Inspection on 22/01/08 for Cholwell House

This inspection was carried out on 22nd January 2008.

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

Cholwell House 16/01/07

Cholwell House 12/07/05

Cholwell House 21/01/05

Cholwell House 09/01/05

Cholwell House 13/07/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Cholwell House Temple Cloud Bath & N E Somerset BS39 5DJ Lead Inspector Jill Cornelius Key Unannounced Inspection 22nd January 2008 10:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cholwell House DS0000046898.V354898.R02.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. Cholwell House DS0000046898.V354898.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cholwell House Address Temple Cloud Bath & N E Somerset BS39 5DJ 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) 01761 452885 Cholwell House Nursing Home Ltd Vacant Care Home 51 Category(ies) of Dementia (51), Dementia - over 65 years of age registration, with number (51), Old age, not falling within any other of places category (51) Cholwell House DS0000046898.V354898.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. May accommodate 51 persons aged 50 years and over. Manager must be a RN on parts 1 or 12 of the NMC register. Staffing Notice dated 20/04/1998 and NCSC letters re: revised staffing levels dated 27/08/02, 03/03/03 and CSCI letter 08/04/05 apply 16th January 2007 Date of last inspection Brief Description of the Service: Cholwell House is registered for 51 residents requiring personal or nursing care. In general the home operates a maximum occupancy of 46 thus reducing the proportion of double rooms. The home is situated in a rural position and can be accessed by car or bus. The home is in part a converted older property with recently built extensions. The home provides single and double rooms on three floors. There is a choice of communal areas including a large conservatory. There is an internal link corridor to the new extension of 11 rooms with en-suite facilities and its own pleasant communal space. There is lift access to all parts of the home. Cholwell House DS0000046898.V354898.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following methods of evidence gathering has been used in the production of this report; observation, discussion with residents, relatives and staff, tour of the home and sampling policies, records, care plans, meals. On the day of inspection the home had occupancy of 46. There were 2 recommendations made following the previous inspection, which has been met. General feedback was given to the deputy manager and proprietors representatives on the day of inspection. All residents and staff are on first name terms. Staff and resident interactions were seen to be friendly and caring upholding the dignity of the residents. Due to dementia only limited conversations were possible with three residents. Two relatives were spoken to who were full of praise for the staff and quality of care. The quality outcome of this inspection is adequate due to the home not having a manager in post. What the service does well: Only two comment cards and two resident surveys, three relatives surveys were returned all gave positive comments about the care, the staff and the environment. The residents/relatives consider the quality of food to be good. The impression of the home is that it remains friendly comfortable and safe place to live and the staff respectful and caring. The environment is of a high standard and clean. The residents are calm and cheerful and the staff assists them to look smart and well kempt. Cholwell House DS0000046898.V354898.R02.S.doc Version 5.2 Page 6 All of the residents and visitors spoken with during the inspection commented positively on all aspects of the home. Survey responses include: “The home has always been good, but since the new manager has arrived the home is excellent. I would always recommend it’. “My xxxxxx is able to receive and take part in services according to xxx faith. xxx disability is dealt with sympathetically as is xxx age’. “Cannot fault the care. All staff nursing, carers, office staff extremely efficient and dedicated” 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. Cholwell House DS0000046898.V354898.R02.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 Cholwell House DS0000046898.V354898.R02.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): 1, 2, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective clients and their families are given relevant information in written or verbal form about the home. Contracts and terms and conditions of services are provided to all clients. The assessment procedure is clearly written and a thorough assessment of prospective residents needs is carried out. EVIDENCE: A clearly written Statement of Terms and Conditions is available to each resident as part of an information pack including statement of purpose and service user guide. Cholwell House DS0000046898.V354898.R02.S.doc Version 5.2 Page 9 A page giving details of the breakdown of the fees have been added. These document are informative and clearly presented. Both documents and the homes brochure are due for review. No intermediate care is offered. The majority of residents continue to be admitted through Social services or via the PCT who provide detailed assessment and enhanced care plan documentation prior to admission. BANES have recently increased a block bed contract from twelve to twenty beds. There is also a waiting list. This is assessed by need and not by ‘being at the top’. On the day of inspection two reviews were being undertaken by Social Workers. The Senior Registered Nurse (RN’s) visits and assesses prospective residents. The admission procedure takes into account the dependency rating and takes account of the existing residents group the staffing numbers and skill mix. One relative spoken with was “impressed by the admission process and helpfulness of the staff”. All residents have Waterlow, handling and continence assessments. Resident’s assessment records showed assessment of the person’s physical, mental and social needs had been carried out. The Standex dependency rating is used and reviewed monthly. The majority of residents are in the medium high dependency banding. The overall dependency is in accord with the current staffing arrangements although two relatives did raise the issue of busy periods around meal times, however the staff spoken to stated they were able to manage the work load with some help from the nurses. Resident Survey comments include: ‘ My daughter visited the home and made the decision for me’. Cholwell House DS0000046898.V354898.R02.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans detail residents care needs and are clearly written and give clear directions to staff. The staff continue to provide appropriate personal and nursing care to maintain residents’ health and well being and dignity. Proper arrangements are in place for residents to access primary healthcare services. The staff properly store, administer and record medication on behalf of residents. Cholwell House DS0000046898.V354898.R02.S.doc Version 5.2 Page 11 EVIDENCE: The named nurse and key worker/co-worker system remains in place. All residents have a biography in the main written by the family and care staff and a section titled my preferences and end of life plans are written. The standex system of documentation is used by the home; of those records viewed the assessments and directions of the care were detailed and clearly presented. Needs were assessed using a model based on the Activities of Daily Living. The four residents documents reviewed have a formal night plan in place. There was evidence of regular review, updating of documentation and relative/resident involvement where practical. It was suggested that residents or in the main relative be asked to endorse the care plans and reviews. Daily records are made for all residents. There were individual risk assessments including moving and handling, nutrition and Waterlow assessments to assess the risk of developing pressure sores. The Stirling index of classification is used. Specialist equipment being used for individual service users i.e. alternating pressure relief mattresses/seat cushions had been related to the risk assessments. There were clearly written descriptions and wound care plans, which gave sufficient information to monitor progress, tracings or diagrams with measurements indicated improvements. Records were up to date, in the main related to leg ulcers. Use of bed rails are regularly reviewed to ensure their use remains necessary. Monthly dependency levels are recorded for all residents along with key observations where indicated. All admissions are referred for a dental review if the individual does not have ongoing arrangements with a dentist. Since April 07 a Community Dentist visits the home to carry out routine examinations. Health call visit regularly to carry out eyesight checks. The chiropodist visits every 6-8 weeks. The local GP from the Timsbury practice Dr Howell has all of the residents on his list visits every week and a Consultant Psychiatrist chairs a residents review meeting each month. Nurses have delegated responsibility for certain clinical issues in the home such as medication, continence, and end of life. Cholwell House DS0000046898.V354898.R02.S.doc Version 5.2 Page 12 The responsibility for the medication has been delegated to one of the Registered Nurses and the records indicated that staff adhere to the appropriate procedures and practices in the home. The receipt, administration, disposal and controlled drug records were up to date and in order. The GP practice is a dispensing practice and currently also receive unwanted medication for disposal. None of the current residents wish to or are able to self medicate at the present time. Comments made form returned survey include: ‘Such personal concern and care, should my xxxxxx become ill outside the usual needs, is excellent. All staff are always well informed and vigilant’. ‘Cannot fault the care. All staff nursing, carers, office staff extremely efficient and dedicated’. ‘From my observations the care staff are either highly skilled or receiving training and instruction’. Cholwell House DS0000046898.V354898.R02.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): 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of social and recreational activities is arranged that seek to enhance the quality of life for the residents. Resident’s families are involved and informed of issues related to their relatives and are able to maintain close contact with families and friends. The food is of a high standard and provides a balanced diet for residents. EVIDENCE: The home has an open visiting policy. The providers Mr and Mrs Thompson maintain regular contact with residents and visitors when in the home on almost a daily basis. Cholwell House DS0000046898.V354898.R02.S.doc Version 5.2 Page 14 Feedback from the visitors spoken to and surveys confirmed that the staff remain easy to talk to and helpful. It was evident in discussions with resident’s staff and visitors that the needs and wishes of residents are considered and acted upon as appropriate. Two people are employed to co-ordinate social activities for 30-40 hours a week enhancing the quality of life for the residents. At present there are no residents with particular cultural needs. A weekly timetable is on display on the notice board. Recreational activities included cooking sessions, planting, sing-along, bingo, crafts, games, quizzes and gentle movement. A range of visiting entertainers performs in the home, a local duo being most enjoyed. The home is making enquiries about dementia care mapping with the hope of introducing some of the principals into the home. Trips out in the community minibus continue to be rare events due to the increasing dependency and frailty of the current residents. A number of residents go out with their families. There are celebrations for various events and festivals such as Remembrance Day, Harvest, summer fete and birthdays to which families and friends can be invited. The Christmas arrangements included a party (to which 12 relatives attended); carol singing and each resident was bought a gift by Mrs Thompson. There has not been any necessity for advocacy; if it were required a number of advocacy services are detailed in the service user guide. For the main meal there is no formal menu choice although variations are provided according to individual likes and dislikes. A breakfast menu has been introduced providing more choice as does the evening meal. The residents who were able to express an opinion stated they enjoyed their meals and felt they received the food they liked. The meal on the day of inspection was well cooked and tasty. Liquidised diets are served as separate elements. The only specialist diets required at present are for diabetics no one has special cultural menus. All dining areas were nicely presented with the tables being set each mealtime. The main meal times are set, however, staff can access beverages and snacks 24hrs a day for those who would like them. Cholwell House DS0000046898.V354898.R02.S.doc Version 5.2 Page 15 The home has ensured that all staff are on hand to assist residents at lunchtime. This has been achieved by delaying the starting time of staff lunch breaks. In addition within the next week a new 10am – 2pm shift is being introduced as a result of increased client need. Cholwell House DS0000046898.V354898.R02.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are robust and comprehensive policies in place to protect residents investigate complaints or manage allegations of abuse. There are good arrangements in place for staff training and awareness of Protection Of Vulnerable Adults matters. EVIDENCE: The complaints procedure is on display in the home, it has contact details for Commission. A complaints log is maintained. There have been no complaints noted for the last two inspections. In responses to surveys sent out relatives were aware of the complaint procedure. In discussion with residents and relatives no complaints were made. Cholwell House DS0000046898.V354898.R02.S.doc Version 5.2 Page 17 The home has adopted the Registered Nursing Home Association policies in relation to Protection of Vulnerable Adults (POVA). The deputy manager attends POVA training and cascade the information to the care staff at induction. 80 of care staff have attended “Alerter” training facilitated by the Local Authority. There was evidence of future training events planned. The home has a copy of the Bath and North East Somerset “No Secrets” or multi agency working policy. The General Social Care Council code of practice has been distributed to the care staff. Cholwell House DS0000046898.V354898.R02.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, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of furnishing and décor remains high to the benefit of residents. The home provides a safe and well-maintained environment for the residents. The bedrooms and communal rooms and facilities are suitable and well presented for their purpose and meet the resident’s needs. The standard of cleanliness remains high. Cholwell House DS0000046898.V354898.R02.S.doc Version 5.2 Page 19 EVIDENCE: The home is in part an older property converted and adapted to care for older people, with a purpose built extensions. The home offers a total of 51 beds although at present only using 46 to reduce double occupancy. It provides care over three floors. There are two passenger lifts and a stair lift, which together give level access to all parts of the home. The home is in good order and well maintained and is fit for its purpose. There were no malodours. The home is smoke free environment. There are several lounges, dining and quiet areas throughout the home as it is split into three specific areas. The main building with communal areas on the ground floor, a unit on the mid floor and the extension have lounge areas. All areas are comfortably furnished and homely in appearance. Bedrooms are well decorated and furnished some with specialist equipment and many have been personalised with resident’s own belongings. It was noted that some rooms had no lockable storage or lockable doors. This was discussed and a plan of action was undertaken for this to take place. Residents have access to all communal areas in their unit. There are communal toilets close to the lounge and dining areas. Many of the bedrooms have en-suite toilet facilities. The home has adequate bathing areas in relation to the number of residents. Baths have thermostatic mixer valves and the monitoring hot water temperatures takes place. Mobile and fixed hoists are provided. A maintenance man works full time at the home and can be available for emergency repairs as required. Radiators were guarded and could be individually thermostatically controlled. Proper arrangements are made for the disposal of clinical waste. Since the last inspection the kitchen has been completely refitted. The Environmental Health Officer visited recently there where no actions to take. Cholwell House DS0000046898.V354898.R02.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment procedures and records are in good order. The home is well staffed with appropriately trained and experienced staff for the number of residents. Proper training arrangements and clinical updating for RN’s are in place. Good training continues for all care staff for the benefit of residents. EVIDENCE: The staffing levels are in accord with or exceed the staffing notice as amended. The administrator post is now a job share but is effectively two full time posts. At present there are no Nurse or carer vacancies. The home has a small bank of staff and agency use is minimal. The domestic, catering, admin and laundry staffing levels are satisfactory. Cholwell House DS0000046898.V354898.R02.S.doc Version 5.2 Page 21 The inspector viewed the personnel records for several staff members including the recruitment of the last three employees. Staff files seen evidenced recruitment procedures were in good order and in line with requirements. Each file has a checklist attached to ensure all documentation is up to date prior to commencement. Enhanced Criminal Records Bureau (CRB) checks were viewed and the log sheets were signed prior to the disclosure being destroyed. These checks are repeated every three years. Registered Nurse verification of registrations has been validated with the Nursing and Midwifery Council (NMC). A monthly electronic check of the NMC list of struck off or suspended staff is carried out. A spreadsheet has been created to flag up PIN renewals and CRB re-checks. There are detailed induction programmes for new registered nurses and the care staff follows common induction programmes facilitated through Training Masters. All new staff are linked with a mentor during their first two weeks of supernumerary shifts. After 6 months all care staff have the opportunity to undertake National Vocational Qualification (NVQ) training to at least level 2 provided by the Norton Radstock College. Eight care staff have a level 3 NVQ’s or equivalent a further three care staff are commencing their NVQ 3 in February 08. The Registered Nurse training records were not checked on this occasion but previously showed evidence of learning and updating both internal and external. Mandatory training for all staff includes fire safety, food hygiene, first aid, load handling and adult protection. The manager has done additional training to train staff in Health & Safety, fire safety and load handling. Eight staff have completed first aid training. As recommended following the last inspection Dementia care training courses are being undertaken in 08. Twenty-four staff are signed up for ASET with the Norton Radstock College. Cholwell House DS0000046898.V354898.R02.S.doc Version 5.2 Page 22 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, 34, 35, 36, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has no manager in place. However it remains well managed by the deputy and staff for the benefit of it’s resident’s. There are good arrangements in place to maintain and service the equipment and facilities in the home. The Home protects the health and safety of residents and staff. Staff supervision is undertaken. Cholwell House DS0000046898.V354898.R02.S.doc Version 5.2 Page 23 EVIDENCE: At the time of this inspection the manager’s post was vacant due to health reasons. The post has been advertised widely. The proprietors support the deputy manager at this time. The deputy manager is a member of the local Primary Care Trust nurses forum, which is useful in keeping up to date in current health care and related issues. Two administrators are working effectively full time to relieve the manager of routine administrative duties. Mr and Mrs Thompson visit the home on a regular basis and actively support the manager and staff. Until the recent vacancy of the manager all staff received regular supervision and annual appraisals. This has now fallen behind. The deputy manager and senior staff are currently trying to continue with these in the absence of a manager. The deputy manager agrees dates, (which are entered on wall charts) with the other staff to carry out dependency reviews and care evaluations. At present residents are able to play a very minimal part in this process due to levels of dementia, a number of relative do show an interest in the process. The home carries out monthly audits of health indicators and accidents. Discussion was made in relation to reporting Reg 37 to the CSCI in future for monitoring. The home has received many thank you cards praising the quality of the care in at Cholwell. The visitors spoken to praised the home and the caring attitude of the staff. Survey comments include: “Keep in touch with their clients, i.e. whilst undertaking their various duties. Care staff will often stop and speak/ touch/make themselves known, if appropriate. A few kind words or a smile goes a long way’. Residents or their families are encouraged wherever possible to manage their own finances. There is an inventory of resident’s cash and valuables held for safekeeping. Two signatures to evidence all transactions endorse the ledgers for the receipt or use of resident’s cash. Preferably one of the signatures being the resident, although it is recognised that this is not always possible due to their disabilities. Monies were kept in a locked safe, with a limited number of key-holders to enhance security. Cholwell House DS0000046898.V354898.R02.S.doc Version 5.2 Page 24 There are items of lost property, which have been recorded in a ledger. The manager has received advice from the police about unclaimed lost property and is writing a brief policy for its management. There is a formal fire risk assessment and fire plan. The fire logbook was up to date and in order. Training, drill and maintenance have taken place. There was a system for monitoring the risk of legionella disease. A record of hot water outlet temperatures is maintained. The home has no manager in place. However it remains well managed for the benefit of it’s resident’s. There are good arrangements in place to maintain and service the equipment and facilities in the home. The Home protects the health and safety of residents and staff. Staff supervision continues to be undertaken but may fall behind due to the lack of an RN manager in place. Cholwell House DS0000046898.V354898.R02.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 3 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 3 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 1 X X 3 3 3 3 3 Cholwell House DS0000046898.V354898.R02.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. 1 Standard OP31 Regulation 9(2)(b)(i) Requirement Appoint a suitable RN manager Timescale for action 30/03/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Cholwell House DS0000046898.V354898.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Cholwell House DS0000046898.V354898.R02.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. 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