Inspection on 26/09/06 for Bonaer

This inspection was carried out on 26th September 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

Bonaer 02/10/07

Bonaer 13/01/06

Bonaer 09/06/05

Bonaer 09/12/04

Bonaer 17/06/04

Bonaer 24/02/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Queensmount

Poldhu

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 Bonaer 17 Station Hill Hayle TR27 4NG Lead Inspector Diana Penrose Unannounced Inspection 26th September 2006 09:30 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 Bonaer DS0000043280.V308775.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. Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bonaer Address 17 Station Hill Hayle TR27 4NG 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) 01736 752090 Anthony Joseph Metalle Sarah Jayne Metalle Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability (7), Terminally ill over of places 65 years of age (5) Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th January 2006 Brief Description of the Service: Bonaer is situated next to Hayle railway station, which is very close to the local amenities. It is a big adapted house with an extension and a large conservatory. There is limited car parking space in the grounds but there is additional free parking nearby, on the roadside. The home provides residential and nursing care for up to thirty-one elderly people. The registration allows for seven people with a physical disability and the home also provides palliative care. Accommodation is on two floors with a shaft lift provided. There are hand washbasins in all bedrooms and there are adequate toilet and bathing facilities. Meals are prepared in the kitchen on the ground floor and served in the three lounges or individual bedrooms if preferred. There is no dedicated dining room in the home but dining tables and chairs are provided in the lounges. To the front of the home there is a veranda and a garden with a large fishpond and seating that is accessible to residents. There is also a garden at the back of the home, which has been made more accessible. The Registered Providers have owned the home since May 2003 and are still in the process of upgrading and refurbishing. They are very involved in the running of the home; Mrs Metalle is the Manager but also works as part of the nursing team. Qualified Nurses and Care Assistants provide care within a friendly atmosphere. Information about the home is available in the form of a residents’ guide, which can be supplied to enquirers on request. A copy of most recent inspection report is available in the home. Fees range from £330 to £495 per week; this information was supplied to the Commission in the pre inspection questionnaire received on 30/08/06. Additional charges are made in respect of private healthcare provision, hairdressing and personal items such as newspapers, confectionary and toiletries. Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An inspector visited Bonaer Nursing Home on the 26 September 2006 and spent seven hours at the home. This was a key inspection and an unannounced visit. The purpose of the inspection was to ensure that residents’ needs are properly met, in accordance with good care practices and the laws regulating care homes. The focus was on ensuring that residents’ placements in the home result in good outcomes for them. It was also to gain an update on the progress of compliance to the requirements identified in the last inspection report dated 13/01/06. All of the key standards were inspected. On the day of inspection 29 residents were living in the home, 1 was receiving respite care. One person attends the home for day-care once a week. The methods used to undertake the inspection were to meet with a number of residents, relatives, staff and the registered providers to gain their views on the services offered by Bonaer Nursing Home. Records, policies and procedures were examined and the inspector toured the building. This report summarises the findings of this inspection. Residents and relatives expressed satisfaction with the care and services provided at the home. Overall the home is providing a good quality of care to the residents placed there, with notable improvements since the last inspection. What the service does well: The home provides a warm, clean, safe environment for residents, staff and visitors. The registered providers continue to upgrade the décor and furnishings in the home and it has reached a better standard. Care provided is to a high standard and residents are only admitted following an assessment to ensure the home can meet their needs. Residents have an individual detailed care plan and relevant risk assessments are undertaken. Residents said their care needs are met and they are very happy living in the home. They said the staff are kind and caring and work very hard. A visitor said the home looks after the residents very well and it is very well managed. Friends and family are welcome in the home and residents can go out according to their wishes and ability. The registered providers endeavour to provide activities and entertainment to suit the residents accommodated. There is a variety on offer and residents said they know what is happening and can choose what to be involved in. Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 6 Sufficient numbers and skill mix of staff are on duty to ensure that resident’s needs are met. There is a robust recruitment policy and appropriate training is provided for staff. Residents said there are enough staff and they do not appear to be rushed. Staff were observed to interact well with residents in a very kind, relaxed manner. Care practices observed were appropriate and safe. Medicines are stored safely and securely and only qualified nurses administer the medicines. Relevant equipment is provided for moving and handling purposes and pressure-relieving equipment is supplied as required. A mattress audit takes place every 6 months. There are suitable systems for dealing with complaints and abuse. Staff and residents said they could approach the manager if they had a problem. What has improved since the last inspection? What they could do better: All staff must attend statutory training as required by law. Fire training in particular had not been attended appropriately especially by night staff. The training records need attention, as it was difficult to assess who had attended and at what intervals. Disposal of medicines needs to be addressed with the waste disposal company as the home has been instructed to dispose of medicines inappropriately. Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 7 The manager agreed to include medicines training in the carers induction programme. She also agreed to get a list of homely remedies confirmed with the doctors. POVA checks are obtained but could not be evidenced; the registered provider said they would print the POVA confirmations from the internet for the files. Confirmation that staff are supervised prior to their CRB check being obtained should be evidenced as well. Copies of nurse’s qualifications must be held on file. 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. Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 8 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 Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 9 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 (6 is not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are only admitted to the home following an assessment of their needs to ensure the home can provide suitable care. EVIDENCE: Evidence was provided in the form of records, interviews with residents, relatives, staff and manager. The home has a specific form for recording the initial assessment. The manager or one of the nurses visits prospective residents and information from Adult Social Care and hospital staff is obtained when appropriate. Residents spoke positively about the assessment process. Forms inspected were completed appropriately, dated and signed. An individual plan of care is compiled from the assessments. Bonaer DS0000043280.V308775.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans are generated for each resident that inform and direct the staff in the care provision. Residents have access to health care services as necessary to ensure their assessed needs are met. There are systems and policies in place for dealing with residents medicines that assure residents safety, some additional safeguards will ensure a safer system. Systems are in place to ensure that residents are respected and their privacy is upheld at all times. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and interviews with residents, relatives and staff. Each resident has a detailed written care plan that is reviewed monthly. Risk assessments include Waterlow scoring, nutrition, moving and handling, falls and Barthel scoring. The care plans are compiled with and signed by the resident or their representative whenever possible. Daily records are maintained and the care staff keep records of personal care provision. Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 11 Residents spoken with said their health needs are met and they have access to their GP or other health professionals when required. Care practice was observed to be appropriate during the inspection and carried out in a calm, efficient manner. Pressure relieving equipment is supplied and a mattress audit takes place every 6 months. When a mattress is replaced it is replaced with the Memorex type. Hospital style beds are provided where needed. There is appropriate equipment in the home for moving and handling and staff now receive regular training in house. Several of the nurses specialise in specific subjects and link with external agencies to remain up to date. The manager said that links with specialist healthcare professionals is good. A monitored dosage system of medication is used in the home. No residents administer their own medicines at present. There is a suitable medicines policy in place for staff to follow, there is a copy of The Royal Pharmaceutical Guidelines for the Administration of Medicines in Care Homes and suitable reference books available to staff. Patient information leaflets are kept in a file on the medicines trolley. Medicines were administered in a professional manner at lunchtime. Storage of medicines is safe and secure and records are satisfactory. Medicines are disposed of through a waste disposal company, the manager will contact them, as the way they have instructed the home to dispose of tablets is inappropriate. She said she would also contact the GP for an agreed list of homely remedies. Some care staff have received training in medicines during the NVQ level 3 training and some have done the safe handling of medicines course. The manager said she would ensure that basic medicines training is included in the induction programme. Residents’ privacy was upheld during the inspection. Residents said they are treated with respect and their privacy is upheld at all times. Shared rooms are provided with appropriate screens. Bonaer DS0000043280.V308775.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of activities and aims to offer a lifestyle that meets individual residents needs. Links with family, friends and the community are good and allow residents the opportunity to socialise. Residents are helped to maintain control over their lives and staff respect their individual preferences and choice. Dietary needs of residents are well catered for with a varied selection of food available that aims to meet their taste and preference. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and interviews with residents, relatives, staff and manager. Activities and entertainment are on offer and posters are displayed. Activities include singers, entertainers, crafts, art, games; massage and nail painting Holy Communion took place during the inspection. Residents have grown sunflowers in the rear garden this year. Trips out are organised and a summer fete takes place. Several people talked about a trip to Marazion for a meal and how enjoyable it was. There were some lovely photos of the trip and the summer fete. The care staff are responsible for activities and individual resident records are maintained, these are not filed with the care records. Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 13 There is a record of visitors to the home and there were visitors in the home during the inspection. Residents said they could receive visitors in private and at any time. Visitors spoken with said they are always made welcome in the home and can call whenever they like. Residents said there are suitable telephone arrangements in the home. Residents said they choose when they get up and go to bed within reason. They choose what clothes to wear and how they spend their day. There are choices on the menu and residents were observed to have a selection of meals at lunchtime. Residents’ rooms are personalised with their own belongings and furniture. Each resident has a nutritional needs assessment and a new form has been introduced to record mealtime choices. This includes likes and dislikes, preferred time for meals, preferred place to eat, and any special requirements. There is a varied menu that spans four weeks. Residents and relatives said the food is good and it was observed to be good at lunchtime. Homemade pasties and stew were on the menu on the day of the inspection. Fresh fruit and vegetables are served and the cook said that all cakes are homemade. Meals are served in the lounges or individual bedrooms and appropriate assistance was observed. The dining tables do not tend to be used apart from on special occasions; this is the choice of the residents. Plenty of fluids were observed to be available for residents in all areas with different sized beakers, straws and feeders for residents use. Staff were seen to offer drinks regularly. Bonaer DS0000043280.V308775.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure that ensures complaints are listened to and acted upon. Arrangements are in place for the protection of residents safeguarding them from harm or abuse. EVIDENCE: Evidence was provided in the form of documentation, records and interviews with registered providers. There is a suitable complaints policy in the home and a method for recording complaints, the action taken and the outcome. There have been 2 complaints to the home in the past year. The manager dealt with the issues promptly and records have been kept. There has been one complaint to CSCI in the past year regarding resident’s choice, furniture, food and activity in the evenings; the issue of shabby bedroom furniture was upheld. The registered providers are in the process of replacing furniture. Thank you letters and cards are kept in the home. The home has an adult protection policy and a copy of the alerters flowchart. In house training takes place, the manager has a training video. Two staff have managed to get on to the local training provided by Adult Social Care. There is a secure facility for the storage of money in the home. Residents said there are no barriers to raising concerns with the management. Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 15 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 and 26 Quality in this outcome area is good this judgement has been made using available evidence including a visit to this service. The home and grounds are well maintained providing a safe environment for residents, staff and visitors. The home is clean and every effort is made to eliminate unpleasant odours making it a pleasant place for residents to live in. EVIDENCE: Evidence was provided in the form of a tour of the building, interviews with residents, staff and registered providers. The home is warm, homely and clean with no offensive odours. A refurbishment programme is in progress and a significant amount of work has been achieved. Further decorating has taken place since the last inspection and several carpets have been replaced. Some residents have chosen the décor for their rooms. Residents said they are happy with their rooms and the facilities provided. All strip lights are now fitted with covers for safety. The taps in the bedrooms of independent residents have been fitted with thermostatic regulators. A new extraction system has been installed in the kitchen. The Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 16 grounds are tidy and a delivery of gravel is awaited to complete the decking area for the gazebo. All laundry is dealt with in house and residents are happy with the service. There are adequate sluices with washer disinfectors. Hand-washing facilities are appropriate and staff were observed wearing protective clothing. Staff receive infection control training in house with the manager. There is a copy of the infection control guidelines for care homes in the home. Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 17 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels meet the needs of residents and staff morale is good. Residents are in safe hands and they benefit from the 54 of care staff trained to at least NVQ level 2 in care. Recruitment procedures are robust and offer protection to the residents. The home provides appropriate training for staff to help them be more competent in their roles. EVIDENCE: Evidence was provided in the form of documentation, records, and interviews with residents, relatives, staff and registered providers. The registered providers said there were no staffing issues and there were sufficient staff on duty during the inspection. The manager is aiming to have two nurses on duty at all times during the daytime. The nurses and the manager were observed assisting care staff in their work. Residents and relatives said there seem to be enough staff in the home and staff do not appear to be rushing around. 54 of care staff have an NVQ either at level 2 or 3 and copies of NVQ certificates are kept on file. Some staff are currently undertaking NVQ training. Three personnel files were inspected; the records required by legislation were included. Relevant CRB and POVA checks are undertaken and nursing registrations are checked with the NMC. The registered providers said they Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 18 would print the POVA confirmations from the internet for the files in future and confirm in the records that staff are supervised prior to their CRB check being obtained. One of the nurse’s files requires a copy of her nursing qualification; the manager said she would get this. There is a suitable induction programme for new staff with records maintained. Induction records inspected have been dated and signed. Individual training records are maintained for staff. There is information on courses available to staff and posters are displayed. Training needs are identified at interview, appraisal, and supervision and during meetings. Staff said there are opportunities to attend external courses if they wish and in house training takes place regularly. Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 19 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 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is a person of good character and fit to run the home. The home is run in the best interest of the residents and they benefit from the Quality Assurance systems in place. There is a suitable system in the home for dealing with residents’ money that ensures that the residents’ financial interests are safeguarded. Appropriate training and safety checks are undertaken to ensure the health safety and welfare of residents and staff; extra vigilance in respect of statutory training and staff attendance will ensure further protection. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and interviews with residents, staff and the registered providers. The registered providers are competent and experienced to run the home; they work hard to comply with legal requirements. The manager is a registered Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 20 general nurse and has achieved the Registered Managers’ Award. She keeps herself up to date on current issues by reading relevant magazines and using the internet. She attends courses when she can and keeps up to date with statutory training in house. Staff, residents and visitors said the registered providers run the home very well; they are approachable and listen to what is said. Mrs Metalle in particular is held in high regard, all those spoken with said she works hard both running the home and looking after the residents. Staff appreciate her participation as part of the team. Staff said they are supported in their roles, there are regular staff meetings and formal supervision takes place. A quality assurance survey is undertaken annually. The next survey is due before the end of 2006. Staff meetings take place regularly and a comfort committee meets monthly, this committee comprises of two staff, two relatives and two residents. The two relatives were spoken with and they find the committee useful, they help with events and have input as to what the money raised is used for. Minutes are maintained for all meetings. An informative newsletter is circulated bi-monthly and residents talked about this. Some audits take place, for example accidents. The manager said she hopes to undertake more thorough audits to concentrate on quality in different areas; this is to be commended. There is a suitable system in place for the handling of resident’s money. Five residents deal with their own money and relatives deal with most of the other resident’s money. Mr Metalle and an administration assistant are responsible for dealing with the monies for seven residents. There is a safekeeping policy with a form for residents to sign as agreeing to the policy. Records are maintained of all transactions and receipts are kept. The monies are held individually in the safe, money checked was correct according to the records. Mr Metalle is appointee for one resident; her money is kept in a separate account. No valuables are held on behalf of residents. Records of power of attorney are maintained. The registered providers endeavour to ensure that working practices are safe and staff confirmed this. There are health and safety policies, procedures and risk assessments for the home. There is a fire risk assessment and fire safety procedures and checks are in place. Relevant service checks and maintenance takes place. PAT testing is due in October 2006; the registered provider said he did not receive the certificate for last years testing despite contacting the electrician on numerous occasions. There are current test labels on electrical equipment in the home stating the test is next due on 25/10/06. Statutory training is provided for staff but not all have attended regularly, in particular fire training, this must be addressed. It is recommended that a matrix be compiled for statutory training to demonstrate that staff attend according to the legal requirements. The registered provider said he needs to Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 21 take further action with night staff in particular and Mrs Metalle agreed to improve the records of training provided. There is a person trained in first aid on duty at all times. The kitchen staff have received food hygiene training and one cook has undertaken nutrition and health training. Accident reporting complies with data protection and there is an audit system in place. The home does not have many accidents. Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 22 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 N/A 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 3 13 3 14 3 15 3 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 Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 23 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. 1 Standard OP38 Regulation 23 Requirement All staff must attend statutory training in line with legislation Timescale for action 26/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP38 Good Practice Recommendations A matrix should be compiled for statutory training to demonstrate that staff attend according to the legal requirements Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Bonaer DS0000043280.V308775.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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