Inspection on 24/01/06 for Critchill Court

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 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

Critchill Court 24/07/08

Critchill Court 12/07/06

Critchill Court 15/07/05

Critchill Court 07/02/05

Critchill Court 24/09/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

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 Critchill Court Lynwood Close Frome Somerset BA11 4DP Lead Inspector Sue Burn Unannounced Inspection 24th January 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 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. Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Critchill Court Address Lynwood Close Frome Somerset BA11 4DP 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) 01373 461686 01373 453114 carol.mohide@somersetcare.co.uk Somerset Care Limited Mrs Carol Ann Mohide Care Home 49 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (33) of places Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registered for 33 persons in category OP and 16 persons in category DE(E) One service user, named elsewhere, under the age of 65 Date of last inspection 15 July 2005 Brief Description of the Service: Critchill Court is a purpose built residential service supporting 49 older people with personal and social care needs. Situated in a quiet residential area of Frome, it is a short walk away from the local shop and approximately threequarters of a mile away from Frome town centre. The home is set in good sized gardens, which includes an enclosed courtyard area. Critchill Court is situated on the ground floor with 33 service users living in the main residential area, in single bedrooms. The other 16 service users, who require support due to dementia, live in a separate self-contained residential area known as Cedar and Oaks (referred to as CedarOaks). This area of the home provides specialist residential care for people with dementia and is supported by a nurse from Somerset Mental Health and Social Care Partnership. Although the home provides two residential areas the service users get together for social events and both areas are supervised by the supervisor on duty. Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out as part of the planned annual programme of inspections. One inspector carried out this unannounced inspection over one day. The last inspection was announced and took place on 15th July 2005. Mrs Carol Mohide has been the registered manager during the last 12 months. She is supported by Mrs Sue Steeds, her deputy manager. The inspector was received and assisted by Mrs Steed. Mrs Mohide soon returned from a visit and they were both available throughout the inspection. 46 people were living in the home. Three of them were in hospital and three rooms were vacant. All service users spoken with, and who were able, told the inspector that they were very happy with the services provided in the home, they thought the staff were kind, that they met their needs and wishes well and that the food served was good. They liked the home and were pleased with some improvements made such as the newly landscaped central garden. A tour of the premises was made, care in the home observed and a range of records was inspected, including care records. The inspector had contact with the majority of service users as they were in the living areas and also spoke with 7 of them privately in their bedrooms, and with two visitors. All service users and the visitors without exception spoke highly of the home. The inspector also had contact with a number of visiting professionals and spoke with one them in private. This nurse supports the home with CedarOaks. She confirmed that the part of the service relevant to her was meeting expected outcomes and that the open and pro-active style of the manager and deputy motivated staff who were keen to learn. She indicated that the home enjoys a good local reputation and service users considering residential care often chose this home. What the service does well: Service users benefit from a friendly, cohesive and enthusiastic staff team. Service users benefit from a home whose managerial style promotes good practice and close relations with involved professionals, relatives and friends. The home is calm, relaxed, well maintained, clean and homely. Service users feel that they have sufficient control over their lives. The home provides a secure area suitable for people with dementia care needs with space to move around freely. Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 Page 6 The home is on a ground level with easy access to all service users areas. It has all necessary adaptations to meet the needs of those living in it. The home has robust recruitment and induction procedures that protect service users from the risk of abuse. Service users benefit from good management systems, such as the management of medication. Service users moneys are appropriately accounted for. The home offers a varied menu of home cooked and nutritional meals. Lunch, seen during the inspection, was appetising and plentiful. A varied activity programme is available. What has improved since the last inspection? What they could do better: Further work to the care plan system is needed to ensure that they detail all service user’s needs and actions required by staff and that service user participation is clearly documented. Please contact the provider for advice of actions taken in response to this Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 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 Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 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, 5 (standard 6 does not apply) ( Standard 2 was met in July 2005) Prospective service users have the home’s Statement of Purpose and Service User Guide available providing them with sufficient details about the home. Prospective service users benefit from the thorough pre-admission arrangements in the home. Prospective service users are given opportunities to visit and have trial periods in the home before deciding to live in it. EVIDENCE: The home has a corporate style Statement of Purpose, adjusted to reflect Critchill Court, which is made available. Additional charges to the stated fee are made for hairdressing, chiropody, transport and personal items. The home provides safe and secure surroundings in CedarOaks, whilst minimising restrictions on service users. Staff receive training in dementia Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 Page 10 care and support from a specialist development nurse. The manager discussed her commitment to a person-centred approach with the inspector. Service users admitted to CedarOaks are assessed by the specialist development team from Somerset Partnership prior to referral to the home. The manager or deputy will then confirm that they are able to meet the person’s needs at Critchill Court. The manager or deputy will assess all service users prior to moving in and a copy of this assessment was examined in the care records. Mrs Mohide had visited two prospective service users in the morning of the inspection for this purpose. A copy of a health professional assessment is also obtained as evidenced in records seen. Service users are encouraged to visit the home before they make a decision and are able to visit as many times as they wish. The home records all these contacts as part of the assessment process. The inspector spoke with a newly admitted service user and visiting relatives. They confirmed to have been given a choice of homes and to have made a positive choice for Critchill Court because of having level access to all areas. They had been well pleased with the reception and ongoing care. Necessary NHS appointments had been made and a medical condition had been improved since the service user’s admission. Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 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, 9, 10. Service users participation in planning they care and their agreement to it is not always reflected in their records, as they should be. Service users benefit from the home’s good relations with social and health care professionals involved with their needs. Service users safety is protected by the medication management of the home that includes monthly audits by the manager, and which has been greatly improved since the last inspection. Service users enjoy personal support offered in a way that maintains the privacy and dignity. EVIDENCE: Three service users’ plans were examined. A great deal of work has been devoted to care planning since the last inspection, aiming to meeting this standard fully, and Mrs Mohide explained that all care records had been reorganised and updated. Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 Page 12 Two of the plans examined still needed extra detail, incorporating all assessed needs and relation between identified care needs and action to be taken. For example, the nutritional needs of a person were described as “at risk” but no obvious detail of this risk given nor instructions for staff on how to minimise such risk. Mrs Mohide confirmed that care planning is done with the service user or their relative or advocate, as appropriate, and agreement is always sought. Service user involvement however was not always obvious in the records inspected. Service users and relatives seen evidenced to working together with staff in meeting care needs and indeed gave examples of improved conditions since living in the home. The records evidenced that other professionals are involved with the service users as required and GPs, district nurse and CPN support the home regularly. A number of district nurses visited service users during the day. A social worker attended a review and the link nurse for the RSC unit spoke with the inspector who evidenced to frequently evaluating the needs of service users in the RSC unit with the staff in the home. Service users are supported with gentle exercise as part of the activity programme. The manager continues to implement tools, such as colour and photographic signing in CedarOaks to better orient and promote service users’ independence. Staff are taking part in Dementia training following the booklets produced by Sterling University and with the assistance of the link nurse. The manager has carried out monthly medication audits throughout the year to ensure that the management of medication is sound. Audits showed that the system had improved during the last months and inspection of the storage, returns and medication records confirmed that finding. The manager was still negotiating with surgeries to ensure that “as prescribed” entries give clearer instructions. Meanwhile the home has to do this. All hand-written entries seen were supported by two signatures. The inspector advised the home to stop using the PRN terminology in favour of clear directions in English. The deputy manager is in charge of the medication area and agreed to do so. All staff members who administer medication have received training. The inspector saw staff assist service users discreetly and promptly and service users confirmed that this is always the case. Service users spoken with and who could provide feedback, gave positive accounts of the staff in the home and indicated that their bells were answered promptly and kindly at all times. Service users have single bedrooms with locks and can lock their door if they so wish. They also have lockable furniture within the rooms. Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 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): 12,13,14,15. Service users are supported to lead the lifestyle they wish, have opportunities to express their individual socio-cultural and religious needs, and to participate in activities that meet those needs Service users benefit from the visiting arrangements in the home that welcome their families and friends at any time. Service users are assisted with maintaining independence and with personalising their private space. Service users enjoy the food provided in the home that offers them choice, variety and considers personal preference. EVIDENCE: Service users spoken with confirmed that they are able to spend their time as they wish. All service users spoken with were very satisfied with their lifestyle. There was environmental, documentary, and first hand evidence of good practice around establishing successfully communication with a person of a Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 Page 14 different language and of making persons from different backgrounds and religions feel at home. The gardens and all service users areas are accessible to them. The courtyard garden has been re-landscaped between staff and members of the local community and now provides an attractive amenity that was valued by service users spoken with. Throughout the inspection there was a relaxed atmosphere as service users, who were able, moved around the home freely and bedrooms seen reflected the individual occupant. Service users on CedarOaks are offered regular opportunities to participate in activities and express their individuality. For example they had assisted with choosing the photographic sign for their doors that meant most to them. The activity organiser on duty demonstrated her enthusiasm and commitment to the role during the inspection. The home usually has 3 activities organisers, however one post is vacant and while activities in CedarOaks always take place the vacant post is not always covered, limiting the provision of activities in the main house. Visitors spoken with confirmed that they are made welcome at any time. Lunch was seen and tasted as part of the inspection. The meal was appetising and in good portions. The menu is varied and offers a choice of 2 main courses and several sweets at lunchtime. The menu was displayed on a board that included the tea meal but it had yesterday’s menu and had not been updated, as it should have been. However, service users had chosen their menu earlier in the day and many knew what they would be having. Those who had forgotten and had changed their mind, were given an alternative. Service users were observed being offered the level of support and assistance they required. Service users spoken with all praised the food served in the home. Special diets were being catered for. Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 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): 16,18. The home has a satisfactory complaints procedure with evidence that formal complaints are acted upon. Service users are protected from the recruitment and training procedures in the home. EVIDENCE: The home has a corporate complaints procedure that is made available. People are invited to make their views known in the corporate leaflet displayed by the main entrance. The home received one complaint since the last inspection that was promptly responded to and resolved in a satisfactory manner with improved communications as a result. Recruitment records examined confirmed that all pre-employment checks are carried out. The home has appropriate policies for the protection of vulnerable adults. Staff spoken with, were aware of what action to take should they suspect abuse and abuse awareness is part of the induction programme. Allegations of not responding appropriately to concerns were received during the inspection and are being examined. These were not from any of the service users spoken with, all of whom expressed a high regard for the staff and management teams. Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 Page 16 Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 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, 26 Service users benefit from comfortable, homely and safe surroundings and the use of accessible, safe gardens. Service users have the bathroom and WC facilities that they require and are adapted to meet their needs. Specialist equipment is procured, as required, to meet each person’s needs. Bedrooms are personalised according to service user preferences and in CedarOaks they are clearly identifiable to assist individuals. Service users benefit from a clean and tidy home and staff that take precautions to diminish the risk of cross-infection. EVIDENCE: A tour of the premises was made. All areas of the home seen were clean and fresh. No odours were noticed. The manager has completed the refurbishment Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 Page 18 of the home that has involved new carpets in private and public areas, a complete refurbishment of the kitchen and replacement of items of furniture and furnishings that needed it. All areas presented well maintained, homely, comfortable and attractive. Service users in CyderOaks have a safe garden that they can use and do so in the warmer months. The courtyard garden provides an accessible and attractive amenity for service users in the main house. All bedrooms seen reflected the taste of the person living in it and all rooms seen were most homely and attractive. There are sufficient and suitable toilet and bathing facilities available throughout the home. Specialist equipment was observed in use during the tour of the home. In addition to bathroom and WC adaptations, they included, mobile hoist, air mattress and cushions for the prevention of pressure sores. Appropriate hand-washing facilities, such as liquid soap and paper towels, are available in all staff and communal washing facilities. They are also provided in bedrooms if anyone suffers from an infection. In addition to hand washing, staff members use a bacteriological hand gel and visitors are also encouraged to do so. The manager has reviewed the provision of facilities to minimise cross-infection also in CedarOaks since the last inspection. The home was clean and hygienic throughout. Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 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 Service users benefit from staff that are suitably trained and experienced and from an adequate staffing allocation, however some absences from the planned staffing provision cannot always be covered, such as activities and care support posts. Service users benefit from a home that takes steps to train and support staff with attaining NVQ qualifications and provides other relevant specialist training. Service users are protected by the home’s robust recruitment practices. Service users are protected by the staff induction procedures in the home and benefit from a staff team that have planned training to better prepare them to meet their needs. EVIDENCE: Rotas for two weeks in January were examined. They confirmed that the home maintains the required number of care staff on duty at all times for the rotas examined. The home employs housekeeping, care support and catering staff. However, there are some part-time vacancies. One on-going activities vacancy, and some support hours were not always covered. There was evidence that this impacted on the remaining staff, which, at times, felt Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 Page 20 pressurised. The manager indicated that there were now a number of candidates for the vacant posts. The majority of staff spoken with described to feeling very pressured when just two care staff are on duty, in each part of the home, early in the mornings, and that the third person allocated for a few hours at that time of the morning was essential, in both parts of the house but not always available, mostly at weekends. Since the inspection the manager has explained that in addition to the two care staff there are also a shift leader and a supervisor who assist care staff early in the mornings. The manager explained that both her deputy and her, worked on shift when necessary to ensure that all care hours were covered. This input was not always represented in the rotas as it should be. The home has good access to NVQ training through the company and aims to have all care staff achieving NVQ qualifications. Training records seen evidence that the home maintains about 75 care staff trained at NVQ Level 2 in Care or above. Of 34 care staff listed in the staff list form provided, 25 had qualifications and 5 others were working towards it. The deputy manager holds NVQ3 in Management. Staff files inspected evidenced robust recruitment practices. Staff receive an induction programme to TOPSS standards. Supervisors undergo an induction programme whether recruited internally or externally and all staff are encouraged to develop their role. The manager submitted an annual training plan that evidences that staff have received a range of training. Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 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, 35, 36,38. Service users benefit from a well run home, and from a manager who promotes an accessible and open style of management. Service users interests are protected by the management practices with regards to the safekeeping of moneys belonging to them. Service users benefit from the staff supervision arrangements in the home, ensuring that staff are supported and developed in their roles. Service users and staff benefit from the Health and safety arrangements in the home. EVIDENCE: The Registered Manager has many years working in care and has held a senior role in another home within the company. Mrs Mohide became the registered Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 Page 22 manager at Critchill Court during 2005 after a period working as acting manager in the home. Mrs Mohide has NVQ4 in Care and the Registered Manager’s Award. A visiting professional, service users and relatives spoken with confirmed that Mrs Mohide is open and approachable and has had a positive impact on the home. Senior staff have designated roles and Mrs Mohide appears well supported by her deputy. While quality assurance questionnaires were not inspected in this occasion, all service users spoken with provided a very positive feedback of their experience of the home. The home does not maintain bank accounts on behalf of service users but do keep cash and cheques for those who cannot or do not wish to hold their own. The record of transactions book was examined and found to be well maintained, with appropriate receipts kept of all expenditure and with inputs and balances agreed with the signatures of staff and service user or relatives. Supervision records were examined and staff confirmed that they received supervision and good support from the management team and from other members of the team. A range of records was examined and, unless already stated, they were well maintained and ordered and demonstrated that satisfactory checks are carried out. In addition to records already mentioned in this report the following were also inspected: • Electrical testing • Fire equipment and systems. • Hot water temperatures and legionella testing • Hoists A tour of the premises was made and areas seen were free from hazards with the exception of some unguarded radiators. Unguarded radiators identified during the last inspection had been provided with covers. A further number of unguarded radiators were noted in a corridor of CedarOaks and in the main house dining-room where radiators were very hot. While these radiators are in usually supervised public areas they do pose a hazard and should be guarded. The manager indicated that she maintains a risk assessment for them but would also seek to guard them. This will be followed at the next inspection. Care staff performs checks to the hot water outlets in service users areas. Staff members record the temperature of every bath and shower given and the handyman tests water in basins. They also document running the water off the Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 Page 23 shower heads daily. In addition a company is employed to test water settings at regular intervals that include tests for legionella. Records however for the baths and showers did not specify if the reading was after staff had mixed water and it was not clear that all baths and showers were read at what intervals. The manager agreed to maintain a record just for body immersion areas that strictly showed testing of the hot water outlets, at quarterly intervals. Hot water outlets have mixer valves fitted. The training charts provided, show that that the majority of staff had received mandatory training and updates and also a range of specialist training. There were some gaps in the fire training updates for 3 care staff and 5 care staff had not received safe manual training update during the previous 12 months. In addition to the forms given, the home also has large charts for mandatory training. It is possible that the training charts given may not have been updated (and the mentioned staff have had the training) but the training record provided should be correct. Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 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 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 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 3 3 2 Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 7 Good Practice Recommendations It is strongly recommended that the improvements made to care plans since the last inspection be continued and extended to all plans, so that all plans are comprehensive, action be specified following identification of need, up-todate and all evidence service user involvement. It is recommended that remaining uncovered radiators in public areas be guarded. It is recommended that at least one mandatory training record be maintained up to date to evidence that all staff have had mandatory training updates. Since the inspection the manager has indicated that this recommendation has been met. DS0000016011.V280527.R01.S.doc Version 5.1 Page 26 2 3 38 38 Critchill Court Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 Page 27 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 Critchill Court DS0000016011.V280527.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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