Inspection on 27/06/05 for Firgrove House

This inspection was carried out on 27th June 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Firgrove House 06/03/08

Firgrove House 05/01/07

Firgrove House 19/12/05

Firgrove House 06/01/05

Firgrove House 11/05/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Firgrove House Station Road Yate South Glos BS37 4AH Lead Inspector Odette Coveney Unannounced 27 June 2005 09:30 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 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. Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Firgrove House Address Station Road Yate South Glos BS37 4AH 01454 310636 01454 310636 Mr Jenny Robert and Kenneth Roberts 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) Mr Kenneth Roberts Care Home for Older People 20 Category(ies) of DE Dementia for 2 registration, with number OP Older People for 18 of places Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: - Date of last inspection 6th January 2005 Announced Brief Description of the Service: Firgrove House is situated in Station Road at Yate. It is within walking distance of local amenities including shops, post office and public house. The home is made up of the Main House and smaller Coach House and provides care for up to twenty older people including two with Dementia. The Main House is on three floors and offers places for fourteen older people while the Coach House has room for six. Firgrove House was registered with Avon Health Authority as a Nursing Home and with South Gloucestershire Council as a residential care home until December 2001 when an application was made to vary the conditions of registration so that all places are for residential care and nursing care is no longer provided. The house is decorated in a homely way with comfortable furnishings. In the Main House there is a lounge with adjacent conservatory and separate dining room. The Coach House has a lounge/dining room. All of the bedrooms are for single occupancy except for two that are for two people. There are ample bathrooms and WCs, the Coach House having some rooms with en-suite and the Main House with 3 ensuite facilities Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted as part of the annual inspection process to examine the care provided, and monitor the progress in relation to the two requirements and two recommendations from the last inspection that was conducted in January 2005. The inspection took place over seven hours. During the process ten clients, three staff, the deputy manager and the responsible individual were spoken with. The inspector looked around some of the building and a number of records were examined. Following consultation with the deputy manager and the staff team it was agreed that those living at the home would prefer to be referred to as clients within the inspection report, rather than service users and therefore this has been reflected within this report. The Commission for Social Care Inspection has produced a leaflet for those living in care establishments entitled ‘Is the care you need, the care you get?’; a copy of this was left at the home to be put on the home’s notice board. What the service does well: What has improved since the last inspection? The home has worked diligently in order to meet the requirements and recommendations made at the previous inspection and are to be commended for their commitment in meeting the National Minimum Standards and care homes regulations. The safety of clients from the risk of fire has improved due to the fire door in the ‘coach house’ being kept closed. Clients are moved in a safer manner now that staff at the home have received manual handling training. Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 6 The needs of the clients have been incorporated when the home reviewed their medication and health and safety procedures. 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. Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3,4,5 There is a well established admissions procedure with appropriate information in order that prospective clients may make an informed decision on whether the home is able to meet their needs. EVIDENCE: There are currently two vacancies at the home. The manager was able to provide clear details of how any future admissions to the home take place. She explained that referrals are often received at the home from a care manager and can also be through word of mouth, individuals are supported in a manner and pace appropriate to them. Also in place were care management assessments and the home’s own assessment that is completed during the trial period, incorporating the support needs of individuals. The service users guide for the home is well written and provides information about the aims and objectives of the home, local amenities and support that individuals living at the home will receive. Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 9 The manager explained that prospective clients are given a copy of the home’s brochure, she spoke of inviting prospective clients to the home in order for them to have an opportunity to look around the home. A meeting takes place with the home, their carers and social workers after an initial months assessment period in order to determine whether the home is able to meet the needs of the individual. During this assessment period the staff make extensive notes and use this information in order to draw up a care plan tailored to the specific needs of the individual. The home has in place a brochure; this was reviewed at the inspection and recorded the aims and objectives and the philosophy of care to be provided at the home, this provides additional information for prospective clients and their carers. Following discussions with the management, clients and their relatives and also the examination of care documentation it was evident that the home is able to meet the assessed, identified needs of those living at the home. There are those living at the home with cognitive impairments and healthcare needs; these are being met by staff at the home and other professionals. The support from these services are clearly recorded, their recommended actions are shared with the staff team in order that continuity of care is maintained. Clients contracts of their terms and conditions of their placement were not available for inspection and therefore will be reviewed at the next visit to the home. The management and many of the staff at the home have worked in the care profession for many years and have a wealth of experience in caring for older people. Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10, 11 Client’s health, personal, social care needs and end of life choices are well recorded and met. EVIDENCE: Clients care records were reviewed at this inspection and it was found that the plans had been generated from a care management assessment, each plan incorporated information on how individuals were to be supported in areas of health, personal, mobility and behavioural needs. All care plans seen had been recently reviewed. The deputy manager was fully conversant with the information held within individual’s plans and the support that individual’s required in order to maintain their health and wellbeing. Two of the clients spoke with the inspector at some length about how staff support them with aspects of their personal care; they both said that staff were sensitive to their feelings due to the nature of the support being given, they said that doors are always knocked for privacy and that they are treated in a respectful way. Staff were observed supporting individuals with areas of personal care, this was undertaken in a caring, discreet manner. Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 11 All of those living at the home are registered with a general practitioner. One of the clients spoken with said that they believed their health had improved since coming into the home due to eating well, being cared for and taking their medication on a regular basis. The inspector also saw evidence to confirm that clients are well supported with their primary healthcare needs such as optician, audiology and chiropody. All of the clients that wanted to, have had a flu vaccination. There are no clients living at the home that require pressure area care. During the inspection a district nurse was visiting one of the clients at the home in order to provide additional support with their healthcare needs. The systems for administration of medication are good with clear and comprehensive arrangements in place to ensure that resident medication needs are met. All medication records were up to date and in order. The home has a clear medication policy which incorporates what to do in the event of a refusal, however the policy does not include what staff must due should a medication error occur, it is recommended that the home add this in order to ensure that staff are fully conversant with their role and responsibility in this area. Upon examination of care records it was clear that the home has sought the views of residents as to their wishes in the event of their death, however not all of the clients had their views recorded, it was recommended that the home seeks to rectify this. Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 12, 13, 14, 15 Client’s are able to maintain contact with family and friends and can make choices about aspects which affect their life. EVIDENCE: A staff member spoken with gave clear examples of how clients are encouraged to exercise choice and control over their lives and some discussion took place surrounding general working arrangements and routines within the home and these are arranged in the best interest of clients. Clients spoken with gave the inspector examples of their own preferred routines and choices made as part of daily living in the home. The systems for clients consultation in this home are good with a variety of evidence that indicates that clients views are both sought and acted upon. Clients told the inspector that meetings take place on a regular basis and their ideas and suggestions are listened to and acted upon, an example given was that clients wanted fundraising money to be spent on additional entertainers to visit the home and also for a gazebo to be purchased in order for them to enjoy the garden, the inspector saw the gazebo in place and Mrs Beer confirmed that clients are consulted on how fundraising monies are to be spent. The home has organised a summer fete for July, clients at the home told the inspector they were looking forward to this. Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 13 Mrs Beer told the inspector that all of the clients living at the home are well supported by members of their family, there are relatives who visit on a regular basis and others who go out shopping or for lunch with family. Individual’s rooms contained many of their personal possessions such as small items of furniture, ornaments, pictures and photographs. During the inspection staff were observed asking client’s for their views and opinions and clients were encouraged to make choices on aspects that affect their life. The systems for client’s consultation in this home are good with a variety of evidence that indicate that client’s views are both sought and acted upon. Client’s told the inspector that meetings take place on a regular basis and their ideas and suggestions are listened to and acted upon. The home produces a newsletter four times per year, the inspector viewed this and saw that this provided useful information on staff training, clients outings and forthcoming events at the home, Mrs Beer explained that the newsletter was developed in order to ensure good communication with relatives and clients, a copy of the most recent newsletter was also seen on the homes main notice board. The inspector viewed the menu for the home and saw that menus were varied, choices were offered and provide a nutritious well balanced diet. The lunch on the day of the inspection was either a cheese salad or a steak pie with potatoes with rice pudding or fruit salad for dessert, two clients on two separate occasions told the inspector that the pastry on the steak pie was not nice and was very chewy, the manager assured the inspector that the pastry was home made and she would discuss this with the cook. Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 16, 18 The complaints process in the home is good and there was evidence that clients views are listened to and acted upon and that clients have confidence in the process. The risk of clients suffering from any form of abuse or neglect is appropriately minimised. EVIDENCE: The inspector viewed the home’s complaints logbook; the last recorded complaint at the home was in July 2004, the complaints logbook records the nature of the complaint, the action taken to resolve the issue and the conclusion. A copy of the homes complaints procedure was on prominent display at the home. All clients spoken with told the inspector that if they had any cause for concern or complaint they would speak to either staff or the manager for the home. All of those spoken with said they had no complaints. No complaints have been received by either the home or the Commission for Social Care Inspection. No staff members at the home are on the protection of vulnerable adults list. No areas of concern were recorded on care documentation. Upon discussion with the manager it was clear that she had a clear understanding of adult protection issues and provides a safe environment to protect clients and to ensure staff are aware of their role and accountability in this area. Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 15 Policies and procedures are in place to minimise the risk to clients from any form of abuse these include a ‘whistle blowing’ policy, ‘No Secrets’ and South Gloucestershire’s Vulnerable Adults policy. The deputy manager has contacted the Commission for Social Care Inspection to inform of incidents that have affected the wellbeing and safety of those living at the home. At this inspection a number of clients money and cash records and bank statements were examined, all were correctly accounted for, with receipts in place. The home has in place clear up to date records of individual’s property and valuables. It was found that two rings were unaccounted for in the cash tin, Mrs Beer said that these had been at the home for sometime and despite efforts to find out who the items belonged to they had never been claimed, the inspector recommended that these items are recorded on a property sheet in order that the home has a clear record of what is held. Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 16 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 standard(s) 19, 20, 23, 24, 25, 26 Client’s are provided with a well-maintained, safe environment and have access to both comfortable private and similar indoor/outdoor and communal facilities. EVIDENCE: Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 17 There have been no changes in the services and facilities provided at the home since the previous inspection. The location and layout of the home is suitable for its intended purpose. The main house is a large detached house with accommodation set over two floors. There is no lift for access to the first floor, however, there is a stair-lift available for those with additional mobility difficulties. The Coach House is located to the rear of the main house and provides accommodation for six clients, with the remaining fourteen living at the main house. The home is situated in the residential area of Yate, the home is characteristic of those in the area and blends in well within the community. All areas of the home are accessible and there are handrails to the front of the property, the rear of the property is accessible by ramps. There are pleasant, well maintained grounds to the front of the property. The rear garden is attractive with well-established shrubs and plants. There are seating areas available to client’s in the garden. There are a number of communal areas available for client’s use, in the main house these include a lounge area, conservatory and dining room, the coach house has a spacious lounge area overlooking the garden. Both areas were clean, tidy with appropriate furnishings, areas were enhanced by the use of plants, pictures and ornaments. The inspector viewed some of the client’s private rooms, these were found to be comfortable with individual’s personal effects on display making the rooms more homely. Lighting within the home is domestic in style and of a good standard, emergency lighting is provided throughout the home, the inspector saw that this is checked on a monthly basis by staff at the home. A hand test of the water temperature found the temperature was not excessive and was at a safe level Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 The relationships between staff and residents are good, and this creates a warm, supportive environment which promotes a good quality of life for client’s. The recruitment of staff is robust, staff have appropriate skills and experience in order to meet the needs of the clients. EVIDENCE: There is a core of well-established staff with varying abilities most of which are skilled and experienced to meet the needs of the residents in the home. There are no staff vacancies at the home, agency staff are not used at the home. Records reviewed provided evidence that a robust recruitment procedure was in place at the home. Staff members spoken with were able to demonstrate a clear understanding of their role and responsibilities within the team. Clients spoken with said that they felt well supported and safe, that staff listened to them. Those spoken with did not raise any concerns about the staffing levels at the home. Comments from client’s were: ‘staff here are lovely’, ‘nothings too much trouble’ ‘every-one is very kind’. The manager provides support and regular supervision all of which were appropriately recorded, the manager monitors staff practice and manner closely and has dealt with staff in a professional way. The inspector saw on the staff notice board a copy of the home’s supervision policy which provides information on what supervision is and of the benefits to individuals and the service delivery. Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 19 The inspector saw that staff appraisals take place at the home on an annual basis and cover areas such as individuals professional conduct, team work and quality of job responsibilities, comments seen from staff were that they found the appraisal system to be very informative and an effective method of enhancing individuals performance and to receive feedback in order that they may enhance the skills and qualities already in place. Minutes of team meetings were viewed, these take place on a regular basis and provide a forum for staff to air their views, exchange ideas and set future team goals in order to provide a good service for those living at Firgrove House. The inspector saw on records that staff have recently attended the following training; March 05 x 11 staff, Care of Aging Skin, June 05 x 5 staff Safe Handling of Medicines, March 05 x 3 staff First Aid, May 2005 x 9 staff continence promotion. Dementia Awareness Training x 7 Staff, March 05 x 3 staff Nutrition and older People. A requirement was made at the previous inspection that those staff identified must undertake manual handling instruction, the inspector saw that this had been undertaken in February and March 2005, Loraine Beer is a manual handling instructor for the home. The atmosphere at the home at the time of the inspection was calm and relaxed with clients looking clearly at ease and ‘at home’. Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 36, 37, 38 Both Mrs Roberts and Mrs Beer aim to provide a good quality service run in the best interest of the client’s within a safe environment and is supported to do this by well supervised staff members. EVIDENCE: Mrs Beer has worked within the care profession for a number of years and has obtained a National Vocational Qualification at both levels three, promoting independence and level four in care management. Mrs Beer has also obtained her registered managers award, she is an assessor for the National Vocational Qualification process and supports candidates within the home in order to develop and improve their knowledge and skills in caring for older people. Mrs Beer is also a manual handling instructor and therefore is able, through observation of practice and during supervision to ensure that staff are working in a safe manner. The registered manager provides a clear sense of direction, Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 21 and had strategies in place to ensure staff develop the skills and expertise to undertake the tasks they are to perform. A requirement was made at the previous inspection that the home must ensure that a fire door identified at The Coach House’ must be kept closed, all fire doors were seen to be closed as required at this inspection. A recommendation was made at the last inspection that the home should review health and safety procedures on a regular basis, the inspector saw that this had been undertaken in January 2005. The inspector viewed the organisational policies and procedures in place at the home, these are robust and provide sufficient information In order to direct and guide staff practice. Records reviewed were kept secure in the office, which could be locked when not in use. The records were well maintained, up to date, legible and in order. Staffing rotas were viewed and staffing levels were discussed with Mrs Beer. There is one waking staff member in each house at night, it is recommended that the home develops a ‘lone’ working policy in order to ensure that clients are safe and that staff are fully conversant with their role and responsibility. The inspector viewed the fire logbook for the home. The home was completing the appropriate checks on the fire equipment and the recording of training, fire drills and the testing of equipment were satisfactory. The inspector saw the fire panel in working order. However it is required that fire records must clearly show the names of those staff who have undertook fire instruction in order to clearly demonstrate that all staff have received sufficient fire safety instruction A requirement was made at this inspection that the home must complete a fire risk assessment; the requirements of this were discussed with the manager and will be reviewed at the next inspection. One of the clients has a handrail in place on their bed, a risk assessment for the safe use of this equipment was not in place and therefore a requirement was made that this be undertaken in order to demonstrate that this is appropriate to meet the individuals needs in a safe way. Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 3 x 3 3 1 Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 23 YES 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. 2. 3. Standard OP 38 OP 38 OP 38 Regulation 23(4)a 23 (4)c 13(3)4 Requirement A fire risk assessment to be completed. Fire training records to clearly record who undertook training/instruction. A risk assessment to be completed re the use of handrail by individuals bed. Timescale for action 27/08/05 27/08/05 27/08/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP 9 OP 11 OP 36 OP 18 Good Practice Recommendations The homes medication policy to include what to do in the evnt of errors. The home must seek the views of clients wishes in the evnt of their death. The home to deveolpe a lone working policy. Lost property in the home to be recorded. Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG 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 Firgrove House D56 D05 S3323 Firgrove House V225306 300605 Stage 4.doc Version 1.30 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!