Inspection on 09/02/07 for Gwendoline House

This inspection was carried out on 9th February 2007.

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

Gwendoline House 29/08/07

Gwendoline House 28/02/06

Gwendoline House 10/12/05

Gwendoline House 31/05/05

Gwendoline House 14/06/04

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

CARE HOMES FOR OLDER PEOPLE Gwendoline House 17-19 Pleasant Road Staple Hill South Glos BS16 5JN Lead Inspector Odette Coveney Key Unannounced Inspection 09:00 9th February 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 Gwendoline House DS0000003325.V315965.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. Gwendoline House DS0000003325.V315965.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gwendoline House Address 17-19 Pleasant Road Staple Hill South Glos BS16 5JN 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) 0117 9571957 0117 9571957 Mr Philip Frederick Moss Mrs Moira Ann Moss Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Gwendoline House DS0000003325.V315965.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 16 persons aged 65 years and over requiring personal care only 28th February 2006 Date of last inspection Brief Description of the Service: Gwendoline House is a privately owned care home for older people situated in Staple Hill, a residential area of Bristol. It is close to local shops and a bus route. Gwendoline House is a detached property with three floors. The proprietor, Mr Moss, lives and works full time at the home, taking overall responsibility. He concentrates his time mainly on cooking and paperwork tasks. Mrs Moss is the registered manager and is significantly supported by the senior member of staff, Marian Vargheese, who oversees the main management of care to the service users. The property has been extended to provide space for sixteen service users. The communal areas comprise a lounge, dining room and conservatory. All bedrooms are single occupancy and thirteen have en-suite facilities. In addition there are three toilets, two shower rooms and a bathroom. There is a secluded courtyard garden with seating, potted plants and a water feature. There is a warm and cheerful atmosphere in the home and activities are organised on a regular basis. Gwendoline House DS0000003325.V315965.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 registered providers and the matron 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 three of the individuals were reviewed. Residents and visitors to the home and staff on duty were also spoken with. A good number of comment cards were received prior to the inspection, all contained many favourable comments about the service provided to individuals who live at Gwendoline House. were from residents, was from a relative of an individual who lives at the home, and were from health/social care professionals who have supported residents at the home. Comments made were reviewed during the inspection visit and comments, maintaining individuals confidentiality were shared with the registered providers and matron 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. Gwendoline House DS0000003325.V315965.R01.S.doc Version 5.2 Page 6 The staff team at Gwendoline House 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, matron 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. 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. Gwendoline House DS0000003325.V315965.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 Gwendoline House DS0000003325.V315965.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): 1,2,3,4,5. 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 Gwendoline House 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 the home. EVIDENCE: The Home’s Statement of Purpose has detailed information about services and facilities provided at the Home. The Home also has a Service Users’ Guide, which is given to the prospective resident or their representative when they visit the Home to enable them to make an informed choice of moving to the Home. Gwendoline House DS0000003325.V315965.R01.S.doc Version 5.2 Page 9 During a discussion, the Manager stated that the prospective resident is encouraged to visit the Home for a day, have lunch and interact with existing residents and receive more information about the services provided at the Home. Residents are informed on the day of initial visit or on admission of the one-month trial period during which she/he can change their mind. On the day of the inspection a new person was admitted to the home. It was noted that the registered manager and care staff spent time with this person, supporting them in order for them to feel comfortable and at ease in the home. The manager completed an initial assessment and obtained additional information in relation to the persons choices and these included information about activities of daily living, social activities, likes and dislikes, medical history and medication. The manager also explained the general routines of the home, a contract was completed and routines were discussed. The above information is evaluated and care plans are provided on how the assessed needs are to be met. Care files reviewed contained a ‘resident’ contract’ detailing the terms and conditions of stay at the Home and provided clear guidance on the rights and responsibilities of both the resident and the registered provider. Information within this document also includes information about fees and services to be provided. It was noted that not all of these contracts are reviewed and updated on an annual basis; it is recommended that the home does this in order that individuals have been provided with up to date/accurate information. Gwendoline House DS0000003325.V315965.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, 11. 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 of administration guidance for ‘as and when required’ medication. EVIDENCE: Four 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. Gwendoline House DS0000003325.V315965.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. Individuals also had in place a copy of their general daily routine, it was noted that some of these were in need of review and it is recommended that these are checked and updated where required in order that accurate information is in place. Six comment cards were received from residents who live at the home; comments made were; ‘Everyone is most helpful at all times’, ‘meals are appetizing and varied and always sufficient’. Seven comment cards were received from health and social professionals prior to the inspection these all said that the home the home communicates clearly and works in partnership with them, that staff demonstrate a clear understanding of the care needs of service users and that they are satisfied with the overall care provided to residents at the home. Additional comments made were: ‘I am very happy with the care delivered by Gwendoline House, I would be very content to recommended to patients and relatives looking for residential accommodation that they view this home because in my opinion, the standard of care in this facility is extremely high and consistently good’. Other comments were; ‘staff are always approachable and helpful, residents are well cared for emotionally and physically’, ‘Gwendoline House is the type of residential home you would want your loved one to be in if they could not cope at home. It is the nearest thing to home’. Thorough examination of care documentation evidenced that residents are well supported with their health care requirements in order to access services. There were records of when individuals have been visited by dentist, optician’s district nurses and general practitioners. Procedure for medication administration, handling, records and storage were assessed. The home had policy and guidelines on medication. A local pharmacy provides medication using a monthly monitored dosage system. A check of the blister packs indicated that medication had been administered as recorded. All medication seen was stored securely. The pharmacy supply printed medicines administration record sheets each month. Records of administration of medicines were clear. Records are kept of medicines received into the home. Waste medication is recorded and disposed of via the supplying pharmacy. It was noted that there are residents who are prescribed medication to be given ‘as and when required’. It is recommended that the home produce clear guidance for staff as to when this medication is to be given in order to ensure consistency and to reduce the likihood of a misjudgement. Gwendoline House DS0000003325.V315965.R01.S.doc Version 5.2 Page 12 Staff members spoken with had full understanding of the needs of the residents living at the home. Staff clearly identified the values that the home promotes and to be afforded to the individuals living at the home: Dignity, Right and Privacy. All the care documentation and related information seen promoted good care based on the above values. All of the residents are allocated a key worker; staff spoken with had a clear understanding of their role and responsibilities. It was noted that information was in place to demonstrate that resident’s wishes concerning terminal care and arrangements after death have been discussed. However not all residents was their wishes recorded. It was recommended that the home seek ways of obtaining and recording the views of residents in the event of their death in order to ensure that individual’s wishes are respected. Gwendoline House DS0000003325.V315965.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. 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: Information seen evidenced that the individuals living at the home are provided with a variety of social activities and are able to participate or not. This is dependent on the individual’s choice. On the day of the inspection an entertainer came in and played the piano to the residents. Residents were seen singing along and those spoken with said they really enjoyed this performance. Six comment cards were received from relatives of those who live at the home all answers were consistent in that all said that staff make them welcome at the home, that they are kept informed of important matters affecting their relative, that there are sufficient numbers of staff on duty and that they are satisfied with the overall care provided at the home. Additional comments made were: ‘My aunt is very happy at Gwendoline House’, ‘More than happy with the excellent care my relative is given at the home’; ‘The staff are attentive, caring, patient and professional’. Gwendoline House DS0000003325.V315965.R01.S.doc Version 5.2 Page 14 Discussion with the manager, staff members and evidence from the visitors’ book showed that the residents maintain good contact with families and representatives. The level of contact varies for each resident living at the home, some receive regular visitors and go out with family, and others do not. The home would contact individual’s next of kin should they need to be they need to be informed of issues, which affect the well being of an individual living at the home. At a brief walk around the building residents were seen spending time in their bedrooms and the communal lounges. Daily records of care showed that residents are able to choose when to get up and retire, what to eat/drink and how they were to be assisted with aspects of their life. The inspector observed residents having their meal at lunchtime. The meal was relaxed and residents were given the meals based on the choices they made after consultation on the meals available to them. Of the comment cards received from residents prior to the inspection no negative comments were made about meals at the home; an additional comment was ‘Meals are appetizing and varied, and always sufficient’. Mr Moss spoke of the importance that meals are within the home and knew of individual’s likes and dislikes and he came across as someone who is committed in providing a good service. He further commented that an important diet improving individual’s health and wellbeing and said that when individuals have been admitted to hospital meals have been taken into residents. Gwendoline House DS0000003325.V315965.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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 are enabled to complain and are confident that their complaint will be listened to. Practices at the Home ensure protection of residents from harm and abuse. EVIDENCE: The Home has appropriate procedures in place for management of complaints. This document contains information about the Commission for Social Care Inspection to enable individuals to contact the Commission if they were not satisfied with the outcome of their complaint to the home. Resident’s responses noted on the comment cards evidenced that residents are aware of whom to complain to. One resident stated, “I have never had to make a complaint, if i had any concerns I would speak to a member of staff’. There is a copy of the South Gloucestershire Council policy on The Protection of Vulnerable Adults from Abuse at the Home to ensure that the Home is aware of the protocol to be followed if incidences of abuse occur. Records of recently employed staff members were viewed and contained personal information and record of identity. Other information seen included two satisfactory references, record of previous employment, and satisfactory Criminal Record Bureau disclosures. Gwendoline House DS0000003325.V315965.R01.S.doc Version 5.2 Page 16 The home maintains a record of complaints and the last recorded complaint was dealt with effectively and the parties involved were satisfied with the response from the home. Marion Varghesse confirmed that no resident’s money is held at the home for safekeeping. Gwendoline House DS0000003325.V315965.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 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, however some improvements are required in order to keep the home ‘odour free’. EVIDENCE: Gwendoline House is a spacious residential Home and is furnished to a high standard. The house is a detached property and is situated in Staple Hill and is close to private houses and a short distance from the local shopping areas of both Staple Hill, Downend and Kingswood and is 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. Gwendoline House DS0000003325.V315965.R01.S.doc Version 5.2 Page 18 There are adaptations in place throughout the Home and specialist equipment including mobility aid, sensory aids, and specially adapted baths. There is a spacious dining area and a comfortable lounge area with a small conservatory. Residents were observed sitting in the lounge, the conservatory and going into their rooms, looking reasonably relaxed and comfortable in their environment The courtyard to the rear of the home are kept safe, tidy and accessible to residents and have plenty of seating available to residents when the weather is good. A brief tour of the building found the home to be comfortable and had an array of soft furnishing which made the home very homely. The home was clean and tidy, however it was noted that one individual’s room had an odour and the home must seek the source of this and eliminate it. It was recommended at the last inspection that the home request a routine inspection visit from the environmental health department. The home arranged this after the inspection. Furthermore the home underwent another inspection by this department in December 2006. Their investigation is undertaken based on the guidance provided by the Food Standards Agency and the home were awarded four stars within the area of food hygiene and the home are to be commended for this. 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. It was evident from interactions between staff and residents during the inspection that staff have developed positive relationships with the residents. Gwendoline House DS0000003325.V315965.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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 responsibility, however staff would benefit from manual handling and first aid training. EVIDENCE: There is a well- established staff team at Gwendoline House. During the inspection staff were able to demonstrate a clear understanding and knowledge of the individuals who use the service, and of their role in the home. Staffing provision appeared to be consistent with levels and skills needed due to assessed care needs of the individual’s. The staff team have a varied range of knowledge and skills, they were observed by the inspector to be good listeners, effective communicators and were interested and motivated in meeting the needs of those living at the home. The home has a structured induction programme. This is to ensure that a new staff member is competent and confident to work with service users to meet their needs. Gwendoline House DS0000003325.V315965.R01.S.doc Version 5.2 Page 20 Staff spoken with and certificates seen in individuals files provided confirmation that the training had been undertaken and staff that were spoke with were positive about how the training they had undertaken, including National Vocational Qualification and understanding the principles of care, its values and attitudes and said how this had influenced their practice and improved their skills in caring for older people. It was noted that the training undertaken in areas such as manual handling and first aid are currently undertaken in the for of video instruction, it is required that this training is undertaken by an accredited trainer, as it involves ‘practical techniques’ must be undertaken by an competent trainer. Six comment cards were received from residents prior to the inspection and all consistently said that they received the care and support they need, that staff listen and act upon what they say and that they are available when needed. An additional comment recorded was ‘Everyone is most helpful at all times’. Staff files were viewed and all of the required documentation was in place in respect of recruitment and selection practices and it was found that these were robust. Contracts were in place for staff which had been signed and dated by staff, this document included terms and conditions of employment, equal opportunities, disciplinary and grievance procedure. Gwendoline House DS0000003325.V315965.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 37, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home benefits from good leadership and management, its practices have offered protection to the health and safety of residents. The home is run in the best interests of the service users. The home is well managed ensuring that individual’s interests and rights are promoted and protected by a knowledgeable and committed staff team. EVIDENCE: The matron, Marion Varghesse and the Registered manager, Mrs Moss both had a clear understanding of their role and responsibility within the home and were able to demonstrate understanding of the needs of the residents. Gwendoline House DS0000003325.V315965.R01.S.doc Version 5.2 Page 22 Mrs Varghesse has completed a National Vocational Qualification at level four in care management and since the last inspection Ms Varghesse has completed the following training; manual handling, first aid, dementia awareness, continence awareness and fire safety. Mrs Varghesse accesses copies of care/management publications and attends specific conferences in these areas in order to keep her knowledge up to date and in line with current good practice. The Registered manager, the matron and their team were positive and motivated throughout the inspection process. There was evidence that the manager and her team were committed to maintaining good levels service provided at Gwendoline House and also to improving services. There was evidence that the home ensures so far as is reasonably practicable. the health and safety of resident’s staff and visitors. The home has robust policies and procedures in relation to aspect of health and safety. The fire logbook was viewed and was well maintained. The home was completing the appropriate checks on the fire equipments and recording of training and testing of equipments were satisfactory. Staff has attended fire drills to ensure that they have clear knowledge of action to be taken in the event of fire emergency. It was recommended at the previous inspection that the home contact the fire authority and request a routine safety check. Ms Vargasse confirmed that this had happened promptly after the inspection and no issues of concern were raised and no action was required to be taken by the home. The home has in place a fully comprehensive fire risk assessment; this covers the identification of hazards, which is at risk, actions taken to eliminate/reduce risk. This assessment be dated and demonstrates that this is regularly reviewed. Staff supervision was reviewed. Evidence from the records viewed showed that staff have received supervision. Staff spoken with confirmed that they have received supervision and that they benefited from the exercise. It afforded them the opportunity to express their opinion about the services provided at the home and to discuss areas of concern in relation to residents’ care. There are clear equal opportunities policies within the home and all staff are given copies of these. Staff meetings are held regularly and there are also other strategies for enabling staff, service users and other stakeholders to voice concerns and to affect the way in which service is delivered. These included staff supervision, resident review meetings, quality assurance, and an open and approachable management approach. Gwendoline House DS0000003325.V315965.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 3 3 3 3 X 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 Standard No Score 16 3 17 X 18 3 3 3 3 3 X X 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 3 Gwendoline House DS0000003325.V315965.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. 1. 2. Standard OP26 OP30 Regulation 16(2) j Requirement Timescale for action 09/03/07 09/07/07 The home must eliminate the source of odour in an individuals room 13 (4 & 5) Staff must received training in manual handling and first aid. 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 OP11 OP2 OP7 OP9 Good Practice Recommendations The home to seek and record the wishes of individuals in the event of their death. Terms and conditions of the placement to be reviewed and updated on an annual basis. Individual’s daily routines to be reviewed and updated where required. Clear guidance to be produced for staff in respect of medication to be given ‘as and when’ prescribed. Gwendoline House DS0000003325.V315965.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. Extracts may not be used or reproduced without the express permission of CSCI Gwendoline House DS0000003325.V315965.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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