Inspection on 31/08/06 for 39 Hawthorne Grove

This inspection was carried out on 31st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

39 Hawthorne Grove 07/03/08

39 Hawthorne Grove 10/10/05

39 Hawthorne Grove 18/04/05

39 Hawthorne Grove 22/11/04

39 Hawthorne Grove 27/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hawthorne Grove (39) 39 Hawthorn Grove Trowbridge Wiltshire BA14 0JF Lead Inspector Ms Sally Walker Unannounced Inspection 31st August 2006 09:05 DS0000036132.V311849.R01.S.doc Version 5.2 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 DS0000036132.V311849.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 Adults 18-65. 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. DS0000036132.V311849.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorne Grove (39) Address 39 Hawthorn Grove Trowbridge Wiltshire BA14 0JF 01225 767441 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) londonroad@tiscali.co.uk Milbury Care Services Limited Miss Adele Lena Caroline Flegg Care Home 3 Category(ies) of Learning disability (3), Physical disability (3), registration, with number Sensory impairment (3) of places DS0000036132.V311849.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th October 2005 Brief Description of the Service: 39 Hawthorne Grove is run by Milbury Care Services Limited which has a regional office in Henley Oxfordshire and runs another care home in Wiltshire. The home is located in a residential area of Trowbridge and the West Wiltshire Housing Association owns the property. The home is a detached bungalow that does not stand out from the adjacent properties. The statement of purpose says that the home is the residents permanent home for as long as it is appropriate to their needs. Residents receive personal care and support throughout the day from a permanent staff team, with two staff sleeping in at night and a minimum of 2 staff during the day. Each resident has their own single bedroom, one of which has its own ensuite facilities. There is a large sitting room, also used for staff sleeping arrangements, a domestic kitchen with dining area, separate toilet, separate bathroom and office with staff sleeping arrangements. There was a standard fee of £1445.00 per week. DS0000036132.V311849.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced Key Inspection took place over 2 days as the manager was on leave on the first day. It began on 31st August 2006 from 9:05am to 10.30am and 2pm to 4.45pm. It was completed on 19th September 2006 between 10.00am and 12.15pm when Miss Flegg was able to provide access to staff records and discuss actions taken to address the requirements and recommendation of the last report. The care records, records of money held on residents’ behalf, staffing records and accident log were inspected. As part of the inspection process, the views of families, GPs and care managers were sought. A care manager reported that the home had managed the resident’s needs well. They also said that the resident was receiving appropriate support to engage in activities outside the home. Some issues had been resolved and the resident had a communication plan. A GP reported that there were no medical issues for their patient or concerns about the quality of the resident’s care. A relative reported that they were always made welcome when they or their family visited. They said the resident was always happy and well cared for. They said the home kept them informed of health issues or concerns. They said the resident ate well and went out and about. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: The home offers a “home for life to residents”. The environment is comfortable, homely and clean. Staff support residents to communicate in the way they prefer and some gestures are used. The majority of the staff had worked at the home for some time and were well known to residents. Residents had good relationships with staff. The uncertain future provision of day services has prompted the home to consider how residents are to be involved in meaningful and fulfilling activities in the future. Staff were taking residents out to events in the locality and were hoping to provide some more home bases activities. Extra funding was needed for activities. Residents had good contact with families. Residents are encourage to follow a nutritious and varied diet and have support to maintain this. Residents also go out for meals. There was good access to GPs and specialist healthcare professionals. Staff were prompt to refer any concerns to the relevant person. Staff were well trained and had previous experience of either working at the home or in similar care settings. A robust recruitment procedure was in place. The home will have achieved 100 of staff with at least NVQ 2 once three staff have received their certificates. Staff are required to read and sign up to risk assessments and all of the company’s policies and procedures. DS0000036132.V311849.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. DS0000036132.V311849.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000036132.V311849.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 No new residents had been admitted to the home since it opened in the late 1980’s. The Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: All of the residents had lived at the home since it opened in the late 1980’s. The home offers a “home for life” to the residents until any nursing care cannot be provided by the district nurse. No new residents had been admitted so the pre-assessment process could not be assessed. Miss Flegg reported that contracts had been given to residents’ representatives but had not all been returned. She went on to say that residents also had a contract with the placing agency which would have been signed when they first took up residence. She did not have copies of these documents as they were kept at the company’s regional office. Residents’ files contained pictorial and worded service agreements dated 5.7.06. DS0000036132.V311849.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Care plans had improved with good detail of each resident’s individual need and preferred daily routines. Residents made some day-to-day decisions and communication methods were encouraged. Residents had access to advocacy services which they had to pay for. Risks were identified in care plans. The Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The care plans were very comprehensive with good detail of all aspects of residents’ current needs. Preferred daily routines were identified for the giving of intimate personal care as well as methods of communication, choice, emotional needs, support with eating, likes and dislikes, moving the resident, healthcare, reducing behaviours and activities. The communication plans showed good detail of various methods that residents used including body language, signs, voice, words and objects of reference. There was good evidence that staff had a good understanding of the residents and could immediately know what residents had communicated. Staff explained how they knew when residents were happy, sad, did not want something, wanted to go out and do something, were in pain or ill. They talked about how residents would take staff to the kitchen and get a cup for a drink, take them to look at something that was bothering them or put night clothes on if they DS0000036132.V311849.R01.S.doc Version 5.2 Page 10 wanted to go to bed. Residents would also take the clothes out of their wardrobes that they wanted to wear that day. Staff said that some residents used some Makaton gestures. The requirement that daily reporting on residents’ needs must be related to the guidance given in the care plans had been actioned. Staff were now reporting more fully on their interventions, observations and monitoring of residents needs in each of the prescribed areas of their daily diary. The recommendation that care plans were kept with the daily records so that staff were aware of residents’ current needs rather than relying on memory had not been actioned. Miss Flegg reported that staff did not necessarily work with the care plans everyday but would review and revise them if needs changed. She said that care plans were formally reviewed by the keyworker on a regular basis and this was evidenced in the monthly summary sheets. There was some evidence that residents were encouraged to make some decisions about what they wore each day, what they had to eat or where they went on trips out. Residents have access to independent advocates as necessary, but they have to pay for this service. Benefits were paid directly to the company and residents’ personal allowance paid into their residents cash accounts held in the safe. Any risks to individual residents were identified in their care plans. These identified their environment, both at the home and when in the locality, activities, choking, moving and handling and bathing. Bathing risk assessments were clear on timescales if residents liked to spend time alone in the bath. They had been reviewed in June 2006. DS0000036132.V311849.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15,16 & 17 Residents made use of local facilities particularly when day services were closed. Residents maintained close relationships with family and friends. Residents were treated with respect and their right to privacy respected. Residents had a good diet based on what they liked to eat and nutritional content. The Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Staff took residents out mid-morning as planned on the first morning of the inspection as the day service was closed. One resident was being supported with eating their breakfast and was looking forward to going out. The home had its own accessible transport. Staff were considering alternative activities as the continued use of day services was uncertain due to funding. Miss Flegg reported that she had submitted proposals to the company to agree funding for more activities to be provided by the home if day services were stopped. But this may not be considered in this financial year. She said that more staff would be needed if each resident was to continue to pursue their own individual activity programme. Staff took residents out regularly. Residents went for walks, swimming, to the pub and out for meals. Staff said that they had taken one resident on holiday to Disneyland Paris, shopping at an outlet DS0000036132.V311849.R01.S.doc Version 5.2 Page 12 village and to local parks. They said that those residents who could not necessarily cope with staying away from home had more special days out during the holiday time. Miss Flegg said that staff would continue to take residents out as much as they could if day services were cut. Staff said they were considering offering in house activities, for example, hand massage, music sessions or baking, depending what residents wanted. A proposal had been submitted to the company to fund some more music equipment. Residents went to all the local events, for example, fetes and the carnival and leaflets were available for local facilities. Residents had regular contact with families; one relative said they and their family were always made welcome when they visited. Some residents would be encouraged to be involved in household tasks but may only be present when staff carried them out. Staff engaged with residents and always involved residents in conversations when supporting with eating or working in the kitchen. A new larger television had been purchased. There was a menu planned for the week showing the main meal which was taken in the evening. Residents had a snack at lunchtime which was recorded in their daily notes. The menu showed a range of meals based on residents’ likes and dislikes. The store cupboard, fridge and freezer were well stocked. Fresh fruit and vegetables were available. Where residents were having difficulties with following a nutritious diet because of dislike of certain foods, a dietician had been consulted and advice was to provide meals that would be eaten rather than trying different meals. The GP checked residents’ nutritional health. Residents also went to a fast food chain as a regular treat. DS0000036132.V311849.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Care plans were clear about how residents preferred to receive their intimate personal care. All aspects of personal and health care needs were identified. Staff made prompt referrals to relevant healthcare professionals when concerns were noted. Residents relied on staff to manage their medication. The Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Care plans and daily routine sheets identified how residents were to be supported. Personal intimate care was provided in the privacy of residents’ bedrooms. Residents got up when they wanted if they were not going to the day service. Residents chose their own clothes. Moving and lifting equipment was in place if needed. Residents who may have difficulties with eating had their meals mashed or liquidised and food supplements and vitamins were available. Staff were monitoring residents food intake. A dietician had also given advice on improving diet. The GP was regularly monitoring residents’ health with regard to nutrition. Regular weighing of residents would support nutritional monitoring. Residents had good access to specialist healthcare professionals when required. Nursing care was only provided by the district nurse who came in twice a week to carry out one treatment. Residents were registered with a local GP and would attend the surgery for appointments. It was clear from the records that staff were prompt in referring residents to the relevant healthcare specialist when concerns were noted. One relative said the DS0000036132.V311849.R01.S.doc Version 5.2 Page 14 home kept them up to date with the resident’s progress. One GP said they had no concerns over the quality of the care provided. None of the residents administered their own medication. One of the staff explained the process of administering residents’ medication from the locked cabinet. Staff would check the medication against the medication administration record before administering and sign the log when it had been taken. All staff were responsible for ordering new medication and checking it in on the regular days if they were on duty. There were no controlled drugs or invasive treatments. Staff were trained in administering medication as part of their induction and had ongoing training but there was no evidence that their competency was regularly checked. The recommendation that all handwritten entries on the medication administration record where medication was changed or stopped were witnessed, dated and signed by 2 staff had been actioned in part. There was one entry for a painkiller which was not dated but showed 2 signatures. The recommendation that the organisation’s medication policy clearly stated that medication was not crushed, potentially rendering it unlicensed had not been addressed. Miss Flegg reported that none of the medication was being crushed or disguised in drinks or food. It was also recommended that alternative mediums should be sought from the prescriber and that where unusual methods of administration were directed by the prescriber, written confirmation of this should be requested. Miss Flegg reported that all residents were able to take and swallow their medication. DS0000036132.V311849.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Systems were in place for residents and their representatives to make complaints about the service. Staff followed the local vulnerable adults policy. The Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home worked to the company’s complaints policy and procedure. Miss Flegg said that residents’ representatives had been given a copy of the procedure. The company intended to produce “help” cards to allow residents to alert the organisation of any concerns or complaints. One relative confirmed that they had received information about complaints and said that their complaint had eventually been resolved to their satisfaction a few years ago. Residents were able to access advocates. The home had a complaints log but none had been received recently. The home worked to the company’s policy on the protection of vulnerable adults and the local policy document for Swindon and Wiltshire was available. Staff had received training in the protection of vulnerable adults which was mandatory. Miss Flegg said the home had not had experience of using the procedure but staff would refer if concerns were noted. The records of monies held on residents’ behalf were being satisfactorily kept. These were regularly audited by the manager and the operations manager at the unannounced visits. DS0000036132.V311849.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Residents’ benefit from a comfortable, homely, clean environment. The company had finally secured works to be carried out by the housing association for the protection of residents. The Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home is a large single storey house in a residential area. Each resident has their own bedroom and full use of the communal facilities. Bedrooms were personalised to suit each individual’s personality and preferences. Lifting equipment was available. One relative said that the resident had a nice bedroom which was described for its comfort, cleanliness and personal items. The requirement that the Commission was supplied with an action plan detailing when the requirements of the Environmental Health Officer’s report had been actioned. A wash hand basin had now been fitted to the worktop in the kitchen to enable those involved in food preparation to wash their hands away from any preparation in the main kitchen sink. The company had been in negotiations with the Housing Association since April 2005 for this to be carried out. A new dishwasher had also been installed. DS0000036132.V311849.R01.S.doc Version 5.2 Page 17 The requirement that the Commission was provided with an action plan detailing when the radiators would be guarded to ensure safe surface temperature had also been actioned. New radiators had been fitted to all rooms ensuring that if anyone fell against the radiators, they would not suffer any injuries. The carpet in the hallway was stained and staff said that although it was reasonably new it was difficult to keep clean. Miss Flegg reported that the supplier had admitted that the carpet was not fit for purpose and was going to replace it but had not yet given a date. The conservatory was also in need of a new carpet. Miss Flegg expected that this would be replaced at the same time. The home was cleaned to a good standard and no unpleasant odours were detected at any time during the 2 days. Staff had access to gloves and wipes for ensuring good infection control practices. DS0000036132.V311849.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Staff were well trained and had had good experience of working with the residents and in other care settings. A robust recruitment process was in place. The Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There were 2 staff on duty with 3 residents. On the first day of the inspection staff said they were short staffed due to a vacancy and leave, but shifts were being covered. They said they tried to cover the shifts themselves as in the past residents had been unsettled by agency workers who were not known to them. Miss Flegg said that she had interviewed successfully for some of the hours and was awaiting references and a negative Criminal Records Bureau certificate. The remaining hours were being covered by a member of bank staff who regularly worked each week but did not wish to work full time. A robust recruitment procedure was in place. Miss Flegg said that she would select candidates for interview and the company would request all the relevant information from candidates. All new staff were inducted and the company had produced a new format for recording progress. Staff talked about their experience of working with people with learning disability in other homes now part of the company and in different care settings. They also said that most staff had either achieved or were completing NVQ 2. Miss Flegg said that they were very near to achieving 100 with NVQs with three staff awaiting certificates. DS0000036132.V311849.R01.S.doc Version 5.2 Page 19 Staff had access to the company’s training programme. Miss Flegg said that training was now provided locally so staff had better access. She kept a matrix showing which staff had achieved the core and preferred training offered by the company. Staff said they had recently trained in person centred planning, autism, non-verbal communication, protection of vulnerable adults and medication. Staff had accessed the internet for information about different diagnoses and medical conditions which was kept on file. Staff said they had regular supervision as evidenced by the plan in the office. Staff were required to sign up to residents’ risk assessments and each of the company’s policies and procedures. DS0000036132.V311849.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 The home is run in the best interests of the residents. Some quality monitoring was being carried out. Staff were trained to ensure the health and safety of residents. Regular checks of the environment, equipment and systems were carried out for the protection of residents and staff. The Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Miss Flegg also manages another home within the company and said she spends between 7 and 20 hours in each service each week, depending on the need. There was a senior staff in this home to take some delegated responsibilities on a day-to-day basis. Staff said that there was a duty manager system for advice and support in an emergency if Miss Flegg was not available. Miss Flegg is a registered nurse although she is not paid in that capacity. She keeps her PIN number up to date with the required amount of training and has the Registered Managers Award. She was undertaking training to become the home’s NVQ assessor. Other recent training included recruitment and selection and disciplinary and grievance. DS0000036132.V311849.R01.S.doc Version 5.2 Page 21 The accident log was being appropriately completed for residents and staff. There were very few accidents recorded. Some questionnaires asking residents their views on the service were on file. More evidence was available from the operation’s manager’s reports on the unannounced visits as required by regulation 26. The operations manager met with residents during these visits and gained residents views with staff support. Environmental risk assessments were in place and the company expected review every 3 months. On one of the visits staff were carrying out some of the checks. Audits of all the health and safety checks were carried out by the operations manager at the unannounced visits. DS0000036132.V311849.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 Adults 18-65 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 X 2 N/A 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X DS0000036132.V311849.R01.S.doc Version 5.2 Page 23 No 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. 1 2 3 Refer to Standard YA19 YA41 YA20 Good Practice Recommendations Regular weighing of residents would support nutritional monitoring. Care plans should be kept with the daily reports for easy reference and revision. The company’s medication policy should make it clear that medication must not be crushed as it could render it unlicensed. Generally most medication can be prescribed in easily administered mediums. DS0000036132.V311849.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: 0845 015 0120 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 DS0000036132.V311849.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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