Inspection on 30/01/07 for Burlington Hall Care Home

This inspection was carried out on 30th January 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

Burlington Hall Care Home 04/04/06

Burlington Hall Care Home 04/10/05

Burlington Hall Care Home 26/04/05

Burlington Hall Care Home 12/05/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Burlington Hall Care Home 9 Station Road Woburn Sands Milton Keynes Bucks MK17 8RR Lead Inspector Sue Smith Unannounced Inspection 30th January 2007 11:00 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 DS0000015049.V327937.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. DS0000015049.V327937.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burlington Hall Care Home Address 9 Station Road Woburn Sands Milton Keynes Bucks MK17 8RR 01908 289700 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) Burlington Care Homes PLC Maureen Cox Care Home 53 Category(ies) of Old age, not falling within any other category registration, with number (52), Physical disability (1) of places DS0000015049.V327937.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 53 older people with 1 person with a physical disability over the age of 65. 4th April 2006 Date of last inspection Brief Description of the Service: Burlington Hall is a care home for Older People in Woburn Sands it is ideally situated for access to the local amenities. Burlington Hall has 52 bedrooms all with en-suite facilities; the home has four lounges, all with small kitchenette facilities. The home has six bathrooms, which provide disabled bathing facilities. An assistant manager and a senior team, as well as a well-trained group of care staff assist the Manager with the management duties. The current fees are between £397.00 and £440.00 per week, the Manager submitted these figures on the 15th January 2007 and are the most up-to-date figures held by the Commission. Relevant information is made available to service users and families prior to admission with copies of the Service Users Guide and the Statement of Purpose available at the home. DS0000015049.V327937.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second key inspection of the service since the implementation of IBL2 (Inspecting for Better Lives). The inspection was undertaken on the 30th January 2007 by Sue Smith (Regulatory Inspector). The Manager of the home was available throughout the inspection. The Inspector used a triangulated methodology to complete this inspection, pre-inspection information and documentation was used in the planning process to ensure hypothesis were formulated to support the inspector to explore issues of concern and verify practice and service provision. During the inspection a variety of documentation was assessed, which included Careplans, Risk Assessments, Monitoring tools, Medication procedures, Rota’s, Recruitment files and Training records. The Inspector for Case Tracking purposes identified three Service Users. In addition the Inspector met with four other Service Users and two family members to gain their views on care provision. All Service Users spoken with at the time of inspection were happy with the service provided and were complimentary of the Manager and her team. Feedback was received from relevant professionals prior to this inspection, the general comments were positive with noted ongoing improvements in the service provided. The Inspector would like to thank the Manager, Service Users and Staff for their hospitality and the support given to complete the inspection process. What the service does well: No service user moves into the home without having his/her needs assessed, and has been assured these will be met. The service users all have individual plans of care, which are reflective of the service users personal preferences when implementing care. DS0000015049.V327937.R01.S.doc Version 5.2 Page 6 The home has robust medication policies and procedures, which aim to protect service users. The lifestyle in the home suits the service users preferences, cultural, religious and recreational needs. Service users maintain contact with family/friends/representatives and the local community as they wish. Visitors are welcomed at the home. Service users receive a wholesome, appealing and balanced diet in pleasing surroundings. Service users and significant others are confident their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse by the current policies and procedures, which include training for staff. The home is well maintained thus ensuring that residents live in a comfortable and safe environment. The needs of service users are met by a suitably trained and skilled staff team with sufficient numbers of staff employed to meet the needs of service users. The home has an effective recruitment procedure, which is reflective of all security checks such as CRB disclosures and two references for each potential employee. Service users live in a home that is run and managed by a suitably qualified and experienced manager who ensures the home is run in the best interest of the service users. The home operates health and safety systems, which ensure the protection of service users and staff. There is a friendly and relaxed philosophy at the home with service users satisfied with the support they are offered. Observations throughout this inspection were of a knowledgeable and professional staff team who undertake their duties in a sensitive and respective manner. What has improved since the last inspection? DS0000015049.V327937.R01.S.doc Version 5.2 Page 7 Improvements in the environment have been taking place since the last inspection with a designated managers office now provided as well as a staff room with kitchen facilities. A new hairdressing salon is being built to meet the needs of the service users. Several changes to bathrooms and storage facilities have been made to provide additional storage for the home. Decoration of bedrooms and communal areas has been taking place, with further decoration planned. Adjustments have been made to the front door ensuring access and exit to the home is made easier for those service users with limited mobility. The homes service users guide and statement of purpose have been updated and submitted to the Commission. All staff have received POVA (Protection of Vulnerable Adult) training. Regulation 26 visits are now being undertaken on a monthly basis. A more thorough quality audit system is in place with service user questionnaires sent to gain the views of service users on the care provided at the home. The home has an up-to-date training matrix in place with all relevant mandatory training now up-to-date for all staff. The management team and Providers have worked hard in the past 12 months to ensure the quality of care provision and facilities available to service users is maintained at a high standard. What they could do better: The home have ensured their training and development programme is in line with current minimum standards, however the home would benefit from an internet facility to ensure they can access outside training and complete the application process efficiently, ensuring they are able to obtain places on courses. DS0000015049.V327937.R01.S.doc Version 5.2 Page 8 The regulation 26 visit reports generated lack in detail with limited information contained in these reports. The Area Manager needs to ensure the views of service users are obtained and reported in these documents and that the administrative inspection information is more detailed. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000015049.V327937.R01.S.doc Version 5.2 Page 9 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 DS0000015049.V327937.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments are undertaken by the home to ensure they are able to meet the needs of all potential service users prior to a decision for admission. EVIDENCE: The home have implemented a new pre-admission assessment document which ensures all potential service users have their needs assessed prior to a decision for admission. Three of these documents were assessed during this assessment with all found to be completed to a high standard. In additon the home are developing a further list of tick box questions to support the accurate assessment of any potential service user. DS0000015049.V327937.R01.S.doc Version 5.2 Page 11 There are no restrictions on admission based on ethnicity, cultural or religiious views or gender. The home endevours to meet the diverse needs of its service users and ensure any such needs are identified prior to admission to aid a smooth transition. Service Users and family members spoken with during the inspection felt they received sufficient information prior to admission to enable them to make an informed decision. DS0000015049.V327937.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides individual plans of care, which highlights any medical, health and welfare issues of service users. Risk assessments are in place, which support the service users to maintain their levels of independence in a safe and supported manner. Robust medication procedures are in place, which protect the health and welfare of service users. Service users are treated with dignity and respect with their privacy maintained throughout the implementation of personal care. EVIDENCE: DS0000015049.V327937.R01.S.doc Version 5.2 Page 13 The home provides each service user with an indivudal careplan which outlines their identified needs. The home is presently using the Standex system for storing and recording careplan information. The information held was extremely informative and was reflective of the personal preferences and needs of the service user. The Deputy Home Manager has worked hard to update these files and will be presenting completed files during careplan training to ensure the standard assessed is implemented for all future careplans. Three Careplans were assessed during this inspection, one for a service user who had been in the home 1 day, one who had been in the home 2 weeks and one service user who had been in the home over 12 months. In all cases the careplans were found to be completed to a high standard with regular reviews of assessments taking place. The careplan for the newly admitted service user was of a high standard with the assesement and risk assessment process already completed in high priority areas such as Pressure Wound Risk, Falls, Nutrition and Mobility, with information as to how this service user would prefer care to be implemented reflected. In additon the service users cultural needs had been identified and how the home were going to support the service user to continue to meet these needs. All Careplans were reflective of up to date risk assessments and how the identified risk will be managed. All risk assessments were reflective of review, signed and dated. The home has a robust medication procedure in place. All staff receive training before they are able to administer medication with one staff member spoken with reporting she had attended an Assett three month Safe Handling of Medications course. MAR (medication administration record) sheet were assessed and found to be maintained to a good standard, there were no gaps evident with all omissions or refused medication entries reflective of the key provided. Medication was found to be stored appropriately in lockable metal cabinets with surplus medication stored in designated clinical storage rooms. It was noted that the clinical rooms could do with a spring clean to ensure they are maintained appropriately, this advise was given to the Manager during the feedback for action. A returns system is in place, which is documented and signed by the Pharmacist. There were no out of date or excessive stocks held in the home. The home are reminded to ensure the opening dates are added to all bottles or vessels carrying creams to ensure they are within their recommended use by date. There were no other issues of concern with the medication systems used in the home with the home meeting the minimum standard required. Service Users and family members spoken with during this inspection were complimentary of the care provided and the sensitive and friendly approach of the staff. There were no issues of concern raised with service users feeling their privacy and dignity was respected when implementing personal care. Throughout the inspection positive interactions were observed between service DS0000015049.V327937.R01.S.doc Version 5.2 Page 14 users and staff, with a friendly and relaxed atmosphere evident. Staff show respect to service users calling them by their preferred name and were knowledgeable of the individual likes, dislikes and routines. DS0000015049.V327937.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 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 an age appropriate activities programme which is enjoyed by the Service Users. The home provides a varied, tasty and nutritious menu, which supports service users dietary requirements. Service Users are supported to maintain contact with family and friends with no restrictions in place on visiting. EVIDENCE: The home has a designated activity co-ordinator who ensures the recreational needs of service users are met. There is a varied and enjoyable programme in place, which supports service users to continue with their preferred hobbies as well as enjoy new experiences. Service users were complimentary of the activities offered. Activities provided include outings out of the home and fundraising activities that provide additional funding to compliment the DS0000015049.V327937.R01.S.doc Version 5.2 Page 16 activities programme. The activities co-ordinator keeps records of all activities undertaken by service users and makes changes to the programme, which takes into consideration the needs of the present service user group. It is recommended a realistic budget be provided for activities to ensure the home is able to maintain the high level of activities both in and out of the home without relying solely on monies accumulated through fundraising projects. A varied and appealing menu is provided at the home, which includes alternative meals on request. Service users spoken with at the time of inspection were complimentary of the meals, family members are able to join service users for meals should they wish. The kitchen is regularly inspected by the environmental health department with all requirements actioned within reasonable timescales. There are no restrictions on visiting in place with families reporting feeling welcomed to the home. Visitors spoken with at the time of inspection were complimentary of the support they are also offered and the open communication they experience with management and staff. DS0000015049.V327937.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home operates a complaints procedure, which is reflective of current guidance and timescales for action, thus ensuring Service Users, and significant others are able to raise their concerns appropriately. The home follows the local authority Protection of Vulnerable Adults Policy and its reporting systems to ensure the ongoing protection of Service Users. EVIDENCE: The homes complaints procedure is comprehensive and available on request. Information on how to make a complaint is now included in the Service Users Guide and the Statement of Purpose. The home reported six complaints received at the home since the last inspection, on assessment of these complaints it was noted these were concerns that had been raised by service users or family members, which had been recorded in the complaints file. All outcomes and correspondence in relation to these concerns was recorded and stored appropriately. The recording of concerns received is evidence of good practice and has supported the home to ensure concerns can be actioned with positive outcomes before they become a formal complaint. Any sensitive or confidential information relating to complaints received are stored in a lockable DS0000015049.V327937.R01.S.doc Version 5.2 Page 18 cabinet with reference to the complaint number and where information is stored noted on the complaints log. The home is presently using the counties Inter Agency policy for the Protection of Vulnerable Adults (Safeguarding Vulnerable Adults) and its reporting systems. All staff have recently attended POVA training to support them in their practice and ensure the ongoing protection of the service users at the home. There has been one reported issue of concern to POVA which is currently being investigated, this is not in relation to care received by service users and is being appropriately investigated by social service with the support of the homes management team. DS0000015049.V327937.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is maintained to a good standard to ensure the health, welfare and safety of service users is protected. EVIDENCE: since the last inspection changes to the layout of the home have taken place to create an office for the manager and a designated staff room with kitchen facilities. In addition a new hairdressing facility is being designed with the old designated area now redesigned and decorated to provide an additional bedroom for service users. A new window has been fitted in the large bathroom and a small bathroom has been changed to provide additional storage space. In addition seven bedrooms have been redecorated and new carpet has been laid on the bridge that conects the two wings of the home. DS0000015049.V327937.R01.S.doc Version 5.2 Page 20 The Lounge on the ground floor has also been adapted to provide a lounge plus dining area. None of these improvements encrouche on the communal space provided to service users and is a positive initiative for the home. Now additional storage facilities have been provided it is recommended the filing cabinets which are presently kept in the lounges of the home be placed in these storage rooms, thus ensuring the administration and record keeping systems of the home are not encrouching on the spaces designated as communal lounges for the use of service users. The front door access has been addressed with the door mechanism adjusted to ensure it is lighter when opening, thus supporting service users who are wheelchair bound to gain easier entry and exit to the home. The home was found to be cleaned to a high standard on the day of inspection with all items of C.O.S.H.H. kept in lockable storage facilties when not in use. The home has sufficient laundry facilities to meet the needs of the service users with adequate numbers of staff availalble to ensure washing is kept up to date. The home has infection control policies in place with sufficent hand washing facitities provided. DS0000015049.V327937.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of suitably qualified and experienced staff to meet the needs of Service Users. The home operates a robust recruitment system, which ensures all relevant security checks are put in place prior to a start date, thus ensuring the ongoing protection of Service Users. The home provides ongoing training to support the staff to meet the needs of the Service Users. EVIDENCE: The home provides suitable numbers of sufficiently trained and skilled carers to ensure the ongoing and changing needs of service users is met. Staffing levels at the home on the day of inspection were sufficient to meet the needs of the service users with service users commenting on the professional and friendly approach of the staff when implementing care and support. Feedback received prior to the inspection was complimentary of the staff team. One family member felt there needed to be additional staff, on inspection of the rotas and the staffing levels on the day of inspection, the home were found to DS0000015049.V327937.R01.S.doc Version 5.2 Page 22 be providing additional staff when and where required to meet the changed needs of service users. The Manager is proactive in ensuring the staff team receive a full programme of training, which will support their professional development and maintain the standards of care in the home. There is an up-to-date training matrix in place, the Manager has worked hard in the past 12 months to ensure all mandatory training is up-to-date and additional training is provided to staff to support them in their roles. There is a strong commitment to supporting staff to achieve their NVQ qualifications in care with support offered by the Manager to achieve this certificate. The home are presently reliant on mailing their interest for outside courses, unfortunately most of the counties provided training is by email application, the present system used by the home is causing a delay when trying to gain places on courses and has led in some instances to them missing out on courses. It is recommended the organisation explore installing Internet facilities at the home to support the Manager in her duties. The home operates a thorough recruitment system, which is in line with current legislation, which includes relevant security checks such as CRB (criminal records bureau) disclosures and two written references for all staff. There has been no completed recruitment of staff since the last inspection with two staff currently being processed for recruitment, therefore the Commission are unable to further assess this standard during this inspection, however this standard was found to be met at the last inspection. DS0000015049.V327937.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A suitably qualified and experienced Manager is managing the home ensuring the home is run in the best interest of Service Users. The home operates a quality audit system, which supports them to make improvements, which will enhance the lives of service users. The home ensures it follows current health and safety guidance with an audit system in place to ensure the ongoing protection of Service Users. EVIDENCE: DS0000015049.V327937.R01.S.doc Version 5.2 Page 24 The home is managed by a proactive manager who ensures a homely and supportive environment for service users is maintained. Staff report finding her approachable and supportive. The current Manager has been in post since September 2005 with her Deputy Manager in post for approximately twelve months. As a management team they have implemented a substantial number of changes to the way the day-to-day operation of the home is managed which has had a positive effect on the outcomes for service users. Service Users and family members reported the management team as approachable and proactive ensuring any changes in care delivery are reported quickly and in an open and transparent manner. The Proprietors and the Manager have worked hard in the past twelve months to promote an effective qualty assurance system. An annual Improvement/Business Plan is developed by the Area Manager following consultation with the homes Manager. A residents questionaire was last undertaken in October 2006 with comments for change included in the annual plan for the home. New policies and procedures are being implemented with a contract in place which will provide the home with the current Mulberry policies and procedures. Regualtion 26 inspections are now undertaken by the Organsiation with reports available in the home for inspection purposes. There is still room for improvement as to the content of these inspectons which need to include the views of service users and significant others spoken with during these inspections. The home implements health and safety systems which are in line with current legislation and guidance. The Deputy Home Manager has recently completed a three month health and safety course and is now responsible for ensuring the ongoing monitoring and audit systems in realtion to health and safety are maintained. The home has generic risk assessments in place known as Working Environment Assessments which highlight any areas of concern and provide risk measures to minimise the affects of any identified risk areas. Medciation audits take place regulary with the last audit taking place December 2006. the home was inspected in October 2006 by the Environmental Health Department under the Backs 2000 initiative which addressed the manual handling systems in place at the home. Two recommendations were made as a result of this inspection, both recommendations have been addressed by the home. Accident/Incident recording is taking place, a monthly log is maintianed which contains copies of all accidents and incidents, this is then used for auditing purposes to look at trends and any identified risk areas. The home has an up-to-date and regularly reviewed fire risk assessment which has been assessed by the Fire Authority. Fire monitoring takes place regularly with records open to inspection. DS0000015049.V327937.R01.S.doc Version 5.2 Page 25 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 DS0000015049.V327937.R01.S.doc Version 5.2 Page 26 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 Refer to Standard OP12 Good Practice Recommendations It is recommended a realistic budget be provided for activities to ensure the home is able to maintain the high level of activities both in and out of the home without relying solely on monies accumulated through fundraising projects. it is recommended the filing cabinets which are presently kept in the lounges of the home be placed in the new storage rooms, thus ensuring the administration and record keeping systems of the home are not encrouching on the space designated as communal lounges for the use of service users. It is recommended the Proprietors explore the option of installing Internet facilities at the home to support the Manager in fulfilling her duties. 2 OP19 3 OP30 DS0000015049.V327937.R01.S.doc Version 5.2 Page 27 DS0000015049.V327937.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000015049.V327937.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!