Inspection on 23/08/07 for Boars Tye House

This inspection was carried out on 23rd August 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

Boars Tye House 24/08/06

Boars Tye House 01/12/05

Boars Tye House 11/05/05

Boars Tye House 21/12/04

Boars Tye House 17/05/04

Boars Tye House 11/12/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Boars Tye House 20 Boars Tye Road Silver End Witham Essex CM8 3QA Lead Inspector A Thompson Key Unannounced Inspection 23rd August 2007 10:15 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 Boars Tye House DS0000017775.V349449.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. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Boars Tye House Address 20 Boars Tye Road Silver End Witham Essex CM8 3QA 01376 584515 01376 585007 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.boarstye.co.uk e-mail: ourteam@boarstye.co.uk Mr Clive Weir Mrs Bernadette Weir Mr Clive Weir Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 27 persons) 24th August 2006 Date of last inspection Brief Description of the Service: Boars Tye House is a fully detached property originally constructed approximately three hundred years ago as a farmhouse. The property has been converted and extended into a twenty-seven place residential home for elderly people (over the age 65). Accommodation is in twenty-three single rooms and two shared rooms. Sixteen of these benefit from fitted en-suite facilities. Accommodation is provided on both floors of the home, with communal lounge/dining rooms on the ground floor. Access between floors is provided by a shaft passenger lift. Boars Tye House is located in the village environment of Silver End and is approached via a private drive alongside a large, landscaped front garden. At the rear of the home there is a small rear garden and patio area, which is fully enclosed. Ample car parking is provided to the front for visitors, and bus services pass the front of the building along the main road. Local shopping facilities are a short walk away. Externally the home is very well maintained retaining an attractive period appearance. Internally much of the character of the original property has been retained. Information regarding fees is displayed on the home’s internet website. Past inspection reports are available from the home, and from the CSCI internet website. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place on Thursday 23rd August 2007. The content of this report reflects the inspector’s findings on the day of the inspection along with information provided by the service and feedback by service users, relatives, staff and other parties. Practice and procedures occurring after this inspection will be reported on in future inspection reports. Discussions took place with seven service users, the registered provider/manager, care manager, cook and four members of staff. Random samples of records, policies and procedures were inspected and a tour of parts of the premises and grounds took place. All residents spoken to were complimentary towards the care they received and with the quality of the food and accommodation offered. Visitors spoken with have been complimentary of the care and support provided to service users by the staff and manager. Questionnaires were also left at the home so that relatives had the opportunity to make their views on the service known to the Commission. The home’s own quality assurance process includes gathering the views of relatives. Evidence of the results of the 2006 survey were seen, along with any resulting actions taken by the management team. Staff confirmed they received good support from the management team. They also confirmed that the management team had continued to provide wide ranging training opportunities, including NVQ training. Twenty-six standards were inspected and the outcomes for service users against four of these were excellent, twenty were good, with two adequate. As a result this report includes just two good practice recommendations as areas to be considered for improvement. What the service does well: Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 6 The home’s management team works well as a supporting and cohesive unit, offering clear lines of communication and guidance to the staff team. Much of the private accommodation available retains the original character of the property. The whole premises, including the grounds, were very well maintained. An excellent range of training opportunities are available to staff. What has improved since the last inspection? What they could do better: The home could improve written evidence for inspection to clarify the areas covered in the in-house medication competency assessment undertaken by staff who have taken on the role of administering medication to service users. -------------------- 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. Boars Tye House DS0000017775.V349449.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 Boars Tye House DS0000017775.V349449.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): 3,5 Quality in this outcome area is good. Admission processes ensure that service users can be confident that the home considers they can meet their needs. This judgement has been made using available evidence including a visit to the service. EVIDENCE: One of the care managers visits prospective new service users to undertake an assessment of need. Evidence of this process was seen. Headings covered included: personal care, health, diet, weight, sight, hearing, communication, oral, foot care, mobility, dexterity, falls, continence, medication, social, interests & hobbies, safety & risk and mental health needs. A care plan is compiled after admission. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 9 Service users and their families are invited to visit before admission, to meet with existing service users and staff, these visits may include staying for the day and include a meal. Initial admission is on a four-week trial basis after which time a review is held to try to be sure that the home considers they are able to meet the individuals needs. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is good. Care plans had been regularly reviewed and provided up to date information on the health, personal and social care needs of service users. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Two care plans were inspected. Included was background information, personal details, next of kin contacts. The residents’ needs/action sheet covered areas of hygiene, mobility, continence, social, medical, diet, night care, acute care and also included was a risk assessment profile and a moving and handling profile. Since the last inspection additional areas of strengths, mental health and communication needs have been added to the format. Needs instructions to staff covered the identified need with daily action required from them and the overall objectives. Care plans seen included records of residents weight, and had been regularly reviewed. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 11 Records of health needs visits, GP consultations and falls were seen included in care plan files. District Nursing services continue to support the home in pressure sore assessment and will also supply appropriate aids and treatment. The home no longer has a dentist who will visit, instead service users go to community based dental services. Relatives support service users to do this but the care manager confirmed that staff will provide this support if necessary. Continence advice is provided by the community Continence Nurse who also visits the home. Specialist dietary advice, when needed, is available from the Dietician based at a local hospital. Hearing tests are available at a local hospital and eyesight tests, and chiropody services are provided by visiting practitioners. A choice of two GP surgeries is available to residents, although most still use the local practice in Silver End. Evidence was available to confirm that staff receive certificated training in medication procedures. Since the last inspection five staff have undertaken a distance learning safe handling of medicines course. The manager advised that all staff who administer medication would soon be enrolling on this course. The homes medication policy and procedure was unchanged. This included the Royal Pharmaceutical Society guidance manual for care homes. Areas covered included ordering, storage, administration and returns of unused stocks. A separate returns book/pad is maintained and was available for inspection. Medication administration records were inspected and were acceptable. The home carries out a competency assessment on all staff new to medication administration. A record had been kept of this process but did not include the areas covered. There is a good practice recommendation on this point in this report. Discussions with individual service users indicated that they were treated with respect by staff, as did observation of staff going about their duties and interactions with service users. Staff on duty were seen to be courteous, caring and professional in their dealings with service users, and those spoken with said staff were helpful and considerate. Some service users had their own private telephone lines, for others a portable phone was available to receive private calls. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is good. The home provides flexible routines and a lifestyle that enables service users to make choices. Service users interests are provided for and their health and welfare is promoted by the provision of a varied and balanced diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service user meetings continue to take place, relatives are welcome to attend these. Minutes of issues discussed and decisions made were inspected. Topics included: meals, routines and activities. Some service users attend a local church each week, with community support. There is also a monthly visit by local clergy to hold a communion service. Two part time staff work to provide daily activities in the home, records had been maintained of types of activities offered, these included: indoor games, quizzes, nail care, puzzles, bingo, visiting entertainers, board games, shopping trips (using dial-a-ride), painting, sing-a-longs, outings, discussions, theatre knitting, videos, DVDs and music. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 13 Regular outings had also been offered to service users, places visited included: Tropical Wings, Layer Marney, Lavenham, Bay Tree Gardens and Maldon. Service users spoken with confirmed they were fully satisfied with the choices and options made available to them regarding daily routines and leisure interests on offer. They were also complimentary about the care support provided by the staff team. Visitors are welcome at all times, the home’s statement of purpose confirms the visiting policy. Seating has been provided in a quiet area on the first floor for use by service users and their visitors who wish to meet away from the main lounge. Advocacy support is available and has been provided in the past. Notices were displayed regarding access to this service. Records seen and inspection of private rooms confirmed that service users had been permitted to bring their own personal items with them on admission. Nutrition records had been maintained, these were seen and evidenced choice and variety. The days menus was displayed in the dining room. The main daily meal is lunch, with two choices. Service users decide their preference the afternoon before. Teas are usually also two choices. All service users spoken with were complimentary about the food. Four said it was very good and that there was always a choice. Meals may be taken in private rooms if preferred. Foods stocks were seen and were considered good. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. Practices in the home safeguard service users, and ensure that concerns are listened to and addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints procedure contains guidance on how to make a complaint and who to complain to. Also included were timescales for responses from the home. Evidence was available to confirm that records are maintained in the home, of complaints received and of any investigation and resulting outcomes. Service users spoken with said they knew who to speak to in the home if they any concerns, and that in the past management had responded positively to any queries/issues they had raised. The registered provider, one of the care managers and a bank member of staff are POVA trainers (approved by Essex County Council & Essex Vulnerable Adults Protection Committee). Certificates of qualification entitled ‘Training for Trainers in the Protection of Vulnerable Adults’ were seen. They provide in-house training to staff on the subject of abuse and adult protection. Training certificates were seen, these were headed ‘Awareness in the Protection of Vulnerable Adults’. The most recent training had been given in June 2007. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 15 The homes own in-house policy on adult protection was inspected, this included guidance for staff on recognising and reporting abuse and action to be taken by staff and the person in charge if abuse is suspected. The home had a copy of the latest POVA guidelines and associated reporting forms. The home also had a ‘whistle blowing’ policy which provided guidance to staff on their responsibilities to report any concerns to management. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 16 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): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. Furnishings in the home looked comfortable and the home appeared safe and was well maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Boars Tye House is a converted farmhouse set in the village of Silver End, nearest towns are Witham and Braintree. The home is accessed via a private drive alongside the home’s large landscaped well maintained front garden, which is fully accessible to service users. There is also a smaller enclosed rear garden accessible from the conservatory and the back of the home. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 17 Individual private accommodation and facilities are all considered to be of a good standard with renewal of equipment and maintenance undertaken on an as and when required basis. Since the last inspection the kitchen refurbishment programme had started, with full completion due in 2007. There is one designated dining room in the home with one lounge/dining room and a further lounge and conservatory area, all on the ground floor. Lighting in communal rooms was considered domestic in character and sufficiently bright. The furnishings of communal rooms were mainly domestic in character, of good quality and appropriate to the range of needs of service users There are three communal bathrooms, two provided assisted bathing and one did not. All three bathrooms in the home have WC’s and in addition there are four separate communal WC’s (three on the ground floor and one on the first floor). Sixteen private bedrooms in the home benefit from fitted en-suite WC. A designated hair dressing room has been provided (this was previously an unused bathroom). Staff call systems were located in all private rooms and communal rooms seen. The home is equipped with a shaft passenger lift to provide access between floors. One set of stairs also had a stair lift fitted, although this was reported as seldom used. Rooms were well decorated, comfortable and evidenced individual taste. Preferences are encouraged/respected. During discussion with service users all said their rooms were comfortable. Door locks and keys are provided according to individual choice and risk assessment. All rooms inspected were naturally ventilated with windows and all were centrally heated. Hot water supplying the home is regularly tested by staff and records were available to confirm that baths are checked to ensure that temperature is 43 degrees celcuis before residents get into the water. However regulator valves were not been fitted to hot water supply to mechanically restrict hot water supply at or near to 43 degrees celcuis. There is an on-going recommendation regarding this item in this report. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 18 It is understood by the inspector that the local authority environmental health department has confirmed acceptance of the current arrangements and risk assessment in the home relating to hot water supply. All radiators in the home, seen, were guarded. On the day of the inspection the premises were considered to be very clean and hygienic. Policies and procedures were available for inspection confirming that working practices are in place to control the spread of infection. A separate sluice is provided. The home’s laundry room was inspected and was equipped with appropriate industrial type washing machines and tumble driers. Washing machines were seen to be equipped with minimum 65 and 90°C wash cycles. The laundry flooring had an impermeable finish. Walls and work surfaces met the standard. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is excellent. Staffing levels met the needs of residents. Staff had been provided excellent training opportunities to equip them with the skills for their role. Staff recruitment procedures aimed at the protection of residents had been followed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s staffing rota was inspected and confirmed that staffing levels are being maintained at five care staff on duty on morning shifts, with four on duty afternoons. Night staffing is three on waking duties. Separate and additional rostered staff were employed to undertake cooking, kitchen assistant, administrative, activities, domestic and maintenance duties. Staff records evidenced that application forms had been completed, two written references obtained, contracts of terms & conditions issued and criminal records checks undertaken. Staff spoken with confirmed they had been police checked. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 20 Training opportunities offered by the registered provider and management team continues to impress. Evidence of this included inspecting records and discussion with staff. The registered provider/manager has completed the Registered Managers Award (NVQ level 4). One care manager was still working through the NVQ level 4. Twelve staff either had or were studying for the NVQ level 3 and twenty five staff either had or were studying for the NVQ level 2 award. This equates to over 90 of the staff team with or studying towards NVQ qualifications. New staff undergo the home’s induction programme. This is based on the Skills for Care induction standards and includes headings of: principles of care, personal care provision, routines, effects of the setting on service users, maintaining safety at work and code of conduct. Staff spoken with confirmed that they had undergone this training when commencing employment. Since the last inspection a written assessment format has been introduced to test staff on their understanding of the training given. Evidence of this process was seen. One of the care managers is a Manual Handling Trainer, a POVA (protection of vulnerable adults) trainer and a Dementia Care trainer. This qualifies her to train staff in-house on these subjects. Staff training records had been maintained and evidenced that opportunities have been provided to staff in: Therapeutic activities, trainers toolkit, role of the care worker, continuing professional development, massage, parkinsons, fire safety, first aid, health & safety, infection control, food hygiene, medication, moving & handling, bereavement, sensory awareness, managing aggression, risk management, tissue viability, introduction to dementia, bowel & catheter care, POVA, preventing falls and fractures in care, funerals, personal safety awareness, pressure care & continence promotion and environmental OT assessment. Courses are provided either by the home’s own trainers or by using external trainers. The home has its own training resources materials and courses are presented to staff by one of the care managers. This includes subjects of: risk assessment, dementia care, supervision, health & safety, fire prevention, manual handling, concerns & whistleblowing, abuse, infection control, medication, role of the care worker and person centred care. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 21 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): 31,33,35,37,38 Quality in this outcome area is excellent. The home had been run and managed very efficiently. Procedures for gaining the views of service users and relatives were in place to ensure their views were listened too. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered provider is also the registered manager. He has completed the registered managers award and has undertaken other training relevant to the service provision. His experience fully meets the requirements for the manager’s role. A comprehensive quality assurance survey exercise was carried out in 2006. Questionnaires had been sent to and completed by: residents, relatives, district nurse, GP, social workers, dentist, opticians and chiropodists. Responses were seen. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 22 These had been collated and reviewed by the home and an action plan summary had then been compiled showing details of any actions needed and effected. This was seen. The 2007 QA process was due to be implemented. Information gathering surveys had been expanded to widen the range of responses available. Views are sought on the service, including staff attitudes & care provided, food, accommodation & facilities, activities and the information provided by the home. Some service users personal allowance monies were held for safe keeping by the home. Records of transactions, receipts and balances held were kept. A random sample of these checked were satisfactory. Random samples of records required to be kept were inspected. These included: assessments, staff rotas, staff recruitment, accident records, visitors book, fire drills, regulation 37 notices, nutrition records, furniture brought in by residents, medication, background info’ and next of kin details, cash held for safekeeping and fire procedures All seen were considered appropriately maintained. The control of substances hazardous to health (COSHH) regulations had been met by provision of a COSHH register, with data sheets for relevant substances used in the home. Comprehensive risk assessments were in place for safe working practices in and around the home. Discussions with staff, management and inspection of records confirmed that training is provided to staff in moving and handling, fire safety, food hygiene, first aid and infection control. Certificates and service records were available for inspection to confirm that the home’s fire alarms and equipment, passenger lift, call alarms, emergency lights, gas supply, portable electrical appliances and electrical installation supply had all been tested/serviced within recommended timescales. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 23 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 3 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X 3 3 Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 24 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. 1. 2. Refer to Standard OP9 OP25 Good Practice Recommendations The home’s medication training competency assessment should include evidence of the areas assessed. The registered provider should ensure that hot water supply in the home is regulated to ensure delivery at or close 43 degrees celcuis. Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Boars Tye House DS0000017775.V349449.R01.S.doc Version 5.2 Page 26 - 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!