Inspection on 05/01/07 for Firgrove House

This inspection was carried out on 5th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Firgrove House 06/03/08

Firgrove House 19/12/05

Firgrove House 27/06/05

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 Key Unannounced Inspection 09:30 5th January 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Firgrove House Address Station Road Yate South Glos BS37 4AH 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) 01454 310636 01454 310636 Mr Kenneth Roberts Mrs Jennifer Roberts Lorraine Sarah Beer Care Home 20 Category(ies) of Dementia (2), Old age, not falling within any registration, with number other category (18) of places Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th December 2005 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 DS0000003323.V315792.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and to review the quality of the care provision for the individual’s living in the home. This inspection employed key elements of the national inspection methodology with the objectives of focusing on outcomes for the individual’s. This is evidenced through evaluation of core standards and verification through a surveying and case tracking approach that included talking with and the observation of individuals who live at the home and the views of the manager on duty. An opportunity was taken to view the home and a number of the records relating to the management of the home and plans of care for five of the individuals were reviewed. Residents and staff were also spoken with. A high number of comment cards were received prior to the inspection, 5 were from residents, 10 were from relatives of those who live at the home, 4 from health/social care professionals who have supported residents at the home and two cards were received from general practitioners who visits individuals at the home. Comments made were reviewed during the inspection visit and comments, maintaining individuals confidentiality were shared with the registered manager and registered provider and these have been incorporated within this inspection report. What the service does well: The home has a clear, detailed statement of purpose and brochure in place; these documents provide sound information about the services and facilities that able to be provided at the home. The home has a structured admission process based on the homes ability to meet the assessed needs of individuals. Good standards of care and service delivery remain at the home. Those spoken with during the inspection said they were happy and enjoyed life at the home. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 Page 6 The staff team at Firgrove are caring and have developed good relationships with residents at the home; they have a sound understanding of the needs of residents. There is a low staff turnover and residents can therefore be confident that they will receive support from people they know. It was clearly evident that the manager and the staff team are committed to ensuring that all of the needs of individuals at the home are met, this is done through consultation and observation and previous knowledge and an understanding of individuals A robust complaint procedure is in place and all complaints are investigated properly and action taken where required. The manager at Firgrove has a commitment and drive in wishing to provide a good quality service at the home, ensuring that residents, their relative and staff are consulted. There are clear lines of accountability within the home. 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. The summary of this inspection report can be made available in other formats on request. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The manager takes a lot of care when admitting residents to Firgrove in order to ensure that the home are able to meet the assessed needs of the individual. Clear information is provided about the services and facilities available at Firgrove. EVIDENCE: Firgrove House was originally registered with the Avon Area Health Authority as a Nursing Home. The home is now registered with the Commission to provide care and accommodation for up to twenty people aged 65 years and over, and within the registration care can be provided for two people who may have a Dementia. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 Page 9 Firgrove House is privately owned and operated by Mr Kenneth Roberts and Mrs Jennifer Roberts, who are jointly registered to manage the home A requirement was made at the last inspection that the home updates their Statement of Purpose to include the categories of registration and that nursing care is not provided this document had been changed. The statement of purpose provides full information about the services and facilities that are able to be provided at the home, information is also given about the management and staffing arrangements. A number of resident’s relatives wrote positively in feedback forms sent to the Commission for Social Care area office before the inspection about the staff and their helpful attitude when assisting residents with their needs. These comments help to demonstrate that residents’ relatives feel their needs are being met, and that they are treated well at the Home. For those residents who are funded by the local authority the inspector saw that the home had in place a comprehensive care management assessment in order to make a decision on whether the home and the skills of the staff team are able to meet the individual’s needs. The manager fully demonstrated a clear understanding of the admission process for individuals to the home. Ms Beer told the inspector about the admission process for the most recently admitted resident to the home The inspector saw that the home holds a review after one months placement at the home, at this meeting the residents and their representatives are present and make their views known, these are recorded and appropriate action is taken. Staff spoken with told the inspector that all of those living at the home are treated as individuals, all with different views and values, they were able to give examples of how specific needs are met. The inspector saw that staff have undertaken appropriate training that will equip them with additional skills and knowledge to meet the needs of older people. There are residents living at the home with specialist 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. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well supported with their needs by staff. Care plans reflect residents’ current personal care and health needs. Generally the practices for storage and administration of medication are safe, however some improvements are needed in respect on medication stock audits. EVIDENCE: Five individuals care records were reviewed at this inspection and it was found that the plans in place had been generated from a care management assessment. Information contained within care records included: an individual’s profile containing information about the reason for admission, health care support services involved, next of kin, family contact details and medical history. Each resident also had a pre- admission assessment form completed by a care manager, risk assessments, records of health professionals visiting, daily records of individuals routines and a care plan. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 Page 11 The care plan identified the areas in which the individual required support, how staff intervention and support would be provided, the support and the situation is in turn evaluated and dated. When examining the care plans it was evident that the home had spent time with individuals discussing their wishes and choices and it was seen that, where able, individuals had signed their care plan confirming the validity of its contents. All of those living at the home are registered with a general practitioner. There was a record of visits to the GP and these were up to date and sufficiently detailed. The inspector also saw evidence to confirm that individuals are well supported with their primary healthcare needs such as optician, diet and chiropody. All of those that wanted to have had a flu vaccination. A resident also told the inspector that they didn’t want this vaccination and their right to refuse had been respected. A comment card received from a general practitioner prior to the inspection wrote that ‘Firgrove is superb’, ‘staff are excellent’ ‘residents are happy and the home contact me appropriately to ensure the healthcare needs of individuals are met’. A comment card received from a healthcare professional wrote; ‘This home has made significant contribution to improving patients complex mental health problems, resulting in a better than expected outcome’. Residents said that ‘they always get the doctor to me if I am not well’. Manual handling risk assessments were seen to be well written and up to date, Waterlow, pressure care risk assessments were seen to be in place for residents. It was noted that two of these were not dated and one did not provide detail of how the assessment decision had been reached. It was recommended that these assessments are reviewed and additional information is added where required. To find out if medication practices in the Home were safe, the practices and procedures for administration, and storage of medication were checked. Medication supplies are stored in a secure cupboard in a secure trolley. Resident’s medication administration charts were looked at. The administration charts were up to date, legible and in order. The staff had signed for medication administrated, or recorded the reasons for any omissions. All staff administering medication attend training to enable them to do this safely. However is was noted that the home does not have an audit of stock held medication, it is required that this a method of recording stock held medication in order to effectively monitor this medication type. Throughout the inspection all of the staff on duty were observed helping residents with their needs in a polite way. Staff knocked on resident’s bedroom doors and spoke to residents respectfully. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can keep close contact with relatives,friends and the community. Residents are offered a varied and nutritious diet, and are able to take part in a range of social and theraputic activities. EVIDENCE: During the day the inspector observed how staff responded to residents. She saw that staff made sure that residents were spoken to at regular intervals and nobody, including those who were quite and withdrawn. No one was ignored. Residents were offered choices and were invited to take part in both individual and group activities. Staff organise a range of social activities and these include bingo, memory and reminiscence groups, gentle exercises and trips to the community. Several residents were observed taking part in a music session with a staff member. Residents looked as if they were enjoying the activity. Residents were observed walking around the home, and approaching staff. Residents looked reasonably relaxed and settled in their environment. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 Page 13 It was reported that the home has a relaxed policy related to residents seeing their friends or family at the Home. One of the residents confirmed that their relative regularly has meals with them at the home and they are always made welcome by staff. A visitor to the home said that staff were always kind and polite. There is a well furnished comfortable dining room for residents to have their meals in. The Home operates a rotating menu. Prior to the inspection the menu choices were looked at to see if residents are being offered a wellbalanced and varied diet. All the choices seen were well balanced, traditional and varied. A recommendation was made at the last inspection that dry foods to have the date when to be used by on them this had been met. The home has recently been awarded a five star food hygiene award. This was issued by South Gloucestershire Council based on standards provided by the Food Standards Agency. The home is to be commended for achieving this award. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ complaints will be taken seriously and acted upon. The Home also has systems in place, and practices and procedures to protect residents from abuse. EVIDENCE: It was reported on a number of feedback forms, prior to the inspection that visitors felt very able to speak to any of the staff if they had concerns. They said staff would respond promptly and take their concerns seriously. Staff also demonstrated in discussion that they had a good understanding of how to support residents, who may be very confused, to be able to make a complaint. A relative visiting at the home said they found the manager and staff very approachable and easy to talk to and would have no hesitation in raising any issues of concerns if they had any. Residents are protected from the risk of harm or abuse by staff following the South Gloucestershire Council’s `protection of vulnerable adults from abuse’ policies and the homes own robust adult protection policies. There was also evidence in the staff training records that staff attend training on the protection of vulnerable adults from abuse, to help ensure residents are protected. The manager has a clear understanding of her role and responsibility in line with the homes internal adult protection protocols. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 Page 15 The homes complaint logbook was viewed and it was found that issues raised with the home are dealt with effectively and to the satisfaction of those involved with a resolution being sought. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 25, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a Home that is safe and the quality of furnishings are of a high standard and suitable for the needs of residents. EVIDENCE: Firgrove House is a spacious residential Home and is furnished to a high standard. The Home is situated in Yate and is close to private houses and a short distance from the local village of Chipping Sodbury and nearby to bus stops. This helps ensure residents can be a part of the community. The Home is wheelchair accessible; and there is a stair lift servicing the upper floor. The home is a three-storey building, and residents have access to all areas. The Home is a large detached building, with a coach House accommodating six residents set within the grounds of the main house. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 Page 17 There are adaptations in place throughout the Home and specialist equipment including mobility aid, sensory aids, and specially adapted baths. There are two dining area and comfortable lounge areas. Residents were observed sitting in the lounges, the conservatory and going into their rooms, looking reasonably relaxed and comfortable in their environment. Bathrooms include specially adapted baths to assist residents who may have reduced mobility. Toilets are situated in readily accessible parts of the Home near to communal areas and bedrooms. The bathrooms and toilets were clean, and were well stocked with hand towels and soap to help minimize risk from cross infection in the Home. The Home looked clean and tidy in all areas that were viewed. Two recommendations were made at the last inspection, one that a bath should be re enamelled and also that a radiator cover to be re attached. A review of both of these areas found that both of these recommendations had been met. There have been a number of areas of refurbishment at the home since the previous inspection, and residents spoken with were very pleased about the improvements that have been made. New bathroom suites have been fitted, vanity units in bedrooms have been replaced, and new dining room flooring has been laid. The whole exterior on the home has been painted, the car park has been extended and re shingled, the rear garden has been re planted. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are cared for by sufficient numbers of competent staff that are provided with training to fulfil their roles and responsibilities. EVIDENCE: There is a well-established staff team at the home. The use of agency staff is not required at the home, there are no staff under the age of 21 left in charge at the home and staff providing personal care to residents are over the age of 18. At the time of the inspection there were sufficient numbers of staff on duty to meet the needs of the residents. Each individual has a key worker to support them with the manager being involved with the overall monitoring of individual care. It was clear that staff have developed relationships with individuals and have worked together with them and others in order to identify the needs of residents and then support the person appropriately. There was information in individual care plans that provided information to guide staff to the appropriate level of support that individuals require. Regular staff meetings are held at the home and appropriate subjects are covered in respect of the service provided at the home and in line with the needs of those living at the home. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 Page 19 Many favourable comment were received about staff at the home from both residents and visitors to the home; comments included: ‘Staff are kindness itself’, ‘all of the staff are approachable, caring and welcoming’, ‘the health of my relative has improved since they came into the home, I have no concerns over their care’. Time was spent observing staff that were supporting and caring for the residents. It was noted that staff were very patient and ‘asked’ residents, rather that deciding for them and encouraged residents to make choices. At this inspection the staff records for four staff members were fully reviewed and two staff members were spoken with as part of the inspection process. The inspector judges that the manager operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of residents. Written references, protection of vulnerable adults checks and criminal record bureau checks had been undertaken for staff prior to their commencement at work. Staff complete a comprehensive induction and receive ongoing training in order to fully undertake their role effectively. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager has a strong sense of leadership and direction and is committed in providing a good quality of life for those living at Firgrove. The health, safety and wellbeing of those living at the home is well managed. EVIDENCE: Lorraine Beer recently underwent the ‘fit person’s’ process and was deemed competent by the Commission to undertake the role of registered manager. Mrs Beer has 17 years experience in the caring profession, and achieved the NVQ level 2 and 3 in care during her career. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 Page 21 Her continual professional development includes achievement in the following subjects: • NVQ levels 1 and 2 • NVQ Level 4 • Registered Managers Award • NVQ Assessor Award • Manual Handling Trainer • Appointed First Aider During a fit-person-interview held on 8/9/06 and conducted by Helen Taylor and throughout the inspection Mrs Beer was able to demonstrate a good understanding of the requirements of the registered manager post. Mrs Beer provided good examples of positive changes in the home whilst undertaking the role of deputy manager. Full support and guidance from Mrs Roberts one of the providers has enabled Mrs Beer to develop her management experience. Improvements to date have included: • • • • Introduction of residents meetings. Reviewed skill mix in the staff team Developing the staff-training programme. Changing the ethos of the home. Mrs Beer also demonstrated a good awareness of legislation that guides practice in a care home. Mrs Beer is able to promote equality and diversity, giving good examples of recent practice. Mrs Beer gave a good account of how the quality of service provision would be monitored and reviewed, these effective systems were reviewed at the inspection and were further validated with comments from residents, relatives, health and social care professionals prior to the inspection. Throughout the inspection Mrs Beer demonstrated a commitment to the provision of good quality individualised care packages in the home. The inspector observed many occasions when Mrs Beer spent time with the residents, she was supporting and reassuring. Mrs Beer has high visibility in the home and gives strong leadership and direction. She encourages openness and discussion and is regarded as someone who listens. Three requirements in respect of this group of standards were made at the last inspection, all had been met and the manager is to be commended for this. Information in respect of these are detailed below. A requirement was made at the last inspection that a self closer to be fitted to the kitchen fire door. The inspector saw that this had been completed and further saw that additional self-closures had been fitted on bedroom doors. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 Page 22 Mrs Roberts confirmed that additional closures had been ordered and these would be part of an ongoing plan for the home. A requirement was made at the last inspection that the home must make suitable arrangements to prevent the risk of cross contamination. This requirement had been met and the home was found to be extremely clean and tidy. The fire logbook records showed fire alarm tests are being carried out. There are also fire drills carried out on a regular basis to help protect the health and safety of residents and staff. In order to ensure the safety of both residents and staff a requirement was made at the last inspection that manual handling risk assessments to be completed for all residents; a review of these documents at the home found that these had been fully completed and identified areas of potential risk and how individuals would be supported in line with their assessed needs. The home has comprehensive policies and procedures in place in order to support and provide a service for older people who have a varied range of needs. The manager has recent reviewed all of the policy documents in place, of which there are 86; those seen included; policy on the code of conduct for staff, confidentiality, policy on the management ethos of the home and equal opportunities. All documents had been signed by the manager and are freely available for staff. During discussion the manager displayed insight into the business planning and has developed a future development for Firgrove, which includes information about staff training, supervision, recording and meeting needs of residents. This document links in well with the quality assurance audit that the home have implemented this seeks and records the wishes of residents and relatives with written responses in place recording how issues raised had been dealt t with. Regular residents and staff meeting are held at the home and provide an opportunity for open discussion, to raise concerns, ideas and suggestions and to plan for the future. Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X X 3 3 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Firgrove House DS0000003323.V315792.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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