Inspection on 27/07/06 for Bickleigh Down Care Home

This inspection was carried out on 27th July 2006.

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

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

Other inspections for this house

Bickleigh Down Care Home 24/11/09

Bickleigh Down Care Home 28/07/08

Bickleigh Down Care Home 13/12/07

Bickleigh Down Care Home 08/11/05

Bickleigh Down Care Home 10/05/05

Bickleigh Down Care Home 17/03/05

Bickleigh Down Care Home 09/11/04

Bickleigh Down Care Home 20/04/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Bickleigh Down Care Centre Woolwell Road Woolwell Plymouth Devon PL6 7JW Lead Inspector Doug Endean Unannounced Inspection 27th July 2006 10:00 X10015.doc Version 1.40 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 Bickleigh Down Care Centre DS0000003574.V303116.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 Older People. 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. Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bickleigh Down Care Centre Address Woolwell Road Woolwell Plymouth Devon PL6 7JW 01752 695555 01752 696406 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.fshc.co.uk Four Seasons (DFK) Limited (wholly owned subsidiary of Four Seasons Health Care Limited) Mrs Deborah Skinner Care Home 64 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (32), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (32), Old age, not falling within any other category (15), Physical disability (4), Physical disability over 65 years of age (40) Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The establishment may admit, from time to time, up to 6 service users between 50 and 65 years of age A maximum of two service users only, in the age group of 50 to 65 years of age, can be accommodated in each of the three units at any time An identified ground floor lounge will be used as a dedicated communal space for the 50 to 65 year old service users on their request 8th November 2005 Date of last inspection Brief Description of the Service: Bickleigh Down is a 64 bedded, purpose built, care home with nursing, and is part of a large national Independent Health Care organisation, Four Seasons Health Care Limited. It is in the suburb of Woolwell just a few miles from the city of Plymouth and close to Dartmoor National Park. The home is divided into three units laid out on two floors. On the ground floor there is an 8 bedded residential care unit for the elderly, and a 24 bedded unit providing nursing care to the elderly mentally ill, including Alzheimer’s and Dementia suffers. On the first floor there is a general nursing unit that has 30 beds. There are a range of disabled bathrooms and toilets in the building and the establishment also has a number of different types of hoists available to meet the assessed needs of the clients. The organisation chooses to provide all single room accommodation at this time although 4 rooms can be used as doubles. Sharing a room would only occur following the agreement of both clients involved. There is a shaft lift between each floor and a range of communal spaces in each unit used for lounge and dining purposes. The gardens areas have received a lot of attention and now provide safe attractive outdoor spaces with good furniture and facilities for each unit. Close to the home is a small shopping complex with a hairdresser, general store and a medical centre. A superstore is just one mile away and can be reached by bus. An experienced Registered Nurse manages the home and there is always a registered nurse on duty in each of the nursing units 24 hours a day. Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s first unannounced Key Inspection and it took place on the 27th July 2006 commencing at 10.00 hours lasting 5.5 hours. The Registered Manager, Deputy Manager and Care Services Manager were present for the inspection and the Deputy Manager took the lead in assisting the inspector with his task. The inspector toured the home speaking to staff and service users during this tour. A sample of 6 service users files was read and 4 used for the purpose of case tracking. The service users provided positive evidence that the planned care was being received. This was supported by the completed 5 service users questionnaires received by the Commission for Social Care Inspection. A further 3 questionnaires were received from relatives. The inspector spoke at length to the Deputy Manager during the inspection and also to a Senior Care staff member, Care Assistant, the Activities Coordinator, the Cook and a Student Nurse on placement. Four staff files were read, fire log book, accident book and other documentation and the Registered Manager provided a completed preinspection questionnaire. What the service does well: What has improved since the last inspection? There has been an improvement to the décor and garden area in the dementia care unit that is very noticeable. With the recruitment of a Manager for this unit who will commence duty within the month more improvements are anticipated. Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 6 The garden area at the rear of the home has been totally upgraded and is safe, comfortable and well used. New furniture, a barbeque and large umbrella’s and a gazebo have altered the character of this area that had been neglected by the previous owners. The service users and their visitors now have easy access to this area, that is not overlooked by any other property, from the home when weather permits. 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. Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home gathers comprehensive information about prospective service users that enables them to judge the appropriateness of an admission and plan for their care prior to admission. EVIDENCE: A sample of six service users files was looked at during the inspection. Each held a completed comprehensive pre-admission assessment that had been completed by a Registered Nurse. There was information about the service users ability to cope with activities of daily living, washing, dressing, eating, etc. In addition there was information about health care such as mobility, continence, nutrition and tissue viability. This information was used, along with information obtained from hospital discharge summaries, care management information and relative’s, to form the care plan. Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The care plans are well structured and supported by assessments. The staff delivers the care in a professional and caring way that maintains the dignity of the service users in their care. EVIDENCE: A sample of six service users care plans was seen during the inspection. Each was well structured and held good amount of information about the service users, their needs, and how the home had planned to meet them. Areas covered included nutrition, pressure care and prevention, mobility, and wound assessment and care. There was also information about social care and what had been planned by the Activities Coordinator and how the service users had responded to the activity whether it had been individual or as part of a group. The care plans had clear evidence of reviews having taken place. The home has good lines of communication with care management, Community Psychiatric Nurse’s, District Nurse’s, Nurse Specialists and the Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 10 General Practitioner’s and were seen to record in the service users files any contact with them and the outcomes. There are also regular arrangements for the Chiropodist to attend the home who charges a fee, payable by the service users when they receive treatment. The General Practitioner will refer service users to physiotherapy, speech therapy and occupational therapy if they feel it will benefit a service user. The service users can also receive dentistry at a dentist of their choice or at the home if needed. The service users can self medicate if they wish and the risk assessment shows this to be safe. There are lockable facilities in bedrooms for this purpose. If this is not possible then medication arrangements are managed by the Registered Nurses who follow strict guidelines in the homes policies and procedures, those advised by the Nursing & Midwifery Council and the legislation. The medication arrangements were looked at and found to be satisfactory. There is photographic identification of each service user, the administration records were signed correctly with no unexplained gaps, procurement details are recorded on the administration record, and the storage methods were good for all medications. The home uses a MDS system from a major pharmaceutical provider. New staff always have a minimum of three supervised medication rounds before they are deemed competent by the home to meet their standards of administration. The staff were seen to address the service users in a respectful way and to treat them in a dignified way whatever they were doing with them. The service users spoken to also commented that they felt that the staff are very good and look after them well always treating them in a kind and respectful way. The inspector spoke to two relatives who were visiting the home and they were very satisfied with the attitude of all the staff who they felt were friendly and approachable. One had seen many positive changes at the home over the last couple of years and said that he would not go anywhere else for the care of his wife. Service users are seen in their own rooms when examined by the General Practitioner and although the home does have 4 double rooms the Registered Person chooses to use those rooms a large single rooms. Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15. The quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. The home provides well for the social care needs of the service users including planned activities daily, excellent food and a good deal of choice in the way their day unfolds. EVIDENCE: The care plans describe to the staff how the service users cope with their activities of daily living and what assistance they might need with such things as dressing, personal hygiene and eating food. The records also inform the readers about the service users interests and this information is used by the full time Activities Coordinator to plan activities for groups and individuals so as to both entertain and meet any therapeutic needs both physical and psychological. Photographic evidence of trips to the Eden Project and also for dinner out was seen at the front entrance of the home. The Activities Coordinator has her own office and resources to meet the service users needs. One service user explained how her life had been improved by being taken to the local superstore that is close to the home that she had not left for several years. Her comments about the way the staff care for her could not have been Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 12 more complimentary. He visitor also said that the care was good and that she knew what to do if she felt her sister had not received the care she needed. Another relative reported that they felt the care and services provided were very good and they had an excellent relationship with the staff that allowed for very free flowing communication and this was observed by the inspector. The garden areas have been greatly improved and have been used for fates, barbeques and just for fun. The enclosed garden in the dementia care unit has been thoughtfully laid out for safety and also visual and tactile stimulation by day and by night using lights and a water fountain. The garden furniture is of good quality and there are umbrellas and gazebos to protect service users from the sun on hot days. The service users have choice in all aspects of their life in the home. They can furnish their rooms with personal items as seen by the inspector. Several have their own telephone line that they fund themselves. Food is produced in a fully functional hotel like kitchen with a very experienced Hotel Services Manager/chef and cook. The food produced fresh and is of a high standard that welcomed by the service users who choose what they would like from the menu the day before. If there is nothing that they like on the menu the chef will produce something to meet the service users desire and nutritional need. Specialist diets both to meet physical and cultural needs are produced in the kitchen. There is flexible visiting at the home and visitors are requested to sign in and out of the home. They can take relatives out if they wish and, if given prior notice the home will have a service user prepared to prevent any delays in leaving the home. There are areas set aside for private visiting if needed and service users can see visitors in their own room if they wish. The home does not manage the affairs of any client or act as their appointee. They can provide advice to service users or there advocate on how they can arrange safe management of their affair’s through a solicitor or Court of Protection. The Commission for Social Care Inspection provided the home with a number of its own quality assurance questionnaires. The inspector received 3 responses from relatives/visitors and 5 from the service users on the. The comments were mostly very positive but one person did remark that they felt that they would like to see more staff in the dementia care unit at weekend to provide more stimulation for the service users. A new unit manager is to begin work in this unit one week following this unannounced inspection. Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home has good procedures in place for the protection of vulnerable adults including training and complaints investigation. EVIDENCE: The home has a complaints procedure that is clearly displayed inside the home at the signing in book. It is also in the Statement of Purpose/service users guide and gives details about how the home will manage a complaint and what in what time frame the home will respond. The inspector has seen that the home does manage complaints correctly and does record the pathway through their investigation to a conclusion keeping clear records of each step taken to resolve the situation. There is a policy and procedure on Adult protection at the home. In addition the home has the local authorities Alerter’s Guide that is on display and describes what types of abuse there are, how they are recognised and what to do if there are concerns that abuse has occurred. The home also has a whistle blowers policy to protect anyone who should raise a concern about abuse. In addition to these documents the home provided evidence to show that most staff have completed their annual Protection of Vulnerable Adults training for this year. Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The homes appearance, inside and out, has improved since the last inspection and is now more attractive and functional particularly in the dementia care unit. EVIDENCE: This purpose built home is well located in a suburb of Plymouth, near a medical centre and local shops including a major superstore within a mile and all relatively on the level to the home. There is also a large hospital, Derriford Hospital, within a short distance from the home. At the front of the home there is good car parking for several cares on tarmac and a further gravel car park for about 14 cars. The entrance to the home is by an automatic door with a pin coded entry. The home is well maintained by the in house maintenance man and also by specialist services for such things as the boilers, hoists, shaft lift and electrical and fire systems. Service dates were seen to be satisfactory. Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 15 The gardens have been reported on elsewhere in this report however it is worthwhile repeating that they have received a good deal of attention and now provide safe, attractive facilities that are used by the service users and their relatives and have provided good facilities for the homes fate and barbeques. The home has wide corridors leading to bedrooms, bathrooms, and dining room etc allowing very good access for the disabled and wheel chair users. The shaft lift makes movement between floors easier for everyone in the home. Toilet and bathing areas are of good size and a variety of designs such as wet rooms (wheel in showers) and disabled baths. The general décor is good and the service users rooms have been personalised using their own furniture and keep sakes. The dementia care unit has been improved with thoughtful use of colour and furniture that provides an improved ambiance to the unit. The garden area is very well planned and provides safe visual and tactile stimulation for the service users who use it. There are safety features for the service users throughout the home such as thermostatic restrictor valves on baths, low surface temperature radiators that can be adjusted by the service users, The home has its own laundry that has 2 large washing machines with sluicing cycles and 2 industrial dryers. It is staffed for 7.5 hours a day 7 days a week. The walls are cleanable and the floor is impervious to liquid. There are disinfecting sluices and a macerator at the home. Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home recruits and trains staff who are on duty in sufficient numbers to meet the needs of the service users. EVIDENCE: The home employs both Registered Nurses and trained Care Staff in sufficient numbers each shift to meet the care needs of the service users. They are assisted by the ancillary team that includes an Administrator, Activities Coordinator, Hotel Services Manager and his catering team, laundry and domestic staff, and the maintenance man who collectively keep the home running as efficiently as possible under the leadership of the Home Manager. One person did comment in the Commission for Social Care Inspection questionnaire that they felt that there were fewer staff working at the weekend. The duty sheets seen by the inspector were evidence of the numbers of staff who had been on duty for shifts prior to the inspection and also those planned for future shifts. At present there is 30 of the care staff who hold a National Vocational Qualification in Care at level 2 or above and further staff have applied to commence their training. The home has very through recruitment arrangements that include obtaining evidence of each applicants identity, a POVA First check before they commence duty and a Criminal Records Bureau check. The inspector saw evidence of this Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 17 in the 4 staff files that he looked at during the inspection that also included details of the induction process and work permits for overseas staff. The home also has Student Nurses on placement from the university as part of their nurse training from time to time. One was in the home at the time of this inspection and she reported positively about the experience drawing comparisons with the experiences had working in the National Health Services. These students are fully vetted by the university who share the information with the home with regard to the suitability of each student in meeting the required checks for working in a care home. The student said that she had a good induction into working in the home and she was very impressed with the home and the level of activities available for the service users. A Senior Care staff member spoke enthusiastically about her role in the home who had encouraged her well to achieve her National Vocational Qualification at level 3 in care and also in obtaining her Management Diploma at Team Leader Level. She supervises care under the direction of a Registered Nurse and is involved in the induction of new staff introducing them to policies and procedures and the environment. She is also responsible for Manual Handling, making sure that new staff knows where the assessments are and how to use them correctly. The Deputy Manager was very positive about the improvements in the home over the last year and how all the staff have been involved in making this possible. She was also looking forward to taking up her new role in the home at the end of the month as Manager. The homes training matrix provided evidence of all the training that all the staff have been involved in during 2006 with renewal dates set. A copy of this information was supplied by the Registered Manager. A Care Assistant with several years experience at the home reported that she was happy with the training she has received and that it has prepared her well for the duties she undertakes. She is also pleased with the support of the management and the loyalty of the staff team that she has experienced. Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is well managed, well maintained and well equipped, including skilled staff, to meet the needs of the service users. EVIDENCE: The Registered Manager is an experienced Registered Nurse with several years experience in charge of a large nursing home. She has provided evidence of her management skills by the performance of the home under her leadership. With the support of her Deputy and other staff the home has continued to improve and any problems from previous inspections have been addressed. She has maintained an overview of the functions of the home and has provided evidence that through good staff training, service user assessment and equipment maintenance the home is achieving a good standard of care to the service users in a safe environment. Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 19 There are clear lines of accountability both internally and externally with the larger organisation who do regularly attend the home as was occurring on the day of this unannounced Key inspection with the presence of the Care Services Manager. The Commission for Social Care Inspection receive monthly Regulation 26 reports about the home from visiting management. The organisation has suitable quality assurance checks in place that include the views of the service users. A folder was seen by the inspector that held information about the quality assurance measures the home has used to assess the effectiveness in meeting the service users needs and satisfying legislation. The home does not manage the affairs of any of the service users who live there and are not appointee for any of the service users. They do have secure arrangements for the safe keeping of money and valuables in the short term. Where pocket monies are handled the home has clear records that account for any expenditure that has occurred. The home has provided the Commission for Social Care Inspection with Regulation 37 notices where this has proved necessary and the inspector looked at the accident record book that provided information about other events that did not need to be reported in a Regulation 37 notice. Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Bickleigh Down Care Centre DS0000003574.V303116.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!