Inspection on 28/11/05 for Horsell Lodge

This inspection was carried out on 28th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Horsell Lodge 04/11/08

Horsell Lodge 22/05/07

Horsell Lodge 16/08/05

Horsell Lodge 15/06/04

Similar services:

Old Hastings House

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Horsell Lodge Horsell Lodge Kettlewell Hill Horsell Woking Surrey GU21 4JA Lead Inspector Pat Collins Unannounced Inspection 28th November 2005 12:15 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 Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Horsell Lodge Address Horsell Lodge Kettlewell Hill Horsell Woking Surrey GU21 4JA 01483 760706 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) Horsell Lodge Limited Kate Gilbert Care Home 46 Category(ies) of Dementia - over 65 years of age (8), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (8), Old age, not falling within any other category (46), Physical disability over 65 years of age (6), Sensory Impairment over 65 years of age (6) Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Of the 46 older people accommodated up to 8 may be in the category MD(E) and/or DE(E) Of the 46 older people accommodated up to 6 may be in the category PD(E) and/or SI(E) All residents to be over 65 years Date of last inspection 16th August 2005 Brief Description of the Service: Horsell Lodge is a care home providing personal care for older people. Registration conditions include 8 places for people with dementia and 6 places for people with a physical disability. The home’s admission criteria stipulates that service users must be able to weight - bear and excludes individuals requiring nursing care. Service provision includes permanent, short term and respite care. Located in an exclusive residential area, Horsell Lodge is within close proximity of Horsell village. It is also accessible to shops and other community facilities in nearby Woking town. Set in spacious, mature landscaped grounds, the building is a large, detached Manor house dating back to 1891. This was extended in 1947 and the modernisation programme over the years has retained the traditional architectural features of the original building. The home has good parking facilities and a secluded garden terrace and summerhouse. Bedroom accommodation is arranged on three floors accessible by passenger lifts. The home is wheelchair accessible except for the second floor and for this reason service users accommodated on that floor must be ambulant. Bedrooms are mostly singles, 24 of which have en-suite facilities. Three of the five shared bedrooms also have en-suite facilities. Communal accommodation is arranged on the ground floor, comprising of two lounges, a conservatory, main dining room, separate smoking room and dining/visitors room. Assisted bathing and shower facilities are available and wheelchair accessible toilets. Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on one half day, over a period of five hours. The registered manager and care/deputy manager were on duty. The inspector spoke with six service users in depth privately, consulting them on their experience of life at Horsell Lodge. The inspector sought opinions about standards of care at the home from their perspective. Eleven other service users were consulted to illicit information about the home. The inspector engaged the registered manager and deputy manager in individual and joint discussions . A senior care assistant, two care assistants, the ‘acting’ activity coordinator and kitchen assistant also contributed information to the inspection process. A tour of the home was undertaken and care records were sampled. These included the statement of purpose, service users guide, the activities programme, financial records, also minutes of staff and service users meetings. Direct observations of care practice also formed part of the inspection process. Information contained in comment cards received after the inspection, one from a general practitioner and three from relatives/visitors also formed part of this process. The inspector would like to thank the service users and the manager and her team for their hospitality and cooperation at the time of the inspection. What the service does well: The home’s management and operation demonstrated a positive attitude towards seeking the views of service users. Systems were in place for exploring ways to further improve standards of care and the services and facilities of the home. Management and administration systems were found to be efficient and effective to the benefit of service users. Staff were observed to be caring in their approach and attitude towards service users. Comments from a relative/visitor received after the inspection highly praised the manager and all staff for their diligence, willingness, care and affection “lavished on those in their care – Horsell Lodge is truly a CARE home”. A service user informed the inspector that “the home is well run, staff are kind, we are well cared for, what more can one ask of a care home?” Another stated “I am immensely grateful to Kate (the registered manager) and all staff for their devotion and excellent care and attention received by my wife and I during her recent, final illness. All staff went that ‘extra mile’ for us both which is of great comfort to me now”. The staff team were clearly working hard to ensure that service users’ needs were appropriately assessed and met, whilst encouraging and enabling service Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 6 users to maintain their independence within individual capabilities. Another comment from a relative was “ the care of my relative at Horsell Lodge is first class, I can sleep easy knowing my relative is in such great hands”. The care environment was appropriately stimulating and a suitable activities programme was in place. The home was clean and hygienic and odour control was overall to a high standard. The grounds and premises were well maintained, affording pleasant and homely surroundings in which to live. What has improved since the last inspection? What they could do better: It was concluded that overall the home was operating to a high standard. The management of the home, policies and procedures and practices ensured delivery of good quality care. The manager reported a five year development plan for the home in which it was the intention to make provision of a sluice machine. In the interim it is necessary to ensure adequate odour control in sluices that currently have only sluice sinks and ensure extractors are efficiently functioning in these areas. On the day of the inspection there was a strong malodour in one of the sluice rooms. Requirement was made for a call bell to be fitted in an en suite toilet on the second floor. Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 7 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. Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 8 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 Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 1, 2. The home was found to be operating effectively in respect of these standards. The inspector was impressed by the availability and quality of information about the home. Prospective service users, with the help of their family and friends were enabled to make an informed choice on whether the home would be a suitable place to live. EVIDENCE: The registered manager had recently updated the home’s statement of purpose and service users guide. The information contained in these documents accurately depicted services provided at Horsell Lodge. Discussed was a minor amendment necessary to the statement of purpose, reflecting a change in policy in respect of bedroom doors being closed at all times on the grounds of fire safety. An information pack was available in the entrance hall. This included the home’s statement of purpose, service users guide, sample contract, compliments/suggestion/ complaint form, fee charges and sample menu. A current brochure and copies of inspection reports by the Commission were prominently displayed. Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 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 the following standard(s): 7, 11 Evidence gathered from this inspection demonstrated that each of these standards was being effectively met. Service users assessed needs were identified and recorded in care plans and an individualised approach to care was evident. Procedures and practices gave special care and comfort to service users and their relatives and friends in the care of the dying. Deaths were managed with dignity and propriety. EVIDENCE: The inspector sampled the care documentation of three service users and found these records to be comprehensive in content. A system was in place for regular review and all documentation was maintained up to date. It was established that service users needs had been fully identified, were known by staff and were being met. There was a system for service users and where appropriate their representatives, to be consulted and involved as far as they wished to be in the care planning process. Most comments from service users regarding their care experience were very positive. Examples of these included “ staff respect my privacy and choices”, “carers are very helpful”, “and my key worker ensures I am kept informed of Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 11 matters affecting me”. One service user stated that staff turnover could at times impact on continuity of care. When probed further it was not the case that new staff were not aware of and did not adhere to care plans. The issue was in relation to new staff needing time to familiarise themselves with individual service users personal preferences in respect of care delivery. Effective systems were in place for establishing and responding to service users views about their care and how the home operates. These included regular service users meetings. Minutes from these meetings were typed and copied individually to service users. These were kept in wall - mounted holders in bedrooms. Large print copies of minutes were stated to be available though not seen. The home had a clear policy and procedure specific to care of the dying and arrangements in the event of a death. The registered manager who is also a qualified nurse, had delivered in – house training for staff in this area of care. The care/deputy manager confirmed she had received external training in bereavement counselling and that bereavement had formed part of her NVQ Level 3 care qualification. It was demonstrated that the team gave special care and comfort to service users who were dying and to their loved ones. Death was handled at Horsell Lodge with dignity and propriety and spiritual needs, associated rites and functions were observed. A sensitive approach to informing service users of deaths in the home was evident. On the day of the inspection the registered manager, care/deputy manager and members of staff attended a funeral service of a former service user. This was noted to be standard practice, which staff chose to do. Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 14 Service users were able to maintain contact with families and friends. The philosophy of care at the home enabled service users’ expectations and preferences to be met, satisfying social, cultural, religious and recreational interests and needs and maximising individual autonomy. EVIDENCE: The activities organiser was on long term leave at the time of this inspection. A senior care assistant was deployed in the capacity of full time ‘acting’ activities organiser. Discussions with this member of staff demonstrated enthusiasm for her new role and commitment to meeting service users social needs through a varied activities programme. Minutes of service users meetings demonstrated an inclusive approach to planning the home’s social and recreational programme. On the day of the inspection individual service users informed the inspector that they had enjoyed participating in a ‘seniorcise’ group session of gentle armchair exercises to music that morning led by an external, fully trained person. Also a game of skittles that morning and reminiscence quiz in the afternoon. The home environment was observed to be appropriately stimulating and a warm and friendly atmosphere noted. Staff frequently interacted with service users and a small group of service users were observed to be obviously Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 13 enjoying a game of cards in the lounge with a care assistant, whilst waiting for the evening meal. This activity was interspersed with humour and laughter. Other service users were watching television in the lounge or in their rooms, or listening to music, reading books or newspapers. Some were resting in chairs. One service user was knitting blankets with the intention of donating these to charities. The activities programme incorporated opportunities for excursions and for entertainers to visit. Plans for the Christmas activity programme were in place. Some staff were going to perform a nativity play for service users’ enjoyment. A Christmas party was planned and key workers were responsible for purchasing a Christmas present for each service user out of the home’s funds. Service users informed the inspector that their visitors and friends were made welcome by staff. Spiritual needs were supported by regular visits from clergy from local churches. Service users had a choice of spending time with others or spending time on their own in their rooms. If preferred meals could be taken in their rooms. There was a range of processes, for example, autonomy in handling financial affairs within individual levels of capacity also the right to bring personal possessions into the home, that collectively evidenced commitment to maximising each service users capacity for control over their lives. Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 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 the following standard(s): 17 The home’s policies and procedures ensured that service users legal rights were protected. EVIDENCE: Discussions with the registered manager confirmed information available in the home to facilitate access to available advocacy services where service users lack capacity. Service users’ rights to engage in the political process were upheld. Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 20, 21, 22, 23, 24, 25, 26. Service users had access to safe and comfortable communal and private facilities that met the assessed standards and were appropriate to their needs. One requirement was made for a call bell to be fitted in an en-suite toilet. EVIDENCE: During a tour of the home all communal areas were inspected and bedroom accommodation sampled. The home was clean and odour in these areas was well managed. There was a programme of routine maintenance and a rolling programme of redecoration; also replacement of worn chairs. The building was compliant with all relevant fire safety requirements. The registered manager confirmed a five - year development plan in place for the premises. It was stated that a second conservatory was planned off the dining room, next year, creating a further light, spacious sitting area. The registered manager advised that funding was also available to landscape the grounds near the new conservatory, providing accessible pathways and a sensory garden. The plan included also the replacement of the two - person Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 16 passenger lift with a lift serving all floors including the basement laundry, aimed to improve safety in relation to the moving and handling of laundry. Furnishings were domestic in character and in keeping with the traditional characteristics of the environment. The home was warm and adequately ventilated. Standards were met for ensuring safe hot water and radiator surface temperatures. The bedrooms viewed were furnished to the required standard and personalised. Service users had the option of a lockable facility in their bedrooms for privacy and security of possessions and documents. Suitable mobility aids, a hoist, grab rails and raised toilet seats were available. A new standing type hoist was on order. All communal areas were wheelchair accessible. The second floor bedrooms were accessible by a two - person passenger lift. The registered manager informed the inspector of the home’s policy for only ambulant service users to be accommodated on this floor as a fire safety precaution. A range of bathing facilities were available. There was a specialist bath with side access, three shower rooms and conventional baths, one including a bath hoist. The home had two sluice rooms with open sluice sinks. One of these rooms was malodorous. The registered manager arranged for the extractor fan in this area to be examined by the maintenance person who was on the premises at the time. The five-year development plan was stated to include installation of a closed sluice machine in due course. In the interim infection control risk assessments must be regularly reviewed relevant to disposal of bodily fluids and hygiene practices for commode pots and urine bottles. Observations confirmed sufficient toilet facilities in terms of ratio to numbers of service users. Twenty-four single rooms and three shared rooms had en suite facilities. The registered manager advised of consideration being given to building a second toilet off the main lounge. There was one toilet noted on the first floor without a wash – hand basin. Three service users in adjacent bedrooms used this. These bedrooms all had washbasins for hand washing after using this toilet. This toilet was also next door to a bathroom with a washbasin. The emergency call system was observed to be functioning at the time of the inspection. A call bell was required to be fitted in an en-suite toilet on the second floor. Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 The number and skill mix of staff met service users needs. EVIDENCE: The registered manager reported stability within the team following a period of staff turnover earlier in the year. The staff rota demonstrated that minimum staffing levels were consistently maintained. Observations at the time of the inspection and feedback from service users indicated that staffing levels were overall adequate to meet the assessed needs of service users. Staff were professional in their conduct and observed to be competent when carrying out their duties. They were caring and respectful in the presence of the inspector in their approach to service users. The staff group included a substantial number of staff recruited from overseas for whom English was not their first language. Individual service users identified communication problems with some staff when they first took up post but most did not consider this a major issue. Discussions between the inspector and staff on duty confirmed their command and comprehension of the English language was adequate to ensure competency in performing their role and duties. They informed the inspector that they had all enrolled on an English language college based course. Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 37, 38 The home was being efficiently and competently managed and administered in the best interest of service users. The strong leadership and direction to the staff team ensured provision of quality care and promoted the safety and welfare of service users. Systems were in place for safeguarding service users financial interests. EVIDENCE: Though the home’s management structure did not formally include a deputy manager post, in practice one of the senior care assistants was designated care manager and deputised for the manager in her absence. The registered manager was suitably qualified and experienced to fulfil her role and responsibilities. She had a professional background in nursing and management. The registered manager had attained the registered managers in Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 19 care award qualification, was an NVQ assessor and was studying for NVQ Level 4 in management. Observations at the time of this inspection confirmed that the home was efficiently managed and administered. Service users benefited from strong leadership and direction to staff by management. There was clear lines of management accountability external to the home that was described as very supportive. The responsible individual on behalf of the organisation, who was also the registered manager’s line manager, visited the home on a regular basis and was accessible between visits. The responsible individual carried out monthly visits in accordance with statutory requirements. Reports of these visits were available in the home and copied to the Commission for Social Care Inspection. An administrator was employed and on leave at the time of the inspection. Financial records sampled related to service users’ personal money being held for safekeeping by the home. These included a record of transactions supported by receipts and signatures. Communication systems within the home appeared effective. It was good to see information clearly displayed in the entrance hall of when the registered manager was on duty; also the name and designation of the person in charge of each shift. Photographs and the names and designation of staff were helpfully displayed in the dining room, which aided recognition and communication. Statutory records were well organised and maintained up to date. Auditing systems for record keeping were effective. Health and safety and fire safety standards were being met. A recent change in fire safety arrangements was noted. Service users no longer had the option of having their bedroom doors open, on the basis of this being a fire safety risk to others. The registered manager confirmed her intention to consult the local fire safety officer regarding plans to fit door guards to two bedroom doors based on needs assessments. Due care and attention was evident in relation to prevention of accidents in the home. Risk assessments were routinely carried out for prevention of falls for each service users and individuals’ at risk referred to a falls clinic by the general practitioners. Discussions with service users identified two individuals who independently drew attention to risks associated with trying to open heavy doors, specifically bedroom and toilet doors whilst using Zimmer frames. They considered their safety to be compromised by the weight of these doors caused by measures for making doors fire retardant. Though staff assistance was freely available in these circumstances both individuals held the view that the environment, for this reason, limited their independence. Quality assurance methods at the home involved regular audit and monitoring systems and arrangements for seeking the views of service users, their Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 20 representatives and staff. Questionnaires from a survey this year canvassing the views of these stakeholders, also minutes of service users and of staff meetings verified continuous, effective self - monitoring systems and an inclusive and open management style. Outcomes of this survey were detailed in a document prominently displayed in the entrance hall and taken seriously by management. It was positive to note the management approach recently in response to critical comments from some service users about catering. A meeting was convened between service users, management and the chef to resolve this matter. Service users reported recent improvement in this area of the home’s operation. Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 21 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 x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 x 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 3 18 x x 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 x 3 3 Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP22OP 22 Regulation 23(2)(n) Requirement For a call bell to be fitted in the en-suite toilet in the second floor bedroom identified at the time of the inspection. Timescale for action 28/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Horsell Lodge DS0000013682.V267224.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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