Inspection on 09/05/06 for Bells Piece

This inspection was carried out on 9th May 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 found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bells Piece 01/11/05

Bells Piece 14/06/05

Bells Piece 15/11/04

Bells Piece 21/07/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Bell`s Piece Bell`s Piece Hale Road Farnham Surrey GU9 9QZ Lead Inspector Vera Bulbeck Unannounced Inspection 9th May 2006 10:00 Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 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 Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 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. Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bell`s Piece Address Bell`s Piece Hale Road Farnham Surrey GU9 9QZ 01252 715138 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.leonard-cheshire.org.uk Leonard Cheshire Tracy Maxine Davies Care Home 13 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (1) of places Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 12, 30-60 years and 1 over 65 years 1st November 2005 Date of last inspection Brief Description of the Service: Bells Piece is a large detached house that has been converted to provide a care home for younger adults with learning disabilities operated by the Leonard Cheshire Foundation. The home is located in attractive grounds at the end of a private driveway on the outskirts of Farnham. There are local shops and other amenities close by. Sharing the grounds of the home is a Horticultural and Craft Centre which service users have the opportunity to work in. The home is spacious and offers mostly single bedroom accommodation on both floors, one with en-suite facilities, some with small kitchen areas and others are self contained flats including one shared flat. There are a variety of communal rooms on the ground floor. The home has car-parking facilities for several cars. Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced site visit to be undertaken by the Commission for Social Care Inspection year April 2006 to March 2007. Mrs Vera Bulbeck Regulation Inspector carried out the site visit. Miss Tracy Davies the registered manager for the home was present. The site visit was undertaken over 8 hours. There are currently thirteen residents living in the home, and the majority have lived in the home for some considerable time. There are two cats named Sooty and Sam living in the home, both receive a lot of attention by the residents and one resident has two goldfish named Gloria and Gaynor in a tank in her bedroom. A few residents were working at the Horticultural Centre next door to the home and some had gone to a day centre on the day of the site visit. The inspector was able to speak with two residents during the time spent in the home in the morning and several later when the residents came home from their activities. A number of staff was spoken to and one commented the home is operating on an open management style and the staff team feel supported and work together as a stable team. The inspector received positive comments from the staff team and all commented on the open management style feeling well supported by management. A number of residents were spoken to, who were able to communicate and able to express themselves. Positive comments were made regarding the staff and residents were happy regarding their daily living routine. On the day of the visit one resident had returned to the home not feeling well from her course, she explained to the inspector she was looking forward to going out in the afternoon to another course as she gets bored at home. Observation made was that residents and staff have a good rapport; residents were relaxed and comfortable with staff on duty. A full tour of the premises was undertaken. Two care plans and two staff files were inspected. The inspector would like to thank the residents, registered manager and staff members for their time, assistance and hospitality during the site visit. The residents living in the home wish to be called residents, therefore service users will be referred to as residents throughout the report Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The majority of staff has completed training, on administering medication. However there is still some staff that need to complete this training. The recording for the temperature of the meat has not been recorded on a regular basis there were a number of gaps, the last entry was dated 22/04/06 The security of the building needs to be reviewed to ensure the premises are safe for residents and staff, particularly sleeping in staff where the french doors are not safe. The bolts on the doors are not fitting sufficiently and the glass panels should be safety glass. Please contact the provider for advice of actions taken in response to this Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 8 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 Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 9 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s needs and aspirations are fully assessed and documented prior to admission and on an ongoing basis in regular reviews. EVIDENCE: There has been one new admission to the home; the resident is currently on a trial basis. The inspector was shown a form used for the assessment for all new residents and had been used for other clients. However, it was noted that a full needs assessment had not been completed for the new resident. This was mainly due to the fact that the resident was known to the home. The registered manager explained that she has undertaken all the relevant details but was waiting to see if the resident would remain in the home following the three-month trial before completing the assessment. The statement of purpose and service user guide is in pictorial form and all the residents have been provided with a copy. Relatives have been provided with information regarding the home and the relatives and families have regular meetings with the management of the home and are very much involved with the running of the home. Care plans or life plans were well documented and used as a working tool. All the relevant documents are included various assessment sheets have been signed and dated. Residents are involved with their care planning and have Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 10 signed to indicate they are aware of the care they receive. Residents also informed the inspector the staff discuss any areas in the care plan that needs to be explained. Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 11 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 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents’ individual plans are clear and comprehensive including details of needs and goals. They also incorporate known or indicated preferences and choices, and include in depth risk assessments. EVIDENCE: Staff stated that residents are supported to make decisions affecting their lives in a number of ways. Each resident has an allocated key worker, who is trained to offer one to one support and who knows the resident well and understands his or her needs. Resident meetings are held to enable residents to make decisions and choices, for holidays, menu planning and outings. For example one resident spoke of attending the meetings and notes of a meeting were seen. Resident’s individual choices of meals were recorded on the weekly menu plan. Staff advised that information is provided to residents to assist with decisionmaking and this is in a format to suit their individual needs. Information is Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 12 provided in makaton, pictorial or visual formats and staff also give information verbally, as appropriate. Information is displayed and provided for residents in picture form on a notice board in the kitchen, informing residents the day of the week, staff members on duty and the evening meal. The inspector noticed telephones in some of the bedrooms checked, not all bedrooms were checked by the inspector due to bedrooms being locked by the residents who had gone out. The inspector was informed that all residents have a telephone in their bedroom, and they all know the number to ring at night if necessary. A resident confirmed she knew what the procedure was in the event she was not feeling well and needed assistance. Two residents go out on a Saturday together shopping, both residents’ have been risk assessed. Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 13 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 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents have opportunities for personal development and to take part in appropriate activities within the home and in the local community. They are supported and enabled to maintain and develop appropriate personal and family relationships. Systems are in place to ensure that residents’ rights are respected. EVIDENCE: Staff stated that they actively encourage and support residents to be independent, to make their own choices and to live their lives as they wish, as far as they are able. Household routines are kept to a minimum and are only in place to enable residents to share their home’s facilities and to maintain harmony within the household. The degree to which residents are involved in the running of their home is described in the statement of purpose. A pictorial rota for household tasks was displayed on the kitchen notice board in the kitchen. Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 14 The evening meal looked appetising and nourishing, residents are involved with the cooking and preparation of the meals with staff support. Two residents nicely laid the table and the residents spoken to confirmed the food is good and they are able to choose from pictures the meals they prefer to eat. Staff stated and it was observed, that they knock before entering resident’s bedrooms and that personal care is offered discreetly. Residents are addressed in the way that they prefer and this is recorded in their individual plan. The majority of residents attend the Horticultural Centre next door to the home as well as accessing a number of courses in the local community. One resident works in a care home for older people on a voluntary basis. All residents have links with family and friends and are able to contact their relative by telephone any time. On a regular basis relatives are invited to attend meetings to discuss any issues or pending arrangements for example holidays and activities. All residents have a holiday once a year and one resident goes on holiday with his family at least four times a year travelling the world. Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance is planned and was seen to be provided, where needed, in a respectful and sensitive manner. Sound policies and practices are in place for the administration and management of medication. EVIDENCE: The system for medication administration was seen and was generally carried out to a high standard. The Medication Administration Record (MAR) sheets were seen and no gaps in the recording were noted. Staff stated key workers, who report in turn to the registered manager, monitor the MAR sheets. Any recurring gaps or errors would be referred to the manager, and this would be discussed at a supervision meeting. However, a new resident to the home had come into the home with a supply of homely remedies and it was noted that the number of tablets seen did not correspond with the amount detailed on the MAR sheet. The inspector advised the registered manager to ensure that all staff administering medication must have up to date training. Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 16 It was pleasing to see that guidelines are in place for medication that is given “as required”. A photograph of each resident is provided with the MAR sheets to guide staff to the correct resident and a medication information sheet gives details of the medications for each resident. Staff stated that any additional entries to the MAR sheet, which have been handwritten on, are signed by the member of staff making the entry and by a second member of staff who checks that it is correct. This had been carried out. Two staff sign the MAR sheet for all medication given and for the receipt of medication into the home. Sample signatures of all staff that administer medication were held with the MAR sheets for ease of reference. Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All required policies, procedures and practices are in place to ensure that residents are safeguarded, as far as reasonably possible, from harm or abuse. EVIDENCE: There were no recorded complaints since 2003; the registered manager informed the inspector there were also no external complaints received. Records seen indicated that complaints would be responded to within the guidelines. The homes complaints procedure for residents is in pictorial form and residents would be able to use it when necessary. The complaints form is written with widget symbols and easy for residents to understand. Staff spoken to, stated that they had undertaken training in the protection of vulnerable adults and would report any concerns they had to the manager. If they had concerns about their manager, they would be reported to the area manager. Staff said they would be willing and able to report any concerns and “would go to any level to protect residents”. Resident’s finances are paid directly into their bank and fees for their placement is deducted by direct debit. The resident, with staff support, manages any personal allowance money and relatives are involved. All residents pay for an insurance costing £5.00 per year to cover up to £2.000 for their personal items. Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 18 Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 19 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for it’s stated purpose. It is accessible, safe and well maintained. The home was found to meet residents’ individual and collective needs in a comfortable and homely way. EVIDENCE: The premises were found to be clean and hygienic, all staff to be congratulated on the cleanliness of the homes. All areas in the home have had paper towel dispensers fitted, to ensure the risk of cross infection is eliminated. Residents are able to undertake their own laundry and have access to the laundry on specific days. All residents have their own bedroom and these had been made personal with pictures and posters, televisions, music and radio facilities and individual bedding and soft furnishings. Bedrooms were seen to be of a good size and some residents had personal computers and desks fitted in their bedrooms. Some residents showed the inspector their bedrooms, of which they were justifiably proud. It is pleasing to see that each room is individually decorated Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 20 and residents are supported to choose the colour schemes to suit their preferences. One resident had recently changed rooms, to a preferred position, joining a resident who had recently lost her husband. The vacant room has been re-decorated in a choice of colours by the resident and her key worker spoke with the resident of going to buy new bedding, to match the room. The communal areas of the home consist of a lounge which seats approximately eight residents, and a separate dining room and kitchen. There is also another small sitting/computer room also used as a quite area, and a large games room, which is also used as a sleeping in room for staff. It was noted that the door is not fitting very well and would not be considered to be secure for the premises. It is also unsafe with the glass in the doors not being safety glass, particularly as this is a games room. A resident had informed the inspector that on occasion’s people walking in the park next door to the home walk through their front garden as a short cut to the road. The home has recently had new fencing and a gate erected to overcome this problem. The inspector would recommend that a bolt be fitted to the bottom of the gate to stop intruders using this area. It was also noted that a shed was unlocked in the grounds. The inspector was also informed that the Horticultural Centre next door has had several thefts. On the arrival of the inspector, the day of the site visit, the front door was left wide open and the inspector waited for several minutes, ringing the bell twice. Eventually the inspector saw two persons talking in the hallway at which point the inspector called out. The registered manager came to the door and introductions took place. The other person was a volunteer from the Horticultural Centre who was busy making chutney in the kitchen. The inspector advised the registered manager the door should not be left open as this left the security of the building at risk. The garden to the back of the house is very pleasant and the front garden is nicely laid out and during the summer months has a fete. Garden tables, chairs and bird-tables were seen in the gardens. Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 21 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, and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All interactions observed between staff and residents evidenced a high degree of respect and skill in working with the individual residents at the home. Staffing is kept under review and provided to meet the needs of the residents at all times. EVIDENCE: It was pleasing to note that staff have a good understanding of the residents needs, are respectful and have a good rapport with the residents. Any person working or using the home for cooking purposes must have an up to date CRB and the registered manager must ensure this is in place. Staff recruitment files are up dated and contain all the relevant documents as detailed in Schedule 2 of The Care Homes Regulations 2001. All staff has had a criminal record bureau (CRB) check and Protection of Vulnerable Adult (POVA) check prior to starting work in the home. It is imperative that up dates to CRB are undertaken. The registered manager to ensure all staff has a copy of the General Social Council & Care, code of conduct document. Two members of staff have completed NVQ Level 3 and another member of staff has nearly completed NVQ Level 3. Five staff members have completed Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 22 LDAF training. A number of courses have been undertaken by staff and the majority are up to date with all other mandatory training. Staff supervision was seen to be undertaken on a regular basis, and staff are provided with a copy. The management of the home has produced a training programme, to enable management to identify when staff require up dates to their training. A number of training courses have been undertaken and all new staff receive an induction programme, which is covered over several weeks. Any specialist training required by staff is considered by HQ for example one member of staff has requested training on diabetes. There is only one member of staff sleeping in and three staff are on the on-call rota indicating the designated member of staff on call. The inspector was informed the staffing levels for the semi independent flat are separate from the main house staffing levels. Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 23 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 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management approach in the home provides an open, positive and inclusive atmosphere. The home has a quality assurance and monitoring system in place that is based on seeking the views of the residents. EVIDENCE: The home has an effective quality audit monitoring system in place. The service manager completes a regular monthly regulation 26 notification visit and the report is well documented. The home has produced a yearly residents/relatives survey in pictorial form, to establish if improvements can be made to the home. The records observed on the day of the site visit were found to be well documented and kept up to date. This included certificates for the testing of Legionella, gas, electrical and a number of other areas tested. However, the probe for the testing of the temperature of the meat must be undertaken on a regular basis and a record to be maintained. Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 24 The inspector would recommend that all residents’ doors be numbered in the event of a fire there would be no problem locating a bedroom. All fire records to be contained in one folder. The home to consider covers for radiators, the heat from the radiators could potentially cause a serious injury and dangerous to residents when very hot. The home has a business and financial plan; the Leonard Cheshire Organisation controls the finances for the home. The service manager monitors the budget for the home. Records are maintained to a high level. Insurance cover for the home is in place. Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 25 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 2 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 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 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 2 X X X 3 X X 2 X Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 26 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. 1 2 Standard YA2 YA20 Regulation 14 13 Requirement A pre assessment needs to be undertaken on all new residents. Stock medication was found to be not corresponding with the administration medication record. A Lock to be fitted to the garden gate for extra security. The garden shed to be locked at all times. The French doors in the games room needs replacing. The testing of the meat probe and a record to be maintained on a regular basis. Timescale for action 09/06/06 10/05/06 3 4 5 6 YA24 YA24 YA24 YA42 23 23 23 12 09/06/06 10/05/06 23/06/06 10/05/06 Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 27 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 YA42 YA42 YA42 Good Practice Recommendations All fire records to be held in one folder. It is advisable for all bedroom doors to be numbered in the event of a fire location of rooms is easily accessible. The home to consider covers for radiators, unless radiators are low surface temperature controlled. Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Bell`s Piece DS0000013567.V291561.R01.S.doc Version 5.1 Page 29 - 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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