Inspection on 09/08/05 for Douglas House Cheshire Home

This inspection was carried out on 9th August 2005.

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

Douglas House Cheshire Home 01/06/06

Douglas House Cheshire Home 14/03/06

Douglas House Cheshire Home 22/02/05

Douglas House Cheshire Home 13/07/04

Douglas House Cheshire Home 18/02/04

Similar services:

The Vicarage

7 Hyde Road

5 Seafield Road

Trevaylor Manor

12 Orchard Mews

Stallcombe House

Stepping Stones

Cornerstones

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

CARE HOME ADULTS 18-65 Douglas House Cheshire Home Leonard Cheshire Foundation Services Douglas Avenue Brixham TQ5 9EL Lead Inspector Rachel Proctor Announced 9 August 2005 th 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Douglas House Address Leonard Cheshire Foundation Service, Douglas Avenue, Brixham, Devon, TQ5 9EL Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01803 856333 01803 859503 info@london.leonard-cheshire.org.uk Leonard Cheshire Miss Kay Louise Taylor Care home with nursing 29 Category(ies) of Physical disability (29), Physical disability over registration, with number 65 years of age (29) of places Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: physically disabled - 29 nursing beds elderly physically disabled - 6 residential beds physically disabled - 6 residential beds A named first level Registered General Nurse with experience in the Younger Physically disabled field must be appointed to support the Manager Date of last inspection 22/02/05 Brief Description of the Service: Douglas House opened in 1973, one of the Leonard Cheshire Homes, a voluntary organisation/charity. The home caters for 29 physically disabled people from 20 years old who require nursing. There is a registered nurse on duty at all times supported by a team of Health Care Assistants. The Douglas house staff are committed to enabling Service Users to live in dignity; encouraging them to develop their own individuality. The home has been recently refurbished and provides single rooms for each resident, some with en-suite facilities. All Service Users rooms have access to hoists most of which are overhead hoists. There are spacious communal rooms and corridors for easy manoeuvrability for wheelchair users. The home is light and airy. The purpose built accommodation also provides environmental aids and computer equipment for those who need it. Douglas House also has a respite or holiday room for Service Users needing short term care. The home provides residential and nursing accommodation. Emphasis is put on helping people to achieve mental independence and on improving quality of life. Douglas House also has a day care service for local Service Users and extensive transport availability. Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The commission for social care inspection has introduced key standards to be inspected over each inspection year. Therefore, unless it is felt necessary by the inspector, some standards will not be inspected. To obtain a full picture of the home it is recommended that previous reports also be taken into consideration. This was an announced inspection which took place on the 9th of August 2005 between 9:30 a.m. and 4 p.m. The inspector spoke to residents and members of staff. The inspector joined three residents in the activity room during the morning. A tour of the home was completed and some records were inspected. What the service does well: What has improved since the last inspection? What they could do better: The bathrooms and toilets that the residents use are not all well presented and maintained. There is potential for the residents to be put at risk of infection by the broken seals around the toilets and sinks which could harbour infection. The manager and the registered nurse team need to pay attention to detail when monitoring the residents prescribed ‘as required’ medication to ensure that out of date medication is disposed of in line with good practice recommendations, and that the residents continue to benefit from the medication that was prescribed for them. Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 6 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. Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, The residents can be reassured that their individual care needs will be assessed by a staff team who are competent, capable and supportive. EVIDENCE: The manager and senior staff team use a comprehensive assessment tool to assess perspective residents for Douglas House. The assessment covers health care, personal care, social care and emotional needs. Copies of completed assessments were available, these allowed the residents care needs to be understood prior to their admission. The way assessments are being recorded provide a pen picture of the resident’s personal history there likes, dislikes and goals. One resident spoken to said the staff worked with them to enable them maintain as much independence as they were able. A comprehensive plan of care had been provided for this resident. The residents had provided information about their likes and dislikes and the goals that they had in relation to their care. The care plan had been developed from the initial assessment and the information the resident provided. Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9, The residents at Douglas house are given the opportunity to influence the way their care is delivered, enabling their individual needs and choices. EVIDENCE: Two of the residents care plans viewed covered all aspects of the residents care needs. This included their personal preferences. This has enabled the staff to plan their care on an individual basis. One resident who had behavioural problems had a plan of care, which identified the triggers for the behaviour. It gave staff clear guidance on how to avoid this and promote this residence independence and sense of well-being. The training staff have received since the last inspection has been planned around the needs of the service and the needs of the resident. Clinical training received links to the needs of the residents. These included catheter care, wound care, infection control and managing challenging behaviour. The manager was able to provide information that showed how she worked with the local district nurse team and other specialist nurses to improve the staff teams understanding of individual residents specialist care needs. The manager has introduced a computer-generated plans of care, an example of this was provided. The senior nurse advised how these could be easily Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 10 updated as changes occurred in the care needs for the resident. A system for reviewing each plan of care was in place. Records of formal reviews were also provided. The examples of care plans seen provide evidence that the residents care needs are regularly assessed and changes to the plan of care are implemented as their needs change. The residents asked indicated that they had been enabled to make choices about their daily lives. One resident advised they were looking forward to moving to a ground floor room with a patio area. They also said they had chosen the colour for the paint and the carpeting. The residents are given a choice of activities they like to participate in. Staff had arranged with one resident to take them out shopping on the afternoon of the inspection. A wheelchair accessible vehicle and driver are provided and staff accompany the residents to assist them as required. A clear and comprehensive risk assessment processes in place for the activities the residents choose to undertake. Examples of these were completed in the plans of care viewed. The way the risk assessments were completed enables the resident to make informed choice about their chosen activity. One resident advised that they felt supported to take part in activities outside the home knowing that their care and the staff who care for them would be provided. Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,17 The residents are cared for by a staff team who are committed to enabling them. The staff endeavour to make the meal times a pleasant experience. EVIDENCE: One resident continues to work at home and at a local shop part-time. They advise that they are still enjoying the work and feel valued and wouldnt want to live anywhere else. Two other residents were being encouraged by the physiotherapists to improve their mobility. Various walking aids were available and in use during the inspection. One resident had been enabled through support to walk the supervision. The manager and the staff team continue to enable the residents to access educational courses through the local community college. During the morning of the inspection the residents were being assisted to play xylophones to accompany background music. Two of the residents were enthusiastically taking part and appear to be really enjoying the experience of playing along with the music. Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 12 The mealtimes at Douglas house are flexible to take into account the activities the residents have planned. The residents asked said they enjoyed the food and were able to influence the menu planning through the regular residents meetings and discussion with members of staff. Minutes of the last residents meeting identified one item on the menu that the residents had asked to be changed, the menu reflected this request. Three comment cards were received from residents who indicated that they liked the food. One other resident thought it could be better and would like more fresh vegetables. During the inspection fresh vegetables were seen to be available in the kitchen. A large dining room is provided for the residents to eat their meals. The recent changes in legislation has meant that Douglas House no longer has a bar for residents to purchase drinks. One resident advised that this had not concerned him as they were able to get out of the home on a regular basis. Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 The staff strive to provide personal and nursing care in a flexible way to enable the residents to receive support, which meets their needs in the way they prefer and require. The way expiry dates for residents prescribed as required medication is monitored must be improved to reduce the risk of residents receiving out of date medication that may have lost it’s therapeutic value. EVIDENCE: The way the resident’s plans of care are provided allows them to receive the personal support they require in a way they prefer. The staff members seen interacting with the residents were doing so in a respect friendly way. The residents are able to choose the clothes they wear and the way they look which reflects their personality. One resident advised that they had chosen to have hair cut shorter in a style they had when they were younger. This resident advised that they had been consulted about the choice of the key worker who worked with them. A variety of technical aids and equipment that enable resident’s to maximise their independence is provided in the home. Equipment is provided following an assessment of need; this is regularly reviewed through the care planning process. One resident had been reassessed for a different type of wheelchair following changes in their ability. Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 14 Specialist support is provided by physiotherapists, speech therapists and other professionals to enhance and maintain the residents ability. The manager has ensured the consistency and continuity of the support the residents received by allocating key workers and ensuring that the likes and dislikes of the residents who arent able to communicate verbally are recorded. The manager has developed a good working relationship with the district nurse team. A letter received from the district nurse team leader demonstrates that the manager continues to work closely with these communitys health professionals. They offer regular advice and support to the registered nurses in the home. The Primary Care Trust had provided the home manager with a signed agreement for homely remedies (medication). The medication within the home was reviewed with the senior nurse on duty. Instructions for staff regarding the administration of medication via a PEG feed were provided. The pharmacy had provided a list of medication not suitable for crushing and the reasons why. Other reference material for staff in relation to medication was available in the treatment room. A new systems for disposing of unwanted medication had been introduced since the last inspection. A clinical waste disposal company now disposes of all pharmaceutical products. Records of their disposal were up-to-date and completed as expected. The nurse giving the medication had signed the residents records of medication given. A photograph of the resident is kept with their medication record. Medication is stored in a locked cupboard in the locked treatment room. A locked drug fridge is provided to store medication that needs to be kept cool. Inspection of the drug fridge contents revealed one residents prescribed as required medication with an expiry date of May 2005. These were disposed of during the inspection. Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The residents can be reassured that any concerns that they have will be dealt with in a sensitive way by the staff team. EVIDENCE: The complaints procedure was easily available for residents and their representatives. Residents spoken to advised that they knew who to complain to if they had any concerns. The home has a comprehensive process for complaints, each complaint is followed through and actions taken to address the concerns raised are recorded. The standard expected in the home is for complaints to be responded to in 21 days. The manager advised that complaints were not seen as negative but as a way of ensuring that the services and facilities were meeting the residents needs as far as possible. The manager explained how each complaint received is used to critically analyse how the issues raised could have been avoided. Changes implemented as a result of this were discussed. Documentation of complaints received and actions taken to address the issues raised continues to be well documented. There are regular meetings with residents to discuss any issues raised. Action planning involved Residents and/or others. A copy of the complaints procedure is contained in the Residents Guide. However one resident advised that they did not have their own copy of this but had been involved in discussions to improve the information available in the guide. Residents spoken to during the inspection advised that they were able to express their concerns and wishes to staff and these were dealt with in a sensitive way. Policy and procedures advise staff how to protect residents from abuse/neglect. This included a whistle blowing policy. The policy manuals were easily available for staff to refer to. A training matrix provided identified Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 16 staff training. Instruction for staff on how to handle challenging behaviour was in place. New staff files viewed contained a record of their Criminal Records Bureau check. Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,27,30 The majority of the residents areas are well presented and well maintained, however the lack of maintenance in the bathrooms to maintain adequate seals around toilets and sinks may put residents at risk of infection. EVIDENCE: The home is generally well maintained; there was evidence of ongoing repairs and renewals taking place. Some Independent wheel chair users continue to occupy rooms below 12 square meters. As the home existed prior to the implementation of the Care Standards Act 2000 the revised requirements for existing homes applied from June 2003. The garden and exterior of the home has been adapted to provide easy access for wheel chair users. Three residents were using the patio area outside their rooms during the inspection. Ceiling hoists are fitted in the majority of the residents rooms, which facilitates more floor space and ease of transfer for the resident. Rooms are approached along wide corridors with a lift to first floor enabling wheel chair independent residents to have access to all parts of the home. The lift had been replaced since the last inspection. The home provides transport for residents to facilitate them to take part in community functions. Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 18 Residents who are able have chosen the furniture in their rooms. Rooms had been individually decorated after consultation with the resident. One resident told the inspector about the colour scheme and carpeting they had selected for their room. All residents rooms have good lighting and ventilation, residents can see out of their windows when seated or in bed. The residents rooms entered contained items of their personal choice. One bathroom had been up graded since the last inspection. Other bathrooms in the home had cracked tiles and broken seals around the sink and toilets, which were stained. This poses a possible risk of infection to residents. Previous reports have recommended that bathrooms should have broken tiles and damaged grout seals replaced. The manager confirmed plans to up grade the remaining ground floor bathrooms and the bathroom on the first floor. Availability of bathrooms and toilets for residents will not meet the higher ratio of one bathroom/toilet facility between three Residents. Bathroom/Toilet facilities for those residents with out en-suit; are shared by 4 residents. Engaged signs are provided for bathrooms when they are in use, these are accessible from wheel chair height. Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,35,36 The robust recruitment practices and the resident focus training the staff receive enables the residents to be supported by a competent and qualified staff team. EVIDENCE: The home has a motivated staff team who work well together. The manager continues to calculated the staff required using a dependencyscoring tool. Staff rotas in place show that staffing is increased at peak periods. The manager advised that staff continue to be encouraged to assist residents to attend activities by accompanying them. The home employs a physiotherapist who works with residents on a one-toone basis to enable them to gain their optimum function. The manager advised that she planned to employ an occupational therapist. A training matrix provided showed which training courses staff had accessed, the training listed supports that staff are able to access training to improve and maintain their skills. Training provided is linked to the care needs of the residents. This included wound management, infection control and specific disease related courses. The Leonard Cheshire organisation has a robust recruitment policy and procedure which is based on equal opportunities and ensuring the protection of residents. Staff files viewed had two references and copies of their completed Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 20 CRB checks. Other information required in staff files was provided. An interview pro forma is being used for interviews this provided evidence that recruitment follows equal opportunities guidelines. A record of all the training staff had received in the last 12 months was provided as part of the pre- inspection questionnaire. The training coordinator demonstrated how the matrix record of training enabled her to target training for individual staff members and the staff team as a whole. The matrix had been designed to identify the training staff members required as well as the training they had already received. Specialist training required by the registered nurses was also taking place. This included syringe driver management, anaphylaxis, vene puncture, continence, wound healing and catheter care. The staff spoken to during the inspection said they felt well supported and had access to training to improve their knowledge and skills to care for the residents. Comment cards receive from the staff also identified that staff felt supported and valued. Supervision and appraisal records were available; these included the training and development plan for the individual staff member. Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39,42, The residents can have confidence that their views are taken into account and their health, safety and welfare are promoted and protected. EVIDENCE: Effective quality assurance and quality monitoring systems are in place. These are based on seeking the views of the residents. There is an annual development planned for the home, which is based on a cycle of planning action and review. Two of the residents said they were regularly asked to provide comments and be involved with the things that affect them. Residents plans of care demonstrated how individual goals had been set and achieved. The residents spoken to had been informed that the inspection was taking place. The manager was able to demonstrate that the policies and procedures and practices are regularly reviewed and good practice advice from specialist professional are incorporated. Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 22 The manager has introduced a system to regularly risk assessed the environment and health and safety of the residents and staff. Copies of completed risk assessments for individual residents and the environment were available. The training staff received included manual handling training, the trainer was able to demonstrate how she ensured that staff have regular updates to ensure their manual handling practices are safe. Fire protection training and fire drills staff had received were recorded. The written statement of the policy, organisation and arrangements for maintaining safe working practices is in place. The manager advised she had responsibility for maintaining the internal budgets with in the home. The commission receives a monthly report about the home from a senior manager with in the Leonard Cheshire organisation. The accident reporting system in place allows the home manager to analyse accidents that occur. The accident records included actions taken to reduce any identified risk Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 4 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 x 4 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x 2 x x 2 Standard No 11 12 13 14 15 16 17 x 3 x x x x 3 Standard No 31 32 33 34 35 36 Score x x 3 3 4 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Douglas House Cheshire Home Score 3 4 1 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 24 no 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 YA 20 Regulation 13 (2) Timescale for action The registered person shall make Immediate arrangements for the recording, handling, safekeeping, administration and disposal of medicines received into the care home. Prescribed as required medication expiry dates must be monitored. The registered person shall make 01/02/06 suitable arrangements to prevent infection, toxic conditions in spread of infection that the care home. The cracked tiles, broken seals around toilets and bathroom sinks must be replaced. Requirement 2. YA 30 13 (3) 16 (J) 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 YA 27 Good Practice Recommendations The bathroom should be refurbished to meet the needs of the current service uses. Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Unti D1 Linahy Business Park Ashburton TQ13 7UP 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 Douglas House Cheshire Home D54-D07 S28666 Douglas House V236851 090805 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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