Inspection on 24/04/06 for Horsfall House

This inspection was carried out on 24th April 2006.

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

Horsfall House 05/01/06

Horsfall House 31/05/05

Horsfall House 14/12/04

Horsfall House 05/05/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Horsfall House Windmill Road Minchinhampton Stroud Glos GL6 9EY Lead Inspector Mrs Janet Griffiths Key Inspection 24th April 2006 09.45 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 Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 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. Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Horsfall House Address Windmill Road Minchinhampton Stroud Glos GL6 9EY 01453 731227 01453 886371 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) Minchinhampton Centre for the Elderly Miss Jennifer Martin Care Home 42 Category(ies) of Dementia (20), Old age, not falling within any registration, with number other category (22) of places Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Temporary Variation to admit one named person under 65 years of age on a respite care basis one week in every six. 5th January 2006 Date of last inspection Brief Description of the Service: Horsfall House is a purpose built home accommodating elderly people who need nursing care, residential care or dementia care. The Home also provides a day centre offering a range of facilities for the elderly residents of the local community and is also open to the residents in the home by arrangement. The Home is situated on the outskirts of the town of Minchinhampton near to the common. The accommodation is attractively furnished and maintained. A shaft lift accesses the upper floor to the nursing General unit, which consists of 18 single and 2 double rooms, all with en suite facilities. The Cotswold (EMI) Unit comprises 20 single en suite rooms. The main dining room is situated in the front of the Home next to the kitchen and is now used mainly for the Day Centre, as residents in the Cotswold (dementia care) unit and General unit have become frailer and are not able to access this room easily, and are at present using the limited facilities on the units. There are plans in place to address this in the next programme of redevelopment, when new dining room facilities are proposed. There are several attractive garden areas also available to the residents, which include a walled garden where residents from Cotswold Unit can wander in safety and a summerhouse, a popular meeting place for residents and their families. At the time of inspection the fees are £660 RNCC in the General Unit and £682 RNCC for Cotswold Unit. Additional charges are made for chiropody, hairdressing and physiotherapy. Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This unannounced key inspection commenced on one day in April 2006, with the site visit that took place over 7 hours 15 minutes. During this time the inspector spoke to a number of residents, some relatives, staff working in the home and the manager of the home. Four resident’s files were looked at in detail to include their medication and accident records. Surveys were either completed during interviews with residents or their relatives, or were handed out by staff to relatives/residents following the inspection and these results were later collated. What the service does well: What has improved since the last inspection? The care planning system is under constant review to ensure that all the current needs of each resident have been identified, appropriate care planned and staff are fully aware of these needs in order to meet them effectively. Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 Page 6 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. Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 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 Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are well informed about the home prior to admission and a full pre-admission assessment is completed. EVIDENCE: Three residents and the relative of another resident, who had been admitted to the home since the last inspection, were spoken with. There was no sign of service users guides within their rooms although the manager stated that they should be there. The residents spoken with could not recall seeing them, although one relative said it was kept in reception and he had read it there. However, all felt well informed about the home and the document had been seen in residents’ rooms at the last inspection. Both the Statement of Purpose and Service Users guide are under review at present and on completion a copy will be sent to CSCI. Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 Page 9 Because of the resident’s conditions on admission, for example two were admitted directly from hospital and one moved from Devon, none had seen their rooms prior to admission, but all knew the area well and knew of the home and its reputation. In some cases families had looked round on their behalf. All had full pre-admission assessments completed prior to admission to ensure that their needs could be fully met and the residents and their families also confirmed that their needs were being fully met. Staff spoken with were fully aware of individual resident’s needs and background social history and how to meet their needs. Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 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): 7,8,9,10 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The service user’s health, personal and social care needs are set out in the individual plan of care. Service users health care needs are fully met. Service users 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. EVIDENCE: Care files of four service users were reviewed during the inspection. Their initial assessments were seen and how care plans were formulated from these to ensure plans reflect the current needs of these service users who have either been interviewed or seen receiving care. For example one had a great deal of information in the initial assessment with specific instructions of methods of communication and nutritional needs. Care planning was set out accordingly and as needs have changed these have been adjusted. Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 Page 11 The husband of this service user confirmed that appropriate care is being given and that he is kept informed of any changes. However, the care plan reviews do not show evidence that they are completed with the resident or their representative. A second service user spoke of the additional care received such as support from a physiotherapist and his doctor and again this was confirmed in his records. A third showed evidence of advice being sought on wound care from the district nurse and an up to date chart on wound care progress was seen. Care planning in general is much more consistent although under constant review and the ultimate plan is for a computerised system to be implemented. One accident notification was followed up at inspection concerning a service user who had wandered out of their room at night and sustained an injury to their leg. The service user has recovered from this accident and because of the general deterioration of their condition over recent months, was being given an adjustable height bed which has been considered more suitable for their present condition. Wherever a risk has been identified through moving and handling or pressure sore risk assessments, appropriate equipment is put into place and was seen much in evidence at inspection. In addition to care records, the medication charts of those service users who care records were reviewed, were seen and discussed with the nurses in charge of each unit. Good records were maintained and showed evidence of medication reviews taking place as conditions changed, for example one had strong analgesia prescribed when wound dressings were completed and another had medication changed as swallowing reflexes deteriorated. Medications are administered and stored in accordance with policies and procedures. The dispensing pharmacist carries out regular medication audits. An additional drug cupboard has been fitted for use in one unit to improve the current storage arrangements. Each service user has their own room with en suite facilities in Cotswold unit. Within the general unit there are two shared rooms but currently, a married couple occupies one of these. Staff were observed knocking on doors prior to entering rooms and ensuring that privacy was maintained when carrying out personal care tasks. Residents who wished to go to the toilet were assisted discreetly. One resident observed had just had a haircut and was upset by some hair not being brushed off her clothes. This was dealt with gently by the carers as they transferred her from a wheelchair back into her armchair, as was persuading one resident who had wandered into another residents’ room to ‘go and help them with the coffees’, so that the situation was handled without the resident becoming agitated or confrontational. Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 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): 12,13,14,15 Quality is this outcome is adequate. This judgement has been made using available evidence including a visit to this service. Not all service users find the lifestyle experienced in the home offers a stimulating atmosphere or meets their recreational interests and needs. Service users maintain contact with family, friends, representatives and the local community as they wish and are helped to exercise choice and control over their lives. Service users receive a wholesome, appealing, balanced diet although the surroundings are not always conducive to social mealtimes. EVIDENCE: Designated staff continue to organise a programme of activities and social events for the residents in the home and clients attending the day centre. Limited places are available each day for residents to attend the day centre and join activities. One resident spoken with was about to go to the centre for the day and had been making visits there since her arrival the previous week, at the request of her daughters and because as she said ‘she was trying to be sociable’. A second resident spoken with said although it wasn’t ‘really his scene’ he had been for a game of bingo and enjoyed listening to a singer with a very good Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 Page 13 voice. A relative of a third said his wife was not well enough to enjoy any activities. Within Cotswold unit where each resident suffers from varying degrees of dementia, more one to one activities are organised although most reportedly enjoy the weekly music and movement sessions. Several were out walking round the gardens with carers late morning and one of the care staff said that it would be nice if a larger area of garden was secured and possibly a small potting shed, raised gardens and even a washing line could be used for day to day activities for some of the residents. A well-presented monthly newsletter is produced and was on display on the notice board advertising a number of events such as a fun day and May Fayre, festival players in June and an orchestra and Christmas Fayre in November. The home had also recently celebrated on resident’s 100th birthday and another’s 62nd wedding anniversary. There were no signs of activities taking place on either unit during the inspection, other than the hairdresser visiting, which the ladies greatly enjoyed. Previous surveys carried out by the home itself revealed that some people felt more activities and social events were needed. One survey handed out at inspection also confirmed that this was still so by saying that ‘the activities and outings advertised before entry (admission) have never occurred. No social intercourse between patients encouraged or arranged- lack of mental stimulation’. A number of residents in the general unit prefer to remain in their rooms and seldom join others for meals and only occasionally for social events. One of the staff spoken with also felt that the residents lacked stimulation. The manager however, reported that a group have formed to include the activities organiser for the general unit, the manager of the day centre, a volunteer who’s husband is a resident and the manager herself, who were going to meet regularly to put together an activities programme and to organise social events. One forthcoming trip planned is to Horse World and a number of residents have already been identified for this trip because of their love of horses. Service users were observed and confirmed that they are able to receive their visitors in private and where possible links with the community are maintained. Several residents spoken with said how they go out regularly with their families and one gentleman still drives his own car. Service users are encouraged to either handle their own finances or delegate that responsibility to their family/representative. Those spoken with also confirmed how they are afforded choice in how and where they spend their days. Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 Page 14 Weekly menus were seen on display and the meal served for lunch - lamb and mint pie with a variety of vegetables and stewed apple and custard - was well received. Well-cleared plates were observed being returned to the kitchen for washing up. Soft/pureed diets are available where required and discreet assistance given by the staff. Special high- rimmed plates are available for those who have some difficulties with their meals, as are slip mats and special cutlery. Pureed diets appeared to be much better presented. The catering manager organised a food survey last year in which individual preferences, portion size and meal times among other things, were audited. Results of these surveys were provided and have been acted upon. Hot and cold beverages are readily available and can be made on request from the kitchenettes on each floor. One resident was observed drinking a special preparation to aid swallowing and supplementary foods were also seen available. Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: Each survey received and resident or relative spoken with were confident that they knew how to complain, who to take their concerns to and felt confident that these would be taken seriously and acted upon. There have been no complaints received related to the home so no records to see. Again, each person spoken with said that they had not had cause to complain about anything. Staff spoken with stated that they had recently received training in abuse and protection of vulnerable adults. This is also included in their NVQ training which most care staff have either undertaken or are currently undertaking. An adult protection file is available in the office and in both units, but the manager was not aware of or had access to Gloucestershire Adult Protection Alerter’s Guide. A copy has been provided. Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe, well-maintained environment. The home is clean, pleasant and hygienic. EVIDENCE: Not all areas of the home were inspected on this occasion, but a number of residents rooms, particularly those visited, were seen, as were the lounges and dining areas. All areas seen were clean, pleasant and hygienic and residents’ rooms were comfortably furnished and many were personalised with chosen items of their own furniture, pictures, photographs and ornaments. All of the residents spoken with were very pleased with their rooms, one specifically made reference to the suitability of the size to accommodate a Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 Page 17 large wheelchair and several others remarking on the lovely views of the local countryside form their rooms. All also confirmed that the rooms are kept ‘exceptionally’ clean and well maintained. However, one resident in Cotswold unit had who recently had a fall was anxious that when sat in the lounge, particularly if they are chair-bound, they have no way to summon help other than shouting to gain attention which was what the were doing on this occasion. This was fed-back to the manager. For large periods of the day when the majority of residents have been assisted with washing and dressing, there is always a member of staff in the communal areas, but at peak times this is not so. The main disadvantage to the environment continues to be lack of dining facilities, although two small dining areas are available. The one in Cotswold unit is used daily, but for those who aren’t able to use this, they are seated at individual tables, which some do not find easy to use. Few wish to leave their rooms at meal times in the general unit, preferring to eat alone, but staff do try to encourage use of the dining room especially at weekends and special occasions. There are still plans in hand for a major refurbishment and building project, hopefully within the next 18 months to two years. This work will include extending the kitchens and day care facilities, altering and increasing office and reception space and joining the two lounge areas in Cotswold unit to create a large lounge/dining room, which will hopefully accommodate all who would like to use it. There will still be a number of attractive areas within the gardens to enjoy, to include two enclosed patio areas adjacent to Cotswold unit. There are further plans to create a herb garden and possibly raised flower beds for the residents to enjoy. Several of the residents observed and spoken with enjoy being able to take daily walks in the gardens either with care staff or their families. Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. Service users needs are met by the numbers and skill mix of staff and are in safe hands at all times. Service users are supported and protected by the homes’ recruitment policy and practices. Staff are trained and competent to do their jobs. EVIDENCE: A qualified nurse and six care staff were on-duty in each unit on the morning of inspection. Staff were observed completing their work unhurriedly and competently and residents confirmed that staff attended them promptly when assistance was required. Five care staff, three qualified nurses and two domestic staff were all spoken with. There were no new staff on-duty although a carer about to commence with the home care service was being shown around Cotswold Unit and was later observed ably assisting a resident with their lunch. They all confirmed they enjoyed their work and most were very enthusiastic about their training and development. Two staff had recently completed NVQ 2 and were to start NVQ 3 in June. This was with Cirencester college which Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 Page 19 they felt was good and offered excellent support. Other recent training included catheter care, abuse training and dementia awareness, gastric tube (PEG) feeding and the End of Life Initiative. The ultimate goal of the manager would be for 100 of staff to have NVQ training but the home already exceeds the National Minimum Standard. There was some anxiety within Cotswold Unit because the unit manager appointed in December has resigned and will be leaving once her notice is worked. Care staff said they were upset about this because she was very supportive and listened to them. They also confirmed that they had regular meetings and supervision and appraisals. There had been only one new member of staff appointed since the last inspection, when a large number of staff files were checked. On this occasion this one file was checked and found to have all the required documentation and checks made. Staff were asked about the new staffing arrangements for night-duty since the last inspection where only one qualified nurse and four care staff are on-duty to cover both units. Most staff felt that this was working well. The only time there could be a problem would be when an untoward event occurred which could fully occupy the qualified nurse delaying other responsibilities. There is an on-call system in place in the event of this occurring. Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. 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 her responsibilities fully. The home is run in the best interests of service users and their financial interests are safeguarded. The health, safety and welfare of service users are promoted and protected. EVIDENCE: The registered manager approved by the Commission has been in post for over a year now and is well established in her position in the home. She is Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 Page 21 currently undertaking the registered manager’s award and hopes to complete it later this year. Staff confirmed good communication systems in place with regular meetings, and one to one supervision and annual appraisals. Residents and their families spoken with confirmed that they were kept well informed of any events related to the home which may effect them and part of this process is the annual satisfaction surveys about to be repeated and a suggestion box in the main reception. The newsletter is another valuable communication tool. The surveys have been reviewed since the last inspection and one for residents and a second for relatives have now been devised. The home continues to employ someone to deal with any financial matters and she is responsible for all the invoices/payment of bills etc. There is no personal expenditure of the residents being dealt with by the home, as residents or their families are encouraged on admission to maintain this responsibility. Records were seen to confirm that regular servicing and maintenance of equipment is carried out. The fire alarms were being tested on the day of inspection, and an electrical check was also being completed. Some of the staff in Cotswold Unit were a little alarmed to see a new water heater delivered to the unit, as they felt this idea had been abandoned after they has raised concerns about potential risks to the service users who wander into the kitchenette and could scald themselves. It was later confirmed that the door to the kitchenette would be locked when there were no staff present and the heater would also be enclosed to safeguard against any risk. Its purpose is to ensure that hot drinks are available in the unit on demand. Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP12 Regulation 16(m-n) Requirement Consult the service users about their social interests and make arrangements to enable them to engage in local, social and community activities; Consult service users about the programme of activities arranged by or on behalf of the care home, having regard to the needs of service users. Timescale for action 24/05/06 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 Refer to Standard OP22 Good Practice Recommendations Call systems with an accessible alarm facility should be provided in every room. Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Horsfall House DS0000016476.V290450.R01.S.doc Version 5.1 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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