Inspection on 25/06/07 for 92 Wilcot Road

This inspection was carried out on 25th June 2007.

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

92 Wilcot Road 13/02/06

92 Wilcot Road 14/07/05

92 Wilcot Road 29/03/05

92 Wilcot Road 31/01/05

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

CARE HOME ADULTS 18-65 Wilcot Road (92) 92 Wilcot Road Pewsey Wiltshire SN9 5NL Lead Inspector Pauline Lintern Unannounced Inspection 25th June 2007 10:00 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 DS0000028656.V336560.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. DS0000028656.V336560.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wilcot Road (92) Address 92 Wilcot Road Pewsey Wiltshire SN9 5NL 01672 563914 01672 563914 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) White Horse Care Trust Mrs Jill Burry Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000028656.V336560.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th February 2006 Brief Description of the Service: 92 Wilcot Road is a care home for three people with a learning disability some of whom were previously cared for in a nearby long stay hospital for people with a learning disability. The home is located in the small town of Pewsey. The service replicates principles of ordinary living and the house, which is semi detached, is indistinguishable from other houses in the street. All the bedroom accommodation is in single rooms and there is a range of communal space including an attractive patio and garden. The service is managed by the White Horse Care Trust, which has a number of similar care homes throughout Wiltshire and beyond. The aim of the service is to provide ordinary living that maximises independence. The home provides transport for accessing the local area and further a field. Service users can attend Marlborough day centre for day activities subject to the availability of places. Typically 2 people staff the home through the waking day. At night time one staff member sleeps in and is expected to respond to any night time and emergency needs as they arise. DS0000028656.V336560.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection took place over five and a half hours. At the time of arrival there was one member of staff at home who explained that one person was attending a dental appointment, one was at a resident’s consultation meeting and one was at the day centre. The manager was not available until the afternoon, when she returned with one service user. The inspector was able to meet with the deputy on her return from the dental appointment during the morning. The inspector had the opportunity to meet one service user in private and spend time with two members of staff. As part of the inspection process three service user surveys were sent out and three were returned. Five staff surveys were also returned to us. The judgements contained in this report have been made from evidence gathered during the inspection, which included examination of two case files, risk assessments, staff recruitment records, staff training, staff induction, quality assurance, medication practices and health and safety. Fees for this service range from £986.44 - £1,062.30p per week. What the service does well: This remains a stable group of three people living together in an ordinary house. There is a current statement of purpose and service user guide. The home is ensuring people’s care plans reflect their assessed needs. There are risk assessments in place to ensure that people can live independent lives. These are kept under review. Person centred plans are being developed further. Each person has their goals identified and there are clear ‘paths’ to how the staff will support the person to reach their goals. Service users are able to express their opinions and participate in the running of the home and any decision making regarding changes or improvements, which are planned. People have the opportunity to attend leisure and educational activities of their choice. Staff members support service users to experience holidays abroad and develop their social skills. Staff members support people with their personal care needs and ensure that all of their healthcare needs are met. Medication is well managed and records were found to be satisfactory. Staff members are properly recruited, inducted, trained and supervised. Health and safety is taken seriously and regularly checks on equipment are carried out. There are mechanisms in place to ensure that quality assurance is monitored. Overall this is a service where people are safe and listened to and a service rarely complained about. DS0000028656.V336560.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. DS0000028656.V336560.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 DS0000028656.V336560.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): NMS 1 and 2 Quality in this outcome area is good. People are provided with current information to enable them to decide where they wish to live. People’s needs are assessed to ensure that the home can provide the service that they require. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s statement of purpose and a copy of the service user guide was examined and found to contain current and relevant information about the service provision. People confirmed that they had been provided with sufficient information about the service prior to moving in. Three out of three people also confirmed that they had been asked if they wished to move into the home. One person commented “I like it here, better than when I was in hospital”. Two case files were sampled and evidenced that a full holistic assessment of people’s needs had been completed. The assessments covered all aspects of the persons life including mobility, communication, daily living skills, health needs, emotional needs, medication, accommodation, personal care needs, sexuality, psychological, spiritual and nutritional needs. Records demonstrate that the assessments are kept under review. DS0000028656.V336560.R01.S.doc Version 5.2 Page 9 Each service user’s file has a copy of their contract and a statement of terms and conditions. There is also a pictorial copy of the contract and the complaints procedure. DS0000028656.V336560.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): NMS 6, 7 and 9 Quality in this outcome area is excellent. Care plans reflect the assessed needs of the people who use this service. Individuals are encouraged to make their own decisions and choices. Strategies are in place to empower people to take informed risks in their daily lives, whilst there are measures identified to minimise any risks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager confirmed that each service user is involved in the planning of their care. Each care plan reflects the assessed needs of the person and identifies things that are important to them. People have identified their ‘goals’, which are illustrated and outlines the next step or action that is needed to reach their ultimate goal or desire. There is evidence to show that some people have reached some of their ‘goals’ and there is guidance on how to maintain them. Staff members explained that one person’s goal was to have their hair dyed and the ‘pathway’ to achieving this goal incorporated buying magazines and suitable hair colours. This is a good example of person centred planning and is an area that was agreed can be DS0000028656.V336560.R01.S.doc Version 5.2 Page 11 further developed. It is evident that service users participate in the decision making in the home, although this good practice is not always recorded. People are allocated a key worker to provide consistency and enable relationships to build. One service user confirmed that they knew who their key worker was and reported that they get on well with them and that they would talk to them if they were unhappy about anything. Choices are made verbally or by pointing to things, which someone may want. One person’s care plan states that although they are unable to verbally communicate their needs, they can demonstrate if they do not want to do something by gestures, body language and facial expressions. The manager confirmed that the person’s communication skills have developed greatly since being at the home. Files show that people have the opportunity to go to church if they wish. One person’s records show that they choose not to attend church regularly, however they enjoy going to the carol service at the Gateway Club at Christmas. Entries in the activity planner evidence that another person regularly attends the church of their choice with staff support. There are measures in place to minimise any potential health and safety risk to the people using the service, whilst enabling them to live an independent lifestyle. Risk assessments are regularly reviewed to take into account any changes to the person’s needs. DS0000028656.V336560.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): NMS 12, 13, 15, 16 and 17 Quality in this outcome area is good. People who use this service have the opportunity to access appropriate activities within the local community. Family and friends are welcome at the home. People are respected as individuals and are able to engage in appropriate relationships. Menus are devised to suit people’s individual dietary needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users have the opportunity to participate in various activities. One case file sampled showed that the service user attends the Marlborough Resource centre four times a week. It shows that they participate in drama, cookery, snoozelen, completing puzzles, swimming and exercising to music. They also attend a music club one evening a week. Another person attends the Gateway club where they play skittles, bingo and have discos. On the day of the inspection one person had returned from a resident’s meeting and reported that they “did some dancing” after the meeting, which they had enjoyed. The Trust run a monthly ‘crafty club’ where service users from other DS0000028656.V336560.R01.S.doc Version 5.2 Page 13 Trust homes can meet up and do arts and crafts. One person confirmed that they enjoyed going there. The manager confirmed in the completed Annual Quality Audit Assessment (AQAA), that they are exploring more ‘out of the home’ activities during the forthcoming winter months and to also devise a list of indoor activities, which people may wish to do so they can explore new experiences. They added that they plan to provide a monthly activity such as a film night and to be able invite people from other care homes to join in. There is pictorial evidence to show that staff members support people to travel abroad on their holidays. One service user showed the inspector her photographs from the previous year in Greece. Staff members confirmed that this year she is going to the Algarve in October so the weather would be more comfortable. Another lady is going to Greece with a service user from another local Trust home, with staff support. It was noted in one persons care plan that their evening routine has now become more structured to meet their needs. The deputy manager explained that one person now has two goldfish, which they look after. This helps the person to carry out their morning routines, as feeding the fish is part of that routine. There is other various activities available to people such as horse riding, massage, beauty treatments, cooking, watching television and videos or DVDs, drawing and ‘music for health’ sessions at another Trust home. The daily notes show that one person recently went to a local church fete. One lady commented that they enjoy sitting in the garden when the weather allows. Staff members report that they support people to send cards to family and friend on special occasions. There is evidence of family involvement and one person also keeps in touch with a previous member of staff. One person has a close relationship with a friend at the day services, which is monitored by the staff team. One service user commented that they clean their own bedroom. They added that they can clean the sink but cannot hoover the carpet as they have a bad back so staff do this for them. One case file records that the person does not have a lock on their bedroom door. The deputy explained that they have a fear of being locked in. The care plan informs that the person is unable to use the telephone independently without staff support, however they can access the telephone in the office if they wish to enable privacy. During the inspection staff were observed interacting with the people who live in the home and not exclusively with each other. Service users were offered the opportunity to choose what they wanted to do and where in the house they wished to sit. One person returned to the home following an anaesthetic for dental work and staff members took time to ensure they were comfortable and pain free and they were offered appropriate refreshments e.g. soup. People appear to enjoy the food offered at the home. One person said “I like cooking shepherds pie, I make it here sometimes”. Care is taken to ensure individual dietary needs are met. One person has to watch their weight, as DS0000028656.V336560.R01.S.doc Version 5.2 Page 14 they are diabetic so a healthy eating plan was devised. Menus were sampled and appeared to be healthy and varied. DS0000028656.V336560.R01.S.doc Version 5.2 Page 15 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): NMS 18, 19 and 20 Quality in this outcome area is good. People are supported with their personal care in a way that they prefer. Input from healthcare professionals ensure that people’s physical and health care needs are met. Medication policies and procedures protect people where possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Guidelines are in place to ensure that service users receive the support and care they require with regards to their personal care. One care plan informs staff that when delivering personal support there needs to be a ‘consistent approach’. It adds ‘Allow her to do things, which she is able to do by herself with support-give praise, respect choices and wishes’. Each person living at the home attends an annual OK health check. It was noted that one lady had attended a ‘well woman’ clinic for a routine mammogram, staff explained the procedure to her but she had chosen not to go through with it. Staff had respected her decision, however would try again next time an appointment came through. There is evidence of professional health care input for example psychiatrist, doctor, dentists and opticians. Behavioural observation charts are in place to DS0000028656.V336560.R01.S.doc Version 5.2 Page 16 monitor and evaluate interventions and outcomes. Management guidelines are also in place. Medication is well managed by the home. There is a weekly stock check of all medication held by the home. This took place on the afternoon of the inspection when two staff diligently checked all medication. At the time of the inspection the home did not hold any controlled drugs. Records showed that there were not gaps in the entries on the medication sheets. There are policies and procedures on place to safeguard service users where possible. All ‘as required’ (PRN) is recorded separately on a yellow sheet so that it is easily distinguishable. DS0000028656.V336560.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): NMS 22 and 23 Quality in this outcome area is good. People who use this service are able to raise any concerns and know that they will be listened to. Service users are safeguarded from abuse where possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users are provided with a complaints procedure in an abridged format using symbols and text. There is also a copy in video format if needed. Each person has a pre-paid addressed postcard, which they can send directly to the Trust’s chief executive if they wish. Service users confirmed that they know the procedure for making a complaint or raising a concern. Comments included: “Yes, I would post my card” “I can speak to my key worker or other staff”. “I will always tell staff if I am not happy”. Five staff survey forms were returned to us and all confirmed that they are aware of the safeguarding adults procedure. Staff who spoke to the inspector confirmed that they would not hesitate to follow the procedure if they suspected any form of abuse was taking place. They were aware of the home’s ‘whistle blowing policy’. Staff members reported that they have seen the ’No Secrets’ guidance. Staff members attend training on abuse awareness and this is also covered as part of the Learning Disabilities Award Framework (LDAF), which provides a good underpinning knowledge of safeguarding people.. Service users money is kept secure. Staff members access funds from their petty cash for service user’s expenditures and then it is claimed back from the Trust. Staff report that the system works well. DS0000028656.V336560.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): NMS24 and 30 Quality in this outcome area is good. The home is ensuring that the people who live there are provided with a homely, safe and comfortable environment. The home is clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector toured the premises and found them to be clean and tidy. The untidy state of the garden was raised at the last at the previous inspection. This has now been addressed and the garden was now found to be in good order. The furnishings and fittings were of a good standard as was the décor of the home. Feedback from service users was positive regarding the environment. One person commented, “I have a nice bedroom, I have a small television and a CD player”. Each room had been personalised with photographs and individual belongings. Staff members confirned that service users choose the colour for their bedroom and also the soft furnishings. There is a separate laundry, which houses the washing machine and tumble drier. This area was found to be clean and hygienic. Food preparation does not DS0000028656.V336560.R01.S.doc Version 5.2 Page 19 take place near this area. It was noted that there was adequate supply of gloves available for staff to use. Staff reported that each person has their own bath mat and anti-slip mat, which are washed after use to minimise any cross infection. All toxic materials are kept securely locked away and the appropriate data is kept for each product. Feedback from the service user surveys confirms that the home is always clean and tidy. DS0000028656.V336560.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): NMS 32, 34 and 35 Quality in this outcome area is good. People who use this service can expect to be supported by competent and qualified staff that have been appropriately trained. The home’s recruitment practices safeguard service users where possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Any new staff members with little or no experience of working with people with a learning disability attend Learning Disability Award Framework (LDAF) training before they commence with their National Vocational Qualification (NVQ) to ensure they have a sound underpinning knowledge of the service user group. At the time of the inspection two staff hold an NVQ level 3, one a NVQ level 2 and one bank staff holds a NVQ level 3. The deputy manager is working towards her NVQ level 3. It was noted that one member of staff’s manual handling refresher training was overdue. This was shared with the deputy who immediately booked the staff member onto a forthcoming course. There is evidence to show that all staff are properly recruited, inducted, trained and supervised. Staff members confirmed that a check with the Criminal Records Bureau (CRB) was sought prior to commencing employment, along with two satisfactory references. The manager explained that service users would be involved in an informal pre-interview process where they would have DS0000028656.V336560.R01.S.doc Version 5.2 Page 21 the opportunity to meet potential candidates. She added that the Trust have previously run a course for service users called ‘Helping to choose staff’ and she hopes to explore this again for the future. Staff members explained what was entailed in the induction process. Mandatory training is provided for health and safety, manual handling, first aid, fire awareness, abuse awareness and basic food hygiene. The home has a training programme, which includes topics such as John O’Brien’s principles, epilepsy, drug competency and relationships. Both staff members who met with the inspector confirmed that they felt there is sufficient staff on duty, one person added “we are never short of staff”. Staff members confirmed that they receive regular one to one supervision and attend regular team meetings. DS0000028656.V336560.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): NMS 37, 39 and 42 Quality in this outcome area is good. People who use this service can expect a well-managed service where their views contribute to the development of the home. The home is considered to be safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of this service has completed her NVQ level 4 and the Registered Managers Award (RMA). She is experienced and competent to manage the home well. The staff team speak positively about her skills and the support they receive from her. One staff member reported that there was an occasion when she had to ring the manager at home for support and that she came to the home straight away to offer her support. There is a general feeling that the staff team all work well together. Comments from the staff surveys include: “All staff and clients get on well, we all have a laugh”. DS0000028656.V336560.R01.S.doc Version 5.2 Page 23 “We all get on really well and have as much fun as possible (staff and ladies). The deputy confirmed that the manager and herself have the opportunity for further development. They have attended training in managerial skills such as supervisions, interviewing skills, grievance and staff’s personal development. The Trust run group meetings for the managers, where they can discuss various topics and share concerns and idea with each other. The Trust carries out various monthly audits including the regulation 26 requirements, which is sent to us. Survey forms are sent out to relatives and staff to obtain their views on the service provided. There is an annual quality audit, which then forms the home’s development plan for the next twelve months. The home had a health and safety compliance audit on 13/12/06. Internally there are monthly health and safety and infection control audits completed by the staff team. The home has been awarded with the Investors in People accreditation for their commitment to staff development. Health and safety is taken seriously and the care staff carry out regular checks. Records evidence that fire drills and checking of equipment take place regularly. Staff members receive fire instruction and complete a fire questionnaire at ad hoc times to ensure staff remain competent. The home has a current fire risk assessment, gas safety certificate and evidence of electric appliance testing. There is a maintenance file to log jobs that need doing and record when they are completed. Radiators are guarded to protect people and hot water temperatures are checked. All the windows upstairs have restrictors on them. DS0000028656.V336560.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 3 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 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 4 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 DS0000028656.V336560.R01.S.doc Version 5.2 Page 25 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. Refer to Standard YA35 Good Practice Recommendations It is recommended that a system is developed to ensure staff are identified as needing refresher training. DS0000028656.V336560.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 - 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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