Inspection on 14/11/07 for Chestnut Walk

This inspection was carried out on 14th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Chestnut Walk 20/04/06

Chestnut Walk 29/09/05

Chestnut Walk 20/04/05

Chestnut Walk 14/10/04

Chestnut Walk 05/05/04

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 Chestnut Walk 15 Chestnut Walk Hungerford Berkshire RG17 0DB Lead Inspector Kerry Kingston Unannounced Inspection 14th November 2007 9:45 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 DS0000031280.V353027.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. DS0000031280.V353027.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chestnut Walk Address 15 Chestnut Walk Hungerford Berkshire RG17 0DB 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) 01488 683263 chestnutwalk@westberks.gov.uk West Berkshire Council Mrs Susan Marie Breakspear Care Home 13 Category(ies) of Dementia - over 65 years of age (5), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (13) DS0000031280.V353027.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 2006 Brief Description of the Service: Chestnut Walk is a care home run by West Berkshire Council. It is registered to care for 13 older people. Within this number up to five of these people could also have a diagnosis of dementia or mental disorder. The home is purpose-built and is of single storey construction. The home is within a local housing development area with many local amenities close by. The main town centre of Hungerford is nearby, as is the GP surgery, library and churches of various denominations. There are 12 bedrooms, one of which is a double room. All the rooms have wash hand basins. There is a large lounge, the main dining room is adjacent to the kitchen and there is a separate conservatory, which is also next to the dining room. Fees at the time of inspection were £650 per week. DS0000031280.V353027.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report for the key inspection of the service, which included a routine unannounced site visit. This took place between the hours of 9.45 am and 4.00pm on the 14th November 2007. The information was collected from the Annual Quality Assurance Assessment, a document sent to the service by the Commission for Social care Inspection and completed by the manager of the service, sixteen surveys which were sent to people who use the service, other professionals and families of residents. Three surveys from families and two from other professionals were returned to the Commission. Discussions with two staff members, the Registered Manager and three residents took place. Some people who use the service have limited communication ability, therefore observation was also used as a source of information throughout the visit. A tour of the home and reviewing residents’ and other records were also used to collect information on the day of the visit. What the service does well: The home makes sure that people have good care and health plans so that staff can offer them the best possible care, in the way that they prefer and need. The people who live in the home are treated with respect and staff are mindful of their privacy and dignity at all times. The home is part of the community, many residents are local and families and friends are welcomed to the home so that people can stay in contact with the people that are important to them. Residents are helped to make as many decisions for themselves as they can and are given choices whenever possible, so that they feel that they can keep some control over their lives. The home is run for the people who live their, their interests are always the most important consideration and their views are listened to and acted upon, if possible. DS0000031280.V353027.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000031280.V353027.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 DS0000031280.V353027.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. People who use the service experience good quality outcomes in this area. The home ensure that there is a full assessment of the needs of prospective residents and it is able to meet the needs identified. There is some flexibility within the service to respond to emergency or unusual situations but the manager ensures that the needs of existing residents are not compromised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The records of the three newest residents were seen all have full assessments. The manager confirmed that the home will no longer accept any resident without a full assessment from the care management team and she generally does the residential assessment herself. DS0000031280.V353027.R01.S.doc Version 5.2 Page 9 The home is developing a form to note how the home will meet the needs of the individual and what extra resources they might need or why the home cannot meet the needs of the referred individual. This is a home run by the Social Services department , which can create a conflict if there is a client who is in desperate need of residential care. The home is developing a specific criteria for admission rather than admitting people who the department need immediate care for. The manager is very aware of her legal obligation not to admit anyone who she does not feel the home can meet the needs of, such as people with nursing or behavioiral needs. All residents have a full assessment on file and the requirement from the last inspection has been met. All residents are reviewed after they been in residence for approximately six weeks, the new contract specifies review times and the introductory period, as well as the time that the bed will be held if people have to have a hospital admission. The home does not, generally, admit people for short term stays but a recent admission has been of a man who needed somewhere to stay until he had been found permanent accomodation. The home has ensured that he has maintained his independance and are preparing him for the move. There is some question of whether the admission was appropriate but the home has managed to meet his needs whilst not compromising the needs of others. The manager imposed some strict guidelines for behaviours that may have caused distress to other residents and it has been a positive experience for all involved. DS0000031280.V353027.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. People who use the service experience excellent quality outcomes in this area. The home has detailed personal and healthcare plans and records to enable staff to meet peoples needs in the most appropriate way. People are supported to access any additional or specialised healthcare that they might need. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Fve care plans were seen,all were dated and reviewed on a monthly basis (the recommendation from the previous inspection had been complied with.) Care plans are of good quality and detailed they include an individual history (peoples background, culture and religion and preferences/likes and dislikes), a detailed care programme (monthly reviews, weight records, communication, mobility, personal hygiene, toiletting, eating and drinking, dressing and undressing, cultural and emotional needs and recreational/leisure and social DS0000031280.V353027.R01.S.doc Version 5.2 Page 11 needs) and a daily task plan (what assistance people need throughout the day to pursue their preferred pattern of living). Residents are inolved in the development of care plans and the reviews, as far as possible, this was confirmed by two residents. Health care is well documented and records of any visits to or by health professinals is recorded in detail. Body charts are kept if there are any marks or bruising to the body. Falls charts, bowel charts and risk assessments are kept as necessary. There was written evidence that a resident had a physiotherapy assessment after suffering a stroke and that she has been supplied with a hoist and an exercise programme to assist with her mobility. One resident was seen to have an appointment at the memory clinic, one persons’ weight record showed some fluctuation and it was clear what the home had done about it. A resident was noted to suffer from depression and there were written guidelines of how the staff were to behave toward her to try to iminimise its impact on her well being. The number of risk assessments reflected the needs of the individual from a few to over ten, these are reviewed regularly and all are up to date. The home use the Boots monitored dosage system, medication is kept in a locked cabinet in the office. Two people are, currently taking controlled drugs, they are stored appropriately and a controlled drugs register is kept, accurate recordings and stock control were seen, on the day of the inspection visit. Other medication records seen were accurate, two staff administer medication after they have received the appropriate training. The home does not have detailed guidelines, in place, for medication prescribed as required. Guidelines may be particularly useful where two types of painkillers, which should not be administered at the same time, are prescribed. Staff clearly described how they afforded people respect and dignity and how they uphold their right to privacy. Staff were observed treating people with respect and sensitivity. Family comments from surveys said,they look after her and consider all her needs, They look after the residents really well making sure that they have the care they need, they are good at overall care. DS0000031280.V353027.R01.S.doc Version 5.2 Page 12 Doctors commented, The staff obviously care about patients, the best care setting, staff and atmosphere I have come across, the place of choice for ones own relatives, to be preserved and encouraged and rewarded Residents said, there is nothing they can do better, I have my own Doctor and get good healthcare, The staff treat me well everything is very good, they look after me very well. The home has experienced nine deaths since February 2007, none were unusual or caused concern as most were of people who had been resident in the home for many years, two were of people admitted from hospital who were quite frail, on admission. DS0000031280.V353027.R01.S.doc Version 5.2 Page 13 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 and 15. People who use the service experience excellent quality outcomes in this area. The home enables people to pursue a rewarding lifestyle, it offers them as much choice as possible and makes every attempt to involve them in the decsion making processes. People are assisted to retain family relationships and friendships and to remain part of the community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Individual activity plans are in peoples’ files, where appropriate. Care plans also include identification of times for working 1:1 with people and their preferred activities, such as one resident ‘prefers to do her own activities but likes word games or talking with staff’. Whilst people are able to make their own choices about particpating in activities, the home has recently appointed a person who works two days per week to focus on motivating people to join in with things they may enjoy. DS0000031280.V353027.R01.S.doc Version 5.2 Page 14 The home is an integral part of the local community and have a league of friends who visit the home and raise funds for luxury items such as a D.V.D. player, D.V.D.s and any other items that the residents would like. The local school are also involved in supplying entertainemnets and visiting the home. Many of the residents are local people and their families and friends live in the area. Daily records showed that people are taken for walks to the local shop and to the park, two residents confirmed that they sometimes go for walks and visit the shop. The manager and staff are very aware of the changing needs of the resident group, it is now more able than it has been for the past few years and there are palns to go to the local pantomime and other community events that are available. Records are kept of the occasional external performer who comes and there is also a clothing sale within the home for people to choose their own things if they wish to, a mobile library also calls on the home. The home displays a good degree of flexibility to enable it to meet the diverse and changing needs of individuals and the group. There is a strong commitment to keeping family and friendship ties for the residents and there were records of frequent visits from families and friends to the people who live there. A Quality Assurance exercise conducted in early 2007 focussed on peoples’ choices, ability to have choice and control over their lives and the quality of the food. 62 of the residents said that they were able to make decisions and exercise control over their lives (of the other 38 a large proportion did not or could not respond to the survey). One resident described the choices and decisions she is able to make such as not being checked at night, this has been risk assessed. Staff described how they offer people choices on an everyday level such as choosing their clothes, choosing what to do and when during the day. Resident meetings that are held monthly are well attended and demonstrated that staff give people choices and keep them informed of any changes that are occuring. The main meal, breakfast and the food is now provided by contractors but this has not impacted on the residents as the same cook is employed by the contractors. At the last resident meeting it was seen that menus were a subject of discussion and menus had been changed as a direct result of requests from residents. The three people spoken to said the ‘food is lovely’, ‘the cook is excellent. Residents said that they could choose whatever they wanted if they didnt like the food and there was always a chocie of two main meals. DS0000031280.V353027.R01.S.doc Version 5.2 Page 15 The home continue to provide the smaller evening meals and snacks and the manager retains control of the quality and choice of food offered. DS0000031280.V353027.R01.S.doc Version 5.2 Page 16 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 and 18. People who use the service experience good quality outcomes in this area. The home listens to peoples views and acts upon them, it ensures people are protected from all forms of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager confirmed that there have been no complaints or safeguarding adults issues in the home since the last inspection. The manager has reviewed the reasons for the lack of complaints and believes it to be a result of the close relationship between the home,the residents and their families. Any small issues raised are dealt with immeditely and do not manifest as complaints. The complaints procedure is robust and family surveys noted that everyone knew how to complain, three people spoken to said that they ‘know who to talk to if they are not happy’, two added that they have never had anything to complain about, one felt that staff always listen to you and will act if you are not happy. DS0000031280.V353027.R01.S.doc Version 5.2 Page 17 The complaints book is available in the entrance hall so that it can be used by visitors aswell as residents. The ways to complain are discussed in resident meetings, on occassion. Due to the lack of use of the complaints procedure staff have recently had a training session on customer care and complaints, conducted by the complaints officer of the Social services department. All staff have safeguarding Adults training and the two staff spoken to were able to express very clearly how they would deal with any concerns of abuse or ill treatment of residents. The commission for Social Care Inspection have received no information about complaints or Safeguarding Adults concerns in regard to this service. Two residents spoken to confirmed that they felt safe in the home and could talk to any member of staff if they were worried about anything. DS0000031280.V353027.R01.S.doc Version 5.2 Page 18 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 and 26. People experience good quality outcomes in this area. The home offers a pleasant environment, it is well kept and maintained, there is an ongoing maintenance and development programme to ensure it meets the needs of current residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is well maintained and presented, it is comfortable and homely and all areas are clean and hygienic. There were no unpleasant odours. The storage of hoists and other large equipment has been risk assessed and provision made. The home is having some alterations which will provide another large storage area that may be utilised for this purpose. DS0000031280.V353027.R01.S.doc Version 5.2 Page 19 Residents who require additional equipment to meet their diverse and changing needs are provided with whatever is recommended by the occupational or physiotherapy assessment. The home has an annual maintenance and refurbishment plan, new furniture is on order and there is building work being undertaken to ensure the bathing facilities meet the needs of individuals. Residents make good use of the buidling which has been designed to ensure there are quiet areas where people can attain some peace and quiet, one person told me that she spends time in her room if things get noisy and she enjoys this. The one shared room has appropriate screens to ensure peoples privacy. DS0000031280.V353027.R01.S.doc Version 5.2 Page 20 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 and 30. People experience good quality outcomes in this area. The home has a competent and qualified staff team that are able to meet the needs of the people in their care. Newly appointed staff will enhance the work of the team when they have been successfully inducted and integrated into the existing team. Staff are well supported and offered opportunities to participate in a variety of training to ensure that they can offer the best care to the residents. The manager ensures that staff are safe to work with the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a full complement of twenty- two staff, there are a minimum of one senior and two care staff on duty during day time hours and two night staff, the manager is usually additional during the week. Recruitment difficulties over the past two years have been rectified and six staff have recently been appointed, to complete the day and night staff team, these staff will take a period of time to integrate into the existing staff team and complete induction and training programmes. DS0000031280.V353027.R01.S.doc Version 5.2 Page 21 The necessity for the use of agency staff has significantly reduced and will reduce further as new staff complete their training and induction. One of the new staff has been appointed to work two days per week and her work will focus on activities for individuals within the home. Additional staff can be rotad on duty to enable participation in any special activities or events. The catering is now done by an external contractor who supply temporary cooks when the permanent cook has days off or is on leave/sickness, this means that staff no longer have to participate in main meal preparation. Staff confirmed that there are always enough staff on duty to complete all the tasks and they are able to spend time helping people with activities and having one to one interactions with them. They were observed chatting to individuals and participating in activities with them, on the day of the inspection visit. Two residents confirmed that staff are always there if you need them. Staff had good knowledge of the residents needs and a detailed handover of shifts was observed, daily shift organisation paperwork ensured that all staff knew what was happening in the home. The files of the two newest staff were seen, they contained all the necessary information to ensure staff safety. Staff begin induction and training work prior to CRB clearance but they are supervised at all times by a senior staff member. The manager sees all necessary paperwork at the recruitment stage but often has to wait for the Human resources department to provide her with copies for her own files. It was discussed that she could find a way of evidencing that she had seen all the paperwork for the prospective staff member. Sixteen of the twenty two staff have attained an N.V.Q.2 or above qualification and all have completed Health and Safety mandatory training, Protection of Vulnerable Adults training and medication administration training (if they administer medication). A variety of other courses are provided and include those relevant to the needs of the home and individuals within the home, such as valuing diversity, skin conditions, heart conditions, stroke care, arthritis care, dealing with difficult behaviour and Parkinson’s disease. Courses for staffs individual development are also provided such as supervision, appraisal and team building. DS0000031280.V353027.R01.S.doc Version 5.2 Page 22 All staff complete an induction programme that complies with the skills for care standards, supervision is monthly and appraisals are held annually. Staff confirmed that they have regular supervision which they find to be very useful and they have plenty of training which includes mandatory up-dates, specialised training and training they request to aid their personal development. DS0000031280.V353027.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 and 38. People who use the service experience good quality outcomes in this area. The home is well managed and run in the best interests of the residents, the people who live and work there are kept as safe as possible. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager who has worked in the home for ten years, remains in post. She is fully able to discharge her duties and runs the home with the focus on resident needs. Staff described management as very good and very supportive, they said ‘ the manager is always available if needed’, ‘everything is done to suit the residents’. DS0000031280.V353027.R01.S.doc Version 5.2 Page 24 The home has robust quality assurance systems which consist of regular regulation 26 visits, monthly resident meetings, regular staff meetings and an annual quality assurance survey. The survey is sent to relatives and friends/advocates (sometimes phone calls are used to ensure feedback) and are completed with residents. These interviews are conducted by the manager of another home to retain some objectivity. Each year the survey focuses on three areas of care and the 2007 survey included control and choice. An annual development plan is completed as a result of the survey and the findings are analysed and published. Changes also occur as a result of day-to -day comments by residents and staff and discussions at residents meetings, such as changing the menu and some of the food offered. The home holds some personal allowance money for residents, but families, currently, act as appointees, one person looks after her own finances. Personal allowance cash is held in the safe and people have individual bank accounts for any excess monies. Cash was not checked at this inspection but the manager advised that they had an internal audit at the beginning of 2007 and all the financial records were in order, only senior staff have access to money and there have been very few errors. A sample of health and safety maintenance records were seen and all were upto date. A health and safety check is completed monthly by the officer responsible for this area of work and the provider holds three monthly health and safety meetings to discuss any arising issues. Safe working practice risk assessments are in place and work in conjunction with individuals care risk assessments. The home keep detailed accident and incident forms, these are kept on a general file and in individual files to promote monitoring. These do not inlcude how the home is to minimise the possibility of recurrence of incidents/accidents although it is clear by action taken that they do so. Individuals have falls records in addition to the accident records. All Health and Safety policies are robust and staff sign to say they have read and understood them. A recent inspection by the environemntal health officer resulted in no requirements and two recommendations that have now been complied with. DS0000031280.V353027.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 3 HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 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 4 X 3 X 3 X X 3 DS0000031280.V353027.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? None 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 OP38 Good Practice Recommendations To develop guidelines to inform staff of exactly when to administer medication prescribed ‘when required’, to improve residents safety and staff consistency. To record on the accident/incident forms how the home is going to minimise the likelihood of a recurrence of the incident or accident, to enable clearer monitoring and checking that the necessary actions have been taken, to further safeguard the safety of the people who live in the home. DS0000031280.V353027.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 DS0000031280.V353027.R01.S.doc Version 5.2 Page 28 - 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!