Inspection on 21/03/06 for Court House Retirement Home

This inspection was carried out on 21st March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Court House Retirement Home 12/10/07

Court House Retirement Home 03/10/06

Court House Retirement Home 16/06/05

Court House Retirement Home 03/02/05

Court House Retirement Home 10/08/04

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 Court House Retirement Home Church Street Cheddar Somerset BS27 3RA Lead Inspector Kathy McCluskey Unannounced Inspection 10:30 21st March 2006 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 Court House Retirement Home DS0000016113.V265933.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. Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Court House Retirement Home Address Church Street Cheddar Somerset BS27 3RA 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) 01934 742131 01934 742054 Mr Brian Dando MRS PEARL DANDO MRS MARGARET ANNE THOMAS Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 2005 Brief Description of the Service: Court House Retirement home is a large Georgian House situated in the heart of the town of Cheddar in Somerset. Accommodation is arranged in three buildings. The main house, which can accommodate 12 service users, The Courtyard is made up of 6 rooms and The Cottage which accommodates 8 service users. The Courtyard and the Cottage are situated in the grounds of the main house. The home is registered with the Commission for Social Care Inspection to provide personal care for up to 29 service users over the age of 65yrs. The home is not registered to provide nursing care. The registered providers are Mr B. & Mrs P.Dando. The registered manager is Mrs M.Thomas. Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over one day (5.5hrs) by CSCI Regulation Inspector Kathy McCluskey. Mr B.Dando, registered provider and Mrs M.Thomas, registered manager were present throughout the inspection. At the time of the inspection 23 service users were living at the home with future admissions planned. Although registered for 29 service users, the home is currently utilising bedrooms which could be used for double occupancy, for single use. (There are a total of 26 bedrooms) The majority of this inspection was spent talking with service users and staff. Records were examined relating to the care of service users, staff recruitment and health and safety The inspector would like to thank the service users, registered provider and manager for their time and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report and the last announced inspection report. What the service does well: The Court House Retirement Home offers service users ‘gracious’ living in an environment which is decorated and furnished to a very high standard whilst maintaining a ‘homely’ feel. Service users have the choice of a variety of accommodation, all of which are set in beautiful and well maintained gardens. Service users are able to furnish their own private accommodation which allows them a sense of ‘ownership’. Service users spoken with during the inspection were very positive regarding life at The Court House. The home takes appropriate steps to ensure that prospective service users are provided with the information they need to enable them to make an informed decision about moving to the home. Service users are fully assessed prior to admission to ensure that the home can meet the assessed needs of the individual. Prospective service users and their families/representatives are encouraged to visit the home and meet with staff and service users before making a decision. Meals and refreshments are offered. Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 6 Service users were very positive regarding the care they received and all spoken with commented on the kindness and willingness of staff. Service users stated that staff always respected their privacy and dignity and that they were aware of their wishes and preferences. Service users are encouraged to be involved in their individual care planning process. Improvements in documentation have been required. Service users benefit from a stable staff team. Staff morale appeared high and the home has very low staff turnover. Staff spoken with informed the inspector that they enjoyed working at the Court House and felt well supported. All service users spoken with spoke highly of the manager and staff team. Service users feel well informed. Service users benefit from an exceptional standard and choice of meals. Fresh fruit is made available in all communal areas and service users’ private accommodation. Sherry is available in the drawing room for service users to help themselves. All service users spoken with at the inspection spoke very highly regarding the meals and choices available. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors. What has improved since the last inspection? What they could do better: The home needs to ensure that care plans are fully reflective of individuals assessed needs. Care plans need to be personalised and contain sufficient information for staff on how assessed needs should be met. Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 7 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. Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5. Standard 6 is not applicable as the home is not registered to provide intermediate care Prospective service users are provided with the information they need to make an informed decision about moving to the home. The home takes appropriate steps to ensure that the assessed needs and aspirations of a prospective service user can be met. EVIDENCE: The home has produced a Statement of Purpose and Service User Guide. Both documents provide information about the home and services offered. These are made available to service users, prospective service users and their representatives. The manager takes time to ensure that all information is discussed with prospective service user and/or their representatives. The inspector was not advised of any changes to the Statement of Purpose or Service User Guide since the last inspection. Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 10 The home’s current fee range is between £313 and £460 per week. Extra charges are met by the service user for personal toiletries, hairdressing and manicures. The home provides a range of daily newspapers, alcoholic beverages and chiropody treatment at no extra cost to the service user. Service users moving to the home furnish their private bedrooms with their own furniture. The manager visits a prospective service user in their home/hospital where information relating to their assessed needs, wishes and preferences is discussed. Pre-admission assessments are completed Prospective service users and their families and friends are encouraged to visit the home, meet the staff team and other service users prior to making a decision about whether to move to the home. Meals and refreshments are made available. Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 11 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 and 10 The home’s care planning systems demonstrate service user involvement but improvements are needed to ensure all assessed needs are clearly recorded. The home ensures that the privacy and dignity of service users is respected. EVIDENCE: Care Records for two service users were examined at this inspection, this included the most recent service user. Whilst care records contained completed assessments relating to moving and handling needs, reducing the risk of pressure sores and falls, other assessed needs could not easily be ascertained from the care plans examined. This was discussed in detail with the registered manager. Examples of this included one service user who was receiving on-going input from the community health team and was currently experiencing some difficulties. No care plan had been raised. This was also the case for personal and social care needs. The inspector discussed with the manager the need to ensure that all assessed needs and preferences were clearly identified in a personalised plan of care which identified clear instructions for staff on how to meet these needs. The inspector Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 12 also informed the manager that she could contact the CSCI for further discussion if she so wished. Although care plans did not contain sufficient information and a requirement has been raised, it should be pointed out that it was evident that the established staff team were aware of individual’s needs and preferences and were delivering care in line with the service users wishes. This was ascertained through discussion with staff and service users. Records seen confirmed that service users were involved in the care planning process. Without exception, all service users spoken with during the inspection were very positive regarding the care they received. All commented on the kindness of staff and stated that personal care needs were met in a manner which respected their privacy and dignity. Service users were very positive about the support and assistance they received from the registered manager. All service users are registered with a G.P, dentist and optician and the manager advised that they received excellent support from visiting professionals. The home maintains detailed individual records pertaining to any visit/contact from healthcare professionals. Court House Retirement Home DS0000016113.V265933.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): 12, 13, and 15 The home goes to great lengths to ensure that service users live in an environment which promotes an individual’s preferred lifestyle, expectations and preferences. The home takes exceptional steps to ensure that service users visitors feel welcome and that service users remain ‘in control’ of their lives. Service users benefit from an exceptional standard and choice of meals. EVIDENCE: The home’s social activity programme was not examined in depth at this inspection but several service users were keen to tell the inspector about ‘new’ weekly events that are taking place on a regular basis. This includes a coffee morning, film show and keep fit. One service user showed the inspector a letter sent to all service users advising them of the additional activities. Ideas and feedback are encouraged from service users at regular meetings. During the inspection, though observation and discussion with service users it was apparent that service users chose how and where to spend their day. Many choose to spend time in the privacy of their own rooms. Some service Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 14 users informed the inspector that, because they did not receive many visitors and some service users choose not to socialise, they sometimes felt ‘a little lonely’ Service users did confirm that staff and the manager always had time for them and would spend time sitting and chatting. Service users can choose where to receive their visitors. Many choose to entertain their visitors in their private rooms though they can use any of the communal areas and gardens. This ensures service users retain a ‘sense of ownership’ and enables them to live life as they would in their own homes. Service users confirmed that their visitors were always made to feel welcome and that refreshments were made available. Visitors are also welcome to stay for meals. On request, service users are provided with a fridge and facilities to make hot drinks. Service users are also able to offer their visitors a sherry, which is available in the drawing room. No visitors requested to see the inspector during this inspection. Service users furnish their private rooms with their own furniture and personal possessions. All service users spoken with were very positive regarding the meals available at the home. All meals are freshly prepared and cooked by the home’s cooks. The main meal is enjoyed at lunch-time and can be taken in the home’s main dining room, cottage conservatory or in the privacy of the service users private rooms. The home’s menu offers three choices of meals and is kept under review. The views of service users are encouraged. The inspector was able to see lunch being served in the main dining room. Tables were beautifully laid with tablecloths, condiments and fresh flowers. Service users were seen to be offered a choice of drinks with their meal and a sherry prior to the meal being served. Some service users enjoyed a glass of sherry in the lounge before lunch. Staff were observed serving meals in a very professional and respectful manner. The ambience during the meal was very relaxed. Fresh fruit was observed in communal areas throughout the home. This was also observed being taken to all bedrooms. Service users informed the inspector that this was the case every day and fresh flowers were available throughout the home. Service users confirmed that snacks and drinks were made available as requested ‘day or night’. Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 15 Meals to the Cottage and Courtyard are carried over by staff from the main home. This arrangement should be kept under review to ensure that it does not pose a health & safety risk to staff. Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has a good complaints process in place with evidence that the views of service users are listened to and acted upon. EVIDENCE: All service users spoken with at this inspection informed the inspectors that they would not hesitate in raising any concerns should they have any. Service users stated that they found the registered provider, manager and staff very approachable and that their views are always encouraged. The home has regular meetings for service users. No complaints have been received by the home since the last inspection and no concerns or complaints have been raised directly with the CSCI. Court House Retirement Home DS0000016113.V265933.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, 20, 21, 22, 23, 24, 25 and 26 Service users live in an environment which is maintained, furnished and decorated to a very high standard. Service users enjoy ‘gracious living’ and can personalise their private accommodation as they so choose. The standards of cleanliness within the home were noted to be high and the home takes appropriate steps to reduce the risk of the spread of infection. EVIDENCE: During this inspection, the inspector was able to examine communal areas and with the service users present, a selection of bedrooms in the main house, courtyard and cottage. The Court House Retirement Home is conveniently situated in the heart of the small town of Cheddar, which allows easy access to all local amenities. The home has beautiful well maintained gardens which are accessible to all service users. The majority of service users private accommodation has views out on to the gardens. Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 18 Accommodation for service users is set out in 3 ‘units’ all in close proximity to each other. The main house is a beautiful Grade II listed property which has been tastefully restored to provide ‘gracious living’ for service users. Furniture, décor and fixtures are of a very high standard. The décor and period furniture are in keeping with the Georgian period of the house. The main house has a drawing room, dining room, kitchen and can accommodate 12 service users. All rooms are fitted with en-suite toilets and bath or shower facilities. Access to the first floor is via stairs which have been fitted with a stair lift. The Courtyard provides 6 rooms at ground floor level, all of which have ensuite bathing and kitchenette facilities. Service users can enjoy a more independent lifestyle if they so choose. The Cottage can accommodate 8 service users and has a very pleasant lounge and conservatory/dining area. Once again, all rooms are fitted with en-suite and kitchenette facilities. A stair lift is available to assist service users to access their first floor accommodation. The very high standards of décor and furnishings continue through all areas. Bedrooms are redecorated and fitted with new carpets each time they become vacant. On the day of this unannounced inspection three empty bedrooms were being refurbished, including new shower facilities in some rooms, for service users soon to move in. Service users bring their own personal possessions and furniture so their private rooms are as ‘homely’ as possible. Service users spoken with were very positive about their private accommodation and of all communal areas in the home. Service users private accommodation is fitted with a lock, which can be overridden by staff only in the case of an emergency. Service users confirmed that they could choose where to spend their day and this was evident on the day of the inspection. Without exception, all service users spoken with informed the inspectors that they enjoyed living at The Court House and felt safe and well cared for. Standards of cleanliness in all areas of the home seen were of a high standard. The home takes appropriate steps to reduce the risk of the spread of infection. Hand washing facilities are appropriately sited throughout the home. Court House Retirement Home DS0000016113.V265933.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 and 29 Staffing levels appear adequate. The home has a low staff turnover and staff morale is high. The home follows appropriate staff recruitment procedures. EVIDENCE: Care hours are provided as follows; 4 care staff in the morning, during which period 2 staff are based in the main house with the other 2 providing support to service users living in the Courtyard and Cottage. During the afternoon 3 are based in the main house and provide assistance to the Cottage and Courtyard as required. An additional carer is on duty between 1830 and 2100hrs. Night staff are based in the main house and consist of 1 waking and 1 sleep-in staff. In addition to care staff, the home employs cooks and supper cooks to cover a 7 day period and cleaning staff. Staff and service users spoken with did not express any concerns regarding staffing levels at the home. The home has a low staff turnover and staff spoken with informed the inspectors that they enjoyed working at The Court House and that they felt well supported. Staff morale appeared high. Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 20 The home has employed one staff member since the last inspection. The staff recruitment file was examined and was found to contain all information as required under Regulation 19 Schedule 2 of the Care Home Regulations 2001. It was noted that the employment application form did not contain a declaration for the applicant to sign under the Rehabilitation of Offenders Act. The registered manager agreed to address this at the time. The registered manager was advised to ensure that any gaps in employment were fully investigated and reasons documented. Court House Retirement Home DS0000016113.V265933.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, 32 and 38 Service users benefit from an open and inclusive style of management. The home takes appropriate steps to ensure the health and safety of service users, staff and visitors to the home. EVIDENCE: The registered manager is Margaret Thomas who has worked at the home for over 14 years and has been registered manager for over 7 years. Margaret has over 35 years experience on caring for older people and updates herself through personal learning. She has also achieved the A1 NVQ assessors award (previously D32/33). Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 22 The manager has an open and inclusive management style which promotes a ‘person centred’ approach for service users at the home. This was very evident through discussion with service users and staff and through observation. Service users and staff were very complementary regarding the manager. Regular meetings are held for service users and service users confirmed that their views/suggestions are encouraged and acted upon. Minutes are maintained. The last meeting was held on 22/02/06. At the time of this inspection, the home is taking appropriate steps to ensure the health and safety of service users, staff and visitors to the home. A tour of the premises took place and the following records were examined; FIRE SAFETY – The home conducts weekly checks on the home’s fire detection systems and monthly checks on emergency lighting. Records are maintained. Fire detection systems and fire fighting equipment is serviced by an outside contractor on an annual basis. This was last recorded as October 2005. Records indicated that regular fire training is conducted for all staff. ELECTRICAL SAFETY – The home’s portable appliances (PAT) are tested annually. This was last carried out in February 2006. The home has an up to date electrical hardwiring certificate which is valid until 04/10/06. GAS SAFETY – The home’s last annual gas safety check was conducted on 10/10/05. EQUIPMENT SERVICING – Servicing records were available to confirm that the home’s hoists and stair lifts had been serviced, in accordance with LOLER regulations on 10/11/05. The home has one Oxford mini mobile hoist, 2 bath ‘lifts’, 2 stair lifts and a ‘Mangaroo’. ACCIDENTS – The home maintains appropriate records for all accidents. Records seen indicated that there had been 17 service user accidents since the last inspection. Accident records include any action taken and follow up required. All accident records were seen to be appropriately stored in accordance with the Data Protection Act 1998. HOT WATER OUTLETS/SURFACES – The home maintains records of monthly checks on all hot water outlets. Records seen indicated that bath hot water outlets were within HSE recommended limits. As the cottage is situated away from the main building and is near to a drive leading to the main road, it has been recommended that the registered person Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 23 conducts a risk assessment to ensure that a satisfactory level of security is maintained. This was discussed at the time of the inspection. Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 24 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 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 x 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 4 4 3 3 3 4 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x x x x x 3 Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 25 Are there any outstanding requirements from the last inspection? 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 OP7 Regulation 15(1) Requirement The registered person must ensure that individual care plans are fully reflective of assessed needs, personalised and that instructions for staff are clearly documented. Timescale for action 31/05/06 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 OP38 Good Practice Recommendations The registered person should conduct a risk assessment, and take any necessary action, to ensure that a satisfactory level of security is maintained for the cottage. Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Court House Retirement Home DS0000016113.V265933.R01.S.doc Version 5.0 Page 27 - 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. 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