Inspection on 08/08/07 for Housman Court

This inspection was carried out on 8th August 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

Housman Court 01/09/09

Housman Court 11/08/06

Housman Court 08/02/06

Housman Court 09/08/05

Housman Court 11/01/05

Housman Court 28/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Housman Court School Drive Bromsgrove Worcestershire B60 1AZ Lead Inspector Yvonne South KEY Unannounced Inspection 08:30 8th August 2007 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 Housman Court DS0000018484.V335729.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. Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Housman Court Address School Drive Bromsgrove Worcestershire B60 1AZ 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) 01527 575440 01527 577439 carolonley@housmancourt.wanadoo.co.uk www.srtrust.co.uk Somerset Redstone Trust Caroline Ann Onley Care Home 30 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (30) Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11th August 2006 Brief Description of the Service: Housman Court is an established care home for older people, purpose built in 1988. It is situated in the centre of Bromsgrove within easy reach of shops, post office, library and swimming pool. There are thirty single rooms with en-suite facilities and communal lounges and dining areas. There are also assisted bathrooms for those who need help and communal toilets. A shaft lift enables easy movement between floors and handrails are fitted where they will be useful. Housman Court provides accommodation and care for up to thirty older people some of whom may have a physical disability or dementia type illness. The home is in the centre of a sheltered housing complex with landscaped gardens. Somerset Redstone Trust runs both Housman Court and the sheltered housing complex of five separate units. Caroline Onley is the registered manager of the home and Maureen Price, director of operations, carries out the monthly visits on behalf of the Trust. On 07.09.07 the manager quoted the current scale of charges for the care home as between £1,690 and £1,950 per month. Additional charges are made for hairdressing, chiropody, papers, toiletries and transport at retail rates. Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection incorporates information received by the Commission for Social Care Inspection (CSCI) since 31.08.06 and the information obtained during fieldwork on 08.08.07. The fieldwork extended over nine hours during which the inspector spoke to five residents, a relative, four staff and the manager. The care of three residents was assessed in detail and documents were inspected. A partial tour of the premises was undertaken. Prior to the fieldwork the CSCI sent questionnaires to ten residents, their relatives and their GPs. These sought opinions on the quality of the service provided. Nine responses were received from residents, four from relatives and three were received from GPs. Prior to the fieldwork an Annual Quality Assurance Assessment (AQAA) document was sent to the registered persons. This was completed on 30.04.07 and returned to the CSCI. This document sought the registered manager’s opinion of the service provided and data concerning the home. This was an unannounced key inspection which focused on the key National Minimum Standards and the requirement and recommendations that arose out of the previous inspection. What the service does well: The home provides a warm friendly atmosphere and individual care for each resident. People only move into the home if the home is sure they can provide the care that is needed. Health care from a range of different professionals is obtained to meet each resident’s health needs. Medication is well managed and independence valued and supported. A wide range of interests, activities and opportunities are made available in which people can participate if they choose. Support can be provided so that people are able to continue their commitments to their different faiths and cultures. A choice of daily meals is provided and special diets are catered for. Residents say the food, quality and quantity is very good. They say ‘I eat most things.’ There are a good variety of meals on the menu. The food is Marvellous.’ Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 6 Residents have said that they are happy in the home and the staff look after them well. Relatives say that there is also good support for families of relatives at the home’. One relative has commented on the stability of the team and appreciates the benefit this is to the relatives. A comment made was; ‘We have seen their very great patience and fondness that they extend to the staff Staff are well recruited and checked to ensure they are suitable to work with vulnerable people. They receive training as soon as they start work in the home and training continues so that their skills and knowledge are kept up to date. Residents like the staff and say that they are very helpful. The home is well decorated furnished and maintained. People have their own personal possessions arranged to their liking in their bedrooms. Communal facilities are pleasant and aids and equipment are provided to help those who have difficulties. The home is well managed and systems are in place to support the service. What has improved since the last inspection? What they could do better: The quality of daily records could be more informative regarding the residents and their daily life and all documents must be dated and signed in full when drawn up and each time they are amended and added to so that the author and chronology is clear. Residents, and/or with their consent their representative, should be consulted and involved in planning the care that is needed. Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 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 Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standard 6 was not assessed as this service is not offered by the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available to assist people in making a decision regarding admission to the home. A qualified person always carries out an assessment of the care that is needed before a place is offered so that they are sure that the individual can be properly cared for. EVIDENCE: The Statement of Purpose and Service Users’ Guide had recently been updated and an unwanted condition had been removed from the registration certificate so that it clearly reflected the service the home currently provided. The updated documents were readily available to visitors and residents. Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 10 In the questionnaire responses returned by residents they said that they believed they received the care and support that they needed and had received a contract. A relative commented that ‘the information pack received was very informative in every aspect of the home’. During the fieldwork three residents were selected as a sample and their care and documentation were assessed. The three residents had lived in the home for varying lengths of time. The care documents demonstrated that each person had been assessed prior to being offered a place in the home. The assessments were conducted to identify the needs of each person and ensure that the home was able to provide the necessary care. The quality of these assessments demonstrated a steady improvement in detail and value. Initial care plans had been drawn up that advised and guided staff in the care that was required. Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents received the personal and health care that they need in a way that is acceptable to them. Prescribed medication is well managed so that residents receive it safely as prescribed. EVIDENCE: The manager stated in the AQAA that: ‘All residents are registered with a GP most of whom they have maintained from before admission, district nurses, social workers, and specialists work closely within our service provision. Regular appointments are upheld for visual, dental, speech and specialist care requirements. We have a robust system of medication supply, training and inspection with Lloyds’ Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 12 In the questionnaire responses the residents considered that they received the care and support that they needed, the staff listened and acted on what they said and they received the medical support they required. Comments made included: ‘I am very happy’. and ‘They always help me’. Relatives stated that they usually received the information they needed and the home always met the needs of their relative. The three doctors had all given positive responses to the questions asked. The three care records that were inspected demonstrated that risk assessments had been undertaken and care plans had been drawn up that described the care that each person needed. These had been regularly and well reviewed and updated. In addition there was a brief summary for a ‘Daily Routine Plan’, ‘Social History’ and ‘Getting to Know You’ documents. These provided staff with valuable information regarding the individual residents. Visits undertaken by a range of health care professionals had been well documented and communication with relatives had been maintained relating to these visits. Daily Care records were maintained however some of these were too brief and lacked information regarding the resident’s day. For example frequent statements such as ‘slept well’, and ‘no problems’ lack insight of the individual. It was suggested that a care plan for pressure care would be useful for one resident and more care and attention was needed that all documents were dated in full and signed by the author each time a document was completed or an entry was made. Although the care plans had been reviewed at least monthly there was very little evidence of involvement in the care planning process by residents or, with their consent, their representatives. It was acknowledged that most residents and relatives would not wish to be involved in every review. However it was suggested that each time reviews took place the resident, and with their consent their relative, should be informed to confirm that they were happy with the care provided. Residents told the inspector that they were well looked after and had no concerns. This was confirmed by a relative during the fieldwork and in a letter received by the CSCI. The home received their medication in ‘blister packs’ from Lloyds chemist and the manager said that the service was excellent. Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 13 It was observed that medication was well managed. Storage was clean, safe and well organised, although a new thermometer was needed for the refrigerator. Security was good; there were sufficient stock levels and an efficient re-ordering system. Medication records were well maintained although there were a few signatures missing from the records of administration. If the procedure for administration is followed every time this would not happen. Topical medication in use was kept in the individual’s bedroom with a relevant ‘body map’ and administration record. Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 14 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 excellent. This judgement has been made using available evidence including a visit to this service. Residents enjoy opportunities to participate in activities and events in the community and home. Their wishes and choices are respected and support is provided to enable them to practice their faith according to their wishes. A choice of good quality food is provided so that residents enjoy their meals. EVIDENCE: In the AQAA the manager stated that: ‘We have a wide range of activities available. Our activity organiser produces a regular programme of activities, which staff work together in providing. This enables individuals, both residents and staff, to participate and enjoy activities of their choice. We have developed a friendship group to also befriend and support residents and relatives. Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 15 Activities and care provision is developed to provide the residents’ care as to individual preferences and choice. We have outside support including advocacy to ensure we are doing our level best to meet these requirements. We work to accommodate individual residents’ culture and ensure they are given the opportunities to have equal opportunities to practice their faith, in social activities, remain activities within their culture’. In the questionnaire responses from the residents they said that there were usually activities they could participate in if they chose. One person said: ‘I like the activities. I go to bingo on Fridays and join in all the other things’. During the course of the fieldwork residents were observed going out with family and friends and the visitors book indicated that many people called each day. This was endorsed by the questionnaire responses from relatives. Copies of the house newsletter were available that contained information regarding events that had taken place, photographs of celebrations and plans for the future. A letter from a relative was full of admiration for the variety of activities arranged and the support that the residents received from the staff. Communication with relatives was good. This was confirmed by a visitor in the home and a comment in a questionnaire: ‘My mother had a couple of falls but each time we were informed and GP was also called in. Also recorded in office register.’ Relatives appreciated the links that were maintained. One person stated that the home provided ‘Good support for families of relatives at the home’. It was observed that an activities programme was displayed around the home and the care records contained information relating to interests and preferences. Staff confirmed that a range of activities were provided such as exercises, bingo, craft, puzzles, flower arranging and cooking. Religious needs and requirements were addressed and services were regularly held in the home. There were no known cultural or sexuality needs that needed support. Residents confirmed that they were happy in the home and made their own choices. Several people were observed in their bedrooms and others were enjoying the lounge areas and walking in the grounds. Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 16 The residents were most complimentary regarding the food and were observed enjoying their lunch. In the questionnaires they said that they liked the meals. Other comments made included: ‘I eat most things.’ ‘Good variety of meals on the menu.’ ‘Marvellous.’ The cook explained that the care staff discussed the next day’s menu with each resident and a record of food provided was maintained. Special diets were also provided according to need and taste. The cook met every new resident when they arrived and discussed with them their likes and dislikes and any special needs they might have. Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 17 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. Information and support is available so that people are able to raise any concerns they may have in confidence that they will receive an appropriate response. Staff are well recruited and trained so that the residents are not put at risk of abuse. EVIDENCE: The manager stated in the AQAA that: ‘Our policy is to be open and to welcome suggestions, and where relevant complaints. Complaints policy is in place with all staff, relatives and residents aware of the way to make concerns and complaints. Complaints are taken seriously and dealt with within the structured procedure of time and action.’ It was observed that a copy of the complaints procedure was contained in each Statement of Purpose and Service Users’ Guide. In the questionnaire responses received from residents and relatives it was confirmed that the people knew how to raise their concerns Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 18 The complaint record held an account of one concern regarding footwear and the understanding and attitude of a member of staff. This had been addressed by the manager. The CSCI had received no concerns, complaints or allegation regarding the service since the last inspection. Staff were well recruited and trained. Three staff were interviewed and their records were assessed. They confirmed that they had made formal applications for their posts, they had been interviewed, checked by the Criminal Records Bureau (CRB) and the Protection of Vulnerable Adults (PoVA) list. Two references had also been taken up. All staff (and their records) confirmed that they had undertaken training to protect vulnerable people and they knew how to respond if in receipt of a complaint or concern regarding someone’s behaviour or well-being. Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 19 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, 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is clean, well equipped, decorated and furnished so that residents live in a pleasant environment that suits their needs. Measures are in place to manage the risks of cross infection so that residents are not put at risk. EVIDENCE: In the AQAA the manager said that: ‘Bedrooms are attractively decorated and furnished with the residents enjoying their personal possessions. Communal areas are warm and inviting. The grounds around Housmen Court are well planted and maintained which all residents enjoy very much.’ Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 20 Residents said in the questionnaire responses that the home was always fresh and clean and this was endorsed by the relatives. A partial tour of the building was undertaken. It was observed that since the last inspection the carpets and decoration in the corridors on the upper floors had been replaced to a high standard and were vastly improved. The lounges were well decorated and furnished as were the bedrooms. Each bedroom had been personalised by the arrangement of the occupants’ personal property. The grounds were well maintained and ramps had been installed from the lounge and the dining room to improve access. The manager said that the next planned project was to redecorate and furbish the dining room. It was also hoped that a snoozelan room would be developed and an enclosed and sensory garden. The laundry was observed to be well equipped, as a new washing machine had been purchased. This had resulted in greater efficiency and economy. However the room needed to be sorted out as the hand basin was obstructed and staff needed to go elsewhere to wash their hands. Personal protective equipment was appropriately provided around the home. A recent infection control audit scored the home as achieving 98 Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 21 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. There are sufficient well recruited and trained staff so residents are provided with the current personal and social care and support that they need. EVIDENCE: The manager stated in the AQAA: ‘Staff qualifications include National Vocational Qualification levels 2 & 3, the Registered Manager’s Award, health & safety, dementia care, food hygiene, infection control, manual handling, the Control of Substances Hazardous to Health, abuse awareness, first aid, extended activity leadership. Staff find an open door style of management supportive and long service core care staff are a testimony of quality support, investment and interest.’ In the past twelve months 13 part time staff had left the home. However recruitment had taken place and at the time of the fieldwork there only remained vacancies for a cook on alternate weekends and a kitchen assistant during the evenings. Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 22 Recently the registered providers had recruited three staff from Slovakia and these people were undertaking their induction to England, the local area, the home and the care profession. Their understanding and spoken English was acceptable and they were all able to make themselves understood. In addition to English staff other staff came from Ireland, Pakistan and China. Communication was acceptable with them all. There was a good age range among the staff team with the majority of staff being between 45 – 54 years. There was one male member of staff on the care team. Of the care staff team of 29 persons, 14 people had National Vocational Qualifications (NVQ) to level 2 or above and 5 were on courses. The residents told the inspector that the staff were good and kind and a relative wrote: ‘We have found the whole team at Housman to be professional, caring and highly supportive.’ During the fieldwork a sample of three staff were interviewed. They demonstrated that they were aware of the differing needs of residents and how to provide the care. They had undertaken training in a range of subjects and knew how to respond appropriately to complaints, suspicions of abuse and emergencies. Their records endorsed this and demonstrated that they had been appropriately recruited. The staff were concerned about the lack of assistance in the kitchen in the evenings but otherwise considered that the staffing levels were acceptable to meet the needs of the residents. The manager confirmed that arranging for staff to work during teatime and the early evening was being addressed as rapidly as possible. Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 23 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, 33, 35, 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is well managed so that the staff and systems in place ensure the residents receive the care they need. Quality is regularly assessed so that the residents benefit from an improving and developing service. Risks are well managed so that the health and welfare of everyone in the home is safeguarded. EVIDENCE: The home was well managed by an experienced and well-trained registered manager who had been in post for some time. Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 24 The quality of management was appreciated by residents, relatives and staff. It was observed that the manager knew the residents and they knew her and were comfortable with her. A relative wrote: ‘I am a firm believer in good leadership and have no doubt that Carol and Jan provide excellent leadership to their team.’ There was a good quality assurance system in use that was based on the good practice in the National Minimum Standards. It had been reviewed and updated since the last inspection and the home had been audited in April this year. Questionnaires had been distributed and it was observed that where necessary responses and changes had been made to improve the service. Some residents held articles in safekeeping and some residents received assistance to manage their personal monies. All income had been receipted and receipts were also retained for expenditure. Records were well maintained. They were audited internally each week by the manager and deputy and each month by the area manager. A sample account was checked and found to be correct. Storage was acceptable. Maintenance and health and safety were well managed. A manual was maintained of general maintenance tasks, demonstrating that staff entered requests and records were kept of when the work had been attended to. A good range of regular checks and servicing was carried out on equipment and services. A manual of risk assessments for the home had been compiled and it was seen that these had been well maintained and reviewed. A fire risk assessment had been carried out by Brookside Fire Service Ltd in October 2006 and the record demonstrated that identified issues had been addressed. Routine checks of the fire safety equipment and systems were regularly carried out and the staff had received frequent and regular training in fire drills and fire safety. Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 25 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 X X 3 X X X 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 4 13 4 14 4 15 4 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 4 X 3 X 3 X X 3 Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP26 Good Practice Recommendations The laundry must be organised so that access to the hand basin is maintained at all times and the management of cross infection risk are not compromised. Housman Court DS0000018484.V335729.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 - 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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