Inspection on 30/09/05 for Dunraven Lodge

This inspection was carried out on 30th September 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

Dunraven Lodge 24/10/06

Dunraven Lodge 03/02/06

Dunraven Lodge 07/12/04

Dunraven Lodge 22/06/04

Dunraven Lodge 13/01/04

Similar services:

Fairfields Country Rest Home

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Fairfax House

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

CARE HOME ADULTS 18-65 Dunraven Lodge 8 - 10 Bourne Avenue Salisbury Wiltshire SP1 1LP Lead Inspector Thomas Webber Unannounced Inspection 30th September 2005 10:15 Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 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 Dunraven Lodge DS0000028277.V255514.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 Adults 18-65. 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. Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dunraven Lodge Address 8 - 10 Bourne Avenue Salisbury Wiltshire SP1 1LP 01722 321055 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) Mrs Brigid O`Connor Mrs Eileen O`Connor-Marsh Care Home 20 Category(ies) of Dementia (2), Mental disorder, excluding registration, with number learning disability or dementia (20), Mental of places Disorder, excluding learning disability or dementia - over 65 years of age (4) Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2004 Brief Description of the Service: Dunraven Lodge is a privately owned care home, which offers accommodation and personal care to twenty younger adults with a mental disorder. Dunraven Lodge is one of three registered care homes operated by Mrs O’Connor and Mrs O’Connor-Marsh in the Salisbury area which have been in operation since 1980s. Dunraven Lodge is a large detached Victorian house, which is located next door to one of its sister homes: Dunraven House. The location of the home is convenient for residents who make use of the facilities and amenities of Salisbury. The administration of all the homes is centred at Dunraven House and staffing is also organised centrally for all three homes. Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, undertaken during the course of one day from 10:15 to 14:25. The primary focus of the inspection was to ascertain the views of the residents regarding the care and services provided. To this end, twelve residents were spoken to on an individual and group basis. The vast majority of the core standards were also assessed, which included residents’ assessments, care plans, medication, menus, complaints and staffing. What the service does well: Residents live in a comfortable, safe and well-maintained environment, which meets their individual and collective needs. The premises provide sufficient lighting and ventilation with the standard of furnishings, fittings and decoration being maintained to a good standard. The home is kept clean and tidy and provides sufficient communal space together with bath, shower and toilet facilities. Residents have personalised their bedrooms to their individual wishes. Adequate laundry facilities are in place to meet the needs of the residents. Residents spoken to commented they were happy with their level of accommodation and they spoke positively about the laundry arrangements in place. The home is run and managed by a person who is appropriately qualified and has considerable experience within the care setting. The home is run in the best interests of the residents where opportunities exist for them to contribute on a regular basis. Residents are supported and protected by the home’s recruitment practices and the home ensures that there are sufficient numbers of staff on duty to meet the needs of the residents. The staff team reflects the gender composition of the residents and residents commented positively about the care provided by staff. Staff continue to receive ongoing training and are appropriately supervised. Residents are assessed by the home, prior to admission, to ensure that it can meet their needs. Residents’ care plans are reviewed periodically, which includes a psychiatric review every six months. Residents are supported to take risks within a risk management framework and are encouraged to achieve their greatest level of independence. Residents are able to access and take part in a range of activities both within the community and arranged by the home. Residents maintain contact with their families, friends and relatives in accordance with their preferences and their rights are respected by staff. Residents receive a varied and satisfactory diet. Residents spoken to commented favourably about the quality and quantity of food provided, stating that they receive plenty. Residents’ physical, emotional, personal support and health care needs are being suitably met with their medication being appropriately administered by staff, in line with the home’s practice. The health, safety and welfare of the Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 Page 6 residents and staff are promoted and protected. Information is provided to all residents on how to complain and appropriate procedures are in place to protect the residents from abuse. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 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 the following standard(s): 2 and 4 Residents are assessed by the home, prior to admission, to ensure that it can meet their needs. Copies of all relevant assessment documentation undertaken by social services are also obtained. Prospective residents and their families are provided with the opportunity to visit and assess the quality, facilities and suitability of the home. EVIDENCE: The home, as part of its admission process, obtains copies of the care programme approach and client history together with a copy of the management plan/risk assessment where a prospective resident is known to exhibit behaviour problems, prior to admission. In addition, the home also undertakes its own assessment. All appropriate documentation was in evidence with regard to the most recent admission to the home since the last inspection. Prospective residents are provided with the opportunity to make introductory visits to the home to meet with staff and other residents. Residents’ families and their social worker are also encouraged to be involved in this process, where appropriate. This process is supported in the admissions policy, which confirms that prospective residents can make as many introductory visits to the home as they wish. Evidence was available to confirm that the most recent resident admitted to the home had made an introductory visit together with her mother and social worker. Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 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 the following standard(s): 6, 7 and 9 Residents’ care plans are reviewed periodically, which includes a psychiatric review every six months. Residents are supported to take risks within a risk management framework and are encouraged to achieve their greatest level of independence. EVIDENCE: All residents are provided with care plans and those seen were well written and informative. Each resident is provided with a long term assessment/care plan and their long term needs are reviewed monthly. Currently short-term goals are identified one at a time and once one has been met, another is identified. Evidence was available to confirm that the initial monthly review had taken place in respect to the resident most recently admitted to the home and all relevant parties were present. However, the home is still waiting for the official minutes of the review. Residents receive a psychiatric review every six months. Residents are encouraged and supported to achieve their greatest level of independence and control over their lives, which includes the right to make their own choices and decisions. The home has an understanding of the rights of residents who can come and go without restriction and opt in and out of any Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 Page 10 activities. Mealtimes can be made flexible to accommodate for this. Residents can, within reason, get up and go to bed when they want within a structured environment. Risk assessments are completed as part of residents’ care plans. However, a “risk screen” is also completed on admission in respect to all residents and these are reviewed at least yearly. As stated in Standard 2, the home also obtains a copy of the management plan/risk assessment prior to admission where a prospective resident is known to exhibit behaviour problems. As also stated in Standard 7, residents are encouraged and supported to achieve their greatest level of independence and come and go as they wish. Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14, 15, 16 and 17 Residents are able to access and take part in a range of activities both within the community and arranged by the home. Residents maintain contact with their families, friends and relatives in accordance with their preferences and their rights are respected by staff. Residents receive a varied and satisfactory diet. EVIDENCE: Opportunities are available for residents to continue to take part in activities engaged in prior to entering the home or establish new ones where they change localities. Some residents have valued daytime occupation and the majority of them attend the Salisbury Industrial Therapy Unit for various days of the week with two residents attending the Shaw Trust Gardening Centre one day a week and another two residents undertake voluntary work. Residents come and go as they wish and there is no restrictions placed on them attending any activities of their choice. Residents use a variety of means of transport, which includes buses (with them having their own bus passes), taxis and walking. Organised activities are arranged which include swimming, bowling and riding for the disabled. Residents attend the drop in centre Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 Page 12 (Greencroft) and access the various activities on offer. Small groups of residents also attend TABS which provides free to learn courses. Some residents also attend the church of their preference. Staff duties cover attending and supporting residents in activities and appointments. Residents have the opportunities and are encouraged to pursue their own hobbies and interests. The range of activities now available to the residents has increased both within the home and externally. Residents are also provided with the opportunities to either go on holidays with the home, Greencroft and/or with SITU. The home has an open policy on visiting hours and residents can choose where to see their visitors, either in their bedrooms or in the quiet area within the dining room. Residents have the opportunities to meet and make friends with people of their choice, including intimate and personal relationships. Staff will involve and assist residents to undertake some tidying of their bedrooms. Although currently locks have not been fitted to the residents’ bedroom doors, staff respect residents’ private areas and knock before entering their bedrooms. This was evident during the inspection. Residents’ incoming mail is given directly to them unopened, although staff would assist residents to understand the content of their mail, if required. Residents can choose how and where to spend their time and this was confirmed by those spoken to during the course of the inspection. Residents have unrestricted access to the home and grounds. Smoking is restricted to the rear garden and “Chalet”, which is located at the bottom of the rear garden. A satisfactory and varied menu is in operation which provides a choice at breakfast, including a cooked meal at weekends with set meals at lunch and teatime. However, alternatives are provided for these meals to cater for residents’ individual preferences. Special diets are also catered for. A cook is employed to undertake the cooking duties. There are various dining areas and there is an expectation that meals will be taken in these. Drinks are also available for residents at other set times of the day and staff would facilitate this. Residents spoken to commented favourably about the quality and quantity of food provided, stating that they receive plenty. Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 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 the following standard(s): 18, 19 and 20 Residents’ physical, emotional, personal support and health care needs are being suitably met with their medication being appropriately administered by staff, in line with the home’s practice. EVIDENCE: None of the residents require assistance with regard to personal/intimate care, although a number of them need support and prompting. A policy has been established which states that male staff will not provide intimate care to female residents. Some flexibility exists in respect to the times for residents to get up, go to bed, have a bath and eat their meals. Residents are reported to choose their own clothes, although support would be provided if required. Residents have a choice of GP and five different surgeries are used within the Salisbury area. Residents can independently access these or any other health care services. Residents normally attend the surgery for any appointments, either on their own or with the support of staff. The community psychiatric nurse visits weekly to provide depot injections and counselling as well as monitor blood levels. As part of these visits the community psychiatric nurse would liaise with the psychiatrist and home if she has any concerns. The psychiatrist visits the home every three months to primarily review any residents by appointment, although other residents would also be seen where Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 Page 14 the home has any concerns. The district nurse would provide any nursing treatment as and when required. Management reported that residents are not able to maintain control over their own medication and as a result residents’ medication is primarily administered by senior staff and staff who have been deemed competent. Management also reported that the vast majority of staff have completed the Boots administration of medication training and have completed an eight week qualification course in medicine administration. The home has also implemented a sheet which is located within the drugs file and shows the names of staff deemed competent to administer medication. The home uses the Boots monitored dosage system for the recording of medication administered and examination of the residents’ drug sheets showed that they are being appropriately signed for. Suitable systems are in place for the receipt and disposal of unwanted medication. The pharmacist from Boots last inspected the home’s system, stock and administration of drugs on the 15th March 2005 and identified no concerns. Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 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 the following standard(s): 22 and 23 Information is provided to all residents on how to complain and appropriate procedures are in place to protect the residents from abuse. EVIDENCE: Management reported that no complaints have been received by the home since the last inspection. The home has established an appropriate written complaints procedure and each resident has been provided with a copy. The procedure informs complainants that they can contact the Commission for Social Care Inspection at any stage should they wish to do so. Since the last inspection the home has developed and established a complaints monitoring form, which will be used for dealing with any complaints received. The home has robust procedures in place for responding to suspicion or evidence of abuse and these include a Whistle Blowing procedure. Copies of the shortened version of the Wiltshire and Swindon Vulnerable Adults Procedures, which are in line with the Department of Health guidance “No Secrets”, have been distributed to all staff. Management also reported that staff cover the issue of abuse during their induction programme and some staff have received training in this area from the Vulnerable Adults Unit. Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 Page 16 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 the following standard(s): 24, 25, 26, 27, 28 and 30 Residents live in a comfortable, safe and well-maintained environment, which meets their individual and collective needs. The home is kept clean and tidy and provides sufficient communal space together with adequate bath, shower and toilet facilities. However, there were some deficiencies to the level of heating to some parts of the building. Residents have personalised their bedrooms to varying degrees but to their individual wishes. Adequate laundry facilities are in place to meet the needs of the residents. EVIDENCE: The location of the home is convenient for residents who make use of the facilities and amenities of Salisbury. The property is in keeping with its surroundings and the residential neighbourhood, although the design and layout of the home is not suitable for wheelchair users. The premises provide sufficient lighting and ventilation with the standard of furnishings, fittings and decoration being maintained to a good standard. However, it was noted that the level of heating to some parts of the building was not being maintained at the appropriate temperature. This deficiency was brought to the attention of the management of the home. The premises provide both single and shared accommodation for residents’ use with two of the single bedrooms being provided with en-suite facilities. Most of Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 Page 17 the residents’ bedrooms are located on upper floors, which are accessed by use of a staircase. Residents’ bedrooms are suitably furnished and they can bring limited items of furniture and personal possessions to make their bedrooms more homely. Residents can and have personalised their bedrooms to varying degrees but to their individual wishes. As stated in Standard 24, it was noticed that the level of heating was insufficient to some of the residents’ bedrooms, particularly those located at the top of the building. Residents’ bedroom doors are not provided with locks but management reported that locks could be fitted at the request of the residents. Residents are provided with a lockable storage space within their bedrooms. Residents, who expressed a view, stated that they were happy with their level of accommodation. The home provides adequate bath and toilet facilities to meet the needs of the residents accommodated. These facilities consist of three bathrooms two of which have shower facilities, two separate shower rooms together with ten toilets, five being separate from the bath and shower facilities. All bathroom and toilet doors are fitted with suitable locks. The communal space consists of two lounges, two dining rooms and a dining area within the kitchen. A chalet is located at the rear of a well-maintained garden, which has been designated as the smoking area for the home thus providing a smoke free zone to all other parts of the environment. These facilities are comfortable and suitably decorated and furnished. There are two designated staff sleeping in rooms, one of which has en-suite facilities. The home continues to be maintained to a satisfactory standard being clean and tidy. Residents are encouraged and supported by staff to keep their bedrooms tidy. The laundry room is located on the ground floor and attached to the building of Dunraven House, which provides adequate facilities to meet the needs of both homes. A smaller washing machine is available for residents who wish to do their own washing. However, staff tend to undertake the laundry duties, although residents can do their own washing and ironing or assist staff in this process, if they so wish. Residents, who commented, stated that they were happy with the laundry arrangements in place. Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 Page 18 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Residents are supported and protected by the home’s recruitment practices and the home ensures that there are sufficient numbers of staff on duty to meet the needs of the residents. Staff continue to receive ongoing training and are appropriately supervised. EVIDENCE: The deployment of staff ensures that there is a minimum of two members of care staff on duty throughout the waking day, although there are usually three with two care staff sleeping in each night. There are also three domestics employed who are deployed to work throughout all three homes, providing a full clean in each home once a week with additional cleaning undertaken daily by the care staff. The staff team reflects the gender composition of the residents and residents commented positively about the care provided by staff. Two newly appointed staff files were checked during the inspection of Dunraven House which showed that the home is following appropriate recruitment practices which includes obtaining two satisfactory written references, POVA first checks and subsequently satisfactory CRB enhanced checks. Since that inspection the home has addressed the deficiencies identified which included obtaining and recording all the dates of a person’s previous employment history. Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 Page 19 Evidence was available in the staff files to confirm that the newly appointed members of staff had received an induction training programme, which is normally completed within six weeks of employment. On completion of this programme staff would be considered for NVQ 2 training as well as undertaking various mandatory training. At the time of this inspection, management reported that 70 of staff are either trained or are training at NVQ level 2. In addition to this staff have or are in the process of receiving training in other areas such as abuse, mental health and dementia. A training matrix has been established by the home, which includes training undertaken and due to be completed by staff. There are a range of mechanisms in place for management to both brief and receive feedback from staff in order to monitor the standard of care and services provided to the residents. These include regular staff meetings, daily handover meetings and both formal and informal staff supervision. Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 Page 20 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The home is run and managed by a person who is appropriately qualified and has considerable experience within the care setting. The home is run in the best interests of the residents where opportunities exist for them to contribute on a regular basis. The health, safety and welfare of the residents and staff are promoted and protected. EVIDENCE: Mrs O’Connor-Marsh has primary management responsibility for the home and has qualified as an SEN as well as having obtained the Certificate in Social Services which includes a Management component. Mrs O’Connor-Marsh also has considerable experience in the care profession. Although a continuous self-monitoring quality assurance system has not been established by the proprietors, the views regarding the level of care and services provided by the home are actively sought from residents in a variety of ways. These include two monthly informal residents’ meetings, residents’ individual meetings with their key workers and residents’ satisfaction surveys. Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 Page 21 Residents’ satisfaction questionnaires will continue to be distributed to them on a yearly basis. The results of these surveys will continue to be published as an addendum to the service users’ guide. Management reported that visitors/relatives questionnaires have been developed and will be distributed and the results will be collated and published by the end of December 2005. Residents spoken to commented positively about the care and services provided by the proprietors and staff. Management ensures that there are safe working practices within the home and these comply with the relevant legislation. Risk assessments are in place to ensure a safe working environment. All bedroom windows are fitted with window restrictors. Evidence was available to show that appropriate testing and servicing of equipment is being carried out. Staff continue to receive the various mandatory training including Health and Safety. Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 Page 22 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 3 X 3 X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 2 3 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Dunraven Lodge Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000028277.V255514.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 26 Regulation 23(2)(p) Requirement The responsible individuals must ensure that all parts of the home are heated to an appropriate temperature. Timescale for action 30/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Dunraven Lodge DS0000028277.V255514.R01.S.doc Version 5.0 Page 25 - 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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