Inspection on 24/01/06 for Chiswick House

This inspection was carried out on 24th January 2006.

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

Chiswick House 19/03/09

Chiswick House 23/02/07

Chiswick House 28/06/05

Chiswick House 25/01/05

Chiswick House 01/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Chiswick House 3 Christchurch Road Norwich Norfolk NR2 2AD Lead Inspector Mr Christopher Handley Announced Inspection 24th January 2006 09:45 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 Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 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. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Chiswick House Address 3 Christchurch Road Norwich Norfolk NR2 2AD 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) 01603 507111 EJP Interests Ltd Mrs Carolyn Doyle Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May from time to time admit a maximum of one service user in the home between the age of 50 and 65 years. 28th June 2005 Date of last inspection Brief Description of the Service: Chiswick House is a large detached property situated adjacent to the centre of Norwich, and is within easy reach of the city centre. The home is set in its own grounds with well maintained gardens containing mature trees and flower beds. Externally the building appears to be in a good state of repair. The home has its own car park at the front of the home, and there is ramped access to the front door. The home can accommodate 20 elderly service users, one of whom can be under 65 years of age with a physical disability. There are 18 single room (two with en-suite) and one double room (en-suite) which is currently in single occupancy. The interior of the home is spacious and comfortable, and there is an air of tranquillity and calmness. The conservatory has additional seating, and provides views out over a pleasant garden. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection which commenced at 9.45 and was completed by 3.25. The pre-inspection questionnaire had been completed and returned to the CSCI office. Ten comment cards were sent, 6 of which had been completed by residents who all answered “yes” to the question “Do you like living here”. The Inspector examined a wide range of documents, and made a tour of the home accompanied by the Manager. Four residents and four staff were interviewed, and others were briefly spoken to. During the afternoon a piano recital was given for the residents which was part of the homes’ activities programme. Mrs Doyle, the Manager, and Mr Clive Hill, Director, of Black Swan International Ltd were present during the inspection What the service does well: What has improved since the last inspection? • • • • The care plans are now signed by the residents and relatives. The recruitment process has been made safer. The safety of the medicines has been improved as staff have undergone training. Hot water regulators have been fitted to some of the sinks in residents rooms. DS0000027427.V273626.R01.S.doc Version 5.0 Page 6 Chiswick House • • Risk assessment in relation to falls and hot water has been undertaken. A new ramp has been built to the front door, which provides good access to the home for wheelchair users. What they could do better: • • The home needs to increase the number of staff who have undertaken NVQ training. Continue fitting hot regulators to the sinks in residents’ rooms. During the process of the inspection the Inspector interviewed four residents and spoke briefly to a number of others. Based on these conversations it does appear that some of the residents may have the early stages of dementia. The management of the home needs to evaluate the needs of the existing resident group and determine whether this represents a significant percentage of the people accommodated. If this is the case this may need a variation in conditions of registration. This will need a plan for implementation which includes training, risk assessment of the building, plans for creating units within the building for meeting needs, which must be shared with the Commission and all other stakeholders. 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. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 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 Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 All residents have a Terms and Conditions. A pre-admission assessment is undertaken of all prospective residents. EVIDENCE: All residents have an individual Terms and Conditions the Manager said, a copy of which was seen by the Inspector. The documents is well set out and divided into separate items, the print is in a size which is large enough to enable residents who may have poor sight to read it with ease. The document was revised in June 2005. The Manager reads through the document with the residents and relatives, to ensure that they have a good understanding of the content of it. The residents/relative is supplied with a copy. The Manager retains a copy which is kept safe. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 9 Residents interviewed were aware that they had contracts with most saying that their relatives dealt with them. A pre-admission assessment is undertaken by the Manager on all residents seeking admission to the home, to ensure that the home can meet the prospective residents needs. The Inspector was shown a copy of the document and later read three which had been placed in the care plan folder. The Manager undertakes the pre-admission assessment either in the individual’s home or in hospital. The document records the physical, mental and social skills assessment, and the ones seen were neatly completed. Because of the completed document will contain confidential information the document is headed “Confidential information”. Once completed the document provides a sound base of information upon which to make a decision as to whether or not the home can meet the prospective residents’ needs. This document has been devised by the Company and is of a high standard. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 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 All residents have an individual care plan. The health care needs of residents are met. The medicines system is safe and effective. EVIDENCE: All residents have an individual care plan, three of which were seen and read by the Inspector. The care plans are kept in a folder which is clearly marked Confidential. The folder has page dividers in place, which helps in the management of documentation. Each care plan has the essential elements of a care plan, namely assessment, plan, implementation, and review. These records are neatly and fully completed. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 11 In the last inspection it was recommended that there should be a photograph of the resident in the care documents. This has since been done. Residents and relatives now sign to indicate that they have been part of the care planning process. This fulfils a requirement made in the inspection dated 28/6/05. A detailed, and comprehensive risk assessment has been carried out on each resident, and three of these were read by the Inspector. This fulfils a requirement which was made in the inspection dated 28/6/05. The residents interviewed were aware that they had a care plan or “Notes” which record their care. The care plans are kept secure. Since the last inspection there has been a noticeable improvement in the care plans and all who contribute to them are commended for this. The Manager described how the health care of residents is met. All residents are registered with a GP, who would refer them onto to other health care professionals if needed. Care staff provided personal care to the residents, and the residents spoke highly of this to the Inspector. Any need for dental, optical, or chiropody services, would be arranged if needed, and these services are provided quickly the Manager said. If needed the advice of the Dietician would be obtained. The home enjoys a good relationship with the District Nurse who calls to the home on a regular basis. The home has a range of moving and lifting equipment and if other types of equipment were required, the District Nurse would arrange the loan of this, and the Manager added that this is done quickly. The Inspector was shown the medicines in the home system by Claire Watson, Care Manager. The medicine cupboard is in the office and it is kept locked. The contents of the cupboard were neat and tidy and there were no loose or unaccounted for medicines. The home has a procedure for the receipt, recording, storage, handling safe administration and disposal of medicines. The home uses a Nomad system of medicines. The records of administration were seen, and they were neat and tidy. The home has a designated list of staff, along with their initials, of those who administer medicines. This fulfils a requirement made in this matter in the inspection dated 28/6/05. All staff that administers medicines have had training for administration of medicines, which was provided by Boots. At the last inspection 28/6/05 comment was made about the drug fridge not being locked, it is now kept locked. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 12 At present there are no Controlled Drugs in the home. The practice is that District Nurses bring prepared syringes with the Controlled Drug in, and they take the empty syringe away with them. In the last inspection dated 28/6/05 it was required that the home obtained a register to record Controlled Drugs in, and this has been implemented. If the practice of the home changes and Controlled Drugs have to be kept in the home then the home will have to purchased a dedicated Controlled Drug Cupboard (Standard 9, 9.5). The home enjoys a good relationship with the supplying pharmacist, the Care Manager said. If staff had any concerns about the effects of medicines on residents they would contact the prescribing doctor. Medicines are reviewed by the GP, and this is recorded. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 & 15 There is a wide range of choice for residents in their daily lives. The menus are nutritious, varied, and interesting, but special diets are not recorded. EVIDENCE: The residents have a wide range of choice in this home and when interviewed by the Inspector they gave numerous examples of this, “I can get up when I like”, “I can stay in bed if I want”, “I can go to my room and can watch the television if I like” and many other such like examples. Many residents handle their own finances with the help of the relatives, they told the Inspector. According to the pre-inspection information, 17 residents have invested Power of Attorney with their relatives. Residents interviewed, confirmed this. Residents bring in personal items to the home with them and many of these were seen, and include pictures, ornaments, items of furniture and other things to which the residents have some strong attachment to. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 14 Residents have access to their records and some have asked to see them the Manager said, as they are now involved, along with their relatives, in the care planning process and sign records to that effect. The Inspector was shown the menus for the home, they appeared varied, nutritious and interesting. The is a good range of choice. The menus for the day are displayed in holders on the tables, and look very well presented. The residents and visitors spoke very highly of the catering services, and that there was always a choice, and this was reflected in the menus seen, which were varied and very interesting. The comment cards spoke highly of the catering with the exception of one which said that the meals were not as good when the chef was not on duty. This comment was raised with the Manager to follow up. There is a vegetarian meal daily. The menus seen are of a very high standard. The Inspector discreetly observed residents quietly enjoying their midday meal. The meals are very nicely presented, and the chef and catering staff are warmly commended for this. Special diets are provided but they are not recorded, and it is required that they are recorded. The Inspector spoke to the chef on this matter who undertook to record them. Residents can take their meal in their rooms if they wish or in the dining room or conservatory. The chef has undertaken a course in basic food hygiene, and the Inspector recommended that he and others who work in the kitchen undertake First Aid Training, because of the possibility of accidents happening in the kitchen. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 15 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, 17 & 18 The home has a complaints procedure which is displayed in the home. Residents’ legal rights are protected. The home has an Adult Abuse Procedure. EVIDENCE: The home’s complaints procedure is displayed in the dining room and the front hall. The one in the entrance hall was read, and it contains all the required information. The document is well set out, and is in a large size print which enables people who may have poor sight to read it. The document is also contained in the Service Users Guide. Since the last inspection there has been a complaint made by a resident, which is clearly recorded and this was seen by the Inspector. The complaint was speedily dealt with and the resident is satisfied with the outcome. Every effort is made to ensure that residents’ legal rights are protected, and the Manager is very conscious of the importance of this matter. If needed the Manager with the assistance of a Social Worker, would arrange advocacy if it were needed. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 16 A number of residents who previously went to vote at the polling stations now use their postal vote the Manager said. The home has an Adult Protection Procedure and all staff have received training in this matter. Some of the staff interviewed were asked about this matter and they were aware of the importance of it, and said that they would quickly report any concerns to the Manager. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 17 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, 25 & 26 The residents live in a safe, well maintained environment. The residents live in a safe, comfortable environment. The home is clean, pleasant and hygienic. EVIDENCE: The home is a large detached traditional style home which is situated in the suburbs of Norwich. The grounds are well maintained and are neat and tidy. The gardens at the rear of the home provide very pleasant views for residents using the sitting room or dining room. Some of the residents’ rooms also overlook these gardens. The building complies with the local fire service and environmental health department. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 18 In the inspection dated 28/6/05 a recommendation was made that the home should have a plan of maintenance. This has since been done and the Inspector saw a neatly typed document, which outlines the work required, the date when it is to be done, and the approximate cost. The home also has a maintenance book, in which work to be carried out by the maintenance man is recorded. These two books provided a clear picture of the maintenance programme for the home. The Inspector visited a number of the residents’ rooms accompanied by the Manager. The rooms are very pleasant, and comfortable and have pictures and ornaments which have been brought in by the resident and give the room a personal appearance. The rooms were comfortable and warm, and there is natural ventilation. Rooms have central heating, which can be adjusted by the resident. In the inspection dated 28/6/05 a requirement was made that hot water valve regulators be fitted to the wash hand basins. Since then the rooms in the ground floor extension, and some rooms at the front of the house have had water valves installed. All baths have had regulators fitted. It is proposed that the remaining rooms will have water regulators fitted when a proposed extension is commenced. The Proprietors need to examine this matter and if this is to be some time away then the regulators must be fitted in the meantime. The Inspector saw the valves in place, and hand tested the temperature of the water, which was satisfactory. There is risk assessment in place. The home was neat and clean and free from offensive odours. The Inspector visited the laundry accompanied by the Manager. The laundry is situated in the cellar of the home, there are hand washing facilities in place, the laundry floor is impermeable, and the walls are readily cleanable. The home has polices and procedures for the safe handling and disposal of clinical waste, dealing with spillages, provision of protective clothing and hand washing. There is a sluicing facility on the washing machines. The washing machines are semi industrial and are on contract, the Inspector was told. The Manager does not know whether or not the machines comply with the Water Supply (Water Fittings) Regulations 1999, and it is required that written evidence of this be obtained. The cellar is of a traditional style and the staircase is difficult to negotiate, the Directors are advised to giving consideration to moving the laundry. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The residents’ needs are met by the numbers and skill mix of staff. The home has a recruitment procedure which protects the residents. The residents are in safe hands of staff who have undertaken a wide range of training. Staff are trained to do their jobs. EVIDENCE: On the morning of the inspection there were 3 Care Assistants, 1 Domestic, 1 Chef, 1 Kitchen Assistant, and the Manager on duty. There are two waking staff on duty each night. The off duty supplied shows the same level of staffing for the week. Based on the observed dependency of the residents this staffing level meets the residents’ present needs. The residents interviewed felt that there were enough staff on duty, and said that they don’t have to wait long for staff to come to them. They recognised that from time to time there can be busy periods. Call bells were answered quickly, and staff was seen talking to residents and visitors, and assisting some residents with their meals. There was a Piano Recital during the afternoon of the inspection, which was part of the home’s weekly activities programme. The home has planned activities for five days in the week, plus trips out. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 20 If needed the Manager said that she can bring in additional staff, and she is aware of the increasing dependency of the residents. The home uses the parent Company’s (Black Swan’s) recruitment procedure, which is based on Equal Opportunities. Posts are advertised, and short listing takes place. Interviews are carried out by two people. POVA and CRB checks are undertaken, and references are taken up. In the inspection dated 28/6/05 a requirement was made that CRB and POVA checks are to be carried out, this is now done the Manager said. This was checked by the Inspector who examined a staff file picked at random, which showed that all the appropriate checks had been made. This is now the standard practice of the home the Manager said. Terms and Conditions are provided and a Contract is supplied. A letter of appointment is also supplied. Successful candidates are provided with a copy of the Code of Conduct issued by the General Social Care Council. The new employee undergoes an induction period, and during that time works with a more experienced member of staff. There are no volunteers in this home. There are 4 members of staff who have NVQ II and 3 members of staff who are taking it. There are a total of 16 care assistants. This shows that 25 of staff have NVQ, the target required being 50 . At present there are three members of staff who are awaiting funding to enable them to undertake their NVQ. This is to be commended. The home has an Induction and Foundation training programmes which meet the needs of the National Training Organisation workforce training. A wide range of training is provided and this includes Fire Prevention, Moving and Handling, First Aid, Basic Food Hygiene, Adult Abuse, Challenging Behaviour, Diabetes Awareness, Health and Safety, Visual Impairment, Funeral Awareness, Visual Impairment, Caring for Strokes, Life Support, Care of the dying and Bereavement, The Law and Vulnerable people, Osteoporosis Awareness, Management Skills, Prevention of Falls, Fractures in Care, and Care of the Elderly. This range of training prepares staff for these events, which sadly may occur in the daily life of elderly people. The home is commended for providing this range of training. There is a very neatly written record made of this training which was seen by the Inspector. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 & 38 Mrs Doyle has undertaken a wide range of training and has been Manager of the home for 4 years. The home has a Quality Assurance system in place. The health, safety, and welfare, of residents is promoted and protected. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 22 EVIDENCE: The Manager, Mrs Doyle, has been in post for 4 years, and has worked in care for 9 years. She is currently undertaking the Registered Managers Award and has previously undertaken a wide range of training which includes, City and Guilds Care Management, Health and Safety, First Aid, Moving and Handling, Osteoporosis Awareness, Care of Medicines, Deaf Awareness, Care of the Dying, Law and Vulnerable Older People, Continence Awareness, Challenging Behaviour, Preventing falls, and Fractures, and Dementia Awareness. This range of training provides her with the knowledge and skills to ensure that a high standard of care is provided. The home has a Quality Assurance scheme in place. Residents are sent questionnaires about the quality of the services provided. Relatives may assist in this process if they wish, the Manager said. The responses are collated by the Manager and Director, and then steps are taken to improve matters. The responses then form one of the elements at the residents meeting, a copy of which was seen by the Inspector and this confirmed what he had been told about this. Residents are also thanked for their contribution in this matter. The home has some of the documentation required by Standard 38, but not all. The Manager and Director undertook to obtain all the documentation required and they both fully appreciate the importance of this matter. The Inspector informed them that it would be a requirement that the home obtains this information. The Inspector advised that once the information has been obtained then it should be place together in a container clearly marked “Health and Safety” and be kept in a place where it would be available at all times. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X X x X X 2 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X X 2 Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP15 OP26 Regulation Shed. 4 13 Stan 26 26.9 Requirement It is required that special diets recorded. It is required that the Manager take steps to ascertain if the Services and facilities in the laundry comply with the Water Supply (Water Fittings) Regulations 1999, in writing. It is required that the Manager obtain all the Health and Safety documentation required by Standard 38. Timescale for action 01/03/06 01/04/06 3. OP38 Stan 38 01/04/06 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 OP15 Good Practice Recommendations It is recommended that the Chef and others who work in the kitchen undertake First Aid training. Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Chiswick House DS0000027427.V273626.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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