Inspection on 04/02/08 for 62-66 Windermere Road

This inspection was carried out on 4th February 2008.

CSCI found this care home to be providing an Excellent 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

62-66 Windermere Road 22/03/07

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 62-66 Windermere Road Up Hatherley Cheltenham Gloucestershire GL51 5PL Lead Inspector Mr Tim Cotterell Unannounced Inspection 4 and 14 February 2008 09:30 th th 62-66 Windermere Road DS0000066770.V345663.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 62-66 Windermere Road DS0000066770.V345663.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. 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 62-66 Windermere Road Address Up Hatherley Cheltenham Gloucestershire GL51 5PL 01242 242684 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) www.brandontrust.org The Brandon Trust Mrs Sarah Katherine Mary Frank Care Home 12 Category(ies) of Learning disability over 65 years of age (12), registration, with number Physical disability over 65 years of age (12) of places 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd March 2007 Brief Description of the Service: Windermere Road is a twelve-bedded home that provides residential accommodation for adults with learning and physical disabilities who may have complex needs. It is a nursing home that provides nursing care for people with learning and physical disabilities and a qualified nurse is always on duty. The home is situated within easy access to Cheltenham town centre. The home benefits from being on the main route into Cheltenham with easy access to public transport. The accommodation consists of three bungalows each with four single bedrooms, a fully adapted bathroom and a lounge diner. The home has a wellequipped sensory room. There is pleasant garden with an accessible patio and raised flowerbeds. The front of the property has ample space for car parking. The home is run by Brandon Trust and Advanced Housing manage the property which include all the repairs. Accurate information about fees were provided and range from £1200 per week. The assessment of fees are calculated according to needs assessment. All personal items are not included by the fees. 62-66 Windermere Road DS0000066770.V345663.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 3 star. This means that the people who use this service experience excellent quality outcomes 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. The inspection was undertaken over two visits and consisted of looking at the accommodation, talking to the registered manager, deputy manager, staff on duty, a number of residents, a visiting health care professional and a relative who were visiting the home. The records in respect of medication, care plans, risk assessments and personal monies were seen. What the service does well: The home was seen as caring and comfortable with a friendly and relaxed atmosphere. Residents, irrespective of the degree of their disability, were seen as individuals and supported in a personal and flexible manner by competent and caring staff. The home plans for future care and the aspirations of the residents through a variety of care planning formats. The home has developed clear procedures to improve the communication between residents and staff, and ensure this becomes the practice of the staff by providing written protocols for each resident. The home has ensured that the changing training needs for staff are met and the ongoing dementia training for care staff evidenced this. The visiting physiotherapist told us that she felt the home were meeting the complex needs of the residents and thought that staff appreciated and practiced any advice offered. She also said that there was a good relationship between the Community Learning Disability Team and the home. The relative seen in the home said that she was always made welcome and was consulted over the support provided for her relative. She said that staff were approachable and friendly and competent in their caring/supporting role. 62-66 Windermere Road DS0000066770.V345663.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. 62-66 Windermere Road DS0000066770.V345663.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 62-66 Windermere Road DS0000066770.V345663.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home undertakes a comprehensive assessment of need and the preadmission procedure allows the prospective resident to make an informed choice. EVIDENCE: The records for a resident recently admitted were looked at in detail and discussed with the manager and a nurse on duty. Residents admissions are well planned and we saw an example of an ‘activities of daily living’ assessment completed before admission by the staff. Brandon Trust are currently developing a more detailed pre-admission assessment form for staff to use. Pre-admission information comes from a multidisciplinary approach and can include the physiotherapist and occupational therapist to help ensure that there are sufficient resources at the home to meet people’s needs. An advocate and the parents came to view the home first for the recent admission looked at, but the resident visited for a two day trial and then a longer trial and made the decision to come to the home. Mobility had been a problem for this person and this home was considered more appropriate as there is generally more space. The home had detailed records from the previous home and healthcare professional assessments, which indicated that there was a 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 9 clear, well planned admission procedure, where everyone was involved in helping to ensure that the home could meet this persons needs well. 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents and relatives are consulted over the plans of care and this ensures that the needs and wishes of the individual are known and wherever possible met. EVIDENCE: Two care plans were looked at in detail where total care is planned with individual actions agreed by the resident/relative, or recorded as ‘best interests’ with healthcare professionals input. here is a ‘planning for life’ section that ensures all aspects of a residents life are recorded, which includes the information needed should a hospital admission be required. A pictorial record is completed with the help of the residents called ‘what I am like’. This record contains a lot of good information and pictures of the resident in different situations, and complements the communication information outside each resident’s bedroom. 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 11 The detailed communication information is excellent and helps everyone to understand how to interpret body language and facial expressions when required. The experienced staff communicate well, understanding exactly how residents are feeling and quickly notice should they be reacting differently, and perhaps are unwell. We saw examples of this when meeting the residents with the staff on duty and comparing the records of responses recorded. The staff appeared to have no difficulty finding out the residents daily choices, and good relationships were seen where residents responded well with staff. Each resident has a weekly activity timetable for the care staff to follow providing suitable stimulation and relaxation as required. Many residents require complete care from the nursing and care staff as they have complex needs, and the detailed care plans record the support and care provided by the staff team. The monthly reviews are meaningful and the daily records completed by the care staff contained a lot of information about what residents do everyday, which included all the activities and day centres attended and their moods to indicate how they felt or responded. The residents’ have an Essential Lifestyle Plan, an example was seen for a resident who had lived at the home for over two years. Dreams and goals are recorded, one resident had a pictorial plan on the bedroom wall and the staff were helping residents to achieve their goals. One dream noted was to watch Manchester United play football, and a resident had recently achieved the goal of visiting Disneyland Paris with the staff. Risk assessments were well recorded and examples seen were for safety in bed, safely sitting in an armchair, and the risk from choking. Relatives are kept informed of any incidents or accidents at the home. Healthcare professionals are included in the risk assessments where required so that good practice is continually reviewed. 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 15 16 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. In spite of the complex needs staff have identified interests and provide a stimulating environment through individual programmes. Relatives and friends are welcome in the home. Mealtimes are seen as occasions where staff and residents can spend unhurried time together. EVIDENCE: The activity timetable was in the corridor and clearly indicated the various activities. 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 13 Residents have individual activity programmes and there was photographic evidence throughout the home of the various events and activities. In spite of the dependency of the residents, staff, through consultation with residents and families ensure that the activities are of their choosing and are appropriate. The local facilities of the community are used and this includes the buses, shops, cinema, parks and the library. All of the residents would need support and after speaking to two, and staff on duty, as well as witnessing residents getting ready to go out, it was evident that their practice included patience and understanding. Family links are seen as important and the home provides support and guidance if this is felt to be appropriate. On the first visit one relative was seen. She told the inspector that her daughter had recently been admitted and that she was impressed with the competence of staff and the efforts that had been made to ensure the admission went well. She also said that she is involved in the care planning and felt that the delivery of care and support was a team effort to include relatives. Routines are only imposed where the needs of the resident dictate that this is necessary. Daily life styles revolve around each resident and they are able to have choice about how they spend their day Considerable time and effort is given to the individual needs of the residents. The inspector was shown the individual menus, a number of which were based on their needs, others on their wishes. The Inspector noted that staff are now asked to eat meals with the residents and join in what is seen as a social occasion. The previous practice was that staff fed some residents and later had their meals separarately. The new practice was seen as inclusive and ensuring everyone was seen as equal. 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18 19 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The resident’s health care needs are met in the way they choose. Medication is held and administered in a safe and appropriate manner. EVIDENCE: During the inspection we met the physiotherapist who advises the NHS Partnership Trust and was visiting the home on behalf of the Community Learning Disability Team. She was talking to staff about posture management and the consequences for residents if their posture is inappropriate. It was pleasing to note the relationship between health professionals and the staff. The qualified and experienced nursing staff, some of which have a learning disability nursing qualification, had completed good healthcare plans to support the many complex needs of the residents. This includes good manual handling assessments, prevention of pressure sores and nutrition plans, which included regular weight checks. A night-time care plan had also been recorded, which included continence care needs. 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 15 We saw evidence of many healthcare professionals support to include the physiotherapist, continence adviser, and clinical notes from the doctor and Speech And Language Therapist (SALT). The clinical requirements from SALT for each resident are displayed in the kitchen for staff to follow. The individual guidance on the consistency of food helps to ensure residents are able to enjoy their food safely. SALT review their clinical requirements every two months, which includes a resident with a Percutaneous Endoscopic Gastrostomy (PEG) feed who is unable to swallow food safely. The nursing staff were able to describe the support residents have for dental, optical and audio checks. The clinical notes completed by the nursing staff were very detailed and included medication. Each resident has a good medication care plan, which details the medication given, why it is given and the potential side effects. There were ‘patient information leaflets’ for all medication used. Each resident has an assessment of his or her capacity to consent to medication administration. The nurse completing this had a good knowledge of the Mental Capacity Act 2005 and had completed a ‘best interest ‘ form. The home has a good medication procedure, which needs more details on the administration of homely remedies. This will ensure the doctor knows what medication may be given and the protocol for how many doses, and how long to give before medical advice is sought. The latest Royal Pharmaceutical Society medication guidance was available and there was an up-to-date medicine reference. There was a good procedure, agreed by the doctor, for when the nursing staff should give antibiotics to prevent chest infections, the doctor should sign this as this is for prescription only medication. The home uses a monitored dosage system where several tablets are included in a bubble wrap section, each tablet is described in details to enable staff to check the medication is correct and identify any not taken. There is a good system for the checking in and the disposal of medication. Medication used ‘as required ‘ is audited monthly. There were some excellent protocols for ‘as required’ medication, particularly for residents receiving multiple medication for epilepsy, who may have a seizure, and require additional medication. Each protocol was different and appropriate for every resident. A pictorial method of administration of medication for each resident is recorded so staff know what method is preferred. Should there be any changes to medication the community learning disability doctor informs the resident’s general practitioner, a detailed letter was seen describing a change. The medication administration sheets were completed well and a spot check of medication amounts by us was correct. 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 16 The use of allergy boxes should be addressed, as currently there was no record to indicate ‘no allergies’ where appropriate. Risk assessments were completed for concealing medication on a ‘best interests’ form completed by the doctor. None of the residents were able to self-medicate. Medication is reviewed every six months with the doctor and audited every three months by the supplying pharmacist. Oxygen was stored safely in the home, with guidance from the fire safety officer, and was taken out on the minibus with suitable warning signs in all areas. We gave the manager some information on updating the registered nurses medication training, and providing training for care staff who may have to check controlled drugs used, when only one nurse is on duty. 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 23. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a safe and understanding environment where they or their relatives are able to comment on the services provided. EVIDENCE: All of the residents have communication difficulties and a written/pictorial complaints procedure may not always be sufficient to meet their needs. In the circumstances the trust and relationship between the residents and staff is important if good communication is to happen. The staff have been trained in issues around communication, and each resident has a written procedure, which clearly tells the reader how that resident is able to communicate. The procedure is detailed, informative and will help the process of residents being able to communicate with others. If residents have concerns the open and inclusive environment in the home enables them to be able to raise the issue in some way with the staff. This was evidenced with the limited but informative verbal/non verbal discussion we had with two of the residents. Relatives are involved in the care of the residents and are aware of what to do in the event of a concern/complaint. There had not been any complaints since the last inspection. 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and pleasant environment where residents are able to join with others or enjoy their own private spaces. More room could be provided for essential equipment to be used and stored appropriately. EVIDENCE: The home was found to be clean and organised. All of the accommodation was seen. Bedroom doors had resident’s names on and this helps them to recognise where they are and aid orientation. The redecoration of all the communal areas will commence on Monday 18 February 2008. Bedrooms are usually redecorated when they are vacated. 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 19 Resident’s bedrooms provide a personal and stimulating area with lots of personal items evident and other decorations e.g. pictures of their favourite football club. The communal areas also have pictures and other pictorial records of what is happening in the home. On the day of the last visit a resident was celebrating his birthday and staff had decorated the lounge where he sits. There is an issue of the need for adaptations and equipment to assist the mobility of the residents and the space available to store it. Bedrooms are relatively small and we were informed that the matter had been brought to the attention of the Trust, who are looking at the options. It is evident that to meet the needs of many of the residents in a private and dignified manner suitable equipment situated in the right place is essential. 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff in the home are competent and caring and provide a flexible service, which is adapted to meet individual needs. EVIDENCE: The home continues to be staffed by the Registered Manager, deputy manager, five qualified nursing staff, (general, mental health and learning disability) and care staff. There had not been any new appointments since the last inspection therefore no staff records were inspected. During the two visits a number of staff were seen on the first occasion and all of the staff on the second occasion. The staff were seen independently and all praised the management style of the manager and felt that she was “ a good listener” and ‘played an important part in the running of the home’. The manager also works alongside staff on some shifts and was seen by them as setting an example in the care and support of the residents. 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 21 All of the staff seen had completed NVQ level 2/3 and had also received inhouse training for fire, first aid, food handling, and more recently dementia. A number of the staff said that they would like to know more about the symptoms and management of dementia. We were told by the staff that the Trust responded quickly to training requests and that the needs of the staff were met. As well as talking to staff we had the opportunity to watch the exchanges between staff and residents and it was clear that the flexible service being offered was provided in a caring, patient and dignified manner. One example was at lunchtime one resident did not feel well and did not wish to eat the meal that had been prepared for her. She was told that arrangements would be made for her to eat later if she felt better. The home has five vacancies for support staff, this number is unusual and has arisen due to a number of factors. We were informed that the positions are being advertised and that appointments would be made in the near future 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a home, which is well run by a competent, registered manager and her staff. In spite of their complex needs and difficulties with communication they are consulted over every aspect of their lives. The home provides a safe environment where health and safety issues are seen as imprtotant to a good quality of life. , EVIDENCE: The registered manager is qualified, competent and has ten years experience running the home. The home was seen as well run and the evidence for this came from our discussions with her, the staff, a health professional and a relative. The staff felt they were clear about their roles and responsibilities and that the manager provided guidance through discussion, and models of behaviour through example when undertaking shift work. 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 23 The registered manager told us that she is supported by her line manager and is able to see her on a regular basis, and the support included individual supervision. At the time of the inspection staff were being appraised by the registered manager. This is an annual event and one that is welcomed by staff. Regulation 26 (visits by the Trust to the home) are being completed and the last report dated December 2008 was seen. Regulation 37 notices had been submitted. These are notifications to us of significance events in the home. The home manages some personal monies and examples of the records were seen. We were informed that the Disability Living Allowances are passed to the Trust to cover transport costs, the home was unsure if this information is passed to relatives/advocates before admission. It is recommended that this practice is mentioned in the Statement of Purpose to avoid any confusion. The home operates on the needs and wishes of the residents and these are determined through regular consultation with the resident, resident’s relatives and friends. There are formal quality assurance systems in place and we had discussions about the results of the last survey, to include how successful the home was in achieving its aims and objectives. The health and welfare of the residents is assured by the safe practices in the home. Many of the residents need help with their mobility and all staff have been trained in moving and handling. We saw a number of occasions when residents were being helped to move with staff and this exercise was seen as being completed in a sensitive and patient manner. A housing association is the landlord of the home and responsible for all repairs/replacement, we were informed that they are completed without delay 62-66 Windermere Road DS0000066770.V345663.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 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 3 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 4 23 4 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 4 33 X 34 4 35 4 36 X 3CONDUCT AND MANAGEMENT OF THE HOME Standard No Score 37 4 38 X 39 4 40 X 41 X 42 4 43 X DS0000066770.V345663.R01.S.doc Version 5.2 Page 25 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 62-66 Windermere Road Score 4 4 4 X 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 YA20 2 YA20 Refer to Standard Good Practice Recommendations Homely remedy procedure would benefit from more detail as suggested in body of this report. The doctor to sign the administration of antibiotics procedure. 62-66 Windermere Road DS0000066770.V345663.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Gloucester LO 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester GL3 4AB 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 62-66 Windermere Road DS0000066770.V345663.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. 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