuse policy that we have in place and of the procedures that needs to be followed in the event of an incident of concern, we would not tolerate abuse of any kind’. The training profile evidenced that safeguarding vulnerable adults training had been undertaken by carers and further training is planned for June 2008. Specific Comments from relatives survey were, I say this home is very good, my mother is very happy here. Another comment was: the carers are kind and have time to talk to the residents which is nice. All surveys showed that St Lukes Nursing Home DS0000054407.V364674.R01.S.doc Version 5.2 Page 15 they, the relatives, and residents know how to make a complaint and no concerns were raised. We looked at one residents file and found a risk assessment and care plan detailing the care required for restraint undertaken by the use of a wheelchair support strap. There was evidence that the use of this device had been discussed with the resident and her representative. The social services safeguarding team had been informed and had agreed the procedure undertaken by the manager. Two residents stated that they feel safe and had no concerns. One resident said that she did not have any complaints, but if she did she would talk to the manager. The providers complaints form was seen and gave details of the process of recording a compliant, its outcomes and method of responding to a complainant. One complaint had been made, which was dealt with in line with the providers policies and procedures. St Lukes Nursing Home DS0000054407.V364674.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): Standard 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in clean, well-decorated, homely and safe accommodation. EVIDENCE: The providers AQAA states that, ‘we have a thorough routine of maintenance in respect of equipment and upkeep of grounds and building. In particular the communal lounges have been beautifully re-decorated with purpose made curtains providing the finishing touch. Service users were consulted in the choice of colour scheme and curtaining creating a feeling of inclusion. St Lukes Nursing Home DS0000054407.V364674.R01.S.doc Version 5.2 Page 17 Our team of cleaners maintain a home that is clean and hygienic, quickly administering to and eradicating any smells that are initiated’. We undertook a tour of the home including residents bedrooms, which were seen to be well personalised, clean, tidy and containing specialist equipment in accordance with assessed needs, such as pressure relieving mattresses and hoists. Twelve hospital beds are now in use and the provider has plans for all rooms to have these specialist beds in the near future. Call bells were accessible in bedrooms and in communal areas and the environment in general was clean and tidy. At a previous visit in 2007, residents said that they like their rooms. Residents surveys showed that one felt the home was always fresh and clean, with five residents stating that the home is usually fresh and clean. Two residents seen during this inspection confirmed that they liked their rooms and that the home is always kept clean. The inspector found no unpleasant odours during this inspection. The providers business plan for 2008 was seen and evidenced that extensive refurbishment is continuing to be undertaken. St Lukes Nursing Home DS0000054407.V364674.R01.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): Standards 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by robust recruitment procedures. Residents benefit from a knowledgeable staff team who are well trained. EVIDENCE: The providers AQAA evidenced that, ‘we have an excellent skill mix of qualified and non-qualified staff. Our nursing staff can also offer different areas of speciality and belong to their speciality groups, e.g. tissue viability, continence, NVQ Assessors. There are 26 of staff working towards completing NVQ level 2. ’. Resident’s surveys show that they feel that they receive the care and support that they need. A specific comment was ‘there is always someone there that I can talk to or ask for help if I need it’. A resident felt that there were not always the numbers of staff required due to sickness and holidays. However, she commented that due to her condition St Lukes Nursing Home DS0000054407.V364674.R01.S.doc Version 5.2 Page 19 when she rings the call buzzer the staff always come quickly, ‘they’re very good’. Staff surveys evidenced that training is provided which is relevant to their role and helps them understand the needs of people living in the home. They also confirmed that they had undertaken Criminal record Bureau checks and two references before starting work. These surveys also showed that staff have undertaken training relevant to their work and are kept up to date with new ways of working. One specific comment was that ‘the manager has enrolled me in several courses and I have completed National Vocational Qualifications (NVQ) level 2 and have now started level 3 in caring for people who are elderly’. A senior carer confirmed that she has undertaken NVQ training level 2 and is currently undertaking NVQ training level 3. She stated that the home has improved enormously over the last twelve months, with a training plan in place for 2008, with all carers encouraged and supported to undertake further training. We looked at the providers training plan, which evidenced that a wide range of training has been undertaken and also planned for the rest of 2008. This includes; fire lecture, Dementia course, moving and handling, diabetes training, palliative care, infection control and managing continence. We looked at two personnel files and found that one did not have those references required for a carer from a previous employer prior to commencing work at this home. The manager stated that she would chase the person who was to supply this reference straight away. St Lukes Nursing Home DS0000054407.V364674.R01.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): Standards 31,32, 33, 35, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed meeting the needs of residents whose health, safety and welfare are protected. Accurate accounts are kept of resident’s monies. People’s interests are safeguarded by their involvement in the running of the home. EVIDENCE: The Providers AQAA states that ‘The Registered Manager, who is qualified to meet the demands of the role within a nursing environment, and Business Manager (Responsible Person) work together to ensure their specialist areas promote and maintain good working practices and a safe environment for service users, visitors and staff’. St Lukes Nursing Home DS0000054407.V364674.R01.S.doc Version 5.2 Page 21 The registered manager at St Luke’s is a qualified SEN and ADNS (Advanced Diploma in Nursing Studies) and has recently completed the Managers Award. With four years at a senior management level, two of which as deputy at St Luke’s, she took on the role of manager twelve months ago. Positive comments were made both by people living in the home and staff about the manager. A resident stated that the manager ‘is lovely and she will listen to you, really excellent’. A senior carer commented that the manager is approachable and always helpful and supportive. She has worked very hard since becoming the manager and brought about lots of changes, which were needed. The home now assists residents with managing their personal allowances and a record is made of all transactions, which is signed by two members of staff. The administrator evidenced that an accurate record of residents monies is kept and receipts were available to show monies spent by residents. The minutes of the last residents meeting and family meeting were held in April 2008 and showed that residents are encouraged to voice their views and are actively involved in issues relating to the running of the home. A resident confirmed that she has attended two residents meetings and stated that ‘ I can voice my opinion at these meetings, I am quite happy and content’. We looked at two residents files, which showed that a record had been made in both about clothing items that residents brought into the home. However, some records had not recorded those valuables that the residents may have brought with them. The manager stated that staff would check residents valuable that they might have immediately and add this to the clothing record. The manager was also reminded that any event that affects the general welfare or health of resident must be reported to the commission. An internal audit is undertaken with residents and visitors view gained through questionnaires which is then assessed and outcomes from peoples comments posted on the notice board. We looked at surveys, which were very positive in relation to the care and service received by residents at this home. The providers AQAA showed that; gas safety inspections have been carried out, electrical wiring checks, fire precautions checks, and portable electrical equipment checks. The manager stated that risk assessments are available relating to the home environment. Staff had been trained in Health & Safety, Fire procedures, etc. St Lukes Nursing Home DS0000054407.V364674.R01.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 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 x X 3 St Lukes Nursing Home DS0000054407.V364674.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Lukes Nursing Home DS0000054407.V364674.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Lukes Nursing Home DS0000054407.V364674.R01.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. 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