Inspection on 30/06/09 for The Bakewells

This is the latest available inspection report for this service, carried out on 30th June 2009.

CQC found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Bakewells 15/06/07

The Bakewells 08/12/05

The Bakewells 03/05/05

The Bakewells 02/11/04

The Bakewells 09/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE The Bakewells 102 Junction Road Deane Bolton Lancashire BL3 4NE Lead Inspector Grace Tarney Key Unannounced Inspection 30th June 2009 09:30 DS0000009282.V376789.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Bakewells DS0000009282.V376789.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Bakewells DS0000009282.V376789.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Bakewells Address 102 Junction Road Deane Bolton Lancashire BL3 4NE 01204 655772 F/P 01204 655772 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) Mrs Helen Bailey Morgan Mr Andrew Philip Morgan Mrs Helen Bailey Morgan Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places The Bakewells DS0000009282.V376789.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the maximum registered number (25), the home can provide care and accommodation for up to 25 Older People (OP) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 9th July 2008 Date of last inspection Brief Description of the Service: The Bakewells provides personal care and support for up to 25 older people both male and female. One of the owners is also the manager. It is a large, extended detached house set in beautiful gardens. It is situated in a residential area, approximately 2 miles from the centre of Bolton. The home is accessible by public transport and is close to local amenities. There are two floors, with a lift to the first floor. The home has 21 single bedrooms, 10 of which have an en-suite toilet, and 2 double rooms. There are 2 dining rooms and 3 lounges on the ground floor. Toilets and bathrooms are provided on each floor. A copy of the latest inspection report is displayed in the entrance hall. The current weekly fees are £430.00 per week regardless of the room occupied. The home provides basic toiletries for the residents and additional charges are made for hairdressing, private chiropody services, personal magazines and newspapers and trips out of the home. This information was received on the 30th June 2009. The Bakewells DS0000009282.V376789.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 stars. This means the people who use this service experience good quality outcomes. The staff at the home were not told that this inspection was to take place although many weeks before the inspection questionnaires (comment cards) were sent out to some of the residents and to the staff. The questionnaires asked what people thought about the care and quality of the service provided. We received 2 comment cards back from residents and 3 from the staff. What they felt about the care and services provided is written in different sections throughout this report. Also before the inspection we (The Care Quality Commission) asked the manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they did at present, what they felt they did well and what they needed to do better. This helps us to determine if the management of the home see the service they provide the same way that we do. We spent 8 hours at the home and during this time we examined care and medicine records to make sure that the health and care needs of the residents were being met. In addition we looked at what activities were available for the residents and whether they were given choices about how they spent their day. We looked at what the residents were having for their meals, to make sure that there was a choice of meals and that they were varied and wholesome. We also looked around the building at some of the bedrooms, bathrooms, toilets and sitting areas to check if they were clean, warm and well decorated. We checked how many staff were provided on each shift to make sure that the residents needs were being met. We then looked to see if management recruited and trained the staff properly and safely. This is so the staff can do their jobs properly and the residents are protected from being cared for by unsuitable people. We also looked at how management check that the care and services they provide is what the residents and their relatives want, or expect. How the residents spending money is managed was also checked. In order to obtain further information about the home we spent time talking to 2 residents, 1 visitor and 3 members of the care staff. The Bakewells DS0000009282.V376789.R01.S.doc Version 5.2 Page 6 What the service does well: Staff make sure that they assess the needs of people before they are admitted to the home. This is to make sure that staff only care for those people whose needs they feel they can meet. Residents feel that they are well looked after by the staff. Residents and relatives made the following comments: “I would have to try very hard to find anything wrong here”. “I can not fault them”. “They are really kind and considerate”. Activities are considered to be an important part of the residents day. The meals provided are varied, nutritious and the residents have a good choice of menu. The residents live in a very safe and very pleasant environment. Management make sure that they check people out thoroughly before offering them a job. This is to prevent the residents being cared for by unsuitable people. Management make sure that the staff are properly trained so that they have the knowledge and skills they need to protect and meet the needs of the residents. What has improved since the last inspection? The management and staff have worked extremely hard to address the issues that were identified during the last inspection: New care plans are in place. They now contain a lot of information about how people are to be cared for, what they can do for themselves and what they need help with. The staff make sure that they continually look at anything that may be a risk to the residents. They then make sure that they write down in the resident’s care plan when they have done this, and what action they have taken to reduce the risk. The way that medicines are handled is much safer. Improvements continue to be made to the already very pleasant and safe environment. The Bakewells DS0000009282.V376789.R01.S.doc Version 5.2 Page 7 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Bakewells DS0000009282.V376789.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 The Bakewells DS0000009282.V376789.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are properly assessed before they are admitted to the home and this gives an assurance to everybody, that a person is only admitted if the staff at the home feel they can meet their needs. EVIDENCE: Before any resident was admitted to the home a senior member of staff from the home, usually the manager, undertook an assessment of their needs. The assessment looks at what help and support the prospective resident needs in all aspects of daily life. The 2 assessments that we looked at were detailed and gave a clear indication of the residents’ needs and what they could and could not do for themselves. Based on this information it was decided that the staff at the home could meet their needs and therefore their admission to the home was possible. The AQAA document sent to us stated that prospective residents and their families are encouraged to have a trial visit. The Bakewells DS0000009282.V376789.R01.S.doc Version 5.2 Page 10 Standard 6 does not apply. The home does not provide Intermediate Care. The Bakewells DS0000009282.V376789.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 & 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans and care practices ensure that the residents needs are met in a very safe, caring and dignified way. EVIDENCE: Individual care plans were in place for each resident. A care plan details the care and support needs that a resident may have and also shows how those needs are to be met by staff. A new type of care plan is now in use at the home. They make accessing the required information a lot easier. The care plans of 2 residents were looked at. They were very detailed and gave clear instruction and guidance on how the care needs of the residents were to be met. They also provided information about the resident’s daily routines, their past life and their interests. This helps the staff and the resident plan for their daily activities so that they can get as much enjoyment out of their lives as possible. The Bakewells DS0000009282.V376789.R01.S.doc Version 5.2 Page 12 The care plans were checked regularly by the staff so that any change in the resident’s condition could be identified and action taken if necessary. We saw that the staff had identified that 1 resident was losing weight. To make sure that this resident’s weight was carefully monitored there was an instruction that the resident was to be weighed after 2 weeks to check progress. There was not however, a plan of care showing how the weight loss was to be addressed. A discussion with the manager showed that the staff were making sure that the resident was receiving a nutritious diet and they were closely monitoring what he was eating and drinking. The manager was advised to develop a care plan for the weight loss so that all staff were aware of what action had to be taken. In the care plans that we checked we saw that the staff looked at whether or not there was any risk in relation to the residents developing pressure sores. They also looked at whether there was any risk of the resident falling and also if a resident was at risk due to problems with their food and fluid intake. Staff also looked at and wrote down how any resident was to be assisted with being moved around and by how many members of staff and what equipment if any, was to be used to assist in safe moving and handling. We saw that residents were weighed regularly and their weight was recorded in their care notes. We saw that staff wrote in the care notes when the residents had received visits from health care professionals, such as dentists, opticians, district nurses and chiropodists. We spoke to a visitor who told us that she felt her relative was very well looked after. She said to us “I am glad that my mum is here”. “I do not want her to go to hospital if she becomes ill”. “I Know she will be well looked after here”. 1 resident told us: “I am very well looked after”. “They are all so good”. We looked at the how the medicines are managed. Only care staff who have received medicine training have responsibility for managing the medicines. We looked at how medicines, including controlled drugs, were ordered, stored and recorded. A safe system of medicine management was in place. Medicines were stored securely and recorded accurately. We did see that the policies and procedures about how to manage the medicines needed to be updated slightly to take account of how the medicines are managed now. Management agreed to amend them. Throughout the day we saw that the staff spoke to the residents in a very friendly and respectful way. Bathroom and toilet doors had safety locks on to ensure privacy. We saw that staff knocked on bedroom, toilet and bathroom doors before entering. The residents looked clean and comfortable, were suitably dressed and looked well cared for. The Bakewells DS0000009282.V376789.R01.S.doc Version 5.2 Page 13 Staff that we spoke to confirmed that the importance of ensuring privacy, respect and dignity is part of their initial training. The Bakewells DS0000009282.V376789.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 & 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents are supported and encouraged by staff to make choices about what they do, so that they can find enjoyment and satisfaction in their daily life and with the activities available to them. EVIDENCE: The residents routines of daily living, such as when they go to bed and when they get up, and their social interests are recorded in their care plans. 1 resident that we spoke to told us that she preferred to stay in her room for most of the day and that is what she did. We saw that an activities person sets the programme of activities for 4 weeks at a time. We looked at the activities file and saw that the activity themes that were set were varied and included things such as seaside memories, floral activities, baking, comedy, musicals and weddings. The residents also have one-to-one sessions such as hand massage and reminiscence therapy. Every two weeks they have movement to music and on the alternate two weeks they enjoy “Music for Health”. This is where the residents can sing and play musical instruments. The residents also have visiting entertainers and have regular trips out. The Bakewells DS0000009282.V376789.R01.S.doc Version 5.2 Page 15 Whilst we were walking around the home we saw that there was a new fish tank for the enjoyment of the residents. The owners have also installed a computer for the residents’ use and are looking to install a webcam so that the residents can speak to relatives who may not live nearby. We were given a copy of the newsletter that is published on a regular basis. This keeps the residents informed about what is going on and what is planned for the future. It is very informative. The AQAA document sent to us stated that presently all the residents were of the Christian Faith. Staff told us that those residents of the Roman Catholic Faith, if they wish, are visited by members of their church and are able to receive Holy Communion every week. We were told that the Church of England clergy visits every month. A visitor confirmed that there were no unreasonable restrictions to her visiting at the home. She said that she was always made to feel welcome and was offered refreshments. We did not eat with the residents but saw what they were having for lunch. There is a very pleasant separate dining room that overlooks the front of the house and a smaller dining room off the lounge. The tables were nicely set with tablecloths, napkins and cruets. The meal served was home cooked, plenty of it, and it looked appetising and nutritious. The residents have a choice of food at breakfast, lunch and teatime. They have the main meal at lunchtime and the lighter meal in the evening. Inspection of the menus showed that there is always a choice of menu. The menu is displayed in the hall. We saw that fresh fruit was given out from the drinks trolley for those residents who wanted it. Hot and cold drinks were being served throughout the day. We were told that none of the residents in the home needed any special diets for religious or cultural reasons. Comments from the surveys were: “The food is good”. “A good choice.” Staff that we spoke to told us that the food was very good, there was plenty of choice and sometimes they felt that there was “even too much at times”. The Bakewells DS0000009282.V376789.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place to ensure that people know how to complain. Staff have a good knowledge and understanding of what abuse is and know what to do if it happens. This helps reduce the possible risk of harm to the residents. EVIDENCE: A notice is displayed in the reception area explaining to people how and to whom they can complain, and how their complaint will be dealt with. It is easy to understand and tells people that complaints will be looked into and a full written response will be given within 28 working days. The complaints procedure is also in the Service User Guide that is given out to all residents. We saw that a record would be kept of any complaint made and would include details of the investigation and any action that the manager may take to put things right. No complaints have been made to us since the last inspection of the 9th July 2008. The AQAA document stated that there was an “open door” policy within the home for all residents, visitors and staff. We spoke to some of the staff and asked them to tell us what they would do if they felt that a resident had been mistreated in anyway. They were very aware of what to do and how to report it. They told us that they had been The Bakewells DS0000009282.V376789.R01.S.doc Version 5.2 Page 17 trained so that they could, as far as possible, protect the residents from harm. We saw evidence of this training in their training files. The Bakewells DS0000009282.V376789.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 24 25 & 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents live in suitably adapted, clean, safe and very pleasant surroundings. EVIDENCE: The home is a large detached and extended property set in very pleasant, well stocked gardens that have seating areas for the residents and their visitors. Accommodation is provided on two floors and can be reached either by a lift or stairs. Downstairs there are 3 lounges and 2 dining rooms. There were enough toilets and bathrooms to meet the needs of the residents. The toilets are easy to get to, as they are close by to bedrooms, lounges and dining rooms. The bathrooms and toilets have a lock on the door to ensure The Bakewells DS0000009282.V376789.R01.S.doc Version 5.2 Page 19 privacy and have suitable aids on them so that the residents can use them safely. Some of the bedrooms also have an en-suite toilet and hand washbasin. We looked at some of the bedrooms. They were clean and warm and were decorated and furnished to good standard. The owners told us in the AQAA document that they undertake an annual maintenance programme to ensure that all rooms and communal areas are maintained and furnished to a very high standard. The radiators throughout the home were suitably covered and we were informed that thermostatic control valves were fitted to baths and showers. This reduces the risk of residents being harmed by protecting them from being burnt or scalded. The home was clean and there were no unpleasant smells. Disposable hand washing equipment (liquid soap and paper towels) was in place in bathrooms, toilets and bedrooms and disposable gloves and aprons were provided for the staff to wear. Providing this equipment helps to reduce the spread of infection and therefore helps to protect the residents health and wellbeing. The laundry is situated in the basement. It had enough equipment to provide an efficient laundry service. The Bakewells DS0000009282.V376789.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 & 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents are cared for by staff that are suitably trained and safely recruited. This helps to keep them as safe as possible. EVIDENCE: A check of the duty rotas and inspection of the training files showed that there was enough suitably trained staff on duty throughout the day and night to care for the residents. The residents told us in the survey forms returned to us that the staff looked after them well and that they listen and act on what they say. The information that we looked at in the training files and the information given to us in the AQAA document showed that 67 of the staff had obtained their NVQ (National Vocational Qualification) level 2 or level 3 in care. This exceeds the standard expected. 4 staff were in the process of doing their NVQ level 2. This would result in an 86 total on their completion. We looked at how the management recruit their staff. The personnel files of 2 staff members were looked at. All were in order and these staff had been properly and safely employed. This helps protect residents from being cared for by unsuitable people. The Bakewells DS0000009282.V376789.R01.S.doc Version 5.2 Page 21 The information received from the AQAA form showed that management provide a staff induction programme for all newly employed staff. This is to make sure that they understand what is expected of them and that people are cared for properly and safely. We also saw that lots of training has been provided for the staff. They have had training in 1st Aid, moving and handling, basic food hygiene, fire safety, health and safety, medicine management, dementia care, mental capacity act and other subjects connected to their jobs. Staff told us that they felt the training was very good. The Bakewells DS0000009282.V376789.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 & 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is safe and well managed. EVIDENCE: The Registered Manager of the home is a qualified nurse and has several years experience in the NHS as well as working in the field of caring for older people. She is a co owner of the home and has a management qualification. She keeps herself regularly updated with training, both in management and care issues. Staff made the following comments in the surveys that were returned to us: “The Manager is very supportive”. “The management always aim to please everybody”. “If the clients want anything they only have to ask”. The Bakewells DS0000009282.V376789.R01.S.doc Version 5.2 Page 23 “The working environment is good and staff training is good”. The staff that we spoke to told us: “The manager is always available”. “She is really approachable”. “I love working here”. The manager and owner of the home check on lots of things that affect the health and well being of the residents. They are about to introduce a new system for checking the care and facilities within the home. We looked at the documents they were going to start using and they looked as though they were going to be a very useful tool for checking the service that they provide. This is to make sure that they get things right for the residents, their visitors and the staff. Management also send out survey forms every year to the residents and relatives asking what they think of the services and facilities that they provide. We saw the results of the surveys. They had been published in the newsletter so that everybody could see what the results were, both positive and less positive. We also saw what the management intended to do to address the less positive comments. They home has also achieved the Investors in People Award. The system in place for the management of residents money was safe. We were told that they mainly handle money brought in for the residents expenses. We saw that receipts were given for any money received and receipts were kept for any money that was spent on behalf of the residents. We saw that regular weekly checking and testing of the fire detection system, fire exits and emergency lights was undertaken and documented. Information from the AQAA document showed us that the equipment and services within the home were serviced on a regular basis. The Bakewells DS0000009282.V376789.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 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 x x 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 The Bakewells DS0000009282.V376789.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations When it has been identified that a resident is losing weight a care plan to address the issue should be put in place. The Bakewells DS0000009282.V376789.R01.S.doc Version 5.2 Page 26 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. The Bakewells DS0000009282.V376789.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!